*+'2P ' . '**& W « • ii J « S^Nsi W % V-: ^■"SS^'ftf! ',M*A 3?:; v 2r" .«a#C4aJou*oolWk.AE»lBO~af T- " Tf»l \ - 3 -3 ;f |- IS'ttrgeon General's Office ) mmw} <* «?\ Sfe^3 No. w$ ^QC^(TO.CQgQ)QOGOgOQQirJQgo^ QOCt . ff- i 'A . *** I i I I PRACTICAL TREATISE DISEASES OE CHILDREN. ex > BY D. FRANCIS CONDIE, M. D., FELLOW OF THE COLLEGE 01 PHISICIAN9; MEMBER OF THE AMERICAN MEDICAL ASSOCIATION; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY, ETC. FIFTH EDITION, REVISED AND ENLARGED. PHILADELPHIA: BLANCHARD AND LEA. 1858. Entered, according to Act of Congress, in the year 1853, BY BLANCHARD & LEA, In the Office of the Clerk of the District Court, for the Eastern District of Pennsylvania. ADVERTISEMENT TO THE FIFTH EDITION. To present a complete and faithful exposition of the patho- logy and therapeutics of the maladies incident to the earlier stages of existence—a full and exact account of the diseases of infancy and childhood, has been the aim of the author of the present treatise. For the furtherance of this object, in the preparation of a fifth edition, the entire work has been subjected to a careful and thorough revision—a considerable portion of it has been entirely rewritten, and several new chap- ters have been added. In the different sections will be found incorporated every important observation in reference to the diseases of which they treat, that has been recorded since the appearance of the last edition; and in the several new chapters, an account of some affections omitted in former editions, and for the accu- rate description and satisfactory management of which we are indebted mainly to the labours of recent observers. The author therefore trusts that he has succeeded in ren- dering the work a reliable and useful guide to the actual IV ADVERTISEMENT. state of medical knowledge in reference to all those diseases which either exclusively or most usually occur between birth and puberty—diseases which form, in some degree, a class apart from those of the adult—and demand for their cure a particular plan of treatment. Philadelphia, September, 1858. PREFACE. In the preparation of the present treatise on the Diseases of Children, while the author has appropriated to his use every important fact that he has found recorded in the works of others, having a direct bearing upon either of the subjects of which he treats, and the numerous valuable observations— pathological as well as practical—dispersed throughout the pages of the medical journals of Europe and America, he has, nevertheless, relied chiefly upon his own observations and ex- perience, acquired during a long and somewhat extensive practice, and under circumstances peculiarly well adapted for the clinical study of the diseases of early life. He has made use of the labours and adopted the opinions of others, only when he has found them to correspond with, or to be confirmatory of the results of his own observations and inquiries. In the few instances in which, from the high professional standing and authoritative character of the individuals from whom they emanate, he has considered it proper to notice pa- thological views or plans of treatment, the accuracy of which he has had no opportunity of testing, or which are in discor- dance with his own observations and experience, the fact is invariably stated, so that the credit or responsibility may rest with their respective authors. And, in all cases, in which an opposition of opinion, upon any leading point, exists between medical authorities of equal weight, he has always' adopted vi PREFACE. those views which comport the nearest with his own observa- tions; presenting, at the same time, when it is demanded by the importance of the subject under consideration, a fair ex- position of the views of others in relation to it. In reference to the directions given for the management of the several diseases of infancy and childhood, these are almost exclusively based upon the results of the personal experience of the author. To notice every remedy that has been pro- posed, at different periods, and by different practitioners, the recommendation of which is founded, perhaps, upon the sup- posed good effects resulting from its use in two, three, or, at the furthest, half a dozen cases, would have been a means, certainly, of filling up his pages, and might have gained for him the credit of extensive research—but would have contri- buted but little towards the instruction of his readers. He has therefore preferred to present only those remedies and plans of treatment which he has found, from actual observa- tion made at the bedside of the patient, to be best adapted to relieve or to remove the several forms of disease of which he treats; and which he is convinced will be the least likely to disappoint the expectations of the practitioner, when promptly and judiciously administered. He has not failed, however, to notice every remedy and plan of treatment which comes to us with the recommendation of practitioners of unquestionable authority, even although he may not have had an opportunity of testing its efficacy. Every species of hypothetical reasoning has, as much as possible, been avoided. The author has endeavoured through- out the work to confine himself to a simple statement of well ascertained pathological facts, and plain therapeutical direc- tions—his chief desire being to render it what its title imports it to be, A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. He feels persuaded that it will be found a useful and faith- ful guide to the student, and that the practitioner, also, should he be induced to consult its pages, may derive from them some few facts and practical hints, not altogether unworthy of his notice. * CONTENTS. PART I. CHAPTER I. THE HYGIENIC MANAGEMENT OF CHILDREN. 1. Air. Temperature, -.-... 2. Cleanliness. Bathing, ..... 3. Clothing,- ....... 4. Food, ....... 5. Sleep, ........ 6. Exercise, ....... 7. Moral Treatment, ...... CHAPTER II. ON THE PECULIARITIES OF ORGANIZATION AND FUNCTION, DURING CHILDHOOD. 1. Infancy, ........ Organization, ...... Functions, ....... 2. Childhood,....... Organization, ....... Functions, ....... CHAPTER III. PATHOLOGY OF INFANCY AND CHILDHOOD, . CHAPTER IV. SEMEIOLOGY OF THE DISEASES OF INFANCY AND CHILDHOOD, 1. Of the Countenance, ...... viii CONTENTS. 2. Of the Gestures, ...... 3. The Phenomena During Sleep, 4. The Cry,....... 5. Respiration, ....•• 6. The Tongue and Mouth, ..... 7. Of the Surface, . ' . 8. The Breath, ...... 9. Discharges by Vomiting and Stool, 10. The Urinary Discharge, ..... 11. The Bones,...... PART II. SECTION I. DISEASES OF THE DIGESTIVE ORGANS. CHAPTER I. DISEASES OF THE MOUTH. 1. Erythematic Stomatitis. Inflammation of the Mouth, . 2. Erythematic Stomatitis, with curd-like Exudation, . 3. Follicular Stomatitis. Aphthae, 4. Ulcerative Stomatitis, ..... 5. Gengivitis. Inflammation of the Gums, 6. Gangrene of the Mouth, . 7. Difficult Dentition, ..... CHAPTER II. DISEASES OF THE THROAT. 1. Tonsillitis, ...... 2. Hypertrophy of the Tonsils in Children, 3. Pseudo-membranous Inflammation of the Throat, 4. Gangrene of the Throat, ..... 5. Parotitis. Inflammation of the Parotids. Mumps, 6. Angina Externa, ...... CHAPTER III. CESOPHAGITIS, CONTENTS. CHAPTER IV. DISEASES OF THE STOMACH. 1. Indigestion, ...... 2. Gastritis. Inflammation of the Stomach, CHAPTER V. DISEASES OF THE INTESTINES. 1. Enteralgia. Colic, ...... 2. Diarrhoea, ....... 3. Cholera Infantum, ...... 4. Prolapsus Ani, ...... 5. Polypus of the Rectum, . . . . . 6. Invagination of the Intestines, .... 7. Intestinal Worms, ...... 8. Enteritis. Inflammation of the Small Intestines. Ileitis, 9. Colitis. Inflammation of the Large Intestines. Dysentery, CHAPTER VI. Peritonitis. Inflammation of the Peritoneum, . CHAPTER VII. The Remittent or Gastric Fever of Infancy, SECTION II. DISEASES OF THE RESPIRATORY ORGANS. 1. Asphyxia, ....... 2. Coryza, ....... 3. Bronchitis, ....... 4. Pneumonia, ...... Atelectasis Pulmonum, . 5. Pleuritis, ....... 6. Tracheitis. Croup, ...••• 7. Spasmodic Croup, . . . • • 8. Spasm of the Glottis, ...••■ 9. Pertussis. Hooping-Cough, .... 10. Foreign Bodies in the Larynx and Trachea, . B X CONTENTS. SECTION III. DISEASES OF THE NERVOUS SYSTEM. 1. Hypertrophy of the Brain, ...... 388 2. Cerebral Hyperaeuiia and Hemorrhage. Apoplexy. Paralysis, . . 394 3. Convulsions, ........ 404 4. Acute Meningitis, ...... . 420 Meningitis Encephaliea, ...... 430 5. Epidemic Meningitis, ...... 431 6. Subacute Meningitis, ....... 442 7. Chronic Hydrocephalus, ....... 457 8. Chorea, . . . . , # t _ 4g0 SECTION IV. DISEASES OF THE SKIN. CHAPTER I. ERUPTIVE FEVERS. EXANTHEMATA, 1. Measles, . 2. Scarlet Fever. Scarlatina, Inflammatory Scarlatina, Scarlatina Anginosa, Congestive Scarlatina, .... 3. Roseola. Scarlet Rash, 4. Variola. Small-pox, 5. Vaccination, .... Phenomena of Vaccination, Period for Vaccination, Mode of Vaccination, . • 6. Modified Small-Pox. Varioloid, 7. Varicella. Chicken-pox, . CHAPTER II. CUTANEOUS ERUPTIONS. Eruptions occurring previous to Weaning, and during Dentition, . 1. Strophulus, . 2. Prurigo, 3. Crusta Lactea, 4. Impetigo, Eruptions chiefly connected with Gastro-enteric Disease, 473 474 485 485 487 501 512 514 534 540 541 543 545 548 552 552 553 551 55G 558 CONTENTS. xi 5. Erythema, ...... 558 G. Eczema, ...... . 559 7. Urticaria. Nettle Rash, . 560 b. Erysipelas, ..... . 562 9. Phlegmonous Tumours, . . . . 569 10. Herpes, . ..... . 574 11. Psoriasis, ...... 576 12. Follicular Warts, ..... . 573 13. Porrigo, ...... 579 Eruptions conuected with Languid Cutaneous Action, . 584 14. Pityriasis, ...... 584 15. Ichthyosis, ...... . 585 16. Ecthyma. Rupia, . . . . . 587 17. Pemphigus, ..... . 590 18. Purpura, . . . • . 591 From Infection, independent of Visceral Disease, . 596 19. Psora. Scabies. Itch, . . . . 596 20. Syphilitic Eruptions, .... . 599 SECTION V. DISEASES OF THE NUTRITIVE FUNCTION. Scrofula, ........ 603 Scrofulous Inflammation of the Lymphatic Glands, . 608 Ophthalmia, ...... 610 Otitis, ....... . 612 Discharges from the Vagina, .... 614 Disease of the Mesenteric Glands. Tabes Mesenterica. . . 615 Disease of the Bones, ..... 616 Rickets, ...... . 616 White Swelling, ..... 617 Hip Disease, ...... . 619 Disease of the Spine, .... 620 Tubercular Depositions, ...... . 622 Tuberculization of the Bronchial Glands, .... 625 Lungs, ...... . 627 Tubercles of the Brain, ...... 627 Treatment of Scrofula, ...... . 630 Scrofulous Enlargement of the Lymphatic Glands,. 635 Ophthalmia, ...... . 637 Otitis, ...... 640 Discharges from the Vagina, .... . 641 Tabes Mesenterica, ..... 641 Diseases of the Bones. Rickets, . 643 White Swelling, ...... 645 Hip Disease, ....... . 645 Disease of the Spine, ..... 646 Tubercular Depositions, ..... . 643 XII CONTENTS. SECTION VI. DISEASES OF THE URINARY ORGANS. 1. Dysuria. Painful and Difficult Micturition, 2. Anuria. Suppression of Urine, 3. Ischuria. Retention of Urine, 4. Enuresis. Incontinency of Urine, 5. Diabetes, .... 649 654 656 658 664 SECTION VII. CONGENITAL AFFECTIONS, AND ACCIDENTS OCCURRING, MOST GENERALLY, WITHIN THE MONTH. 1. Fractures, ..... 2. Congenital Malformation of the Intestines, 3. Tongue-tie,. .... 4. Hemorrhage from the Navel, . 5. Cephalaematomia, .... 6. Cyanosis. Morbus Caeruleanus, 7. Intestinal Hemorrhage, 8. Spina Bifida. Hydro-Rachis, . 9. Inflammation and Ulceration of the Navel, 10. Intumescence and Inflammation of the Breasts, 11. Ruptures. Heruise, Arrest of the Testicle, 12. Vaginal Hemorrhage, 13. GEdema of the Prepuce, 14. Cohesion of the Labia and Nymphae, 15. Hare-Lip, .... 16. Club-Foot. Talipes, 17. Induration of the Cellular Tissue, 18. Naevus, ..... 19. Cysts of the Neck, 20. Jaundice. Icterus Infantilis, 21. Purulent Ophthalmia, . 22. Hydrocele, .... 23. Paronychia, .... 24. Burns and Scalds, ,668 669 671 672 678 684 691 693 698 700 701 706 706 707 708 709 711 713 718 722 725 728 735 737 741 THE DISEASES OF CHILDREN. CHAPTER I. THE HYGIENIC MANAGEMENT OF CHILDREN. "When we reflect upon the many painful and dangerous maladies to the attacks of which children, from the earliest period of their ex- istence, are liable, and by which so large a proportion of them are annually destroyed, and when we consider, also, that in many, perhaps in the majority of cases, these, attacks might easily be avoided by a proper attention to those external agents, to the influence of which the infant is subjected from the moment of its birth, and which, while they are essential to its existence, become, when counteracted or mis- managed, the cause of nearly all its infirmities and diseases; the phy- sician can scarcely be considered as fulfilling all his duties, when he neglects to point out and urge the administration of the means by which the occurrence of disease may be prevented, as well as those which, when disease is already present, are adapted to remove it."— (Faust.) These remarks, made upwards of a century since, by one whose writings have been consigned to unmerited oblivion, are still substan- tially true. A vast amount of the disease and suffering that occur in early life, is unquestionably produced by errors committed in regard to diet, clothing, and exercise,— by impure air, unwholesome dwellings, imprudent exposure, and a general neglect of physical and moral edu- cation. The proper management of infancy and childhood is still but imperfectly understood, and many erroneous opinions in relation to it, giving birth to practices the most pernicious, are entertained, even by physicians. A general notice of the more important particulars con- nected with the subject would seem, therefore, to be a proper and ne- cessary introduction to the consideration of the pathology and treat- ment of the maladies incident to the early periods of life. 1.—Air. Temperature. The first want of a new-born infant is a free supply of air; and this want continues to recur during every moment of its future exist- ence. It is not only necessary that the infant should be supplied with o 18 , MANAGEMENT OF CHILDREN. a sufficient amount of air to carry on the function of respiration, but it is equally necessary that the air it breathes should be perfectly pure; an impure and stagnant atmosphere being even more deleterious during infancy and childhood, than in more advanced life. From this cause alone, according to the statement of Dr. Clarke, in the year 1782, out of 7650 infants, born in the lying-in-hospital of Dublin, 2944 were destroyed within the first two weeks after their birth. They nearly all died in convulsions—many of them foamed at the mouth—their thumbs were drawn into the palms of their hands—their jaws were locked—and their faces swollen and of a bluish tint, as though they had been strangled. So soon as proper measures were taken, at the suggestion of Dr. Clarke, to insure a free circulation of pure air throughout the wards of the hospital, the dreadful mortality that had previously occurred among the infants inhabiting them, was almost immediately suspended. A vitiated and stagnant atmosphere, even when not immediately productive of any violent or fatal train of symptoms, by gradually impairing the powers of life, produces a general unhealthy condition of the organs, prevents their due development, and lays the foundation for maladies that are always difficult, and often impossible, to remove. Children who are confined for the greater part of the day and night to small, unclean, badly ventilated or overcrowded apartments, almost invariably exhibit the deleterious influence of an impure and stagnant air, in their pallid countenances, flaccid muscles, and emaciated limbs; their impaired digestion—their panting respiration upon any trifling exertion—their stunted growth, and sickly appearance generally, and by their predisposition to some of the most dangerous affections of the lungs, alimentary canal, brain, and other organs. There is no doubt, that in these cases the injurious effects of a vitiated atmosphere are in some degree augmented by the want of proper and sufficient exercise; it would be in vain, however, to attempt to counteract them by any amount of exercise, so long as the little sufferers are debarred from breathing a pure, fresh atmosphere. The importance, therefore, of selecting as a nursery the largest and the most lofty room in the house, and of taking every precaution to insure, at all times, the purity of its air, by free but cautious ventila- tion—by the strictest cleanliness of the apartment and its furniture and by removing from it every possible source of vitiation, should be frequently and forcibly urged upon parents; and every neglect of the means adapted to preserve the infant from the influence of an impure and vitiated atmosphere, should receive a prompt rebuke on the part of the physician in attendance. Among the most usual causes, independent of a neglect of domestic cleanliness and ventilation, by which the purity of the air in rooms occupied by young children is liable to be impaired, are, the smoke of lamps, and of wood fires—the gases produced by the combustion of stone or charcoal—the washing, drying, and ironing of the infant's garments—the cooking of various articles of food—the smoke of to- bacco,—and all domestic processes that have a tendency to rob the atmosphere of its oxygen, or to load it with effluvia of any kind; all of these should therefore be carefully guarded against. AIR—TEMPERATURE. 19 There is no doubt that one of the most efficient causes of the start- ling mortality which occurs in all our larger cities among children under five years of age, is the infected air so many of them are there forced to breathe, in the small, confined, unclean, and crowded apartments in which they spend the greater portion of the day and night. As soon as a child is sufficiently old, it should be carried daily, for a few hours, into the open air, whenever the state of the weather, and the temperature of the season will permit. By no other means can we so effectually secure to it the full enjoyment of a pure, fresh atmosphere— and contribute so essentially to insure its health and promote itsspright- liness. "The open air," Struve with great justness remarks, "is par- ticularly grateful to the feelings of infants. "When they have been accustomed to it for a few times, they evince, even at a very early age, a strong desire to return to it. When unable to walk they point anxiously to the door, and make efforts to approach and open it. When they can scarcely crawl, they instinctively advance towards that part of the room from which they have a prospect of escaping. Often their cries can be arrested in no other way than by carrying them into the free open air." Even when there is nothing to object to in the condition of the at- mosphere which the child respires within doors, and notwithstanding it is carried abroad, at short intervals, into the open air without, it is not unfrequently deprived of the full benefit of a pure atmosphere by various practices originating in ignorance, prejudice, or misconception. Thus, during the many hours passed by infants in sleep, by covering their faces carefully with the bed-clothes; by enclosing the cradle or cot with a closely-drawn curtain; or, when they are taken abroad, by enveloping the entire head in a hood, or with a shawl; or, carrying them completely enclosed beneath the shawl or cloak of the mother or nurse, they are made to breathe a confined atmosphere, which their own respiration and the exhalations from their bodies tend constantly to render impure, and in the highest degree noxious. We have, in several instances, seen convulsions and symptoms of decided asphyxia produced by these absurd and indefensible practices. A healthy and robust infant may be carried daily into the open air, in dry weather, and when the temperature of the season is sufficiently mild, as soon as it is two or three weeks old. Even during the winter season, days will often occur when a robust infant, of more advanced age, may be exposed, for a short time, to the open air, provided its body be protected with a sufficient amount of clothing, not only with- out danger, but with positive advantage to its health. From the period when a child becomes able to walk alone, it should be allowed to pass many hours, every day, in the open air. The ro- bust, fully developed and active limbs, and the ruddy and sprightly complexion exhibited by children who pass much of their time out of doors form a striking contrast with the pallid countenances, the general listlessness, the fragile frames, and the inactive disposition of those who are confined nearly the whole day to the house. The temperature of the air to which infants and young children are exposed, is equally important with its purity. It has been shown by 20 MANAGEMENT OF CHILDREN. the experiments of Dr. W. F. Edwards, that in the young of the hu- man species, as well as of the warm-blooded animals generally, the power of generating heat is but imperfectly developed, and that con- sequently, not only is the temperature of their bodies less, but their capability of resisting the depressing influence of cold is far below what it is in after life. We can readily perceive, therefore, that exposure to air of too Iowa temperature must be peculiarly prejudicial to young infants;—and although the power of producing heat goes on increasing until adult age, still, young children, and especially those of a feeble constitution, will suffer discomfort, and have their health impaired by a degree of cold that would be tolerated with impunity by, or be even pleasant to those who are older and more robust. According to Drs. Milne Edwards, and Villerme, of Paris, and Dr. Trevisano, of Castel Franco, in Italy—and the accuracy of these gen- tlemen's statements is fully confirmed by Drs. Lombard, of Geneva, and Quetelet, of Brussels, and by subsequent observers—the greatest mortality among children, from birth to the age of three months, oc- curs during the season of greatest cold, and consequently, we find that the mortality among children is greater in northern than in southern climates; and in the northern climates, during winter than during the other seasons of the year. Allowance, however, must be made for particular local circumstances, or the occasional visitation of epidemic diseases:—thus, in most of our larger cities, in the middle and southern states, the excessive heat of the summer, when conjoined with causes which prevent free ventilation, and tend otherwise to di- minish the purity of the air, produces annually a very great mortality among children under two years of age; rendering, with us, the sea- son of greatest warmth far more fatal to infants than even that of the greatest cold. From the foregoing facts it must be evident, that to maintain a suffi- cient degree of warmth in the air of the apartments occupied by chil- dren, is indispensable, not only to their comfort, but for the preserva- tion of their health and lives. It will not do, however, for parents or nurses to judge of the temperature required for the well-being of an infant by their own sensations—for what may be sufficiently comfort- able to them may be destructive to the latter—nor should they sup- pose that because no alarming symptoms supervene immediately after the exposure of children to cold, their constitution does not suffer—un- easiness, at first slight, is, by a repetition of the cause, almost invari- ably converted into serious disease. Thus, inflammation of the throat, air passages, or lungs, more or less severe, or a predisposition to in- curable affections of these and other parts, is, in infants and young children, often the result of exposure to a degree of cold, from which dangerous consequences are least suspected to ensue. Infants, and children of a feeble constitution, or in whom, from any cause, the powers of life have been depressed, should especially be guarded from exposure to the external air during decidedly cold, or damp chilly weather. Important as the enjoyment of the fresh air is to the health and comfort of infants, the practice of taking them abroad in cold weather, under the plea of confirming their strength or render- CLEANLINESS—BATHING. 21 ing them hardy, is not less cruel than absurd. A child of sufficient age and vigour to enable its system to react promptly under the de- pressing influence of cold, and, by an increased evolution of heat, to maintain its temperature, may, it is true, sustain with impunity, or even derive advantage from exposure for a short period to a moderate degree of cold,—but, in all others, so far from an increase of strength and vigour, or the ability to endure without injury sudden vicissitudes of temperature, being acquired by their exposure to cold, either in or out of doors, the very opposite effect will ensue—if an attack of se- vere disease be not immediately produced. While urging the importance of a due degree of external heat, to the comfort and health of infants, and the necessity of carefully pro- tecting them from exposure to even a slight degree of positive cold, we would not wish to be understood as recommending that the air of the rooms they occupy should be kept at a high degree of temperature. To subject children of any age constantly to an over-heated atmosphere, is highly improper. From the excessive stimulation thus produced, and the profuse perspiration in which their bodies are almost constantly bathed—especially during sleep—they soon become relaxed and en- feebled,—their nervous system, at the same time, acquires an undue degree of irritability; every trifling vicissitude of temperature causes them to suffer, and they become liable to attacks of severe disease from the slightest causes. A temperature of from 68° to 70° of Fahrenheit, is that best adapted to the nursery—a less degree of heat would not be prudent for very young children, and even those more advanced in age will scarcely tolerate, with perfect impunity, a much lower temperature. It is to be recollected, that notwithstanding a robust and healthy child, when a few years old, will suffer no injury from a dry and cold atmosphere, whilst engaged in active exercise—in or out of doors—yet, when at rest, its health and comfort will be best promoted by the air of the room it occupies being sufficiently warm to prevent the slightest sense of chilliness. The injurious consequences we have pointed out as resulting from constant exposure to too high a degree of artificial heat, will indicate the propriety of protecting children, as much as possible, from the in- tense heat which usually prevails during the summer months, especially in the cities of our southern and middle states—by a free ventilation of the apartments they occupy, and by frequent exposure to the fresh air, in open, healthy, and shady situations. The deleterious effects of the heated and confined air of a large city upon the health of children, may, in a great measure, be counteracted by these means, as well as by daily rides into the surrounding country, or by excursions upon the water; the means for which, in most of our larger cities, is placed within the reach of all by the numerous steamboats that depart for short trips, at almost every hour. 2.—Cleanliness. Bathing. The important functions of the skin, and the intimate relations which exist between it and every other part of the body, point out the necea- 22 MANAGEMENT OE CHILDREN. sity of guarding it from whatever is calculated to impede its free and healthful action. More especially should the utmost attention be paid to preserve it, by frequent ablutions, from the influence of foreign im- purities, as well as from an accumulation of its own excretions. When- ever this is neglected, disgusting, painful, and obstinate cutaneous erup- tions are liable to be produced, or the foundation is laid for derange- ment of function or serious disease of one or other of the internal or- gans. At no period of life is injury more liable to be produced by a neglect of cleanliness, than during infancy—at no period, therefore, are repeated ablutions of more importance. Immediately after birth, the body of the infant requires to be care- fully washed, and the same operation must afterwards be performed daily to insure its comfort, and to preserve it from disease. The skin of the new-born infant is more or less covered with a white unctuous matter, the vernix caseosa: whatever may be its office during foetal life, it is unnecessary, and even injurious, to allow it to remain for any length of time after birth. It may be very readily removed by washing the skin with warm water and a soft cloth or sponge. Dewees and others recommend, in order to facilitate the removal of the vernix caseosa, to "smear every part of the child with fine hog's lard," and then to wash with soap and water. Dr. Eberle recom- mends smearing the body with the yolk of eggs, when, he remarks, "simple warm water will be sufficient to cleanse the surface thoroughly." Notwithstanding the high authorities by which these practices are re- commended, we doubt their necessity, and are far from being convinced of their propriety. When a sufficient amount of water, of a proper temperature, is employed, and sufficient care is taken in the process of washing, we have seldom seen any difficulty experienced in clearing the skin of its caseous coating. In washing a new-born infant, no degree of friction should be used, for fear of irritating or abrading the tender skin; and notwithstanding it is important to remove, as soon as possible, the caseous matter from the folds of the joints, where it is generally most abundant, yet if this cannot be readily done at first, it is of little importance, as every por- tion of what remains may, with ordinary care, be removed at the se- cond washing. The washing being completed with as little delay as possible, the surface, particularly the folds of the joints, the neck, the groin, &c, should be carefully and thoroughly dried with a soft napkin, before the child is dressed. We have directed the infant to be washed in warm water. This is not a matter of indifference; to plunge the body of a new-born child in cold water, and keep it there until the process of washing is com- pleted, is to subject it to unnecessary suffering—if not to endanger its life. When the same process is pursued, day after day, although the robust and vigorous may survive, and even acquire additional strength and vigour from the dangerous ordeal through which they have been made to pass, the generality of infants will suffer serious discomfort, if not permanent injury; while the feeble and debilitated will inevi- tably perish under it. CLEANLINESS—BATHING. 23 The absurd notion so generally entertained, that the cold bath is adapted, in all cases, to augment the strength and invigorate the powers of life, and which has induced so many to view it as an im- portant agent in the physical education of infancy and childhood, has been fully exposed by the experiments of Dr. Edwards and others. By these it is shown that the direct effect of cold water, when applied to the surface, is invariably to depress the strength and vigour of the system; and that this depressing effect is always in a direct ratio with the feebleness or exhaustion of the individual subjected to its in- fluence. When we add to this, that by the same experiments it has been proved that the power of generating heat, and consequently, the ability to support a diminution of temperature, is at its minimum at birth, and goes on gradually augmenting as the child approaches ma- turity, we can readily understand the folly and danger of applying cold water to the skin of a young infant, as well as the necessity of the water in which it is washed being always sufficiently warm to pre- vent the production of the least degree of chilliness. The temperature of the water may be gradually reduced, as the in- fant increases in age,—watching, however, its effects the more closely, the nearer it is reduced to a state of coldness. If its application to the surface be immediately followed by a glow all over the body, and a sense of comfort in the child, it is not too cold; but should it occasion the slightest degree of chilliness, with pallor of the face, or evident lan- guor and depression, it must be immediately exchanged for water of a higher temperature. As a general rule, however, during no period of childhood should the washing be performed in perfectly cold water. Tepid water is better adapted to remove impurities from the surface, and to preserve the skin in a healthy condition, while injury to health is less liable to result from its use. As it is important that the entire surface of the body should be sub- jected to daily ablution—for without this, personal cleanliness cannot be maintained—we are in favour—even from the period of birth, of applying the water in which the child is washed in the form of a bath. It is much better to immerse the body of the new-born babe in a large basin of warm water, its head and shoulders being supported by the hand and arm of the nurse, than to subject its tender body to the handling and exposure which are necessary when it is washed upon the lap. By immersing it in a sufficient quantity of warm water, the washing, also, can be more promptly and effectually performed than by the too common practice of sopping porticm after portion of the surface with a wet rag or sponge—while at the same time, the infant is spared the danger of becoming chilled, which can scarcely be done by any other plan. Nothing should be added to the water—with pro- per attention an infant may be kept perfectly clean without the use of soap. When, however, from any cause soap is required, the finest white kind should be employed. The practice so generally pursued of bathing the head of infants, at the first and subsequent dressings, with some spirituous liquor, should be discountenanced; it does no possible good, but by irritating the scalp, cannot fail to cause considerable smarting, and may produce more serious mischief. 24 MANAGEMENT OF CHILDREN. During the entire period of infancy, the whole surface of the body should be washed in warm or tepid water every morning—and during the day, such portions of it as may become soiled by the natural eva- cuations, or from any other cause. Nor should the maintenance of personal cleanliness, by similar means, be neglected after the child has passed beyond the term of infancy. The daily use of the bath, and more frequent ablutions of the face, hands and feet, should still be en- joined, and any neglect in regard to them prevented by a careful sur- veillance on the part of the parents or guardians. Frequent bathing in tepid water, independently of its removing from the surface every source of impurity, benefits the health of the child by promoting the functions of the skin, and encouraging the free and regular circulation of the blood through its numerous vessels, securing thus the regular growth and full development of every portion of the body. "I consider bathing," remarks Struve, " as the grand arcanum of supporting health, on which account, during infancy, it ought to be regarded as one of those sacred maternal duties, the performance of which should on no account be neglected for a single day." The time during which the child should remain in the bath will vary according to its age. For the first month after its birth the immersion should not continue longer than three or four minutes—the time being gradually prolonged as the child advances in age—continuance in the bath beyond ten or fifteen minutes, is, however, unnecessary, and scarcely prudent at any period of childhood. Children should not be permitted to enter the bath when in a state of profuse perspiration, nor for some hours after a meal. Intimately connected with the subject of cleanliness is a proper at- tention to the hair. In early infancy, all that is necessary is to sub- ject the head, in common with every other part of the surface of the body, to daily ablutions in warm water; as the child increases in age, and the hair begins to grow, a little soap may be occasionally added to the water with which the head is washed, and the hair should be re- peatedly but gently cleansed with a soft brush. This will prevent the greasy matter which exudes from the scalp accumulating and forming a dry black crust—disgusting in its appearance, and liable to occasion ulcerations of the skin beneath it of a most obstinate and painful cha- racter. Many parents are opposed to frequently washing the head of an in- fant, from a supposition that it will render it liable to take cold, and be otherwise prejudicial to health; no such fears, however, need be entertained—the child's health will be much more endangered by neg- lecting to keep its head scrupulously clean than by the frequent ap- plication to it of water of a proper temperature. A soft brush should always be used instead of a comb, for cleansing and smoothing the hair of young children, there being less danger of the brush scratching or unduly irritating the skin. During the entire period of infancy and childhood the hair should be kept short. Nothing is more common than to see a luxuriant head of hair accompanied in children with paleness of complexion, weakness of the eyes, and frequent complaints of headache; independently of CLOTHING. 25 this, eruptions and ulcerations of the scalp are more apt to occur, than when the hair is kept short and thin. The degree of heat, also, which a profuse growth of hair produces in the head, invites to the brain an undue amount of blood, and augments its liability to those diseases to which at this period of life it is always more or less pre-disposed. "The trouble, also, of keeping long hair sufficiently clean, and the length of time necessary for that purpose, are often a cause of much ill humour, and many cross words between children and their attend- ants, which would be better avoided. Mothers, whose vanity may be alarmed, lest constantly cutting the hair, until the eighth or ninth year, should make that of their daughters coarse, may be assured that they have no cause for this apprehension, if the hair be kept con- stantly brushed. I have never seen softer, better hair, than on girls who have had it kept short, like that of schoolboys, until they were in their tenth year." 3—Clothing. "The essentials in the clothing of children," remarks a sensible writer of the last century, " are lightness, simplicity, and looseness. By its being as light as is consistent with due warmth, it will neither encumber the child, nor cause any waste of its powers: in conse- quence of its simplicity, it will be readily and easily put on, so as to prevent many cries and tears; while by its looseness it will leave full room for the growth and due and regular expansion of the entire frame; a matter of infinite importance for the securing of health and comfort in after life."—{Willis.) The texture and amount of clothing, during infancy and childhood, should be such as to preserve every portion of the body of a sufficient and equable warmth—neither allowing it, on the one hand, to expe- rience the slightest sensation of chilliness, nor, on the other, unne- cessarily augmenting its heat. The younger the infant the warmer should it be clothed, and the more care should be taken to protect every part of its surface by an appropriate covering. Older children, especially in the variable climate peculiar to our northern, middle and western states, require their clothing to be adapted in its mate- rial and amount to the average state of the weather. It should be neither too flimsy and light in summer, nor too warm and oppressive in winter; a medium covering being that ordinarily worn throughout the year, with appropriate additions, adapted to changes in the wea- ther, to the prevailing temperature of the season, or to particular cir- cumstances of exposure. For the under garments of children flannel is indispensable during the autumnal, winter, and spring months. Worn in contact with the skin, flannel preserves, better than any other material, a moderate and equable warmth of the body, and more effectually protects it from the influence of sudden alterations in the temperature of the at- mosphere. During the summer season, however, the flannel may be changed for muslin or cotton; the softer species of which, that which is neither of a very fine texture nor highly dressed, should be se- lected. Even in winter, when from any unusual sensibility of the surface, the contact of the flannel excites an irritation of the skin, or 26 MANAGEMENT OF CHILDREN. produces profuse perspiration, thick muslin may be substituted, or a soft muslin dress may be worn next to the body, and over this a flan- nel garment. The fashion of a child's clothing is a matter of perfect indifference if the material of which it is composed be sufficiently warm, and it be made perfectly loose, and protect effectually every part of the body. To leave the neck, shoulders, and arms of a child nearly, or quite bare, however warmly the rest of the body may be clad, is a sure means of endangering its comfort and health; violent attacks of croup or bronchitis, or even inflammation of the lungs, are often in- duced by this irrational custom; and it is not improbable that the foundation of pulmonary consumption is often thus laid during child- hood. It is an important precaution, therefore, to have the dress worn by children so constructed as to protect the neck, breast, and shoulders, and with sleeves long enough to reach the wrists. By having its garments of sufficient length, the lower extremities of an infant may be kept perfectly warm, especially if in cool weather the feet are covered with soft woollen socks; but when it becomes old enough to be carried abroad, or commences to walk, its legs and feet should be defended by soft woollen stockings which reach above the knees, but without garters, and by easy comfortable shoes, of some soft material, with leather soles; the latter are indispensable whenever the child is placed upon the floor, to protect its feet from being injured by any sharp substance with which they may acci- dentally come in contact. The head, even from birth, may be fully protected, under every degree of exposure to which it is proper to subject an infant, without the necessity of enveloping it day and night with a cap. When on the lap of the mother or nurse, if the room be of a proper tempera- ture, a soft woollen shawl, thrown loosely around the infant's neck and shoulders, and brought up over its head so as to form a kind of hood, will be sufficient to guard it from any accidental draft of cool air. When carried abroad in cool weather, a similar covering will render any other than a thin, light, and soft cap, unnecessary. Caps, when worn within doors, are objectionable by keeping the child's head too warm, and thus inviting to the brain an additional amount of blood, at a period when, from its soft texture and great vascularity, it is prone to hyperaemia, and to inflammation from slight causes. The material of which the cap is composed, being generally lace or worked muslin, by the roughness or harshness of its surface, is calculated also to fret and irritate the delicate skin with which it is in contact, and if not productive of eruptions, cannot fail to occasion considerable uneasiness to the child. By covering and confining the ears, and compressing them against the side of the head, the cap, even if it occasion no other injury, is apt to produce pain and inflam- mation of these organs, or a disgusting, sometimes dangerous, sore- ness and running behind them. It is all-important that every part of a child's clothing should be sufficiently loose to give perfect freedom to all its movements, and to prevent compression of any portion of the chest, loins, or extremities: FOOD. 27 without this the muscles will fail to acquire their proper development and strength, the chest its full expansion, or the figure that upright- ness and perfectness of form, upon which beauty and health so inti- mately depend. As a general rule, the clothes worn at night should be both lighter and looser than the day clothes. The additional warmth produced by the bed and its coverings renders unnecessary the same amount of garments as is required during the day, and would be liable, were no change in the clothing made, to overheat the body, or to exhaust it by causing profuse perspiration; while the least restraint or compression of the limbs, chest, or abdomen, renders the sleep disturbed—and by impeding the free action of the heart and lungs, is liable to produce various uneasy sensations or even partial or general spasms. Every article of dress worn during the day should be changed on retiring to rest: this is demanded for the promotion of the comfort as well as the health of children; it allows the different portions of the clothing to be aired at short intervals, and prevents any injury that might result from the gaseous and vaporous exhalations given off by the skin, and imbibed, to a greater or less extent, by the clothes being retained too long in contact with the body. For infants, a simple long gown of flannel in cold, and of muslin in warm weather, made with wide sleeves covering the whole of the arms, is the most appropriate night-dress. For older children, of both sexes, who are very apt in their sleep to thrust their arms and legs from be- neath the bed-clothes, it is better to make the night-dress in the form of a jacket and long trousers, with feet; the whole being, however, in one piece, and secured, where it is left open behind, to enable it to be put off and on, with tapes. Every article of clothing worn during infancy and childhood should be kept scrupulously clean, to which end it should be frequently changed. It is all-important likewise that it be preserved as dry as possible. During the early period of infancy especially, the under garments should be examined at short intervals, and if any one of them has become wet, it should be immediately removed and replaced by a dry and clean one. If this be neglected, the child is liable to become chilled, and its health to be endangered. We have known severe in- flammation of the skin about the upper portion of the thighs and nates to be induced when a wet diaper has been allowed to remain on for too long a period. For fastening and adjusting the clothes of young children, tapes should be substituted as much as possible, for pins; painful punctures and scratches, from the points of the latter being brought in contact with the skin in handling infants or even by their own movements, are of daily occurrence, and we have numerous instances on record of more serious consequences resulting from the pins, accidentally detached, becoming imbedded in the infant's flesh. 4—Food. The milk of the mother is the natural and only proper food for an infant. "Nature does not afford, nor can art supply any substitute." 28 MANAGEMENT OF CHILDREN. To it, therefore, should the child be entirely confined, whenever it is possible, until the process of dentition has made some progress. The difficulty of rearing an infant, when from any cause it is de- prived of the maternal breast, or that of a healthy nurse, is pointed out by almost every writer that has treated on the subject of infantile hygiene. In the asylums for foundlings and young infants, where feeding by the hand has been substituted for the natural nourishment, the mortality has been, invariably, the most appalling. Forty, fifty, sixty, and even as high as eighty and ninety per cent, of the infants being destroyed.—{Annales d'Hygiene, t. xix.) It is true, as Auvity very properly remarks, that, in the domestic nursery, and where the utmost care and attention are bestowed at every moment, upon a single infant, feeding by the hand is far less destructive to life. Under such circumstances robust and healthy children have certainly been reared entirely without the breast. Still the task is a difficult one, and, against the few instances in which it succeeds, we must place the very many in which it entirely fails. "I am convinced," says Dr. Merri- man, " that the attempt to bring up children by hand proves fatal, in London, to at least seven out of eight of these miserable sufferers; and this happens, whether the child has never taken the breast, or having been suckled for three or four weeks only, is then weaned. In the country, the mortality among dry-nursed children is not quite so great as in London, but it is abundantly greater than is generally imagined." When, therefore, from any cause, and the case is one of very rare occurrence, a mother is unable to suckle her infant, the breast of a proper nurse should be substituted. The danger which attends every attempt to rear an infant by the hand, as it is termed, is indeed now very generally recognised by mothers; the importance, however, of confining it entirely to the breast during the first months subsequent to birth, is still far from being un- derstood. It is too often the case that an infant is forced to partake daily of substances, to the digestion of which the powers of its stomach are totally inadequate, or which are altogether unadapted to afford to it wholesome nutriment, under the absurd notion that some amount of food, in addition to the mother's milk, is necessary to support its strength, and promote its growth. The beneficial effects of the natu- ral food are, in this manner, in a great measure counteracted, while the infant is subjected to many of the dangers resulting from dry nursing; the functions of its digestive organs become almost invariably deranged; it suffers more or less from flatulence, griping pains, and irregularity of the bowels, and becomes weak and emaciated, even if distressing spasms of the glottis, general convulsions, or still more se- rious disease be not induced. As a general rule, subject to few exceptions, the mother's milk alone will afford, during the first eight, ten, or twelve months of existence, adequate nourishment, while it is that best adapted to promote the proper and regular growth of the infant's body, and to maintain its stomach and all the other organs in a state of health. Circumstances may, however, occur under which it will be necessary and prudent, notwithstanding the infant continues at the breast, to supply it with FOOD. 29 additional nourishment; thus, when the milk furnished by the mother is too small in quantity, although perfectly good in quality, in addi- tion to the food it receives from the breast, the infant may be supplied, at proper intervals, with a mixture of cow's milk and water, sweetened with loaf sugar. The milk should be taken fresh from a healthy cow, and, if possible, always from the same animal: because, as Dewees judiciously remarks, different cows, feeding upon the same materials, often give different qualities of milk, and the stomach, very generally, becomes reconciled more readily to any one certain quality, than to a mixture. The quantity of milk required for use should be diluted with nearly an equal quantity of warm water, and well sweetened with the best loaf sugar. Neither stale nor skimmed milk, nor that which has the slight- est tendency to acidity, should, on any consideration, be employed; nor should any greater quantity of the mixture be made than will be required within a short period, lest it turn sour by standing. With this mixture the infant should always be fed by means of a sucking- bottle, such as is now supplied by all our apothecaries. The advan- tages of the bottle are, that the infant draws from it its nourishment by precisely the same process as it does its natural food from the breast of its mother. In this manner the food becomes mixed with the saliva previously to being swallowed, and the stomach is less apt to become over-distended by too much being taken at one time, as is the case when the infant is fed by means of a spoon. The utmost care should be taken to preserve the sucking-bottle and its tube perfectly clean and free from sourness. After each time it is used, any portion of the contents that remain should be poured out, and the bottle with its tube immediately well washed in hot water, and always rinsed out with warm water before it is again used. We have recommended diluted cow's milk, sweetened with loaf su- gar, as being, under ordinary circumstances, the most appropriate ali- ment for an infant that may require nourishment in addition to what it obtains from its mother's breast. We believe it to be the best, also, during at least the first four or five months, when, from any cause, the child has to be brought up entirely by hand. It affords sufficient nu- triment, in general agrees well with the stomach, and in most situations is readily obtained pure and fresh. The milk of the ass and mare, which in their composition certainly approach nearer to that of the human female than the milk of the cow or goat, is strongly recom- mended by many of the continental writers for the nourishment of in- fants; while a late writer, Carault, (Guide des Meres,) gives the pre- ference to rennet whey and a decoction of malted barley. The nearer the aliment that is given to an infant, in addition to or as a substitute for its mother's milk, approaches in its qualities to the latter, the better. Scarcely anything in the form of food could be devised that is so little adapted for nourishment, during the first months of existence, or more liable to produce derangement of the stomach and bowels, and injury to the infant's health generally, than the vile compounds of flour and milk, bread and water, or oatmeal and water, large quantities of which, under the names of pap, panada, and water- 30 MANAGEMENT OF CHILDREN. gruel, were, until a very late period, forced down an infant's throat, under the absurd supposition that this was necessary in order to pro- mote its strength and vigour, and to save the mother from the too great exhaustion which it was imagined would ensue if the infant was per- mitted to depend upon the breast for its entire nourishment. But as the powers of the infant's stomach are altogether inadequate to digest properly or entirely the articles of food thus forced upon it, gastric irritation, griping pains, disturbed sleep, fits of violent screaming, fre- quent watery discharges from the bowels, discoloration of the skin, and rapid emaciation, are the usual consequences of their use; to relieve these, the little sufferers, too often, are made to partake of an addi- tional quantity of the same kind of food, or it is liberally supplied with carminatives and cordials, and thus the mischief is constantly increased, until some severe or incurable disease is induced. " That the jaundice of infants is generally produced by dyspeptic irritation, I have not," says Eberle, "the slightest doubt; mucous irri- tation of the duodenum is well known to be an active and frequent source of this malady, and this affection is very rarely found to occur in new-born infants, without being preceded by decided manifestations of irritation of the digestive organs. Let the infant's stomach be once or twice filled during twenty-four hours with gruel, or any of the ordi- nary preparations employed by nurses for this purpose, and the chances will probably be as ten to one, that acidity, vomiting, colic, griping, and jaundice, will supervene." Very vigorous and healthy infants, it is true, often pass through the gastric irritation and distress, produced by improper nourishment soon after birth, without sustaining any permanent injury in health, or constitutional infirmity. After four or five months of flatulence, griping, and disordered bowels, the digestive powers gradually become inured to the impressions of the food, and a considerable degree of health and vigour is obtained. In many cases, however, the irritation which is thus kept up in the stomach and bowels, does not pass off in so favourable a manner. Jaundice, chronic and unmanageable diar- rhoea, emaciation, slow fever, enlarged mesenteric glands, dropsy in the brain, scrofula, chronic affections of the liver, epilepsy, and other dan- gerous maladies, may, and not unfrequently do, result from this state of the alimentary canal, during infancy. After dentition has made some progress, a portion of gum, barley, or rice water may, with propriety, be added to the sweetened milk ; or we may give, in addition to it, a little plain beef or mutton broth, or the juice of the same meats when not over-roasted. But as a variety of food is more apt to disagree with the stomach, than one simple article when properly selected, in every instance in which the infant appears to be well nourished, there should be no hurry in changing or adding to its diet, which, until several of its teeth have been cut, should consist, pretty much, of the articles above enumerated. Whatever may be the food with which the infant is nourished, whe- ther it be solely the breast-milk of the mother, or a mixture of cow's milk, water, and sugar, care should be taken that it be allowed to par- take of it only in such quantities, and at such intervals, as are abso- FOOD. 31 lutely necessary to its proper nourishment. The stomach should never be overloaded; nor should the process of digestion, which, though ex- tremely rapid in the earlier periods of life, nevertheless requires a cer- tain period for its perfect accomplishment, be interfered with by the too frequent introduction of food. In the early period of infancy, the rapidity with which the digestion is effected requires the stomach to be supplied with food at very short intervals; but as the infant increases in age, these intervals are gra- dually to be lengthened; so that, while at first it takes the breast al- most every few hours, or even oftener, it subsequently requires it only three or four times in the course of the day and night. The rule to be observed in nursing or feeding an infant is, never to withhold from it the breast or bottle when it indicates a desire to par- take of it, but, at the same time, by no means to provoke it to partake of either when it exhibits no such desire. It is surprising how very early, by a neglect of this rule, a morbid appetite may be created. It is too often the custom with mothers and nurses to take it for granted, that because an infant cries, it must be hungry, and to force it, then, to take the breast; or, when fretful from any cause, to attempt to ap- pease it by administering food. No fixed rule can be laid down as to the number of times, or pro- per periods, at which an infant should partake of nourishment; the natural wants of its system should alone be consulted; and these are made known, even in the youngest infant, by signs which the most superficial observer can scarcely mistake. By a little care, instead of having the child, when awake, constantly hanging at the breast, it may be soon taught to require it only at re- gular periods; and the danger of over-distending its stomach with milk will then be, in a great measure, avoided. It is not uncommon for an infant to be accustomed to lie all night at the breast; a practice from which injury may result, not only by inducing the child to overload its stomach, but by interrupting its sleep, and causing it to breathe for many hours a confined, heated, and impure atmosphere. Infants who are confined entirely to the breast-milk of a healthy mother or nurse, or at least, with no other addition to it than cow's milk diluted with water and sweetened with loaf sugar, until after the first dentition is accomplished, have always appeared to us to thrive well, and to be seldom troubled with affections of the stomach and bowels. Nevertheless, after dentition has made some progress, we may, with great propriety, allow them, once or twice in the course of the day, in place of the milk and water, to partake of rice flour, arrow-root, or tapioca, prepared with milk, and well sweetened—milk in which grated cracker or stale bread has been well stirred—animal broths with bread or cracker mixed in them—or roasted potatoes reduced to a fine thin pulp with cream. These articles should, however, be given in mode- ration, and be invariably prepared fresh each time they are used. Dr. Gumprecht, of Hamburg, praises highly, in a communication published in the Journal fiir Kinderkranlcheiten, the carrot pap as an article of food for young children. It is made by mixing an ounce of finely scraped, full grown carrot with two cupfuls of cold soft water, 32 MANAGEMENT OF CHILDREN. and allowing it to stand for twelve hours, it being frequently stirred during that period. The fluid portion is then to be strained off and the residue pressed to deprive it of the juice it still retains. The juice thus obtained is to be mixed with a sufficient quantity of powdered biscuit, bruised crust of bread, or farina, etc., to form it into a pap, and then placed over a slow fire, care being taken to prevent its boil- ing, which would coagulate the albumen. When removed from the fire, the pap is to be sweetened with loaf sugar. According to Dr. Gumprecht, this preparation presents the combination of albumen, gluten, starch, sugar, fat, and the phosphates of lime and magnesia, re- quired in the food of young children. It has been employed by Mul- ler, of Hamburgh, Mauthner, of Vienna, Miinchmeyer, of Lunenberg, and other distinguished practitioners, all of whom bear decided testi- mony to its value. For infants brought up by hand, the following is recommended as preferable to the pap made as above. One ounce of very finely scraped yellow carrot, and two drachms of biscuit powder, with two cupfuls of cold soft water, are to be allowed to stand in a covered vessel, in a cool place, for twelve hours, and frequently stirred. It is now to be strained through a linen cloth, a pinch of salt being added to the fluid, this is then to be sweetened with sugar-candy, and given to the child, at a proper temperature, by means of the sucking bottle. The foregoing preparations cannot be used for the diet of infants when there is any tendency to diarrhoea. Until after the first dentition is completed, solid animal food, in our opinion, should form no portion of an infant's diet; it is apt to increase the febrile excitement to which the system is already predisposed, and to augment the irritability of the digestive organs, which is an almost invariable attendant, to a greater or less extent, upon the process of teething. Subsequently, however, to the completion of the first set of teeth, a small portion of the more nutritive and digestible meats may be allowed, when the child is in perfect health, once a day; but these should never constitute his principal food; which should consist of prepa- rations of milk with various farinaceous substances, plain custard, soft boiled eggs, bread and milk, and plain rice pudding. "Many people, from a mistaken expectation of strengthening weakly children, give them much animal food, sometimes twice or thrice a day; but it will be found much more frequently to add to their debility than to in- crease their strength. Those children, on the whole, who eat the least animal food, are the most healthy." (Clarke.) Infants experience, from even a very early age, the sensation of thirst, and are highly gratified and refreshed by a few mouthfuls of cool water, which, particularly during the period of teething, they earnestly and repeatedly solicit, and swallow with avidity when pre- sented. The gratification of this craving should not, therefore, be neglected, but the infant should be offered occasionally a portion of pure water, cool, but not decidedly cold. From the inattention of mothers and nurses, young infants suffering from thirst are not unfre- quently refused the only effectual means of gratifying it; and under the supposition that they are hungry, are made to take the breast, or FOOD. 33 food is forced into their stomachs, of which they stand in no need, and which rather enhances than diminishes the uneasy sensation they ex- perience; while a few spoonfuls of water would immediately satisfy their wants and quiet their restlessness or crying. As a general rule, it is undoubtedly a duty incumbent upon every mother to nourish her own infant; occasionally, however, when from disease, any constitutional infirmity, or a defect in the nutritive pro- perties of her milk, the mother is incapacitated from performing this delightful task, it becomes necessary, as well for her own good as for that of her offspring to transfer the care and nourishment of the latter to a proper nurse. The choice of a proper nurse is, however, a matter of no little importance. It is essential, in the first place, that the female at whose breast an infant is to be nourished, should be in the prime of life; between twenty and thirty years is the most desirable age, though a few years below or beyond this period will be of little importance, provided she is of a sound constitution, and enjoys perfect health. This latter is an all-essential requisite, upon which the due support of the infant and its future health, in a very great degree, depend. No female, there- fore, should be selected as a child's nurse who is labouring under any bodily infirmity; or who is even strongly predisposed to consumption, scrofula, or convulsive diseases. Her breast should be full, firm, and well formed, the nipples sufficiently salient, and yielding the milk upon the slightest pressure. Hor catamenial discharge should be entirely suspended. Her milk, also, should be as nearly adapted to the age of the infant as possible; a slight difference is, however, no objection; and the fact of her milk being adapted to a somewhat younger infant than the one she is about to suckle, is of less importance than if it were adapted to one many months older. Not only should the foster mother enjoy the physical advantages just enumerated, but she should possess, likewise, great mildness of disposition, considerable cheerfulness of temper, and an inexhaustible stock of patience. There are a number of moral defects which render a female totally unfit to give nourishment to an infant, or to assume the charge of it in any manner. Thus, an irritability of disposition, giving rise to fre- quent gusts of violent passion, has been known to produce so delete- rious an effect upon the milk, as to render the infant liable to convul- sions on partaking of it during or immediately after such exhibitions of ungovernable temper. Grief, envy, hatred, fear, jealousy, and peevishness, likewise, independently of their abstracting the mind from the duties necessary to be fulfilled towards the infant, by their influ- ence upon her health, tend so to alter the qualities of the nurse's milk, as to cause it to disorder the stomach of the infant, and, at the same time, render it altogether unfitted for the proper nourishment of the latter. We take too little into consideration the pernicious and long-con- tinued, if not permanent, injury, which the character of the nurse may have upon the temper, the intellectual powers, and the disposition of an infant, by producing, through the nourishment she imparts, to it, 3 34 MANAGEMENT OF CHILDREN. as well as by her treatment, permanent derangement of the digestive function, with consequent imperfect nutrition of the several organs, and disturbance of the nervous system. The ancients evince, by their writings, a far greater acquaintance with this important truth than exists at the present day, if we may judge from the advice of Plutarch to mothers who refuse to nurse their own offspring. "They should," he observes, "be cautious at least, to choose carefully the nurses and attendants of their children; not taking the first that offers, but rather selecting the best that can be obtained. These should, in the first place, be Greeks in morals; for not more attention does the body of man require from the period of his birth, to insure the growth of his limbs in strength and symmetry, than does his mind, in order that to his moral qualities may be imparted the same firmness and perfection as to his physical. During the period of infancy the tender and plastic mind receives readily whatever im- pressions, and assumes whatever form we may desire to give it." Much, it is true, of the physical as well as moral evil resulting from the misconduct of a nurse may be obviated, if the mother still exerts a constant watchfulness over the welfare of her offspring, and does not suppose that, because she is obliged to delegate to another the task of giving nourishment to her infant, she is thereby exonerated from the duty of attending herself constantly to the promotion of its health and comfort. The diet of a nurse—whether that nurse be the mother or a stranger —should be a subject of strict attention; the quality of the food she takes exerting a powerful influence upon the character of the nourish- ment she imparts to the infant at her breast, and consequently upon the health of the latter. Her diet should consist of such wholesome aliment as is in ordinary use, simply cooked, and eaten in moderation. Soups properly prepared, fresh beef or mutton plainly roasted or broiled, with a proper amount of vegetables, are to be preferred to made dishes, rich gravies and highly seasoned viands, as well as to salted and smoked meats. As to vegetables, the different leguminous and farinaceous seeds or roots, variously prepared—the saccharine fruits of the season, either cooked or perfectly ripe—and the various dishes consisting of milk and vegetables, in common use, are all well adapted as food for a nurse; and, with bread, should compose a con- siderable portion of it. Acid and unripe fruits, pickles, and similar articles, will very generally prove injurious to her milk, and of course to the infant she suckles. " I have known," remarks Marley, " a plentiful secretion of milk to be diminished in quantity, from the over anxiety of the mother; who, thinking it necessary her nurse should live well, allowed her to eat a greater proportion of animal food than her stomach could digest. Others, who are fond of indulging an excessive and gross appetite, take advantage of their situation as wet nurses to satisfy their pro- pensity for eating, under the plea of having two to support; others object to certain meats, as being injurious to their little charge. In fact, it is well known that upon taking the situation of wet nurses, those women who, a short time previous, would have been thankful for a plentiful meal, however homely, are suddenly transformed into fas- FOOD. 35 tidious and dainty beings, considering their wants and wishes of the greatest importance. I have always observed, that if a woman who is nursing eat heartily, but not immoderately, of plain food, avoiding that which is stimulating, she will, generally speaking, preserve her health, the result of which will be a plentiful secretion of milk. I consider meat once a day as quite sufficient." The only drink of a nurse should be water—simply water. All fermented and distilled liquors, as well as strong tea and coffee, she should strictly abstain from. Never was there a more absurd or per- nicious notion, than that wine, ale, or porter, is necessary to a female whilst giving suck, in order to keep up her strength, or to increase the quantity, and improve the nutritive properties of her milk. So far from producing these effects, such drinks, when taken in any quantity, invariably disturb, more or less, the health of the stomach, and tend to impair the quality, and diminish the quantity, of the nou- rishment furnished by her to the infant. They "excite," to use the words of a modern writer, "a feverish state of the body, and create an artificial thirst,—a thirst which is not expressive of any real want of the constitution, but a certain proof that the want does not exist. The greater the craving for them, under these circumstances, the more certain we may be that they are not needed, and that they will cause positive mischief to both mother and infant. The constitutions of both are stimulated by them beyond what nature ever intended they should be. The laws which govern the animal economy are positively infringed, and it is impossible that either mother or infant can escape the penalty of that infringement. Both will suffer, to a certainty in some shape or other, if not immedi- ately, at a future period." "Thousands of infants are annually cut off by convulsions, &c, from the effects of these beverages acting upon them through the mother." (Courtenay.—London Lancet, 1840.) Moderate daily exercise in the open air, which, while it is sufficient to counteract the effects of her sedentary occupation, is not carried to the extent of producing fatigue, a nurse should never be induced to neglect. The place in which the nurse resides, if the infant be committed to her charge in her own habitation, is far from being a matter of indif- ference. It should be either in the driest, most open and healthy part of the city, or, Avhat is preferable, in a healthy situation in the coun- try—always freely ventilated and kept scrupulously clean. A coun- try residence for a nurse has one important advantage,—it indemni- fies, in some degree, the infant for its removal from the maternal breast, particularly when the mother inhabits the confined and illy ventilated streets of a crowded city, the air of which is always more or less pre- judicial in early life. Infants have been found invariably to suffer, to a certain extent, in health, when, after being accustomed to respire the pure atmosphere of the country, they are removed to the city, and made to breathe the stagnant and impure air which prevails in too many of its streets and dwellings. The proper period for the infant to be taken from the breast, or weaned, and nourished altogether independent of the mother's milkj 36 MANAGEMENT OF CHILDREN. may be stated, as a general rule, to be at the termination of a year; within which period, however, the occasional use of other food may with propriety be allowed, according to the directions already given. At the termination of the twelfth month, the cutting of the first set of teeth is, in general, considerably advanced, and the digestive organs of the child are in a condition to effect promptly the solution of almost every species of plain and wholesome food; hence the propriety of de- priving it entirely of the breast at this period. But when, as is occa- sionally the case, the process of dentition is more rapid, and the in- fant is at the same time healthy and vigorous, it may be weaned at any period after the tenth month; while, on the other hand, when den- tition is more tardy, or the infant is weak and sickly, it may be pru- dent, if the mother have a sufficient supply of good milk, to continue it at the breast somewhat longer than a year. We are to recollect that, while the health of an infant is very generally impaired by its being too early weaned, on the other hand, by confining it too long to the breast, it may likewise be seriously injured, as well from an in- sufficiency of nutritive properties in the mother's milk, as by this being no longer adapted to the condition of the digestive organs of the in- fant—the functions of which have become more developed—nor to the perfect nutrition of the several organs of the body. The injurious effects of prolonged lactation, are experienced by the mother to a much greater extent even than by the infant. In deciding upon the proper period for weaning, the season of the year should be taken into consideration. In many parts of the United States, especially in the larger cities, this is indispensable to the safety of the infant. When deprived of the breast at the commencement of or during the summer months, its liability to a disordered state of the bowels, or to a severe attack of cholera infantum, is always much increased. Hence the spring or autumn should, if possible, be. inva- riably made choice of for the period of weaning; and only under cir- cumstances of the most imperious necessity, should it ever be attempted during the season of greatest heat, unless the stomach of the infant has already become fully accustomed to other species of food, and the functions of the digestive organs are performed with perfect ease and regularity. In almost every instance, therefore, when, upon the ap- proach of summer, a mother ascertains that, from any cause, she will be unable to suckle her infant until cool weather again returns, it will be more judicious to wean it somewhat earlier than, under other cir- cumstances, would be desirable; so that its stomach may become ac- customed to the new kind of food which is to take the place of the breast milk, before the intense and continued heat of the weather shall have augmented the irritability of the entire alimentary canal, and rendered this liable to disease upon a change of diet. When, however, nothing occurs to prohibit it, the infant's safety from disease will more certainly be secured, if the period of weaning be postponed until after the heat of summer is over. When the diet of the infant has been properly attended to, previously to weaning, and it has, for some months, been accustomed to other food than the milk of its mother, it may be deprived at once of the FOOD. 37 breast, without the least fear of inconvenience resulting. It will, nevertheless, not be proper to allow the infant, immediately after it is weaned, any amount of solid or stimulating food; neither should its diet be composed of too great a variety of articles. It should still be kept for some time, upon a simple, bland, semi-fluid aliment, taken in moderate quantities, and at proper intervals; otherwise we run great risk of over-stimulating the system, or of oppressing the stomach, im- peding or disordering the digestive process, and thus impairing or dis- turbing the regular nutrition of the different parts of the body. At first, the principal food should be bread with milk—milk boiled with rice—soft boiled eggs—roasted potatoes with milk—oat meal gruel—plain rice pudding—the different preparations of arrow-root, tapioca and sago, and simple meat broths, mixed with the crumb of bread or grated crackers, or in which rice or barley has been well boiled. After a time the child may be gradually accustomed to a more solid and nourishing diet. In the diarrhoea which often occurs during the process of weaning, farinaceous food is liable to disagree with the stomach: it should there- fore be proscribed, and, for the sole diet of the infant, milk, cream diluted with milk, or milk with the addition of gelatin, as recommended by Dr. Stewart of New York, (New York Med. Journal, 1844,) should be made use of. Professor Weisse of St. Petersburg, recommends the use of raw meat—beef or mutton—finely chopped, to the amount of two tea spoonfuls daily, or more if craved, should that which is taken be readily digested, to a child of one year old, (Journalfur Kinderkrank- heiten, 1845.) Of the diet of raw meat, many of the German physicians speak in favourable terms. It is said that children who refuse all other kinds of food, will eagerly take it, and thrive under its use. Until the ago of puberty, preparations of milk and the farinaceous vegetables should, in fact, constitute the principal nourishment. During youth, a large amount of animal food is not necessary, as many ima- gine, to promote the growth and vigour of the body, or to preserve it from the inroads of disease: these important ends are much more certainly attained by a more simple and less stimulating diet. Whatever may be the kind of food allowed during childhood, it should never be taken in excess: we are to recollect, at the same time, that children have usually very keen appetites, and that a sufficient supply of nourishing food is absolutely necessary to renew the waste of their systems, and to supply materials for their daily growth. Three, or perhaps four, light meals a day, will, in general, be all that is ne- cessary. At one of these, the dinner or mid-day meal, animal food —beef, mutton, or fowl, plainly boiled or roasted—may be allowed in moderation: for the others, bread, or potatoes and milk, various pre- parations of rice, or rice and milk, plain rice or bread pudding, or cus- tard, will form a proper and wholesome diet. All salted and high- seasoned dishes, all fat gravies, every kind of overdone and richly cooked food, should be forbidden. Some have objected to butter for children; experience, however, proves that a moderate allowance of butter, when eaten upon bread, is by no means unwholesome. "As a general rule," remarks Dr. 38 MANAGEMENT OF CHILDREN. Kuttner, of Dresden, "it is an error to forbid children butter, and other mild fatty substances; these constitute an important article of nutriment, which appears essential to the due assimilation of albumen and its modifications. They are found in the maternal milk, the fatty matter being most abundant the shorter time that has elapsed since delivery."—(Journ. fur Kinderkrankheiten. Bd. 26.) It has been supposed by some that a diet in early life deficient in fatty matter is a cause of scrofula and other diseased conditions dependent on de- fective nutrition. Of vegetables, potatoes, carrots, turnips, beets, and cauliflowers, will be found the most wholesome for children; they should all be of good quality, and, with the exception of the potatoes, well boiled. In general, however, the potato is most easy of digestion, and agrees best with the stomach, when roasted; it, as well as the turnip, should be eaten without being reduced to a fine pulp, or mixed with butter or fat gravy. Children should never be indulged in cakes or pastry of any kind: they may occasionally take a little of the cooked fruit of a pie, but even of this only in moderation. Their drink should be simply water; or, occasionally, they may be allowed milk, milk and water, whey, or very weak tea, with milk and sugar. Pure water, however, is the only beverage calculated effectually to quench thirst, and promote a free and healthy discharge from the various excretory surfaces and glands; and when children are accus- tomed solely to its use, they crave no other drink, but prefer it on all occasions to every other. Stimulating liquors, whether distilled or fermented, are not only unnecessary but positively injurious; by the undue excitement they produce, they endanger the occurrence of fever, indigestion, inflammation, or convulsions, to say nothing of the danger of a taste for "these pleasing poisons" being induced, leading, in after life, to habits of confirmed and beastly intemperance. The periods of a child's meals should be so regulated, that the in- tervals between them may not be so great as to permit a sensation of hunger being experienced for any length of time; but at the same time a sufficient period should be allowed to elapse between the meals, to prevent disturbance of the digestive process by the introduction of new food into the stomach, before it has properly disposed of that already taken. The first meal of the day or breakfast should be taken by children as soon as possible after they have risen, and have been properly washed and combed. Their stomachs aft^then empty, and the appe- tite is, in general, keen, and if food be too long withheld, the craving of the appetite becomes either too importunate, and too much food is taken, or the appetite entirely fails. Supper, or the last meal, should invariably be composed of the plainest and lightest articles of food, and be taken an hour or two before bed-time. As little variety of food as possible should be set before children, since every additional article becomes a new incentive to appetite, and consequently to excess. They should never be indulged with a second course. If they sit down with an appetite, they will always satisfy it, by eating freely of the first article presented to them; hence all the rest is superfluous, and consequently injurious. If the appetite be but FOOD. 39 slight, the less they eat at the time the better,—as by taking but little the appetite will more certainly return at the next meal. But should this instinct of nature for the observance of moderation be neglected, or attempted to be overcome by variety, repletion, with all its evils, will certainly ensue. Instead of a renewed and healthy appetite fol- lowing, as would have been the case had the instinct been obeyed, the appetite will be found diminished, and even headache, fever, oppres- sion, nausea, or vomiting may occur. Children should not be allowed to eat frequently of bread, bread and butter, bread and molasses, sweetmeats, cakes or fruit, between meals, for this will either destroy the regular appetite, or induce them to eat too much. In the first case, the stomach will be inter- rupted in its regular routine of function, and the appetite will become either irregular or capricious; in the second case, all the evils attend- ant upon an over-distention of the stomach must follow. They should, therefore, not be suffered to carry food in their pockets, to eat between meals, or during school hours,—as this produces the injurious habit of requiring food at improper times, by which the digestion of the pre- vious meal is interfered with—a fresh quantity of food being forced upon the stomach before it has properly digested that previously re- ceived. We are far from advocating the plan which debars a child from " an adequate quantity of wholesome food at any period through- out the day, when the cravings of a natural appetite actually demand it;" we nevertheless believe it far better that the child should be ac- customed to partake of food only at regular periods, which is very soon effected, when those periods are made to correspond pretty closely with the periods of stomachic digestion. They who have no regular times for their meals, in general eat too much, and when refused food, however often they may crave it, be- come fretful and discontented. " They eat all day long—and soon impair their digestive powers and become sick and debilitated." Children should be early taught to eat slowly and deliberately, so that each portion of whatever solid food they take may be fully mas- ticated. To huyry them at their meals, by insisting that they should finish eating as soon as their parents, though they may be helped last, and have usually much greater appetites than adults, is injurious, by obliging them either to leave off before they have had enough, or to swal- low their food without its being properly comminuted by chewing. They are to be restrained from all violent exercise immediately after eating. It is not necessary^ keep them in a state of perfect rest, but merejy t<5" prevent them from engaging in any pastime or occupa- tion that nrpquires* considerable bodily exertion. As children should be early aotustomed to eat slowly, and chew their food well, on this account alfcne the habit of resting after a meal is of importance, as it prevents ^nem from swallowing their food hastily, in order that they may return more quickly to their play. In regulating the,diet of children, care should be taken not to force any particular article upon them, after it is found, by fair trial, not to agree with their stomachs. The contrary practice is both cruel and injudicious: cruel, because the poor child is forced to swallow what is 40 MANAGEMENT OF CHILDREN. disagreeable to it; and injudicious, because it is liable to perpetuate a disgust which, most probably, would have subsided, had no forcible attempt been made to overcome it. At the same time, however, great care must be taken that permanent, capricious dislikes are not formed at this period of life against certain wholesome articles of food. This, however, is often a matter of very great difficulty—a good deal of close observation and discernment being required in order to distinguish be- tween a wayward prejudice and an actual disgust. The former, if in- dulged in too long, may be converted into the latter—while the latter may often, by judicious and well adapted means, be entirely removed. Children should never be allowed to eat alone, unless the proper amount of food be meted out to them; otherwise they will, almost always, eat too much. Whenever a child demands more than is judged proper for it, its importunities should always be resisted with firmness, or it will too certainly acquire habits of gluttony. Children would seem to have a natural taste for sugar, and all arti- cles in which saccharine matter abounds; and they, in fact, are able to partake of a greater quantity, and for a greater length of time, of these articles, without their appetite becoming cloyed, than is the case with adults. Whether or not they should be indulged in the use of sugar and other saccharine substances, has, however, been made a grave question of dispute by physicians. "He," says old Slare, "that undertaketh to argue against sweets in general, taketh upon himself a very difficult task; for nature seems to have recommended this taste to man and all sorts of creatures." Nevertheless, there are writers, and of no mean eminence, who condemn, in the strongest terms, the use of sugar and other sweet substances, as injurious to the stomach, destructive to the teeth, and otherwise prejudicial to the health of the system. How such an opinion could have originated it is certainly very difficult to imagine; so far from any bad effects being produced by the free use of sugar, at least under the ordinary circumstances of health, it is shown, by the most conclusive evidence, to be a highly nutritious and useful article of diet. \ It is, in fact, to the saccharine matter they contain that a long list of fruits and other vegetable productions, which constitute so large a portion of the food of man, and of the inferior animals, owe their nu- tritive properties; and experience has fully shown that sugar forms a very proper addition to the food of children as well as of adults. "It is the only condiment," says Leroy, "proper during the period of in- fancy." Whether, however, pure sugar can be eaten by itself, with perfect safety, is somewhat doubtful. To ensure its ready digestion, and in that manner prevent its turning sour in the stomach, it would appear to be necessary that it should be combined with other alimentary substances. It is in combination with mucilage and other vegetable matters, that it is met with in the juice of the cane, and in those fruits which the experience of mankind has shown to be the most nutritious. Hence, as a general rule, sugar should be given to children rather as an addition to less palatable articles of diet, than as the principal food. Much difference of opinion, also, exists as to the propriety of allow- FOOD. 41 ing children to partake of fresh fruits: by many they are entirely in- terdicted, while by others their allowance is qualified by a number of restrictions not very easy, under ordinary circumstances, to be ob- served. By a healthy child, nearly all the saccharine fruits, when perfectly ripe and mellow, may be eaten in moderation with perfect safety; they furnish a very grateful and proper addition to their ordi- nary food. It must be recollected, however, that the wholesomeness of fruit is always in proportion to its pulpiness, and to its saccharine and mucilaginous qualities. Unripe fruit, of every species, is deci- dedly injurious—as well on account of its being almost entirely indi- gestible, as from the injury inflicted upon the stomach by the crude acid juices it contains. All fruits that are invested with a firm cuti- cle or skin, are also improper for children: but the ripe pulp of those fruits, as in the case of grapes, where it can be entirely freed from the skin and seeds, is in general sufficiently wholesome and nutritive. Fruit containing an abundance of small, hard, and insoluble seeds, as strawberries, blackberries, whortleberries, currants, and the like, should be eaten by children only in very moderate quantities, as the seeds are liable to be retained in the alimentary canal, and may excite con- siderable irritation of its lining membrane. Cherries are among the most pernicious fruits in common use, and ought to be wholly excluded from the list of articles with which chil- dren may be occasionally indulged. Even when eaten without the stones, they are peculiarly apt to derange the bowels; and when swal- lowed with the stones, which, with children, is notunfrequently the case, they are capable of producing violent, and even fatal disease of the alimentary tube. No small number of instances have come under my notice, Dr. Eberle remarks, where the most alarming, and, in a few cases, fatal consequences, resulted from the irritation of cherry-stones lodged in the bowels. Convulsions, inflammation, unconquerable con- stipation, and exhausting and harassing diarrhoea, are among the af- fections which are apt to arise from this cause. Fruits stewed or roasted, with the addition of sugar, are always very acceptable to children, and when tolerably ripe, and not too sour, in general agree well with their digestive organs. The same remark will apply to fruits preserved in sugar: when eaten in moderation, with milk or bread, they form an innocent, and in the case of the habitu- ally costive, an advantageous addition to their meals. They are im- proper only when the bowels are peculiarly irritable and liable to be disordered from slight causes—when taken in immoderate quantities, or upon a loaded stomach. Dried fruits, when deprived of their skins, and stewed with the addition of sugar, seldom produce any injury to the stomach of a child; but when uncooked, and eaten with their skins, they are difficult of digestion, and disorder, often to a very considera- ble extent, the digestive organs. We have, in repeated instances, seen attacks of violent vomiting and purging—distressing colic—and even convulsions of a very dangerous character, produced from the use of this kind of fruit—notwithstanding the amount taken has not been in the least degree immoderate. 42 MANAGEMENT OF CHILDREN. 5.—Sleep. During the first period of its existence, an infant passes the greater part of its time in sleep; it awakes merely to satisfy the instinctive calls for food, and, when these are appeased, falls again into a state of repose. This tendency to sleep is a wise provision of nature—abstract- ing the infant, for a time, from the influence of those agents, the con- tinued action of which would cause too great an excitement of its nervous system, and interfere with the regular and perfect perfor- mance of the functions of its various organs. Almost constant sleep is, in fact, equally important to a new-born infant as sufficient and proper nourishment, in promoting the growth and due development of its system. We may rest assured, that whenever an infant is wakeful and rest- less for many hours, during the day or night, it suffers from too much or improper food, tight clothing, or from some uneasy sensation pro- duced by other causes. After the lapse of a few weeks, however, the senses become cognizant of external objects, and the sleep is less con- tinued, occurring only when the organs, fatigued by the exercise to which they have been subjected, require to have their energies renewed by repose. The infant sleeps now less during the day, but at night its repose is seldom broken. When six months old, it may be accus- tomed, by proper management, to require sleep only at regular periods, and soon after, principally during the night. As soon as this can with propriety be effected, it is of advantage to both child and mother. The sleep of an infant, to whatever period it is confined, should be the result, always, of the natural tendency to repose, prompted by proper nursing, and never, either by day or night, should it be procured by the administration of opiates. The mother or nurse, who, to gain time for other occupations, or to prevent her own repose from being disturbed by the wakefulness of the child during the night, causes it to sleep by the administration of stupifying drugs, runs the risk of pro- moting her own ease and comfort at the expense of the health and life of the infant. "Many an infant," says Combe, "the true cause of whose death was not always suspected, even by the guilty person, has thus passed prematurely to its grave." A young infant requires a soft, warm couch for its repose, with sufficient covering to protect it from the slightest impression of cold. The covering should, however, be at the same time sufficiently light to prevent undue pressure upon any portion of the infant's body, and so accommodated to the state of the weather, as to preserve a sufficient degree of warmth, without overheating the child or endangering pro- fuse perspiration. It is too much the custom to lay an infant, when asleep, with its body warmly clad, in a feather-.bed, and to cover* it carefully with a thick blanket or two. The consequence is, that in mild weather, or in a warm room, a copious perspiration is quickly produced, which, besides weakening the child, exposes it to catarrhal or even more dangerous affections, when, upon its awaking, it is ex- posed to the air of the room, or perchance to the draft from an open door or window. SLEEP. 43 During the first few weeks after birth, it is perhaps best that the infant should sleep at night in the same bed with its mother, especially if the weather be cold; subsequently, however, it may be accustomed by night, as well as by day, to sleep in a cradle or cot. By a few physicians it is advised to have the cradle invariably with- out rockers—the motion communicated to the child in rocking being considered decidedly injurious. There are few infants, however, to which this motion does not appear to communicate a pleasing sensa- tion, predisposing to quietude and sleep; and we are convinced that when gentle, and not employed to induce a state of repose at impro- per periods, it can be productive of no possible inconvenience or injury. We admit that violent, long-continued rocking, by the sudden and repeated jolts it communicates to the tender organs of the infant, may be productive of injury, and should, therefore, never be allowed. There is one disadvantage, however, resulting from the use of a cradle, which is, that infants often become so habituated to its motion as to be with difficulty made to sleep without it: they require, in consequence, an almost constant attendance, awaking the moment the motion of the cradle is suspended, and continuing to cry until rocked to sleep again; whereas, infants who have been accustomed to sleep in a cot, will remain comfortable and quiet for hours even after they awake. The cot has unquestionably some advantages over the cradle; nevertheless, with proper precautions, either may be adopted, according to the taste or convenience of parents. It is, unfortunately, too often the case, that in infants the natural instincts in regard to sleep and wakefulness are but little attended to. An infant is often aroused improperly from its repose, because it may be convenient for the mother or nurse at that particular moment to wash and dress it, or from a supposition that it has been too long without the breast; while, on the other hand, every means, and often very improper ones, are frequently made use of to force it into a state of repose when not inclined to sleep, or to prolong its repose when it is about to awake. The effect of this improper interference is to render the infant restless, peevish, and far more troublesome than it would have been had it been allowed to indulge freely its natural dis- position to repose or to wakefulness. When an infant is in perfect health, properly clad, and judiciously nursed, it seldom gives much trouble; it awakes when it requires nourishment, and falls readily asleep when its system demands repose; and every attempt to inter- fere with this natural state of things is attended with more or less in- jury to the health of the little being. When a healthy infant does not fall speedily asleep on being placed in its cradle, but lies awake, fretful and restless, we may in general be certain, either that it does not feel the want of repose, or that some- thing incommodes it or causes it pain; that some portion of its dress is too tight; or the point of a pin is in contact with its body; that it is in want of food, or has been over-fed or with improper aliment; or that it is suffering from cold or heat, or from a too confined or impure atmosphere. It will be readily perceived, therefore, that the only proper means to lull it to sleep is to remedy at once the cause upon which its wakefulness depends. 44 MANAGEMENT OF CHILDREN. It is important that the sleeping couch of an infant be placed in such a position that the eyes of the occupant shall be screened from a daz- zling or unequal light, and the latter prevented from falling upon them sideways or very obliquely. When the light which enters the apart- ment is moderate, and of a mellow character, the face of the infant should be directly in front of it; but when intense or dazzling, it is better to place the infant in such a direction as to allow it to fall upon the back part of the head, or on the back of the cradle or cot. When, in the evening, a lamp or candle, or an open fire is burning in the room, the same precaution should be observed. As an infant, the moment it wakes, directs its eyes almost instinctively towards the light, there is danger, unless this be uniformly diffused throughout the apartment, or placed in a direct line with the eyes, that a permanent obliquity of vision will be acquired, from the habit of viewing it side- ways. This deformity is more particularly liable to take place, and to a much greater extent, when, from the head of the child being sunk in the pillow, or enveloped in a cap with a projecting border, the light can be viewed only with the eye which is the farthest from it. The position in which an infant when asleep is laid upon its couch, is a matter of much greater importance than, at first view, it would appear to be. If it be placed upon its back, the fluids which are abun- dantly secreted by the glands of the mouth and throat, are in danger of flowing into the windpipe, and thus impeding respiration, or causing a violent—almost spasmodic—paroxysm of coughing, which may be avoided by the infant being laid upon its side. Care should be taken, however, not to lay it always upon the same side of the body, lest per- manent deformity be occasioned in consequence of the circulation of the blood, in the limbs upon which the body constantly rests, being partially impeded, and their proper growth in this manner prevented. The face of an infant should never be entirely covered, nor so im- bedded in the pillow as to obstruct, in the least degree, the freedom of respiration. Occasionally it happens, that when a young infant is placed in a soft feather bed with a thick, soft pillow, its own weight causes it to slip, so that its head is brought entirely beneath the ex- ternal coverings, and, in common with its body, becomes so completely buried in the feathers as to endanger suffocation. This accident is best guarded against by dispensing with the pillow entirely. In cold climates, and during the winter season, a feather bed is cer- tainly a very effectual means of securing to a new-born infant a ne- cessary degree of warmth; but after a few months, especially in sum- mer, or when the temperature of the air is mild, a well-constructed hair mattress, with a proper amount of light, soft bed-clothes, is to be preferred. Independently of the undue degree of heat which is gene- rated by a feather or down bed and pillow, and the exhaustion which thence ensues, the attitude into which the infant's body falls during sleep may induce, when it is resumed every night, a permanent dis- tortion. A feather pillow, also, by keeping the head too warm, not unfrequently becomes the remote or exciting cause of catarrhal af- fections, inflammations of the ear, eruptions, pain of the head, or even more serious disease. For the same reason, children should be accus- SLEEP. 45 tomed, from an early age, to sleep with the head bare—the covering with which nature has, in general, so plentifully supplied this portion of the body being amply sufficient to protect it from cold. The cots occupied by infants should always be without curtains, which do injury, by preventing the proper circulation of the air; they become also receptacles for fine particles of dust, which are liable to be inhaled during sleep, whenever disturbed by the motion of the curtains or of the cot: this alone, according to Willich, is a cause to which may be referred the origin of many a consumptive attack in early life. Children should never be allowed to sleep on beds placed upon or too near the floor. It is well known, that in all apartments occupied by living beings, the inferior portions of the atmosphere are always the most impure. The most wholesome situation for a bed is in the middle of the room, and raised some feet from the floor. From the vitiated state of the atmosphere immediately above the latter, and the great importance of a free ventilation, the practice of placing the chil- dren's bed or cot beneath another bedstead, during the day, cannot be too severely reprobated. The chamber occupied by children, during their hours of repose, should be kept scrupulously clean, and free from dampness; and at all seasons, when the weather is not rainy or otherwise very humid, it should be freely ventilated during the day. It should be divested of all unnecessary furniture; and,'unless of considerable size, should never contain more than one bed. There cannot be a more pernicious custom, than that pursued in many families, of causing children to sleep in small confined apartments, in which two or three beds are crowded together. Plants, flowers, and strong perfumes of every kind, should be care- fully excluded from the sleeping apartments of children. The first have a tendency to render the air of the apartment impure, and the latter have been found to produce a very deleterious impression upon the nervous system of young children. An instance is related by Kopp, of a child, two weeks old, destroyed by the scent of savine oil, which became diffused through the room in which it was sleeping, while the father was applying it to his thigh as a rubefacient for the remo- val of a rheumatic affection. The child until then had been perfectly healthy, and no other apparent cause of death could be discovered. Children should not be allowed to sleep with persons advanced in age, nor with those of a broken down or debilitated constitution, or who are labouring under any chronic disease. The idea that any in- jury to health can result from passing the night in the same bed with the aged, or those who are labouring under any other than contagious or infectious maladies, has been ridiculed by some physicians, while by others it is considered as fully established by numerous facts. We are among the number who believe the apprehension of injury from this cause to be well grounded. Although we are not prepared to assert, with Carault, that in "young infants, accustomed to sleep with their grandfathers or grandmothers, or with an aged nurse, that part of their bodies, which, during sleep, approaches the nearest to their bed- 46 MANAGEMENT OF CHILDREN. fellows, will become enfeebled, pale, and emaciated," yet we have seen, in more than one instance, the general health of children sensibly im- paired by sleeping with old and diseased persons—and quickly restored when the practice was discontinued. To prevent the too frequent, and close contact of young children with adults generally, of whose entire health we are not well assured, is considered by many of the continental writers, and we think very properly, an important precaution. It is unquestionably a filthy and pernicious custom, remarks Struve, to suffer infants to be indiscrimi- nately embraced, fondled, and kissed, by strangers or servants; be- cause in this manner there is danger of their becoming infected with many virulent diseases. But even though no particular malady should be imparted by their close contact with strangers, it is to be feared that the humours of the child may be contaminated by absorbing the poison- ous saliva of a diseased individual. A young child should not be aAvoke from its sleep suddenly, nor by any rude motion or loud noise. The shock which is thus inflicted on its delicate brain and nervous system may occasion a severe attack of convulsions, spasmodic closure of the glottis, and other equally severe and dangerous effects. "Being of opinion," remarks a quaint old writer, (the Marquis of Halifax,) " that it did trouble and disturb the brains of children, suddenly to awake them in the morning, or snatch them violently and over-hastily from their slumbers, wherein they are much more profoundly involved than we, my father caused me only to be waked by the soft strains of some musical instrument." To prevent infants from starting from their repose in affright at every slight noise which occurs in their vicinity, no particular pains should be taken to maintain perfect silence when they are about to fall asleep, nor during their repose. If accustomed to the ordinary sounds of the nursery, they will fall readily asleep amidst them, and much of the danger of their being suddenly awoke or unnecessarily disturbed, is removed. With Combe we agree, that an infant, when asleep, should be excluded from "light and noise:' "Even when these do not pre- vent sleep, they tend to render it troubled and unrefreshing;" and they commit a great and pernicious mistake, who " act in direct oppo- sition to this rule, and think it of no consequence what talking or noise goes on in the nursery, provided the infant be not roused up broad awake." It is to the opposite error, of attempting to exclude from the vicinity of a sleeping child every kind and degree of sound, that we object. We have known children who have been so accustomed to a dead silence when falling into sleep, and during its continuance, that the occurrence of the most trifling sound would immediately awake them, and, if a little louder, would cause an alarming excitement, of long continuance, and difficult to subdue. Children should be accustomed, from a very early age, to retire to bed early in the evening, and to rise the moment they awake after day-light. Habits are thus formed, of the utmost importance to their health and comfort throughout life. EXERCISE. 47 6.—Exercise. For the first few weeks of its existence the infant requires but little exercise of any kind; and it is not until some months have elapsed that its organization has acquired a sufficient degree of firmness to permit of its enjoying any other than such as is of the most gentle, passive kind. From an early period, however, gentle friction with the hand over the whole surface of the infant's body, carrying it about in a horizontal or slightly reclined position on the nurse's arms, either within doors, or, when the weather will permit, in the open air, will not only communicate a pleasurable sensation to the child, but, by pro- moting a free and equal circulation of the blood, contribute to the full and regular development of every part of its body. But while this amount of exercise is decidedly beneficial, and should not be neglected, we are to recollect that every species of dandling and tossing—every kind of motion, in fact, excepting of the gentlest kind—is liable to produce present discomfort, if not permanent injury. For the first month or two the infant should be handled as little as possible, and never placed in an erect or sitting posture. To set it upon the lap while its bones are soft and pliable, its joints slight, and imperfectly developed, and its muscles small and feeble, and to jolt it thus by the hour—its poor little head moving about as if palsied, and its tender back bending and twisting from side to side—is the very worst plan that can be adopted to minister to its comfort, or to pro- mote its regular and symmetrical growth. Many nurses would appear to think that the greater the amount of motion to which an infant is subjected, the better; they toss and roll it about as if it were a bundle of rags, and pull and twist its limbs till the joints crack. Under such treatment, it is not to be wondered at that the poor thing moans, cries, or screams, during the whole time occupied in dressing it, or that it should suffer from deformities and other injuries. Another barbarous practice is that of tossing an infant up and down in the arms, held at full length from the body. The motion thus com- municated is of too violent a kind to be borne with impunity by its tender frame, to say nothing of the serious accidents which may result from the practice, even when the utmost care is observed. Until an infant is able to sit alone, it may be allowed to amuse itself upon its cot, or on a soft cushion spread upon the floor. Here it will lie for hours, until it acquires strength to roll about, and is much more contented, and thrives far better than when continually nursed in the arms or upon the lap; the danger of deformity is likewise avoided, and the child acquires, at a more early period, the power to raise itself, and sit upright, without assistance; and at nine or ten months, will, in general, be able to get upon its feet and walk. When sufficiently old to be attracted by surrounding objects, carry- ing it frequently into the open air, especially into the country, during the mildest seasons of the year, has a highly beneficial tendency. The freshness, beauty, and variety of the scenes of nature, are highly at- tractive, even at a very early period of life; and, independently of the healthful influence of a pure and unconfined atmosphere, the impres- sions thus resulting are always of a decidedly salutary kind. 48 MANAGEMENT OF CHILDREN. In carrying an infant, some important precautions are necessary. The spine, being soft and yielding, is incapable of supporting the weight of the head and other parts of the body which rest upon it in the erect posture. To prevent deformity, therefore, an infant should not be held seated upon the arm of its nurse or attendant; it ought always to be carried in an inclined position, so that the head, and every part which bears upon the spine, may receive^ an equal and adequate support. Neither should the child be carried for too long a time in the nurse's arms without changing the position in which it is held—otherwise there is a danger of its becoming permanently deforirrtd, from its body being twisted to one or the other side. To obviate this, it should be carried, alternately, on both arms. Even in suckling an infant, it is important that it be not confined exclusively to one breast, but nourished alternately, from both—as well to pre- vent its contracting a crookedness of form, as to guard against its ac- quiring a habit of squinting, from one of its eyes, while nursing, being constantly directed towards the same point. Infants, in general, derive much pleasure from riding in a little car- riage drawn by the hand—and as it affords a convenient means of conveying them, frequently, when the weather is mild and otherwise favourable, to one of the public squares or parks which exist in most of our larger cities, or even to a garden or field without the town, where they may enjoy a free and fresh air—this species of exercise may be occasionally substituted for carrying in the arms—to which, for out-door excursions, it is, for very young infants, in many points of view preferable. The body of the carriage should be long enough to permit the in- fant to lie down at full length; and the sides ought to be sufficiently high to prevent it falling or rolling out. The wheels should be low, in order to lessen the liability of oversetting; and they should be carefully secured against running off while the carriage is in motion. Very young infants should be laid down in the carriage on a pillow or soft mattress, with the head slightly elevated, and so confined at the sides as to prevent them from rolling when in motion. After the child has acquired some degree of strength, it should be placed in a semi-recumbent posture, with its head and back supported by pillows, &c.; and when it is capable of supporting its head, it may be permitted to sit upright, so secured as to prevent its being thrown from side to side, by the rolling of the carriage. The carriage should be drawn by none but a prudent and trusty person, with a moderate and steady motion, and never over rough or uneven ground; when the motion is too rapid, or uneven or jolting, much injury may be inflicted on the infant. Children, when placed in the carriage, should never be kept fur any time in the sun, if it be warm; nor should the carriage be kept motionless, when the weather is cool. In cold weather they should be amply covered, since from the passiveness of their situation, they will require additional clothing. The ride should never exceed half an hour at a time, especially if the child is observed to become sleepy— it being hazardous to allow it to fall asleep in the open air; it likewise EXERCISE. 49 the benefit of the exercise, and interferes with the infant's regular habits of repose. (Dewees.) It is only towards the end of the ninth or tenth month, and, when the child is feeble, even much later, that it is proper to teach it the use of its feet. It is perhaps always better that, before an infant at- tempts to walk, it should first learn to crawl. With this intention, it should be placed upon a soft carpet, where it soon busily employs it- self, moving and extending its limbs, or rolling about to reach its playthings. The instinctive desire for locomotion, and the various things that attract it in different parts of the room, will soon induce it to crawl upon its hands and feet. This it should be allowed, and even encouraged to do; as children who are permitted this " useful inter- mediate muscular discipline," are sure to acquire a much firmer step, and enjoy more robust health, than those who have been taught to walk without it. In no instance should any particular attempt be made to induce an infant to use its feet at an early period, nor until the bones have ac- quired a sufficient degree of solidity to sustain the body, without the danger of their becoming bent by its weight. In teaching a child to walk, it should be left pretty much to its own efforts; all artificial support is injurious. As generally applied, such support has a tendency to produce an unnatural elevation of the shoulders, while the infant, depending upon it, almost alone, for main- taining the upright position of its body, is accustomed to bend too much forward, or to one side. In this manner may be laid the foun- dation of a permanent deformity, or at least of an ungraceful gait, which it is impossible in after life to correct. While in the nursery, infants may be taught to rise from the floor by laying hold of chairs; and, if occasionally supported under the arms, they will easily learn to stand erect; but they should never be raised up by one arm only. At an early age they may be held under both arms; and when thus supported, if the hands of the attendant be occasionally withdrawn for a moment, they will soon acquire the power of standing alone. Mild and persuasive language ought to b,e used in these experiments; while the infant may be encouraged by some toys, placed at a little distance, which will induce it to stretch out its little arms, and endeavour to advance towards the place containing the de- sired objects. By such means, it may be allured to visit different parts of the room. The first journey of this kind ought to be at- tempted only from one neighbouring chair to another; afterwards the little traveller may run towards its mother, or nurse, who, with ex- tended arms, stoops to receive it. As the infant improves in ite ef- forts to walk alone, the chairs may be placed at a greater distance from each other, until, finally, it walks firmly in every direction, with- out assistance of any kind. (Struve.) The practice of assisting an infant to walk, by holding him by one of his hands, is extremely reprehensible; the arm being thus con- tinually, and more or less forcibly, extended upwards, should the little pedestrian lose his balance, or trip, or if, from the feebleness of his limbs, he be unable for any length of time to maintain the erect 4 50 MANAGEMENT OF CHILDREN. posture, the whole weight of his body becomes suddenly suspended by one arm. It is easy to perceive that this practice must necessarily and in no inconsiderable degree, tend to draw the shoulder and side of the chest out of their natural position, and, when frequently repeated, to cause permanent deformity of these parts. From the sudden and violent extension which the arm usually receives when the child stum- bles, the shoulder and elbow joints, also, are liable to be dislocated or sprained, or the clavicle may be torn from its attachment with the scapula. Dr. Eberle remarks that he has met with several instances of dislocation of the shoulder joint, which were occasioned in this manner; and the occurrence of painful sprains—often of several weeks' continuance—from violence done in this way, is by no means uncommon. Similar injuries are also inflicted by raising the child from the ground by one arm, in order to help it over some obstacle, or to hasten its progress over a rough and difficult piece of ground. We have seen a heavy child carried thus, by one arm, for a considerable distance. The practice cannot be too strongly condemned. Some of the most violent and troublesome affections of the elbow and shoulder joints that we have met with in children were thus induced. As soon as a child has acquired sufficient strength to walk alone, he should be allowed the most perfect freedom of exercise; upon this, with the free use of pure air, will depend, in a great measure, his health, vigour, and cheerfulness, during the period of youth, while it will contribute essentially to the permanence of the same blessings until the close of life. Throughout the whole animal kingdom the young are prompted, by an instinctive impulse, to almost constant exercise. Conformably to this intimation of nature, a large portion of the youth of man should be passed in those harmless sports, which exercise the limbs, dilate the chest, and communicate motion and vigour to every part of the body susceptible of it, without, at the same time, requiring any mi- nute direction from the head. Experience has shown that when attempts are made in early youth, to interfere with the natural movements and exercise of the body; when, from a false idea of improving the shape, or giving grace to the carriage, children are debarred the free and unrestrained exercise of their limbs, and are confined to any particular position for too long a period, they become restless and uneasy, and their muscles ac- quire tricks of involuntary motion. Twitching of the features, ges- ticulation of the limbs, even dangerous and permanent deformity, or some severe nervous affection, may be the result of such unnatural restraint. Error in this respect, it is true, is but Of occasional occur- rence in the physical education of boys. But how often has an over- anxiety for delicacy of complexion in a daughter, or the apprehen- sion that her limbs may become coarse and ungraceful, and her ha- bits vulgar, been the means of debarring her from the enjoyment of either air or exercise, to an extent sufficient to insure the due deve- lopment, health, and vigour of her body. The consequence is, that in too many instances, females acquire in infancy, a feeble, sickly, and languid habit, which renders them capricious and helpless, if not the EXERCISE. 51 subjects of some troublesome or painful disease, which may continue throughout the whole course of their after lives. The bodily exercises of the two sexes ought, in fact, to be the same. As it is important to secure to both all the physical advantages which nature has formed them to enjoy, both should be permitted, without control to partake of the same rational means of insuring that vi- gour of body and cheerfulness of mind, which will enable their va- rious organs to perform, regularly and perfectly, their respective functions; and by which alone their health and comfort can be con- firmed. Girls should not, therefore, be confined to a sedentary life, within the precincts of the nursery, or, at most, permitted a short walk, veiled and defended from every gleam of sunshine, and from every breath of air. The unconstrained enjoyment of their limbs and muscles in the open air, without a ligature to restrain the free- dom of their motions, or an ever-watchful eye to curb the lively joy of their unclouded spirits, is equally important to their health and well-being, as it is to that of their brothers. To hope to communicate graceful form and motion to the limbs of a child, health and vigour to its constitution, and cheerfulness to its spirits, by confinement, belts, ligatures and splints, superadded to the lessons of the posture-master, is about as rational as would be the attempt to improve the beauty and vigour of our forest trees, by transferring them to the green-house, and extending their branches along an artificial framework. Equally absurd and irrational is it to fetter the active motions of a child, almost as soon as he has acquired the free use of his limbs, under the pretence of improving his mind. To confine a lad within doors, and especially in the heated and impure air of a crowded school-room, for the greater part of the day; to chain him to a desk, and require him to fix his attention, hour after hour, upon tasks, al- ways without interest, and often beyond his comprehension, may be a certain way to train up enervated puppets, or to produce, per- chance, a short-lived prodigy of learning; but it is illy calculated to form healthy, well-informed, and accomplished men. Every feeling heart must have looked with pity upon the sickly countenance and melancholy aspect of the poor little puny creatures of eight, ten, or twelve years, sometimes exhibited by parents, as pro- ficients in learning, or for their early acquirements in languages, elo- cution, music or drawing. Debarred from the healthful and joyous pastimes adapted to their age, and from inhaling "the pure fresh breath of heaven," their mind has been forced, through constant, pain- ful application, to a premature but imperfect and unequal exertion of its faculties, the effect of which is to exhaust its powers and impede its full development; while, at the same time, the natural cheerfulness of youth is destroyed, the health and vigour of the body materially im- paired, the duration of life shortened, and the remaining period of existence rendered too often a burden rather than a blessing. We are far from objecting to an early attention to the proper cul- tivation of the intellect. All we insist upon is, that it should not, in early youth, be taxed beyond its powers; but that the greater part of every day should be devoted to active exercise in the open air. r,0 MANAGEMENT OF CHILDREN. There is not, perhaps, remarks a sensible German writer, a greater and more reprehensible mistake in education, than the very common practice of compelling young children to extraordinary mental exertions, and exacting from them an early and rapid progress in intellectual pursuits; this is, too often, the grave both of their health and of their talents. The age of infancy is designed for bodily exercise, which strengthens and perfects the frame, and not for study, which then en- feebles it and checks its growth. Let the beginning of life, the first six years, perhaps, be devoted entirely to forming the body and the organs of sense, by exercise in the open air. It is not necessary that the child should be permitted to grow up like a wild animal; for, with proper care, his mind may be made to receive considerable and valuable instruction, through the medium of the senses, and the conversation of those around him. In these two ways, he may, indeed, acquire more useful knowledge, by the end of his sixth year, than a child who had learned to read in his fourth. In his seventh year, he may spend an hour or two daily at his books; in his eighth, three hours; and so on until his fifteenth, when he may have six or seven hours allotted for study. Children are frequently confined to the school-room for many hours daily, when not occupied in any useful pursuit;—which time, without detracting from that necessary for the cultivation of the mind, might, with great propriety, be devoted to those bodily exercises and recrea- tions which tend to develop the strength, and promote the regular and energetic action of every organ of the frame—the brain and ner- vous system included. The first occupations of the day should be abroad, for the benefit of inhaling the early morning air. There is always a striking differ- ence in the health, the freshness of complexion, and the cheerfulness of features exhibited by a child who has spent some time in out-door exercise before his morning task, and one who passes immediately from his couch to study, or other in-door occupations. Children are always fond of early rising, when their natural activity of disposition, and disinclination to remain long in a state of quiet have not been counteracted by habits of indulgence. We are to recollect, that it is not amusement alone that is sufficient to confirm the health, and promote the growth and regular develop- ment of the frame, in childhood. Hence, as Struve well remarks, sedentary games are improper for children, whose principal occupa- tion should be to exercise their limbs. To walk, to run, to skip, to jump, to put things together, and sepa- rate them; to erect and destroy houses built of blocks and other simi- lar materials; to trundle a hoop, fly a kite, or arrange, construct, and manage little vehicles in their own way; all these are diversions' that ought to be sedulously encouraged, and the necessary articles for their pursuit supplied. The latter, however, should be simple, and of little intrinsic value, as this is soon enhanced in the possession of the youn 20Q lg5 124 n 22 the Brain, 552 3180 1343 1118 449 96 6186 Being rather more than one-fourth of all the deaths in individuals under fifteen years of age. 92 PATHOLOGY OF INFANCY AND CHILDHOOD. movement of the affected limb. The attack, in those cases, is said by M. Chassaignac, who first described this particular form of the disease, to disappear as suddenly as it appeared.—(Arch. Cren. de Med., June, 1856.) Paralysis may occur at any period of infancy and childhood. It often dates from so early a period as to render probable its congenital origin, or its production from some injury inflicted on the infant during or immediately after birth, as pointed out by Dr. Evory Kennedy.— (Dublin Journal, Vol. X., p. 430.) The causes of paralysis during infancy and childhood, are either some pathological condition of the brain or its membranes, or of the spinal marrow, as a partial effusion of blood, tumours, inflammation, abscess, or chronic softening, etc. It occurs in many cases after slight cerebral disturbance of short continuance, and it may be produced by reflex action, during the irritable state of the nervous system which often co-exists with the process of teething, and by irritations seated in the alimentary canal. It may, probably, in some cases be the result of pressure upon the roots of par- ticular nerves, from excessive congestion. This would appear to have been the case in the instance related by Dr. Heiss, (London Journal of Medicine, Jan., 1850.) Paralysis in children has, also, been known to appear after an attack of eruptive fever, of remittent fever, of otitis, or of parotitis, etc. In many of the forms of paralysis occurring during infancy and childhood, the disease is unattended with danger, and is often of very short duration. In other cases, however, it continues for life, pro- ducing an altered condition of the nutritive function in the affected muscles, and leading often to irremediable deformity. Infants and quite young children are liable to a paralytic affection, which, unlike the one just described, is entirely independent of any appreciable lesion of the nervous system. It has been denominated essential or myogenic paralysis. It is dependent on a diseased condi- tion of the proper tissues of the affected muscle or muscles, and has a close relationship to certain forms of rheumatism. It can scarcely be called, in a proper pathological sense, a true paralysis. The muscles are not always relaxed as in the case of genuine palsy, but are more generally firmly and permanently contracted. There is much uncer- tainty, however, connected with the published observations in respect to this affection, some of them having reference to cases of paralysis dependent upon disease of the nerves or nervous centres rather than to myogenic palsy. This form of disease most usually steals on slowly and almost imper- ceptibly. Sometimes, however, especially when it is the result of the action of cold, it occurs suddenly, without any premonitory symptoms; in other cases the affection of the muscle or muscles is preceded by pain which is increased by pressure. A single muscle only is often attacked, as the sterno-mastoid, the flexors of the fingers, or the disease is confined to the muscles of one arm or leg, or to those of the upper and lower extremities of the same side, or of the two lower extremities. The loss of motion is often incomplete. The paralyzed muscles are sometimes painful to the touch, but more especially so when attempts PATHOLOGY OF INFANCY AND CHILDHOOD. 93 are made to put them in motion. They are slightly swollen, usually pale-coloured, though occasionally reddish or livid, and sometimes colder than the unaffected parts. The disease occurs alike in both sexes, and does not appear to be more frequent in any particular state of the constitution or condition of the general health. It has not been found to be more common during the periods of teething, nor has its connexion with gastric ir- ritation, as asserted by some, been clearly shown. Its*most usual cause in infants is, unquestionably, the action of cold, from improper exposure, improper clothing, or deficient protection at night during sleep. According to Dr. Kennedy, it often results from the bad habit of allowing young children to repose in crooked and constrained postures. The pressure of the body upon one or other of the limbs, while the child lies upon its side being sufficient, he believes, to cause a loss of motion in its muscles. The disease may disappear somewhat rapidly and completely; or, it may continue, and give rise to atrophy and degeneration of the tissues of the affected muscles, and in this manner be the cause of con- siderable and permanent deformity. The extreme development and activity of the whole lymphatic sys- tem during infancy, causes it to become, readily, the centre of irrita- tion, giving rise to enlargement, inflammation, and suppuration of the lymphatic glands, to a tuberculous condition of the lungs, brain, and other organs, to serous infiltration of the cellular tissue, and to va- rious other symptoms of scrofulous disease. Tumefaction, inflammation, and suppuration of the lymphatic glands, particularly of the neck, axilla, groin, &c, frequently occur during in- fancy and childhood, independently of any scrofulous taint. Engorge- ment, often running into inflammation, of the parotid gland, would appear to be, in some respects, peculiar to the period of infancy. It often prevails as an epidemic, and is attended with several peculiari- ties, which give it somewhat of a specific character. It seldom occurs more than once in the same individual; and has always a strong ten- dency to cease suddenly and be immediately followed by an inflamma- tion of the testicle in the male, and of the mammae in the female, ge- nerally of the same side as that on which the disease in the neck is seated. (Edematous swellings of various parts of the body, are very com- mon during infancy, either in the course of protracted irritations of the alimentary canal, or towards the close of certain febrile affections. Serous effusions into the several cavities, or infiltrations into the tissues of the organs, constituting the various forms of dropsy, are in fact among the most frequent affections of childhood. They may be either active or passive, primitive or secondary. The primitive form is confessedly very rare. Barthez and Rilliet have, however, collected some incontrovertible cases of it. It is usually a mild dis- ease, attended with a distinct, though slight febrile movement, and seldom or never proves fatal. The acute secondary form presents a somewhat similar character, excepting that in its consequences it is far more serious. It occurs either as a very acute disease, causing death 94 PATHOLOGY OF INFANCY AND CHILDHOOD. in a few days or even hours, or as a less acute affection readily cured, or it may become chronic, and then sometimes terminates fatally. The cachectic dropsies, as they have been termed by Barthez and Rilliet, or those resulting from a general diseased condition of the organism, are frequent—being sometimes of short duration, and pro- duced almost instantaneously. They resemble the chronic form in be- ing unattended by febrile symptoms, in giving rise to but few general symptoms, and causing great enlargement of the cavities or parts into which the serum is effused. The acute and active forms of dropsical effusions are most frequently met with in robust children, especially males over six years of age, while the chronic and cachectic forms are most usual in girls and feeble children, generally under six years of age. (Tome i. p. 750.)1 A very peculiar condition of the cellular tissue occasionally occurs in young infants, from an extensive effusion of serum, giving to the parts affected, a feeling of hardness, as if an induration of the subcu- taneous tissue had already taken place. The actual cause by which this effusion is produced, it is somewhat difficult to determine. Ac- cording to Billard, who appears to have examined the subject with a good deal of care, the predisposing causes are the natural feebleness of the infant; a state of general plethora; a superabundance of ve- nous blood in the tissues; and a dry state of the skin previous to the exfoliation of the epidermis; while the immediate causes are, an ob- struction of the circulation of the blood, from over-distention of the vessels; its engorgement in the cellular tissue; and lastly, the action of external agents on the skin, by which the cutaneous transpiration is suspended, and consequently the accumulation of serosity in the cellular tissue promoted. In the infant, there exists a very strong predisposition to the forma- tion of tubercles in almost every part of the body. Even at birth, their existence, in various stages of advancement, to complete soft- ening, has been detected. During the latter part of infancy, tubercles occur very frequently in the lungs, pulmonary consumption being, at this period, a not unfre- quent and destructive disease.2 It often assumes a very acute form, and rapidly destroys the patient, while in other cases it is extremely chronic, and unless pneumonia supervenes, it may continue for a great length of time before the child sinks under it. The occurrence of severe pneumonia in the course of phthisis, ap- pears to be nmch more frequent in children than in adults. In the acute form it sometimes co exists with the earliest symptoms of the deposition of tubercles, but more generally it does not set in until after the indications of pulmonary tubercles have existed for some time. 1 During the ten years already referred to, 289 children are reported to have died in Philadelphia from dropsy, viz.: under 1 year, 32; between 1 and 2 years, 42- 2 and 5 years, 106; 5 and 10 years, 79; 10 and 15 years, 30. 2 During the period already referred to, the deaths from consumption, in individuals under 15 years of age, were as follows: under 1 year, 225; between 1 and 2, 206; 2 and 5, 256; 5 and 10, 140; 10 and 15, 136.—Total 963. Being 3.7 per cent, of the whole number of deaths that occurred under fifteen years of age. J PATHOLOGY* OF INFANCY AND CHILDHOOD. 95 It is a curious fact, that haemoptysis is of rare occurrence in any of the forms of pulmonary phthisis occurring during infancy or child- hood. Sir James Clark, in his work on consumption, states, that he does not recollect to have met with any case in which it was present. Though a less frequent accompaniment of phthisis in children than in the adult, it is by no means invariably absent. We have observed its occurrence in numerous cases; and in 118 cases of pulmonary tubercle in children, observed consecutively, and within the same year, by Dr. Hennis Green, with the view of forming a groundwork for the history of phthisis in children, he met with five examples of haemop- tysis, and in a few other cases the parents of the children alleged that spitting of blood had occurred at some period previous to their admis- sion into the hospital. In 70 other cases, observed, not consecutively, but at different periods, haemoptysis did not once occur, at least, while the patients were under observation. Dr. Green remarks, that the absence of haemoptysis may, in part, be accounted for by the circumstance, that children—especially those of tender years—do not expectorate, but swallow every thing which may be brought up into the mouth from the pulmonary mucous mem- brane, lie cites a striking example of this fact from the thesis of* Mr. Murdoch. A child, two years old, died suddenly, from the rupture of a blood-vessel which traversed a tubercular cavity in the right lung. A very small quantity of blood had been discharged by the mouth, the child having swallowed the greater part of it. The stomach and other portions of the small intestines were found, upon examination after death, to be filled with enormous clots of blood, which were moulded over their internal surface. Two cases some- what similar to this have fallen under our own notice. A form of pulmonary hemorrhage is noticed by Dr. Green, which is peculiar to children, and invariably and instantly fatal. It occurs in cases of bronchial phthisis, and results from a perforation of the pulmonary artery: of this he has seen one example. In a second case there was no hemorrhage, but the artery Avas so completely flat- tened between two masses of diseased bronchial glands, that the pas- sage of the blood was interrupted, and death took place as from dis- ease of the heart. The main character by which tuberculization of the lungs in chil- dren is distinguished from that of adults, is the much larger surface of the lung it occupies, its more rapid secretion, and its more frequent complication with tubercular disease of other organs. Hence, chil- dren often sink under phthisis before the complaint has arrived at its third stage, while, on the other hand, the modifications produced by an extensive diffusion of tubercular matter, often render the diagnosis obscure and difficult. We have, in addition, the peculiarities occasion- ally induced by extensive tuberculization of the bronchial glands, a form of disease altogether confined to the child. The physical signs are rarely as well marked as in the adult, and the young child frequently dies before the practitioner is able to de- cide whether the lung is actually the seat of cavern or not. The cause of which is, that in children, the tubercular matter is widely diffused, 96 PATHOLOGY OF INFANCY AND CHILDHOOD. and has implicated many important viscera; in the brain it may excite hydrocephalus or meningitis; beneath the serous membrane of the chest, pleurisy; in the abdomen, peritonitis; in the intestines, ulcera- tion. These complications rarely fail to undermine the resisting power of the little patient; diarrhoea sets in, and death ensues long before the period at which a fatal termination takes place in the adult. The symptoms which constitute hectic fever in the adult are seldom present in any marked degree. To show that the general diffusion of tubercular matter forms a stri- king characteristic of phthisis in children, Dr. Green compares some of M. Louis's results with those deducible from a table of 180 cases which fell under Dr. G's. own observation. Thus, in 358 cases of phthisis in adults, M. Louis notices the existence of tubercular matter in the brain or its membranes only once. In the bronchial glands, tu- bercles were found in about one-fifth of the cases; in the mesenteric glands, in one-fifth; in the liver, only twice; in the kidneys, five times in 170 cases; on the other hand, ulceration of the larynx existed in one-fourth; ulceration of the bowels, in five-sixths of the cases. The history of phthisis in children presents us with very different results. The brain was affected in one-ninth of the cases; the bron- chial glands, in 100 out of 112; the mesenteric glands, in one-haif; the liver, in one-ninth; the kidneys, in one-eighteenth: but ulceration of the larynx occurred only once; and ulceration of the bowels, six- teen times in 112 cases. The bronchial glands, as stated, were more or less affected in 100 out of 112 cases. In a few of these cases only, were the glands suffi- ciently enlarged to produce symptoms through their mechanical effects, or by communication between caverns in the lungs and the bronchi, and to such cases the term bronchial phthisis should be confined. Un- derstood thus, this form of phthisis is peculiar to children, and at- tended with very characteristic symptoms; but it is not, as some writers assert, of frequent occurrence. M. Cless, of Stuttgard, has also published the results obtained from the examination of upwards of 180 bodies affected with tubercular dis- ease. In 152 autopsies of adults affected with tubercles, M. Cless found the lungs free from tubercles 6 times. In 21 autopsies of chil- dren, he only found the lungs free from tubercles once. This was in a boy 11 years of age, who, besides a considerable serous effusion into the ventricles of the brain, had two large masses of tubercle in the ce- rebellum, many small ones on the surface of the liver, and caries of the vertebrae. In 146 adults affected with tubercles in the lungs, there were only 35 in whom the disease was not confined exclusively to the lungs. In children, M. Cless found only three cases out of twenty in which all other organs were free. In 146 adults, in whom the lungs were dis- eased, vomicae were found 105 times. In children there were only nine cases out of tioenty, in which they were found. Usually, the younger the child the less frequent is the occurrence of vomicae. The very young ones most commonly sink, according to the observations of M. Cless, under an acute tuberculization, which causes death be- 1 PATHOLOGY OF INFANCY AND CHILDHOOD. Vi fore passing on to suppuration; moreover, young children are frequently carried off by other diseases superadded to the tubercular deposit, such as acute hydrocephalus, &c. M. Cless never found the bronchial glands in children affected with tubercular deposit without the existence of tubercles in the lungs also. In 13 adults and one child there were tubercles in the pleura. In 61 adults, and four children, the tubercles were limited to the perito- neum eight times. The four children were between six months and ten years of age. In 152 adults affected with tubercles, the small intestines were af- fected 83 times, and the large intestines 37 times,—and in 21 children the small intestines were affected 7 times, the large ones only once. Among 152 adults, 32 had tubercles in the mesenteric glands, while they occurred in these glands in 7 out of 21 children. In all the cases tubercles were found in other organs. Tubercles in the liver occurred once in an adult, twice in children, while other organs were affected. In 4 adults and 12 children, the spleen was affected with tubercles, these at the same time existing in other parts of the body. In children, M. Cless remarks, the paren- chyma of the spleen is often completely invaded by tubercles. In the kidneys, tubercles were met with four times in adults, and three times in children. Of five children, aged from 8 months to 11 years, in whom the mem- branes of the brain presented tubercles, 4 died of acute hydrocephalus. In all there were tubercles in the lungs and other organs also. The tubercular granulations had always their seat on the external surface of the arachnoid, between this membrane and the pia mater, never with- in the cavity of the arachnoid. In 27 children who died from tuber- cles, four had tubercles in the brain, as also in other organs; M. Cless never found any in the brain of adults. Besides, in the mesenteric and bronchial glands, M. Cless found tubercles in the glands of the neck in five adults and one child. (Q-az. Med. Jan. 1845.) Diseases of the heart are not of very common occurrence during in- fancy and childhood. When present, the symptoms by which they are attended, are usually so slight that their existence may be overlooked, until their serious results prompt to a more strict investigation. Of pe- ricarditis twenty-four cases have been collected by Rilliet and Barthez. They describe the disease as occurring almost exclusively in children over six years of age, as a complication in the course of some other dis- ease, especially rheumatism and scarlatina; it may be distinguished by an obscurity in the beating of the heart, dulness on percussion, promi- nence of the precordial region, and a rubbing sound or bellows mur- mur during the first sound of the heart. It is not considered a very grave affection, especially when partial and occurring with rheumatism; it is more so when general. The occurrence of pericarditis and endocarditis, as a complication of scarlatina, is noticed by Drs. Joy, Burrows, Bird, Von Ammon, and others, and attention has been recently directed to the fact in a paper by Dr. Alison: we doubt, however, the frequency of the complication. Of endocarditis, Rilliet and Barthez have collected and analyzed three 7 98 PATHOLOGY OF INFANCY AND CHILDHOOD. cases; in these, evidences of inflammation of the internal membrane of the heart, similar to those observed in adults, but at a less advanced stage, were detected. They relate also one case of chronic valvular disease, in which acute endocarditis supervened and destroyed the pa- tient. Dr. West describes six cases of what he considers tohave been ex- amples of endocarditis; in three of these, which terminated fatally, other lesions were detected equally as important as those peculiar to endocarditis. In the commencement of endocarditis, the symptoms are slight and obscure. There is usually a slight febrile movement of short duration, a somewhat accelerated respiration, of similar character to that in pericarditis, obscure pain at the praecordia, and difficulty of lying on the left side. Of dilatation and hypertrophy of the heart, thirteen cases are given by Rilliet and Barthez. The two affections would appear to be of nearly equal frequency. Those gentlemen, however, are of opinion that children are much more disposed to dilatation than to hypertrophy of the heart—a circumstance which they consider to be not at all as- tonishing when it is recollected that feebleness and atony of the organs is the origin or consequence of the greater number of the diseases of children.1 To the existence of tubercles in the brain, and the connexion be- tween tuberculous depositions in that organ and hydrocephalus, atten- tion has only of late years been directed. According to Dr. Carswell, tubercle of the brain is more frequent in young infants than at a later age; while Dr. Hennis Green found that the age at which it most generally occurs is from three to seven years, inclusively. In numerous instances, tubercles of the brain give rise to no par- ticular symptom by which their existence can be detected; in other cases, the phenomena produced by them are, in their chronic stage, severe pain of the head, partial or general convulsions, paralysis, weakness or contraction of certain muscles, change of temper, amau- rosis or strabismus, and coma; in their acute stage, the symptoms pro- duced are those of acute hydrocephalus, or of softening of the brain. Tubercles, varying in size from that of a pin's head to that of a pea, are very generally found scattered irregularly over the surface of the pia mater, following it between the convolutions; occasionally, however, they occur in distinct patches of an inch or more in extent. They are commonly hard, and semi-transparent, sometimes opaque, and of a whitish, grayish, or yellowish colour. They are found upon all parts of the surface, the convex and lateral portions as well as the base, in the anfractuosities of the convolutions, and in the fissures. According to Rilliet and Barthez, they are more frequent upon the convex surface of the hemispheres than at the base. Dr. Hamernjh, (Schmidt's Jahr- bucher, 1845,) found them more frequently at or near the base of the brain. They are much more abundant upon the brain than upon the ce- 1 In Philadelphia, during the ten years preceding 1845, 130 children are reported as having died of diseases of the heart, other than congenital malformation, viz.: under one year, 42; between 1 and 2 years, 9; between 2 and 5 years, 21; between 5 and 10 years, 29; and between 10 and 15 years, 29. PATHOLOGY OF INFANCY AND CHILDHOOD. 99 rebellum. They are met with, also, imbedded in the gray matter of the brain, and are here often surrounded by a halo of redness, usually connected with an enlarged vessel, ramifying from the pia mater. More rarely, tubercles are detected in the medullary portion of the brain, where they are often overlooked, in consequence of their pale, semi-transparent, yellowish tint. The plexus choroides is, also, often covered with tubercles. They are very commonly met with, likewise, on the serous membranes of the thorax and abdomen, in the lungs, and occasionally in the substance of the liver. In twenty-seven out of thirty-three cases of hydrocephalus, Barthez and Rilliet found tu- bercles or granulations, associated with inflammation of the pia mater; in four cases the meningitis was unattended by any trace of tubercular deposition in the encephalon; and in two cases the granulations or meningeal tubercles were unattended with any traces of inflammation. In all the thirty-three cases the symptoms were nearly the same. The identity between these meningeal granulations and genine tu- bercle' has been denied. Dr. Barrier, (Des Maladies de VEnfance,) declares that they have no analogy with tubercular granulations, but are the result of a kind of chronic inflammation common to the serous membranes of the brain and those of the thorax and abdomen, giving rise in the latter to the same non-tubercular granulations as in the pia mater. This opinion is fully adopted by M. Bouchut. According to the micrographic account of these granulations by M. Robin, there are two varieties. The first variety are of a yellowish tint, softish to the touch, and friable. Nine-tenths of these consist of fine granular amorphous matter. They contain a small quantity of cyto-blasts, a few capillaries, and, occasionally, fibro-plastic formations. The second variety of granulations most generally co-exist with the former in the meninges of the brain; they are also found, coincidently, in other serous membranes. It is the form especially known as the gray or semi-transparent granulation. The bulk of this is composed of the same amorphous granular matter as in the first variety, but of a firmer consistence. The cyto-blasts are in large numbers, as shown especially on the addition of acetic acid. Fibro-plastic elements, and a net-work of fine areolar tissue, accompanied by a few vessels, are also present. In these granulations, the cyto-blasts are described as differing from tubercle corpuscles: first, in being polyhedric, with irregular and slightly toothed, instead of oval or round, margins; secondly, their diameter averages half the size of the latter; thirdly, the tubercle corpuscle is rendered pale by acetic acid, but is not dissolved—the con- tour of the cyto-blasts is rendered more defined; fourthly, the granu- lations contained in the tubercle corpuscle are scattered uniformly throughout it, while in the cyto-blasts they are congregated in the centre; fifthly, although the cyto-blasts contain no nucleolus, they belong to the cellular element, which commonly exhibits the presence of free nuclei. These latter are seldom met with unaccompanied with cells containing a nucleus resembling them. Dr. Liegard, physician to the Hopital de VEnfant Jesus, basing his conclusions upon the fore- o-oino- description of M. Robin in relation to the nature of the menin- 100 PATHOLOGY OF INFANCY AND CHILDHOOD. geal granulations as they are met with in the meningitis of children, and the almost certain mortality by which the disease was attended in the hospital referred to, when treated under the assumption of its tubercular character, is inclined to regard the inflammation which determines the formation of the granulations in question as of a spe- cific character. (Rev. Medico-Qhirurg. de Paris, Jan. and Feb., 1855.) Dr. Liegard believes that it is impossible to distinguish the granular from the simple form of meningitis; he proposes, therefore, the classi- fication of the disease, according to the violence of the symptoms, and the rapidity of its course, into the inflammatory and sub-inflammatory forms. Whether the granulations so generally met with on the meninges of the brain in those children who die from hydrocephalus, are, strictly speaking, tubercular in their character, is a question that must be considered as still unsettled. Of their intimate connexion with that peculiar diathesis in which alone tuberculosis occurs, there can be no doubt. This is clearly shown by the circumstance of their being al- ways found in connexion with the presence of unquestionable tuber- cular deposits, either in the brain itself, or in one or other or several of the remaining organs. Many infants present at birth a particular organization, indicated either by a fair, transparent complexion, with light eyes and hair, or by a dark, muddy complexion, with hazel eyes, and black hair. In the progress of infancy, the forehead, in general, becomes projecting, the upper lip tumid, the thorax remains narrow, or flattened, the abdomen protuberant, and the lymphatic glands of the exterior unusually large and prominent. Children thus constituted grow rapidly, and often present great quickness and precocity of intellect. The impression of any of the usual morbific agents is liable to produce in them a diseased condition of the glands of the neck, or of the mesentery; and the slightest irritation, affecting either the lungs or bowels, very generally gives rise to the formation of tubercles, particularly in the brain or the pulmonary tissue. The peculiar condition of the organism above described is often produced, after birth, from a variety of morbific causes, by which the healthy condition of the blood, and the regular and perfect nutrition of the several organs, are impaired; but especially, from deficient or improper food; from exposure to an atmosphere rendered unwholesome, whether by want of ventilation, by humidity, or by impurities; from long-continued exposure to a degree of cold, which, while insufficient to produce inflammation, or any acute disease, nevertheless exerts upon the organism a decidedly depressing influence; from neglect of per- sonal cleanliness, and from deficient exercise. In such cases, the limbs remain small, the muscles soft, flaccid, and deficient in energy; the skin assumes a pale or a dirty yellow appear- ance ; the articulations become enlarged, and the bones soft, so as to be readily bent and distorted, by the action of the muscles, or by the weight of the body. The lymphatic glands are liable to chronic en- largement, or to inflammation and suppuration, giving place to a thin serous discharge, containing flakes—often large masses—of a curdy PATHOLOGY OF INFANCY AND CHILDHOOD. 101 appearance. The ulcers which result are long in healing, and, very generally, leave large, permanent cicatrices, of a very peculiar and unseemly appearance. Inflammatory affections, when they occur in such children, are, for the most part, subacute, and of long duration, and are most frequently attended with the development of tubercular disease in the lungs and other organs. Diseases of the skin, of a very obstinate and intracta- ble character, are also of common occurrence. The same is true of inflammation of the edges of the eyelids, with more or less injection of the conjunctiva; and of inflammation of the external meatus or deep-seated portions of the ear, giving rise to long-continued and highly offensive discharges from that organ, and often to a complete destruction of its internal structure: Inflammation of the kidneys is not unfrequent during childhood. The most accurate account we have of the disease during this period of life is that contained in the work of Rilliet and Barthez. Agree- ably to the observations of these gentlemen, a very remarkable differ- ence exists between the albuminous nephritis of adults, and the same affection in children, and which renders difficult the anatomical dis- tinction at this age between simple and albuminous nephritis,—the disease in children rarely producing the granulations of Bright, and in the generality of cases passing only to the third stage. Of eleven children who presented during life the symptoms of albuminous ne- phritis, viz.: more or less extensive anasarca, with albuminous urine during a longer or shorter period,—four only presented the third stage, two the second, and four the first, while in one case the kidneys were putrescent. In a twelfth case, the existence of granulations was de- tected upon dissection; but the urine had not been examined during life, and furnished no albumen after death. On the other hand, in the few cases of simple nephritis these gentlemen have seen, they never met with suppuration, either diffused in scattered points, or collected in abscesses. Granulations have, however, been detected in the ne- phritis of children, by Bright, Guersent, Blache, and Christison. According to Rayer, the two forms of nephritis are with difficulty distinguished at their commencement; the only difference he points out is the consistence of the kidney being increased in the one and dimi- nished in the other. In simple nephritis the increase of consistence has appeared to Rilliet and Barthez to be more marked in children than in adults; while in the first three degrees of albuminous nephritis they have noted a marked diminution of consistence in the cortical sub- stance. Thus, in respect to their anatomical relations these two forms of nephritis closely resemble each other. And when we add that during life the difference is not always more marked, it must be ad- mitted that in infants the two affections are but slightly separated from each other. Anasarca, which is the prominent, as well as the first symptom no- ticed, for in no case was the urine examined by Rilliet and Barthez before this appeared, is liable to vary in extent, and even to disappear, leading to the hope that a cure has been effected. The cessation of albuminuria is, however, alone, a positive symptom of the restoration of the kidneys to a healthy condition. 102 PATHOLOGY OF INFANCY AND CHILDHOOD: It is from the complications of the disease that the greatest danger arises. The most important of these is inflammation of various tissues and organs; most frequently of the serous membranes and of the lungs, and attended always with a more or less copious serous effusion. The only cases of simple albuminous nephritis which Rilliet and Barthez met with were in children; all of which terminated favourably. Secondary albuminous nephritis is chiefly met with after eruptive and intermittent fevers. After scarlatina it occurs generally during the period of desquamation—from the twelfth to the nineteenth day from the commencement,—and is caused generally by exposure to cold, or a change of temperature. It is, according to the observation of the gentlemen just quoted, as frequently met with, relatively to the frequency of the two affections, after intermittents as after scarlatina. In one of every six cases collected by them, it followed the former. It was in these cases chronic, and contributed, with the other com- plications, to produce a fatal termination.1 Dysuria is often met with in young children. It may result from irritation, seated at the neck of the bladder, or reflected upon it from disease of the digestive organs. It also occurs frequently during den- tition, and occasionally in the course of certain febrile affections. An increased flow of urine is very common in infancy, during dentition, and in certain disordered conditions of the digestive functions. Genuine diabetes is said to occur in infants, accompanied with a co- pious diarrhoea, intense thirst, and rapid emaciation. Cases are men- tioned by Isenflamm,2 Morton,3 McGregor,4 Willis,5 Venables,6 Mott,» Prout, and a few others; we have never met with them. During the twenty years preceding 1845, but one death is reported to have oc- curred in Philadelphia from diabetes, in an infant under five years, and one in a child between ten and fifteen years of age. Dr. Prout has pointed out a modification of diabetes as of occasional occurrence in infants, to which attention was first formally directed by Dr. Venables. There is present excessive diuresis, the urine fre- quently containing albuminous matter, while in other instances there is an excess or deficiency of urea; and in a few cases, saccharine mat- ter, more or less perfectly developed, is found. The specific gra- vity of the urine ranges, according to the particular form of the dis- ease, from 1.025 to 1.005, or even less. It is generally transparent, and occasionally of a greenish tint. It is often associated with tubercu- lous cachexia. _ According to Dr. Prout, if the affection is neglected or maltreated, it most usually terminates in organic lesion of the kid- ney. The urine, particularly in irritations of the digestive organs, has often a whitish appearance, or it lets fall a whitish deposit, as it cools or is evaporated. Very deep-coloured urine is often passed in the febrile affections of children. i But six cases of death from disease of the kidney are reported to have occurred in children, m Philadelphia, during the ten years referred to, viz., in those under Wei 4; between 1 and 2, 1; and between 2 and 5, 1. y ' * Uber die Eingeweide, 1784. • Phthisiologisc, Lib. 1, cap. viii 1697 * Lond. Med. Gaz. vol. xx. 5 0n Urinary Diseases • On Diabetes, 1825. i Amer. Med. and Philos. Register, v. i. p. 387. PATHOLOGY OF INFANCY AND CHILDHOOD. 103 Gravel often forms in children from derangement of the digestive function, either from improper food, confinement in a close and im- pure atmosphere, or from exposure to cold and dampness. It may occur in the form of a red deposit consisting of uncrystallized lithic acid, when its passage is attended with little or no irritation of the urinary organs; or, it may consist of the acid, in a crystalline form, causing in its passage more or less irritation. Urinary calculi are occasionally met with in children; they ordinarily consist of the lithate of ammonia, and are small in size, and of a clay colour. Incontinence, or an involuntary flow of urine, is of frequent occur- rence, during infancy and childhood. We have already noticed in what manner the anatomical condition of the bladder renders it difficult for the urine to be retained, after it has accumulated to a cer- tain extent. Incontinence of urine is often, in children, the result of habit, or it occurs during deep sleep, at a particular hour, and may often be remedied by accustoming the child to regular periods of urinating, or by awaking him from sleep, for the purpose of evacuating the bladder, previous to the hour when the involuntary discharge usually takes place: in a short time the bladder becomes accustomed to en- dure the presence of its contents, until they are evacuated by a volun- tary effort. Incontinence of urine, in children, is attributed, by Willis, to a de- rangement of the secretory function of the kidneys, by which a copious separation of watery fluid from the blood takes place, in which there is a deficiency of the characteristic ingredients of the urine. This is certainly not true in all cases; we have seen it result, as it appeared to us, from the irritation of the rectum by oxyures. It would often seem to arise also, from a want of proper control over the sphincters of the bladder; or to a morbid irritability of the bladder itself, causing it to expel the urine almost as soon as it reaches its cavity. We have seen many instances, in which incontinence of urine was a con- genital affection—the urine dropping constantly from the urethra; in a majority of these cases, the patients died early, from disease of the brain. Dr. Slade believes incontinence of urine to be occasionally a hereditary affection. He has known several members of a family to labour under it as did their parents before them. (Amer. Jour, of the Med. Sciences, July, 1855.) Most of the acute diseases of infancy and childhood are attended with more or less febrile reaction, which usually assumes the remit- tent type, with exacerbations towards evening, or during the night. Gastro-intestinal irritation or inflammation, which, being one of the most common of the affections of early life, is that which most usually gives rise to the remittent fever, described by writers as a disease pe- culiar to children; and attributed, by many of them, to the presence of worms. To nearly all the fevers, infants and children are liable; but not to the same extent as adults—if we except the exanthematous, many of which are of rare occurrence after the age of puberty. In those dis- tricts in which intermittent fever is endemic, children, even at the 104 PATHOLOGY OF INFANCY AND CHILDHOOD. breast, will become affected with it. The same is true of the bilious and yellow fevers. It is more than probable that typhoid fever will be found to be a much more frequent disease among children than has heretofore been supposed. The memoirs of Rilliet and Taupin afford sufficient evidence that many of the cases of what was formerly con- sidered as enteritis in children, as well as of that form of fever which has been vaguely denominated worm or gastric fever, are in fact cases of genuine typhoid fever. In severe epidemics of typhus and typhoid fever, large numbers of infants have been known to be attacked, and fall victims to the disease.1 A most interesting paper on the typhoid fever of infants occurs in the Archives fur Physiologische Heilkunde. It is by Dr. Friedleben, and presents the results of his observations during four epidemics of the disease: the first extending from February to April, 1844, and from July to August in the same year. Then in January and Feb- ruary, 1846, and during July and August, of the same year. During the months of January and February, 1846, the fever was confined al- most exclusively to children, affecting the adult more particularly during April and May. In the course of the three years from 1844 to 1846, both inclusive, Dr. Friedleben had under his charge 1842 children, (880 boys, and 962 girls,) of which 98 cases were of typhoid fever, namely, 46 boys and 52 girls. Among these only one was under one year, 23 ranged from two to five, 32 from five to eight, 22 from eight to eleven, 12 from eleven to fourteen, and 8 were above fourteen. The epidemic, therefore, fell with its greatest force on children between two and eleven years of age, and was more prevalent in winter and summer than in autumn and spring. The pathological characters of the disease, as exhibited in those who fell victims to it, are thus described by Dr. Friedleben. The glands of Peyer were much swollen, some of them being a line and a half in thickness. The swelling was not, however, always uni- form,—the centre being frequently more elevated than the margins. The surface of the gland was unequal, owing to the presence of cap- sules, which gave rise to an appearance resembling ulceration. The 1 In Philadelphia, during the ten years preceding 1845, the deaths of children from Between 1 and 2 years. 2 Between 2 and 5 years. 6 Between 5 and 10 years. 3 Between 10 and 15 years. 1 Totals. 16 14 37 ' 43 14 128 6 11 8 8 36 2 18 22 23 69 5 12 22 14 57 3 5 3 1 21 0 0 3 0 6 1 2 1 0 7 0 1 0 0 1 1 1 0 0 2 1 2 1 1 5 25 42 16 5 146 60 137 122 67 494 fever are as follows:— Under 1 Intermittent, year. 4 Remittent, 20 Bilious, 3 Typhus, Typhoid, Congestive, Inflammatory, Brain, 4 4 9 3 3 Mesenteric, 0 Miliary, Hectic, 0 1 Fever, without any dis I 58 tinctive appellation, 109 PATHOLOGY OF INFANCY AND CHILDHOOD. 105 number of the diseased glands varied from six to twenty. They were of a bluish-livid tint, soft, and easily detached. No change seemed to have occurred in the other coats of the intestine, with the exception of the sub-glandular cellular tissue, which presented the appearance of softening. Such were the appearances noticed in cases which proved fatal before the twenty-third day. When the disease was protracted beyond that period, induration of the glands occurred. According to Dr. Friedleben, all the glands which became developed before the twenty-first day were the soft (follicles,) those developed later were the hard (glands of Peyer.) His observations establish the views of Rilliet and Barthez, as also those of Barrier, on the progress of inflammation of the glands. Severe ulceration of these may occur in exceedingly young subjects,—they were witnessed in the case of a child only two years and a half old. They may take place at a very early period of the disease, even on the eighth day, but cicatrization does not begin before the twenty-first day,—its progress is found to be more rapid than in adults. The mucous membrane is usually sound, being changed in appear- ance only in the immediate vicinity of the affected glands. In one in- stance, the mucous membrane of the stomach was observed to be in- flamed. The submucous cellular tissue was always natural. Changes were invariably discovered in the mesenteric glands,—they were usually red and swollen, particularly at the beginning of the disease,—infiltra- tion and softening were rare,—and, in the opinion of Dr. Friedleben, the former only occurs in very serious cases, where there has been dis- organization of the condition of the blood. The general conclusions are as follows:— 1. The glands of Peyer, and, as a consequence, the mesenteric, are the local seat of the typhoid fever of the infant. 2. During the first three weeks there is only simple inflammation of the follicles. 3. This may terminate in resolution without ulceration. 4. When ulceration takes place, the progress of cicatrization is very rapid. 5. When the morbid action extends beyond the twenty-first day, infiltration of the glands of Peyer may occur. 6. The infiltration begins in the glands in the neighbourhood of the great intestine. 7. This leads necessarily to ulceration. 8. In this form of ulceration cicatrization takes place very slowly. 9. After the twenty-first day, the two forms of ulceration may be discovered in conjunction. 10. In all the cases terminating favourably, and in the generality of those ending in death, the mesenteric glands are only affected by a simple inflammatory softening. 11. Changes in the spleen occur simultaneously with those above described. 12. All the complications which happen before the twenty-first day are of a very distinct inflammatory character. 13. The chemical character of the blood agrees with that state. 106 PATHOLOGY OF INFANCY AND CHILDHOOD. A diseased condition of the blood is of far less frequent occurrence during infancy than in after life; some have even doubted whether it ever occurs then. Anaemia, or poverty of blood, however, Professor Von Mauthner, of Vienna, (Journ. f. Kinderkrankheiten, 1854,) has shown not to be of so rare occurrence in the infant as has generally been supposed. An anaemic mother will be very liable to give birth to anaemic offspring; anaemia may, therefore, be congenital, or, it may be produced subsequently to birth from too rapid development, from confinement within doors in a damp stagnant atmosphere, and in apart- ments excluded from the light. The cause of congenital anaemia is to be referred to the general corporeal debility of the mother. The want of proper food, impure air, over-fatigue, and extreme care during preg- nancy, exert a powerful influence upon the nutrition of the mother, and while this renders her offspring anaemic from birth, it also may deprive her of the capacity to afford adequate nourishment to the infant subsequently. An infant born of a female who has continued to suckle a child during the greater portion of her pregnancy, gene- rally suffers from poverty of blood; the same is true of the offspring of mothers whose health has suffered deterioration in consequence of losses of blood, or profuse mucous discharges. The children of an aged or diseased father are commonly anaemic; congenital syphilis may also be regarded as a cause of anaemia in the infant. The anaemia of development becomes most commonly manifest at the period of dentition and of puberty. From experiments upon animals, Nasse has shown that animal food renders the blood more coagulable than vegetable, and increases the number of blood-corpuscles. From sugar and starch-meal there is formed a glutinous lymph-plasma, but no corpuscles. A purely vege- table diet, therefore, is not suitable during infancy. This is farther manifest from the anatomical fact that, in young children, the caecum, that part of the intestinal canal where vegetable digestion is perfected, is but partially developed. Anaemic children are very liable to suffer from inflammation. Nature endeavours to excite a reaction from the depressing influences of an impoverished state of the blood, in consequence of which stasis of blood commonly occurs in organs unfitted for active circulation. The exudations which ensue tend still more to impoverish the blood, while venesection would tend materially to augment the evil. One of the most unfavourable results of infantile anaemia is hemorrhage from congestion of the delicate vessels of the large intestine. This oc- currence is often overlooked or confounded with diseases of an entirely different character. When, says Canstatt, the plastic power of the organism is exhausted by rapid organic evolutions, whether natural or morbid, tuberculosis may suddenly take place; and the imperfect material becomes depo- sited, upon the occurrence of any excitement, in the different viscera. This is to be feared during the blood impoverishment of dentition, and especially in children subject to perspirations, and to increased pulsa- tions of the heart from trifling causes of excitement. It should never be forgotten, in investigating the diseases of chil- PATHOLOGY OF INFANCY AND CHILDHOOD. 107 dren, that sudden attacks of severe illness, even death itself, may occur in them as well from anaemia as fromhyperaemia. Thus attacks of convulsions and of other affections, formerly regarded as the result of an inflammatory condition of some one or other of the tissues or organs, will require, at the present day, a more careful examination into their true pathological character, and a more accurate diagnosis. The general observations, made in reference to the diseases incident to infancy, will equally apply to those of the earlier period of child- hood. Though cutaneous affections are still frequent, yet the skin is less liable to disease, than during the preceding stage of existence. Furunculi, or circumscribed phlegmonous inflammations of the inte- guments, are common at this age. The respiratory mucous membrane, as well as that of the alimentary canal, become readily irritated and inflamed. The brain, also, from the great activity of its functions, is now peculiarly exposed to disease; hence, violent pains of the head, and cerebral inflammation, are of frequent occurrence; convulsions are, however, less frequent than during the period of infancy. From the great development of the capillary system which continues during youth, and the tendency to hyperaemia, and to irritation of the respiratory mucous membrane, hemorrhages from the lungs are very liable to occur towards the close of childhood: about this period, also, profuse epistaxis is not unfrequent. Tubercular disease of the pul- monary organs is often developed during childhood; and scrofulous swellings and ulcerations of the superficial lymphatic glands are of common occurrence. From the amount of exercise to which the body is subjected during youth, inflammations of the joints are liable to be produced; rheuma- tism is, also, more frequent at this age than previously. Dr. Fuller, in his very excellent Treatise on Rheumatism, Gout, &c, sets down the period of life during which acute rheumatism generally occurs as that between fifteen and fifty—few cases occurring either earlier or later in life. We have, however, observed well marked at- tacks of rheumatism to occur quite frequently in young children,—so frequently, indeed, as to lead us to believe that it is a more common dis- ease in early life than is generally supposed. Dr. Fuller reports sixteen cases as occurring in patients between ten and fifteen years of age. In one instance only was the patient under the age of ten. He has had, however, under his care at the hospital, a child only eight years old, suffering from dropsy and diseased heart, the result of two attacks of rheumatism, one of which occurred at the age of two years and nine months, and the other at the age of six years and four months. Dr. Heberden reports that " rheumatism had appeared in a child of four years old." Dr. Watson states in his Lectures that he has "frequently seen it in children, sometimes as early as the third or fourth year;" and Dr. Davis states, (Medico-Chirurg. Rev., Oct., 1817,) that "se- veral cases of acute rheumatism were admitted, occurring in children of three, four, five, six and seven years, and upwards." We have met with many cases of the disease in children between two and ten years of age. The heart readily sympathizes with the various irritations that occur 108 PATHOLOGY OF INFANCY AND CHILDHOOD. in the other organs; hence, most of the diseases which take place during childhood, are accompanied with febrile symptoms of a more intense character than in infancy. Cancer, although of unfrequent occurrence during childhood, is never- theless occasionally met with in patients at a very early age. Guersant remarks, (Jour, de MH. et de Chirur. Prac, 1855,) that not a year passes during which he does not meet with cases of it. For a long period, it was supposed that in children cancer was confined entirely to the orbital cavity, whether originating in the globe of the eye, or from the base of the orbit. It has been shown, however, to occur also in the testicles of the male. Both Dupuytren and Guersant have operated on a number of such cases. Cancer has also been found to occur during childhood in other parts, but less frequently, unless, per- haps in the vulva of girls. The fibro-plastic tumours of the latter part in children are considered by M. Guersant to be closely allied to can- cer, in consequence of their tendency to recur after removal. Such recurrence is, however, confessedly less frequent in them than in true cancer, evidencing thus their more benignant character. The progress of cancer, during childhood, is always far more rapid than in older patients; the prognosis is in consequence very unfavour- able. As there is no hope of the disease, when it once makes its ap- pearance in the child, remaining stationary, the indication would ap- pear to be to operate early and with great boldness; but, from the liability of the disease recurring after a very short interval, we cannot expect in any case to eradicate it by an operation; the utmost we can hope to effect, is to procure temporary relief from the intole- rable suffering to which cancer gives rise in childhood. In respect to the fibro-plastic tumours of the vulva of children, M. Guersant, viewing them somewhat in the light of polypous growths, re- commends early excision, and cauterization of their base with liquid caustics; and, if the vagina should be large enough to permit of these measures being properly accomplished, he would not despair of effect- ing a more or less permanent cure. The causes of disease are nearly the same during infancy and child- hood, as in the subsequent periods of life—from but few are they en- tirely exempt—while nearly all the ordinary morbific agents act upon the infant with much greater severity than in after life. Many of the affections that occur in early life, may exist at birth. Thus children are occasionally born affected with syphilis, small-pox, a tuberculous condition of various organs, softening of portions of the stomach and bowels, inflammation of the different organs; hydro- cephalus, and various malformations. Or there may exist, from birth, a peculiar condition of the organism, predisposing it, subsequently, from the action of slight causes, to a particular form, or class, of dis- eases. This condition of organism may exist in all the children of certain families, and would appear, in many cases, to be hereditary— the same diseases prevailing, for many generations, in the same family. Mental impressions—deep anxiety—and the various intense affec- tions of the mind, whether of a depressing or exciting character, which constitute so fruitful a source of disease in the adult, are scarcely ope- PATHOLOGY OF INFANCY AND CHILDHOOD. 109 rative in the infant; and are seldom the cause of serious disturbance in the child. Violent excitement of the nervous system, however, from loud and unexpected sounds; arousing the infant suddenly from its sleep; or exciting in it intense alarm or fright; have been known, in many in- stances, to produce, even at an early period of infancy, the most seri- ous effects, resulting in a fatal attack of convulsions, or, at a later pe- riod, in confirmed idiocy. Violent paroxysms of anger, by whatever cause excited, are equally injurious, during infancy and childhood. Notwithstanding the lively and cheerful disposition, so common in childhood, its quick forgetfulness of past suffering, its little anxiety for the future, and its perfect contentment with the enjoyment of the pre- sent moment, yet, by improper treatment, or a neglect of moral edu- cation, the passions, even at this early period, may be made the source of much disease and suffering. By parental unkindness—a mistaken, and over-rigid discipline—confinement from childish amusements and exercises—indiscreet ridicule of faults or imperfections, and the with- holding every species of encouragement; the spirits, even of the child, maybe depressed, and discontent, hatred, jealousy, maybe engendered, and become the remote or exciting causes of serious disease, either mental or bodily. Too much, or deficient and improper food, are among the most com- mon of the causes of disease, from birth until puberty. By the disor- der of the digestive function induced by errors in diet, the blood be- comes vitiated, or imperfectly elaborated, and the nutrition of every part of the body deranged, or defective; while, at the same time, irri- tation of the alimentary canal is produced, running on to inflammation and rapid disorganization, or irritation becomes, sooner or later, trans- mitted to the brain, or reflected upon other organs, disturbing their functions, or producing serious disease of their substance. In infants disease is often produced by the impure or innutritive state of the mother's milk, even in cases where no such deterioration of the milk is suspected, the health of the female being apparently unimpaired. A very interesting paper on this subject, by M. Girard, has recently appeared in the Archives Ghie"rales de Medecine; in which is pointed out the importance of testing the character of the milk by a microscopic examination in all cases in which the infant, when nourished solely by the breast, becomes affected with symptoms of in- digestion. Every physiologist is aware of the change produced in the proper- ties of the mother's milk, by the nature, as well as by the quantity, of the food habitually taken. Too much, or too little food; a too stimula- ting diet; the use of vinous or distilled liquors, more especially if taken in excess, and articles of food of difficult digestion, cannot fail to affect the secretion of milk, and render the latter unfitted for the nutriment of the infant who partakes of it; milk thus deteriorated will very gene- rally produce irritation of the infant's stomach, and all the symptoms of indigestion. If an infant, in consequence of the inability of the mother to suckle it, is nursed at the breast of a female whose own child is many months 110 PATHOLOGY OF INFANCY AND CHILDHOOD. older than it, indigestion will very generally ensue, in consequence of the milk containing an undue amount of caseum, to the digestion of which the stomach of the younger child is inadequate; the proportion of caseum in the milk of the human female always augmenting with the age of the infant. The occurrence of the menstrual discharge is generally enumerated as a cause of deterioration in the milk, calculated to occasion serious injury to the infant who partakes of it. When the catamenia are sus- pended during the first eight or nine months subsequent to parturition, and then reappear, \here will, very commonly, be found to take place a diminution in the supply, and a decided change in the properties of the milk; and the child will very generally suffer if it be continued at the breast. But we are by no means convinced that every occurrence of the menses, during lactation, is calculated to produce similar effects upon the milk. We have known several females who menstruated re- gularly during the entire period of suckling, and their infants throve equally well with those of mothers in whom the catamenial discharge was suspended. From a series of observations recently published, by Raciborski, it has been ascertained that the health of children nursed by menstruating females suffers no kind of injury. If, however, upon the appearance at any time of the menses, the milk is found to dis- agree with the child at the breast, it will be prudent to cease suckling it so long, at least, as the discharge continues. Pregnancy is also set down as producing an alteration in the milk, unfitting it for the nourishment of the infant. During the first three months of pregnancy, we have certainly seldom noticed any particular change to occur in the milk; at a later period, however, it is probable that the safety of the mother, as well as the health of the infant at the breast, will require it to be weaned, or, if too young for this, that the milk of a healthy nurse be substituted for that of the mother. It is true, that infants have been suckled to a late period of pregnancy, or even to its termination, without apparent injury; while, in other cases, according to Dewees, so great a deterioration of the milk has oc- curred, as to require that the child should be taken from the breast at a very early period. Another cause which is generally supposed to render the milk of the mother injurious to an infant, is, continuing the latter for too long a period at the breast. This is unquestionably true. If, after the ap- pearance of the molar teeth, the child be confined exclusively to the breast, symptoms of indigestion will very generally occur; and even with a supply of other food, continuing it at the breast after the ninth or tenth month, will often be found productive of injury. There are, however, striking exceptions to this rule; some of the finest children we have seen were among those who were suckled—taking, however, at the same time, a portion of other food—until they were fifteen months old. We may remark that, in all these cases, the menstrual discharge was suspended during the whole period of lactation. Intense grief, mental anxiety, paroxysms of violent passion, or any long-continued or violent emotions of the mind are, unquestionably, causes of very considerable deterioration in the milk. Severe vomit- PATHOLOGY OF INFANCY AND CHILDHOOD. Ill ing, and even general convulsions, have been known to result from the child being applied to the breast immediately after the nurse has ex- perienced any intense mental excitement—whether of an exhilarating or depressing character; and it is a general remark, that the children nursed by females, who are labouring under intense grief, or mental anxiety of any kind, seldom thrive. We have met with several cases of this kind, in which the safety of the child required it to be taken from the mother's breast, and where every symptom of disease ceased soon after it was furnished with the breast-milk of a healthy nurse. Another fruitful source of disease, in infancy and childhood, is im- pure or confined air. This acts upon the blood through the medium of the lungs, and, probably, of the cutaneous surface also. Indepen- dently of preventing, in this manner, the due oxygenation of the blood, impurity and want of ventilation in the atmosphere would appear to produce a deleterious effect upon the infant organism, by acting imme- diately upon the nervous system. The convulsions which occur within the first two or three months—trismus nascentium, spasm of the glottis in young infants, and other spasmodic diseases,—seem evidently, in many cases, to result from the action of impure air upon the nerves. In children exposed, for any length of time, to the influence of a corrupted or confined atmosphere, the powers of life become depressed; digestion and sanguification are imperfectly performed; and nutrition is impeded, or disturbed. The skin assumes a pale and sickly aspect; the muscles a soft and flabby feel; and disease of the alimentary canal, lungs, brain, or lymphatic glands, sooner or later ensues. Children who are confined to badly ventilated and imperfectly lighted apart- ments, even where no cause exists capable of imparting foreign im- purities to the air respired, present, invariably, a pale and unhealthy appearance, and are prone to disease. It is probable that to the purity and freshness of the air, and the greater amount of exposure to its in- fluence, as well as to that of the light, are to be chiefly attributed the deeper colour of the skin, and the larger amount of health and robust- ness, possessed by children who inhabit elevated country situations, compared with those who are brought up entirely within the confines of a large and crowded city. Alison and Baudelocque ascribe more influence in the production of scrofulous affections, to impure and con- fined air, than to an impoverished diet or improper food. Cold, either alone or combined with dampness, so fruitful a source of disease during every stage of existence, is peculiarly so in infancy and early childhood—in consequence of the defective power which then exists of generating heat, and, consequently, of resisting the influence of even a slight impression of cold. Exposure to too low a degree of atmospheric temperature; to draughts of cool air, when the body is in a state of perspiration ; too slight clothing, or that which protects, only partially, the surface; occupying damp rooms or beds, and allowing portions of the dress that have become wet from any cause to remain unchanged; or exposure to rapid and sudden alternations of tempera- ture, are the usual means by which, in children, the heat of the sur- face is reduced, and the organism subjected to the deleterious influence of cold, and inflammations of the alimentary canal and respiratory or- gans are induced. 112 PATHOLOGY OF INFANCY AND CHILDHOOD. The morbid effects of cold are invariably increased by its being com- bined with dampness; hence, children are often seriously affected by a degree of what is termed rawness of the air, not amounting to positive cold. Cold, combined with dampness, is the fruitful source of bron- chitis, croup, and of certain forms of diarrhoea and dysentery in chil- dren. It is this which renders low, damp situations, and deep, secluded valleys, so especially prejudicial to health, in the early stages of life. During sleep, children areeAren more subject to the morbid influence of sudden alternations of temperature, than during their waking mo- ments. An attack of bronchitis, croup, or abdominal inflammation, is frequently caused by their being put to sleep at night, in a colder apartment than they occupied during the day; by their throwing off the clothes, during sleep, when heated, or in a state of perspiration, or by the cradle or bed, in which they repose, being placed in a draught or current of air. The injurious effects of cold and dampness are not always exhibited in the immediate production of acute disease. Continued exposure to a cold and damp atmosphere, in early life, by depressing the vital powers of the organism, may gradually undermine the health of the system, or give rise to chronic affections, the existence of which is only first rendered apparent towards the period of dentition or of puberty or, upon the occurrence of some acute affection, resulting from the action of any of the causes of disease to which children are liable, and which is invariably in such cases rendered more unmanageable. Intense heat, which is always more or less injurious to infants, be- comes, under certain circumstances, a fruitful source of disease in early life. Thus, when succeeded by a sudden reduction of temperature, or when the body is accidentally exposed to any cause by which its tem- perature is suddenly diminished, serious disease is very generally pro- duced. But it is principally in the narrow lanes, courts, and alleys, and in the damp, ill-constructed, crowded and filthy dwellings, occu- pied by the poor and improvident of the larger cities of the middle and southern states, that, during the summer months, excessive heat, in conjunction with a confined and impure air, displays its baneful influ- ence upon the infant—subjecting them, upon the occurrence of the slightest irritation of the alimentary canal, to an attack of infantile cholera, which can seldom be arrested, excepting by a prompt removal from the heated and infected air by which it was generated. From what has been said, it must be evident that the seasons of the year exert a considerable influence upon the health of infants, and, to a certain extent, also upon the form and character of their dis- eases; thus bronchitis, croup, and pulmonary inflammation prevail to the greatest extent, among children, during the more changeable and colder months; while bowel complaints, and especially cholera, prevail during the season of greatest heat, and dysentery and certain forms of diarrhoea most commonly during the autumnal months. The spring or autumn is the season during which the epidemics of scarlatina, measles, and hooping-cough, usually prevail; while small-pox is more common during the winter. In the city of Philadelphia, the mortality among children varies greatly with the season. Thus, under five years, the largest number PATHOLOGY OF INFANCY AND CHILDIIOOD. 113 of deaths, during a period of eight years, occurred in the months of June, July, August and September, namely, 8781—this being the sea- son of greatest heat, the mean range of the thermometer averaging from 70° to 79°. The next highest amount of mortality occurred during the months of December, January, February, and March, namely, 5641—this being the season of greatest cold, the mean range of the thermometer averaging from 32° to 35°. The smallest amount of mortality occurred in the months of April, May, October, and No- vember, namely, 4815; the mean of the thermometer ranging from 45° to 65°. The relative mortality of children under five years, com- pared with the whole number of deaths, at the respective periods, is as follows: from June to September, inclusive, 56-91 per cent.; from December to March, inclusive, 45*32 per cent., and during the remain- ing four months, 41*39 per cent. The following table exhibits the entire mortality during the eight years referred to, and the mortality of the several periods of infancy; the months being arranged according to their greater or less mortality at each of the periods respectively; Mean Temperature and Total number of deaths at all ages. No. Total deaths in children under fif-teen years. In Child'n under 1 year. Between 1 and 2. Between 2 and 5. Between 5 and 10. Between 10 and 15. July, 77° 4U31 August, 75° 4604 January, 32° 3627 March, 40° 3379 June, 70° 3372 April, 50° 3179 February, 32° 3171 May, 60° 3063 September, 65° 2904 October, 55° 2854 November, 45° 2537 December, 35° 24S9 July, 3297 Aug. 2709 June, 2u30 Jan. 1907 Mar. 1869 Apr. 1092 Sep. 1638 Feb. 1534 May, 1195 Oct. 1350 Dec. 1214 Nov. 1143 July, 1889 Aug. 1310 June, 1052 Jau. 861 Mar. 762 Apr. 674 Sept. 642 Feb. 606 May, 557 Oct. 480 Dec. 457 Nov. 429 A us. 733 July, 715 Sep. 430 Mar. 354 June, 351 Jan. 344 Apr. 330 Feb. 318 Oct. 288 Sept. 2S3 Dec. 217 Nov. 201 Jan. 469 Mar. 468 July, 402 Apr. 381 Juue, 378 May, 366 Aug. 357 Feb. 323 Oct. 317 Sept. 312 Dec. 29 2 Nov. 291 Mar. 194 Apr. 191 Aug. 186 Jan. 170 June, 166 Feb. 101 July, 159 .May, 155 Oct. 144 Dec. 130 Sept. 129 Nov. 113 May, 04 June, 63 July, 62 Feb. 56 Sept. 55 Aug. 53 Jan. 53 Oct. 55 Mar. 51 Dec. 48 Apr. 46 Nov. 39 Annexed, we present the proportionate ratio, in the first column, of the mortality in children under fifteen years of age, compared with the entire mortality; in the second column, the ratio of the mortality in infants under one year, to the whole mortality; and in the third column, the ratio of mortality in infants under two years, to the entire mortality:—the months being ranged, as above, according to their re- spective mortality; Ratio of deaths in children to whole mortality. Ratio in infants under one year. Ratio in infants under two years. June, 61.7 per cent. July, 61. " Aug. 58.8 « Sept. 5G.5 " Mar. 55.3 " April, 53. " May, 48.8 Jan. 48.7 " Dec. 48.77 " Feb. 48.37 " Oct. 47.3 " Nov. 45. " July, 40.7 per cent. June, 31.37 " Aug. 28.4 » Jan. 23.46 " Mar. 22.55 " Sept. 22. " APr. 21. Feb. 19. " Dec. 18.3 " May, 18. " Nov. 16.9 " Oct. 16.8 " July, 5G. per cent. Aug. 44.37 '• June, 41.6 '; Sept. 36. " Jan. 33. " Apr, 31.58 Mar. 30. " Feb. 29. May, 27.42 " Deo. 27. " Oct. 26.9 Nov. 20.89 8 114 PATHOLOGY OF INFANCY AND CHILDHOOD. Worms in the bowels are generally ranked among the most usual causes of the complaints of infancy. That their presence may give rise to a morbid degree of irritation in the gastro-enteric mucous membrane, and secondarily, in the mesenteric glands, the brain or the lungs, there can be little doubt; nevertheless, they are less often a cause of disease, than they are popularly supposed to be, or even than they were formerly esteemed to be by physicians. The symptoms which are commonly ascribed to the presence of worms, are produced, in the majority of cases, by a diseased condition of the alimentary canal, entirely independent of the presence of these animals, and may continue, notwithstanding the destruction or removal of the latter. • The first dentition is frequently accused of being the immediate cause of the diseases which occur during the second period of infancy. Dentition, however, cannot, of itself, be considered a disease, during either infancy or childhood; but when a predisposition to morbid action exists, the process of dentition may then become the exciting cause of the most alarming symptoms. The irritation produced in the gums, during the progress of the teeth to the surface, almost invariably gives rise to increased heat and redness of these parts, and sometimes to positive inflammation; and as the irritation of the gums extends to the gastro-intestinal mucous membrane, which at this period, from the development and activity of its muciparous follicles, is readily excited to an increased secretion of mucus, some degree of diarrhoea very com- monly attends the process of teething. If, from any cause, the sto- mach or bowels have been brought previously into a state of morbid irritability, excessive vomiting and purging, fever and other symptoms of more severe disease may be induced. In other cases, when the process of dentition is accomplished with great difficulty, violent inflammation or even sloughing of the gums may occur; and in children in whom the powers of life have been re- duced, and the nutrition of their bodies impaired, by constant expo- sure to a cold, damp, and confined atmosphere, or by deficient or im- proper food, the irritation developed during the process of teething, may induce the peculiar gangrene of the mouth of children, to which the terms cancrum oris, water canker, &c, have been applied. In Philadelphia, and other large and crowded cities, the irritation of teething is a very common exciting cause, during the summer months, of the cholera infantum. In many instances, not only does the process of dentition excite ir- ritation of the stomach and bowels, but in consequence of the increased amount of blood which it attracts to the vessels of the head and face, the tendency to disease in these parts is increased; hence, convulsions, ophthalmia, inflammation of the glands of the neck, ulcerations behind the ears, eruptions of the face and scalp, meningitis, and hydrocepha- lus, very frequently occur at this period of infancy. Deformity and disease are often occasioned during infancy by falls, by improper postures of the body long continued, by improper forms ot clothing, calculated to impede the motion of the limbs, or to prevent the development of certain parts of the body, and by too early attempts to induce the child to assume the erect posture or to walk. SEMEIOLOGY OF INFANCY AND CHILDHOOD. 115 Some discrepancy of opinion exists, among pathological writers, as to the susceptibility of infants to contagion, some ascribing to them an entire immunity from its influence, while nearly all consider them to be less subject to it than adults. In very young infants, it is true, we seldom meet with any of the febrile affections, the propagation of which is generally ascribed to contagion; but after two years of age, conta- gious diseases, if we include under this term small-pox, varicella, scar- latina, measles, and hooping-cough, are of far more frequent occurrence than after the period of puberty. CHAPTER IV. SEMEIOLOGY OF THE DISEASES OF INFANCY AND CHILDHOOD. The detection and diagnosis of disease in the infant is based, the same as in the adult, upon a careful examination and analysis of its various phenomena; but in the infant, the occurrence and extent of these phenomena must be derived, altogether, from the attentive ob- servation of the physician, compared with those of the parents or nurse. From the little patient he can derive no other information than such as is expressed by the countenance, the positions of the body, the motions of the head, trunk, and limbs, the nature of the cries emitted, and the condition of the respective organs, as indicated by the regularity of their functions, or the extent and manner in which these are disturbed. In the infant, the condition of the skin, the state of the various se- cretions and excretions, the appearance of the eye, the manner in which respiration is performed, have the same amount of value, as in- dications of the seat, nature, and extent of morbid action, and are as readily detected as in the adult. But, in the infant, the physician can derive no assistance in forming his diagnosis, from the character and location of any pain or other uneasy sensation the patient may expe- rience—constituting, in many cases of disease, an important patholo- gical feature—excepting from the external physiognomy peculiar to the various grades of suffering that occur in the different organs. It is this physiognomy of suffering, as derived from the expression of the face, the cries, and the movements, which constitutes, in a great measure, the special semeiology of infantile diseases. M. Jadelot has attempted to present a correct exposition of the indications of disease, as founded upon the expressions of the countenance, from the period of the first dentition until puberty:—his remarks, as furnished us by M. De Salle, in his edition of Underwood, are certainly interesting, but, in many respects, they are purely hypothetical. The general phenomena of disease in infancy, notwithstanding they experience certain modifications, dependent upon the peculiar state of the organization, differ, nevertheless, but little from those observed 116 SEMEIOLOGY OF INFANCY AND CHILDHOOD. in the adult. There are, however, a few morbid phenomena that^ are peculiar to the infant; and others, which in the correct diagnosis of disease, have an importance far beyond what they possess in after life. As a preliminary to the study of the semeiology of the diseases of infancy, it is essential that the physician should make himself fully ac- quainted with the external appearance usually presented by an infant during health: the expression of his countenance, the attitudes of his body, as well as with the physiological condition generally, at the dif- ferent stages of development of his several organs, and of their re- spective functions. It is only from the nature and extent of the de- viations from the normal standard, that, in many cases, he will be ena- bled to appreciate the value of the morbid phenomena that exist, either individually or collectively. It is but within a very short period, that the physiology of infancy, and the manner in which its organism is developed, have been accu- rately investigated; and it is curious, that not a few of the phenomena which writers on the diseases of the early stage of existence, of no very remote date, described as important indications, or as results of morbid action, are found to be invariably present* in the infant, during health. We have already presented a brief sketch of the condition of the different organs, during infancy, and the manner in which their re- spective functions are successively brought into action. We need here only remark, that, in the healthy infant, the limbs are uniformly covered with flesh, rounded and plump, and to the touch, present a certain feeling of firmness and elasticity. The skin is soft, flexible, and of a rosy hue; the complexion lively and fresh. The eye, when attracted by any object, has a peculiar quickness and suddenness in its movements; the pupil is usually large when the infant is awake, but often minutely contracted during sleep; and always more or less turned upwards, beneath the upper eyelid. The countenance, when in repose, exhibits, in the earlier stages of infancy, but little or no ex- pression, except that of perfect calmness; but at a later age, it becomes quickly lighted up, smiling, and animated, upon the approach of its parents or nurse, or when attracted by any pleasing object. The sur- face of the infant is cool; the abdomen full and soft—gentle pressure upon it seeming rather to please, than to cause the slightest uneasi- ness. The tongue is generally slightly covered with a whitish mucus; the mouth is always moist, and the lips fresh-coloured, and often pro- truding. The sleep of the healthy infant is quiet and profound: it awakes from it cheerful and smiling, and soon demands food. During its waking hours, after, at least, the first month or two, it is inclined to as much activity as its limbs will permit, and exhibits a surprising springiness and rapidity in all its movements. It delights to be played with and carried about, and, when old enough, to roll and crawl about upon the carpet. In health, infants seldom cry, excepting to express their wants, or in consequence of experiencing some accidental uneasiness or pain, SEMEIOLOGY OF INFANCY AND CHILDHOOD. 117 and are immediately quieted upon their wants being gratified, the cause of their uneasiness removed, or their pain appeased. Crying is not, however, always the indication of either ungratified wants, pain, or disease:—some infants cry repeatedly, being with difficulty ap- peased, Avithout our being able to detect any apparent cause of suf- fering, and without any interruption to the full nutrition, and regular development of their bodies. Every deviation from what we have just given, as the picture of a healthy child, is not, however, to be considered, of itself, an indication of disease. The limbs of an infant may exhibit a certain degree "of meagreness—its complexion may be somewhat pallid—its sleep short, or occasionally restless—or many of its waking hours may be passed in crying, without the existence of any positive disease. All changes, however, occurring in an infant, either suddenly or gradually, whether in the ordinary expression of its countenance—in the condition of its body—its habits or disposition—should be looked upon with a suspi- cious eye, and be the signal for a careful examination into the con- dition of its several organs; in one or other of which, some com- mencing disturbance will, in general, be detected. Whenever there is observed in an infant any marked alteration in the countenance, or in the external appearance of the body—an un- wonted dulness of the eye—an indisposition to playfulness—a loss of its accustomed gaiety—unusual listlessness—disturbed sleep—uncom- mon wakefulness—sudden starting in slumber, or awaking with appa- rent affright—an unusual degree of somnolency—the occurrence of sud- den paleness of the face, or paleness alternating with a suffusion of red, more or less deep—increased heat of the hands and feet, or of the entire surface—unusual coldness of the extremities—unaccustomed fretfulness—frequently repeated or prolonged fits of crying, or a marked change in the character of the cry—frequent or constant cor- rugation of the brow—twitching of the muscles of the face—rejection of the breast or of food—unusual movements of the head and limbs— and crying or moaning when the body is moved or handled, are inva- riably to be considered as the indications of nascent or confirmed dis- ease. No disturbance or irregularity of function occurring in an infant, however slight, should be considered as unimportant. The sudden- ness with which some of the most violent affections of this period of life are developed, and the rapid occurrence of effusion or of disorgan- ization in the tissues and organs in which morbid action is seated, give to every indication by which the inception of disease can be detected, even a greater degree of importance than in after life. In their com- mencement many of the maladies of infancy may be promptly arrested by simple remedies, that if allowed to become fully developed, are scarcely within the control of the most judicious and active plan of treatment. A slight irritation of the gastro-intestinal mucous membrane of the infant, will often, by being suddenly reflected upon the brain, give rise to a violent convulsive attack, or produce some other and equally se- rious train of symptoms, which might have been prevented by the early detection and removal of the primary irritation. 118 SEMEIOLOGY OF INFANCY AND CHILDHOOD. Not a few, also, of the maladies that occur during infancy, give rise, during their first stages, to so few prominent symptoms, that their ex- istence is often unsuspected, until disorganization of some important organ has taken place, or a sympathetic affection of the brain occurs, and their character and extent are thus revealed, at a period when their cure is impossible. Even in these insidious forms of disease, by a close attention to the countenance, manners, and gestures of the little patient, the physician will seldom fail to detect the_ presence of morbid action, and make out, with sufficient accuracy, its diagnosis, at a period when it is still within the control of appropriate remedial agents. The principal sources of diagnosis in the diseases of infancy, are the expressions of the countenance—the gestures—the phenomena of sleep—the mode in which respiration is effected—the cry—the condition of the tongue and mouth—the condition of the surface— the state of the breath—the evacuations. 1.—Of the Countenance. The infant's countenance offers to us the most interesting and the most intelligible page in nature's book. In its calm, we read the health and ease of all the organs,—of all the functions. In its smiles, we read the happiness of body and of mind. In its expressions of un- easiness or pain we first discover the invasion of disorder or disease. Our attention will probably be first attracted by some undefined change, which it will require a stricter observation to decipher, and associate with its peculiar cause. (Hall.) Although we cannot go as far as does M. de Jadelot, and assert that, from the movements of the infant's face, we may determine the loca- tion of its diseases, in one or other of the great splanchnic cavities— the disturbed expression of the upper part of the face, the forehead, eyes, and brows, indicating disease of the brain, or of the nervous sys- tem ; the altered features of the middle portion of the face, particularly of the nose, being indicative of affections of the thoracic organs; while the expression of the lower part of the face, the mouth and lips, point to the abdominal region as the seat of morbid action; yet we are con- vinced that, from the condition of the countenance alone—often from some indescribable expression of suffering—the observing physician will be able to detect, at once, the existence of disease, and not unfre- quently to determine its location. In most of the diseases of the alimentary canal, the face of the in- fant is pallid, and exhibits a very peculiar expression of fretfulness or peevishness—excepting when these diseases give rise to febrile reac- tion, during the exacerbations of which, the face is more or less flushed. In many of the chronic affections of the digestive organs, especially when attended with disease or functional derangement of the liver, the face and surface generally acquire a dirty brown, or a deep yellow hue. Great paleness of the face, if accompanied with diminished tempe- rature, or alternating suddenly with flushing and heat, is often the in- dication of exhaustion, as from profuse diarrhoea: it is likewise fre- OF THE COUNTENANCE. 119 quently observed previously to the occurrence of convulsive attacks, or of acute meningitis. In extreme cases of exhaustion, particularly from profuse evacua- tions from the bowels, as in protracted cases of cholera infantum, the cheeks are cold and pallid, and of a waxy appearance; the eyelids are half closed; the pupil contracted; the eyeball sunk in the socket, and rolled upwards, so as to conceal entirely the pupil beneath the upper eyelid; the conjunctiva is injected with dark-coloured blood; the cornea covered with a thin film of mucus; and the orbitar circle is of a livid or dark brown colour. In the acute affections of the head, the face is usually flushed, some- what turgid, and hot. In affections of the respiratory organs, the face is generally of a dusky red, and swollen; and in extensive hypersemia of the lungs, the lips and cheeks are often of a deep livid hue. In hydrocephalus, the skin of the face, and especially of the fore- head, is tense and shining. The smooth and shining appearance of the skin upon the forehead is also very generally observed in protracted cases of cholera infantum. Deep blueness of the countenance, in young children, is indicative of morbus cseruleanus, arising from an impediment to the free circula- tion of the venous blood. It usually exists from birth, and is increased in intensity by any exertion of the body. A sudden contraction of the countenance, especially if accompanied by a sudden motion of the body, and a sharp scream, is generally the indication of some sudden attack of pain, usually of a spasmodic cha- racter. If, at the same time, retraction of the abdominal muscles, drawing up of the knees, or a sudden extension of the body takes place, the pain is seated in some part of the alimentary canal. In this case there is also a whitish circle often observed about the mouth. When the painful sensation comes on more gradually, and is more prolonged in its duration, the brows are corrugated, the upper lip is stretched and elevated, and the nostrils become sharp and contracted. The contraction of the brows is usually most marked in pain of the head; sharpness of the nostrils, in painful affections of the chest; and drawing up of the upper lip, in abdominal pain. Upon the approach of convulsions, the upper lip is often stretched firmly over the gums, and of a whitish or livid hue; there occurs a slight divergence in the axes of the eyes; there is an unusual upturn- ing of the eyeballs, or a singular rotation of the latter upon their own axes, or a fixed staring condition of the eye, with a rapid contraction and dilatation of the pupils; there are often slight twitchings of the mus- cles, on one or other side of the face, and a quick alternation of flush- ing and pallor of the countenance. All these appearances are not ob- served to precede every convulsive attack; the occurrence, however, of one or more of them is sufficient to call attention to the gums, alimen- tary canal, or nervous system, in order to detect the source of irrita- tion, that, by its removal, the threatened attack may be prevented. Whenever there exists any great impediment to the freedom of re- spiration, the nostrils are widely dilated during inspiration, and strongly 120 SEMEIOLOGY OF INFANCY AND CHILDHOOD. contracted during expiration, the mouth is held open, and the lips are often puckered, and always of a livid hue. In the more severe forms of gastro-intestinal inflammation, the mouth is extended, the lips—often pale, dry, and cracked—are applied closely to the teeth, and the chin has the appearance of unusual projection. In chronic irritations of the bowels, the nose and upper lip are often tumefied. A peculiar puckering of the corners of the lips is frequently observed to precede the occurrence of gangrene of the mouth in chil- dren. The countenance of infants that have been subjected to an almost habitual use of opiates, has a peculiar and striking appearance: the skin is of a sallow or dirty brown hue, and thrown into wrinkles, from the emaciation of all the soft parts beneath it; the eyelids are red and tumid; the eyes dull and watery; the lips dry and pallid, and drawn, so as to leave the mouth partially open, and the chin projecting. The whole countenance presents, indeed, a faithful miniature likeness of a sickly aged person. The eyes are usually prominent and suffused, their superficial blood- vessels being often minutely injected with blood, in violent paroxysms of crying, and of cough, and in all affections of the respiratory organs attended with much difficulty of respiration, as in croup, the more vio- lent forms of bronchitis, hooping cough, &c. The pupil of the eye, in infancy, is usually dilated, during health, and it is often closely contracted during sleep, and rapidly dilates upon the child's awaking. The state of the pupil, however, varies frequently, and it is only from its fixed or permanent dilatation or con- traction, that the indications of disease are to be derived. In the course of most diseases, the occurrence of a fixed dilatation or contraction of the pupil, indicates the extension of irritation to the brain. In the early stage of encephalic inflammation, the pupil is, in gene- ral, contracted, and, in the last stage, dilated, and insensible to light. Occasionally the form of the pupil is irregular; this has been ob- served by M. De Jadelot in cases of intestinal irritation from worms. The sudden appearance of strabismus, in the course of disease, is usually an indication of the occurrence of some cerebral affection, and is then always an unfavourable symptom. Slight irritation of the bowels, as from worms, indigestible food, &c, often gives rise, however, to temporary strabismus. 2.—Of the Gestures. In infants old enough to be attracted by surrounding objects or to be played with and amused, the approach of disease is often marked by a total disregard of every thing that had previously pleased them, and an indisposition to motion of any kind; instead of being active and playful when awake, they lie still and listless upon the nurse's lap, and no efforts to attract their attention or to excite a smile upon their countenance, are successful. The cooing, chirruping sound, with which they expressed their feeling of satisfaction or delight, gives place to perfect silence, or to a short querulous plaint when moved or teased by the importunities of those around them. OF THE GESTURES. 121 If the infant had already commenced to hold up its head, to sit alone, or to stand, on the approach of disease there often occurs a degree of muscular debility, which prevents these attitudes from being con- tinued, and the position assumed by the body and limbs is expressive of extreme languor. When in suffering, particularly in cases of intense abdominal pain, the infant will often draw up its knees, and bend forward its body, or throw about its limbs in a wildly agitated manner; or, as we have often observed, forcibly extend its whole body, and then suddenly relax it. When one limb is kept motionless, or moved with sudden jerks, par- ticularly if its motion excites or augments the cries of the child, that limb is generally the seat of pain. If, after an infant has commenced to walk, it is found to apply only the toes of one of the feet to the ground, and to exhibit a gradually increasing limp in his gait, particularly if it complain of pain in one of the knees, and exhibit uneasiness when that limb is handled, we should suspect the presence of articular inflammation of the hip. When a child is observed frequently to trip and stumble, in walk- ing, or when, as he moves hastily or unguardedly, his legs cross each other; when he stands upright, his knees totter and bend under him, and when seated, his legs are crossed and drawn up under the seat; particularly if he exhibit, at the same time, great languor and list- lessness, and complain of frequent pain and twitchings in his thighs, we may suspect some disease of the lower portion of the spine, proba- bly caries of the vertebrae. A frequent application of the hands to the head is, generally, an indication of suffering in this part of the body, the seat of which is to be detected by other symptoms. A pulling at one of the ears, and violent, often frequently repeated scratching of the parts in its imme- diate vicinity, with frequent moans, or short acute cries is, generally, indicative of otitis. Rolling the head constantly from side to side, as it lies upon the pillow, or bending it forcibly backwards upon the spine, is usually an indication of cerebral disease. Picking at, or frequently rubbing the nose, is, usually, a symptom of irritation of the alimentary canal; it is a very common indication of the presence of worms. Convulsive movements of one or other of the limbs, of the muscles of the face, of one side of the body, or of the voluntary muscles generally, may result from irritation or inflammation of the brain, or spinal marrow; or they may be produced by an irritation seated in other organs, and transmitted to the nervous centres. Convulsions are often the precursors of eruptive diseases. Contraction of the fingers and toes, in consequence of which the first are forcibly flexed upon the palms of the hands, and the latter towards the soles of the feet, whilst the back part of the hands, and the upper surface of the feet, present a soft, puffy swelling, is an in- dication of convulsions. An opposite condition, or when the fingers and toes are forcibly extended, whilst the first are semiflexed upon the metacarpus, and this, at times, upon the carpus, and in the same manner the toes upon the metatarsus, is a common attendant upon laryngismus stridulus. 122 SEMEIOLOGY OF INFANCY AND CHILDHOOD. As early as the fifth or sixth day subsequent to birth, infants are oc- casionally attacked by spasms of the muscles of the face, lower jaw, or neck, and, in severe cases, there is often a complete fixation of the jaw. This condition has been attributed to retention of the meco- nium, or to inflammation of the vessels of the cord :—it is more ge- nerally, we suspect, produced by a confined and impure air, or cer- tain conditions of the atmosphere, endemic to particular localities. During dentition, and from trifling irritations of the digestive canal, infants are frequently affected with slight convulsive movements of the muscles of the face, which give to the countenance an appearance of smiling. This symptom is frequently the precursor of severe ge- neral convulsions. A rigid extension of the limbs with a turning inwards of the thumbs and great toes, is often the precursor of a convulsive attack. When, upon the child being put to the breast, it sucks eagerly for a moment or two, and then suddenly ceases, throwing back the head with an expression of anxiety in its countenance, it will, in general, be found that it is labouring under some disease of the respiratory organs, as severe bronchitis or pneumonia. The same phenomena, with a rolling of the head from side to side, are often'the precursors of an attack of convulsions. Sudden rejection of the breast after sucking for a few moments, the infant at the same time exhibiting pain or uneasiness by its cries and the movements of its body, is common in cases of coryza and of inflammation of the throat,—it is often observed, also, in severe cases of stomatitis. Weakness or contraction of certain muscles, or partial paralysis often marks the formation of tubercles in the brain. Partial paralysis, as of one leg, is not, however, an uncommon symptom, during dentition and in cases of gastric irritation. Although this, in some cases, is a serious symptom, yet, very generally, the paralyzed limb, sooner or later, regains its power. An uplifted step, or staggering gait, and rocking of the legs, or a total inability to stand erect, are indicative of serious disease of the brain or spinal marrow These symptoms are often the precur- sors of sudden serous effusions upon the brain. A sudden increase of muscular activity in young children, with un- wonted exhilaration of spirits, and liveliness of manner, denotes in- creased excitement of the brain, and often precedes acute attacks of meningeal inflammation. Great restlessness, and frequent involuntary movements of the limbs, are, in general, when they occur in the course of protracted maladies, unfavourable symptoms, and depend upon disease of some portion of the brain. 3.—The Phenomena during Sleep. In a healthy infant, sleep is calm and profound; the position is, generally, upon the side, with the limbs perfectly relaxed; the respi- ration is full, slow, regular, and quiet. The eyelids are never for- cibly closed, and not unfrequently, are slightly separated; the cornea THE PHENOMENA DURING SLEEP. 123 is partially concealed beneath the upper lid, the ball of the eye being turned upwards; the pupil is often greatly contracted. The skin is soft and cool. It is not uncommon in the sleep of infants for imperfect respiration to occur for a time, followed by a deeper inspiration or sigh, to supply the previous deficiency in the function. This has sometimes been mistaken for an indication of disease; it is, however, a perfectly healthy phenomenon, and results from the reduction of innervation that occurs during sleep. Cutaneous transpiration is always increased during the period of sleep:—if the room in which the infant reposes is warm, or he is too warmly clad, or covered with too many bed- clothes, profuse perspiration is liable to occur, particularly about the head and neck. On awaking from sleep, the healthy infant is lively and cheerful, and quickly seeks the breast or calls for food. The younger the infant, the greater is the time passed in sleep; after the first month or two, the intervals of waking and repose be- come more regular, and the infant will, very generally, fall asleep and awake, very nearly at stated hours. During sleep, the countenance of the infant will, by its expression, often give intimation of the existence of uneasiness or pain, of which no indication is presented during the period of wakefulness,—the in- fant's attention being then diverted from slight degrees of bodily suf- fering, by the various objects and sounds that occupy its external senses. The commencement of irritation in the bowels, or brain, may often be detected by slight twitchings of the mouth and eyelids, or by the grinding of the teeth, that occur during sleep, when no symptom is manifested while the child is awake. In the same rnanner, the approach of disease will be indicated by frequent movements of the body and limbs, and by sudden starts that take place during sleep. Sleeplessness, when not the result of suffering, is usually caused by a morbid excitability of the brain; it is often present during conva- lescence from acute affections. Sudden starting from sleep, with a wild alarmed expression of coun- tenance, or without the child appearing, for some time, to recollect himself, or to recognise surrounding objects, is often caused by irrita- tion of the alimentary canal, and may, in many cases, be the precursor of convulsions, or of acute meningeal inflammation. Children often awake from sleep in affright, and quickly burst into tears; at other times, their sleep appears troubled, and, without awaking, the child sobs, or utters words or indistinct sentences; this is, yj-jenerally, produced by the occurrence of dreams, excited by intestinal irritation, or by the presence of too much or improper food in the sto- mach. An unusual degree of somnolency in general indicates hyperaemia of the brain; it is sometimes observed during teething, or when the stomach is overloaded with food. Deep soporose sleep, or coma, always indicates serious disease of 124 SEMEIOLOGY OF INFANCY AND CHILDHOOD. the brain; and, when it occurs in the course of acute diseases, or sud- denly supervenes after protracted illness, is to be viewed as an unfa- vourable symptom. Short, disturbed sleep, the infant on awaking, being fretful, peevish or morose, is, very generally, an indication of disease of the alimen- tary canal. 4.—The Cry. Crying is the natural language by which the infant expresses its wants and sufferings. During health, an infant, properly nursed, cries but seldom, and never exhibits violent and repeated paroxysms of cry- ing, or the continued plaintive cry of distress. In new-born infants, loud and vigorous crying is always an unequi- vocal sign of health and vigour; and is, doubtless, produced by the im- pression upon the body of the various novel stimuli to which it has be- come suddenly subjected. After the sentient surfaces have become accustomed to these, the infant's cries proceed from some want, from uneasy sensations or pain, accidentally induced, or from disease. Violent paroxysms of crying are usually the result of intense pain; occasionally, however, they are the expression merely of passion; and, when this is the case, the child will often suspend its breath for some time, and the face will become livid from the interruption of the cir- culation through the lungs. Violent and prolonged fits of crying, from whatever cause they re- sult, are always injurious, and in some instances, have been imme- diately succeeded by an attack of convulsions. A fretfulness of disposition and frequent crying, may be produced from the child being continually vexed and teased by its nurse, with- out the actual presence of pain or disease. Violent and frequently repeated crying, or shrill and piercing screams, are the indications of acute pain; and are, hence, observed to occur in most of the inflammatory affections to which infants are liable, espe- cially in their early and acute stages. In inflammation of the gums, the cry will be more or less protracted; while in inflammation of the chest and abdomen, the increase of suffering to which they give rise, will in- duce the child, as much as possible, to control its cries; the cry be- comes then sudden, short, and at intervals. In severe pain of the head, as in the acute stage of meningeal inflammation, the cry is often a short, piercing scream, occurring at intervals. The same is the case also in spasmodic pains of the alimentary canal. To the seat of the pain we will be directed by the local symptoms. Intolerance of light, contraction of the brows, and tossing of the head, with often increased heat of the latter, will point to the brain as its seat. A quick, panting, or difficult respiration, rapid contraction and dilatation of the nostrils, and cough, to the lungs; constipation, diar- rhoea, or vomiting,—tenderness on pressure, and increased heat of the abdomen, to the alimentary canal; and loud, crowing, and difficult re- spiration, to the larynx. When the cry is hoarse or husky, it is an indication of effusion with- in the bronchi, preventing the free passage of the air to the glottis, or of inflammation and thickening of the mucous membrane of the fauces larynx, or trachea. ' CRY.—RESPIRATION. 125 When the cry has a nasal sound, there is inflammation or engorge- ment of the tonsils, inflammation and thickening of the Schneiderian membrane, or a polypous tumour at the posterior nares. A peculiar ringing sound of the cry is often the first indication of an impending attack of croup, or of laryngismus stridulus. When the cry is scarcely audible, and accompanied with a low, sibi- lant prolongation, there in general exists some disease of the glottis. Fretfulness, or peevishness, when habitual, or occurring in children who had previously exhibited a lively and cheerful disposition, may either be the indication of uneasy sensations, resulting from the action of a variety of irritating causes, and the consequent impairment of the general health of the system; of some chronic irritation, seated, most commonly, in the alimentary canal, or of the invasion of acute disease. Habitual fretfulness, or its sudden occurrence, should, therefore, never be overlooked. A low moaning cry is, in the infant, invariably an important and alarming symptom of disease. In acute affections, the moaning is con- tinued at each expiration. During painful dentition, the infant is often heard to moan, and grind its teeth at intervals. Moaning is particularly characteristic of painful diseases of the alimentary canal. When it occurs after violent excitement, accompanied with acute screams, and is attended with stupor, it is an unfavourable symptom, indicating, in general, the early occurrence of effusion from cerebral disease. 5.—Respiration. In the healthy infant, respiration is full, regular, and quiet; more frequent than in the adult, and performed almost exclusively by the movement of the ribs. Difficult and loud respiration is present in all the diseases of the pulmonary apparatus. In affections of the larynx, glottis, and upper portion of the trachea, inspiration is performed with difficulty; while in diseases of the bronchi, the difficulty is experienced in expiration. When the difficulty of respiration gradually augments in intensity, it is an unfavourable indication in all affections of the lungs. Respi- ration often becomes irregular, and occasionally intermittent, in the course of pneumonia, and in affections of the brain this is always an unfavourable symptom. In pleurisy and peritonitis, inspiration is rendered short and difficult from the increase of pain to which it gives rise. Difficult respiration, attended with heaving of the upper portion of the chest, elevation of the shoulders, violent exertion of the muscles of the neck, or rapid motions of the mouth and nostrils, is attendant upon serious disease of the thoracic viscera, and is usually the indication of an unfavourable result. In the healthy respiration of the infant, no sound is heard unless the ear is applied to the chest; it is hoarse in bronchial inflammations; it is sibilant in affections of the larynx, glottis, and upper portion of the trachea; and presents a sighing sound in hypersemia of the lungs, and in cases of exhaustion, or debility of the respiratory muscles. The 126 SEMEIOLOGY OF INFANCY AND CHILDHOOD. sighing sound is an unfavourable indication in acute affections of the brain. The respiration is very quick and panting in most febrile affections, during the exacerbation; when rare, there in general exists debility of the muscles of respiration; a quick and rare respiration exists in pleu- ritis, or it may occur from exhaustion, from violent exertion of the re- spiratory muscles; it is also present in pneumonia, chronic bronchitis, or pleuritic effusions. The indications derived from auscultation and percussion are nearly the same in children as in adults, and need not, therefore, be noticed here. The respiratory murmur—puerile respiration—being remarka- bly loud over every part of the chest in infancy, is not, as in the adult, so important an indication of disease. It is diminished in intensity in inflammation of the bronchial ramifications, and entirely absent in in- duration of the lungs, and in pleuritis. Cough may result from disease of some portion of the respiratory apparatus, or it may be caused by irritation transmitted to the respi- ratory organs from the alimentary canal, or from disease of the brain. In the first case, it is generally attended with mucous expectoration; in the second, it is usually dry and irritative; and in the last, spas- modic. A short, hacking cough, with little expectoration, is present in pleu- risy, and in the incipient stage of tubercular phthisis. Continued cough accompanies inflammations of the larynx, trachea, bronchi, and lungs. Intermittent cough is a symptom of croup, laryngismus stri- dulus, and hooping-cough. In the commencement of inflammation of the respiratory organs the cough is dry, but is soon accompanied with expectoration when the disease is seated in the mucous membrane; but in pneumonic inflam- mation it continues longer dry, and the expectoration is seldom copious. In catarrhal affections, the cough is hoarse; in croup, it has a pecu- liar barking or crowing sound; in hooping-cough, a loud shrieking sound; and in the early stage of bronchial inflammation, previous to the occurrence of effusion within the bronchi, it has a whizzing sound, without hoarseness. Sneezing may arise from any accidental irritation of the Schneide- rian membrane, or from irritation transmitted to this part from the alimentary canal. It is one of the prominent symptoms of coryza in children, arising then from the increased irritability of the nasal mu- cous membrane, consequent upon inflammation. Hiccough is a frequent symptom in children of slight irritations of the alimentary canal; it may arise also from cerebral irritation, and be then a precursor of convulsions. When occurring in the course of inflammatory affections of the bowels, peritoneum, or brain, it is in general an unfavourable symptom. 6.—The Tongue and Mouth. In the infant, during health, the tongue is moist, smooth, and gene- rally covered, in its middle and towards its root, with a thin coating of whitish mucus. The mouth is always moist and of a palish hue, and the gums of a bright red. THE TONGUE AND MOUTH. 127 When the tongue is loaded with a white curdy matter, disturbance of the digestive process, or slight irritation of the alimentary canal, is generally present. Increased redness, heat, and dryness of the tongue and parietes of the mouth, indicate the first stage of stomatitis, and often accompany inflammations of the alimentary canal. Small white points or patches, dispersed over the tongue and pa- rietes of the mouth, are the result of inflammation of the epithelium of these parts, and are usually symptomatic of disease of the stomach or bowels. As a local affection, this condition of the tongue may be produced by confined and impure air, want of cleanliness, &c. Aphthae of the tongue and mouth, are the result of follicular inflam- mation; they may depend upon improper food and vitiated or confined air; or they may be developed by dentition, or be symptomatic of disease of the alimentary canal. A pale, flabby tongue is the indication of great debility or exhaus- tion. Redness of the tongue is symptomatic of acute inflammations of the gastro-intestinal mucous membrane. In scarlatina, the papillae of the tongue become enlarged and pro- minent, presenting numerous red points—the tongue itself is also red, and the throat covered with efflorescence. Swelling of the tongue occurs in scarlatina, measles, croup, laryn- gitis, and small-pox, and is usually an unfavourable indication. In febrile diseases, and in most of the affections of the alimentary canal, the tongue is covered with a whitish coat. In protracted irri- tations of the bowels, the coating of the tongue generally assumes a dirty yellow or brownish colour. Increased secretion of saliva occurs immediately preceding, and during the process of dentition, and in the course of stomatitis, it is also a common precursor of the gangrenous affection of the mouth in children. A diminished secretion of saliva takes place in most of the acute and febrile affections that occur during childhood. Great dryness of the mouth, with constant thirst, occurring in the course of acute diseases, is generally unfavourable. Increased heat and redness, with swelling of the gums, occur at the period of dentition. A dark, red, and tumid state of the gum3, gene- rally precedes the occurrence of gangrene of these parts. Increased redness of the throat occurs in scarlatina, measles, and small-pox, in inflammations of the tonsils and larynx, as well as in chronic inflammations of the digestive and respiratory organs. 7.—Of the Surface. In infancy, the skin, during health, is soft, moist, and cool, and uni- formly distended, from the large amount of soft cellular tissue, and subcutaneous adipose matter. Whenever it becomes harsh, dry, and hot, or flabby and wrinkled, it is an indication of the existence of more or less extensive disease in one or other of the organs. A hot and dry skin is common in all the febrile and acute affections 128 SEMEIOLOGY OF INFANCY AND CHILDHOOD. of infancy; the heat is not, however, always diffused over the entire surface, but is often greater in one region than in the other's; thus, in inflammatory affections of the brain, the heat of the head is in- creased, while the rest of the body maybe of its normal temperature, or the lower extremities even cold; in inflammations of the abdominal organs, the increased heat will often be confined to the epigastric, umbilical, or hypogastric regions, or to the surface of the abdomen generally. A dry, burning feel of the palms of the hands, is often attendant upon disturbance of the digestive function, irritations of the alimentary canal, or irritation of the lungs connected with tu- bercles. A uniform redness, or rosy hue of the surface, is the indication of health in infancy; when, however, the lymphatic temperament is strongly marked, the skin, particularly of the face, may be pallid and puffy, without the existence of positive disease. Such a condition of the skin should, however, be always a warning for additional precau- tions in the hygienic management of the child, lest a scrofulous con- dition of the lymphatic glands, or tubercular depositions occur. This state of the skin is common in children who are too much confined within doors, and in insufficiently lighted apartments, or who are ex- posed to a damp, stagnant, or impure atmosphere, or fed upon food deficient in nutrition, or of a bad quality: it occasionally presents it- self when, after scarlatina, and some other diseases, effusion, more or less extensive, takes place in the cellular tissue. Increased redness of the surface, general or partial, is either an indication of inflammatory or eruptive diseases of the skin, or it may result from febrile excitement, or acute inflammations of internal or- gans. Thus in inflammation of the brain, the face becomes flushed; and in certain diseases of the lungs and digestive organs, a circum- scribed redness of the cheeks is not unfrequently observed. Intense redness of the skin in children we have known to be pro- duced, in many instances, by certain articles of diet, and to cease the moment these were discharged from the stomach by spontaneous vo- miting, or by the operation of an emetic. An alternate paleness and flushing of the face is common in menin- geal inflammation. Intense blueness of the skin is observed in certain cases of malfor- mation of the heart; or it may arise from any cause which prevents the oxygenation of the blood in the function of respiration. Yellowness of the skin is usually connected with irritations of the alimentary canal, or with some affection of the liver, in. consequence of which the serum of the blood becomes surcharged with the colour- ing matter of the bile; in this case, the adnata of the eye exhibits the same yellow hue as the surface of the body. In very young infants, however, yellowness of skin is occasionally produced by an unusually yellow colour of the serum, and in such cases is seldom a symptom of much importance. In protracted diseases of the alimentary canal—chronic diarrhoea, cholera infantum, &c.—the skin assumes a sallow, dirty yellow or brownish hue. OF THE SURFACE. 129 The fulness and tension of the surface is increased from hyperemia of the cutis and subcutaneous tissues, in eruptive fevers, and in local cuticular inflammations. In hyperaimia and inflammation of the brain, the integuments of the face are very generally increased in fulness and tension. Tension of the integuments of one cheek, accompanied, at first, with increased redness, and subsequently with a shining white- ness, is an indication of one of the most common varieties of gangrene of the mouth. Tension of the abdominal integuments, when accompanied by ten- derness, is an indication of inflammation of the abdominal viscera, par- ticularly of the alimentary canal; when unaccompanied by tenderness, it may be produced by the formation of gas within the intestines, or by effusion within the peritoneum. General or local tension of the surface of the body, may be produced by the effusion of serum within the cellular membrane generally, as in anasarca, or in some particular portion of it, as in oedema: it is then distinguished by the diminished temperature and paleness of the parts where the effusion occurs, and by the pitting upon pressure. A reduction of the fulness and tension of the skin, may be produced by the action of cold, or by deficient food, or it may result from ema- ciation, resulting from protracted disease. In serous diarrhoea, and the cholera of infants, it often occurs with great rapidity. Perspiration is readily excited in children;—during, or immediately succeeding a violent attack of coughing, of convulsive paroxysms, and of intense pain of the bowels, it is a common occurrence for a copious perspiration to break out about the head and face. A general mois- ture of the surface, occurring in acute diseases, with an abatement of their respective symptoms, is, in general, a favourable indication; but when the perspiration is local, and confined to the head and face, or to the extremities, it is, in general, an unfavourable symptom. A cold, profuse perspiration, with sunken eyes, a livid hue of the countenance, and short, slow, imperfect respiration, is a sign of great prostration, and is always an unfavourable occurrence. The natural odour of the sweat in young children is acid; in the miliary eruption, the acidity is very decided. In particular forms of cutaneous eruption, the sweat presents a very peculiar and character- istic odour. Many of the cutaneous eruptions are indicative of disease of the ali- mentary canal, and other organs, or they may depend on simple de- rangement of the digestive process. Thus the several species of stro- phulus, prurigo, urticaria, and erythema, result, in general, from im- proper, or too much food, an unwholesome condition of the mother's or nurse's milk, acid food or drinks; from certain articles of food eaten at improper seasons, as fish; from food of too stimulating a character; and, in certain constitutions, or in particular conditions of the stomach, from articles of food not generally esteemed unwholesome, as straw- berries, honey, &c. Many of these eruptions are attendant upon the process of dentition. Herpetic and erythematous eruptions, and pemphigus, are very generally connected with disease, either acute or chronic, of the di- 9 130 SEMEIOLOGV OF INFANCY AND CHILDHOOD. gestive organs. The occurrence of ecthyma is often favourable in the acute affections of the intestinal canal; and herpes labialis in all febrile and acute diseases. Minute vesicular eruptions often occur in chronic diarrhoea and in protracted cases of cholera infantum. Petechias are common in many of the intestinal diseases of children; they are usually an unfavourable symptom. Roseola may arise from irritation of the digestive tube, or it may occur in the course of catarrhal and other complaints. Itching and pricking of the skin are produced by gastric derange- ments or intestinal irritation. Itching of the nose is a common symp- tom of intestinal worms, and itching at the orifice of the rectum of the presence of oxyures. An itching and tingling of the skin often pre- cede the occurrence of exanthematous diseases. 8.—The Breath. The breath of a young infant has often the smell of the breast-milk; occasionally its smell is slightly sour; it is generally, however, during the entire period of infancy and childhood, destitute of any peculiar or very decided odour. Every marked change in the odour of the breath is the indication of disease of the mouth, nostrils, or digestive apparatus; or of disturbance of the digestive function. When the breath of an infant is decidedly acid, it is usually in con- sequence of imperfect digestion of the food, and hence the occurrence of an acid breath is generally accompanied, sooner or later, with diar- rhoea or colic. In the diseases of the alimentary canal, and in the febrile affections of children generally, the breath has a peculiar smell, difficult to de- scribe, but when once observed, always readily recognised. A fetid state of the breath may arise from indigestion, from disease of the alimentary canal, from ulcerations of the nose, mouth and throat, and from gangrene of the gums or cheek. It is present, also, in small-pox, and the latter stages of the more violent forms of scar- latina anginosa. A rancid smell of the breath is, ordinarily, the result of indigestion, from overloading the stomach with animal food. 9.—Discharges by Vomiting and Stool. Infants at the breast often vomit from mere repletion of the stomach with milk; a greater amount being sucked than the stomach can digest. The vomiting, in this case, is beneficial, and is favoured by the pecu- liar position and structure of the stomach during the first months of existence. The milk thrown up is unchanged, or partially coagulated. Vomiting, however, may be induced by some disturbance of the di- gestive process; the milk discharged, in this case, being decidedly acid. Repeated vomiting is, in general, however, an indication of disease of the alimentary canal, and is often accompanied with purging. In certain cases the caseous portion of the milk is retained in the stomach, undigested, in the form of a hard, tenacious coagulum', and gives rise often, to gastrodynia, colic, and even convulsions; when DISCHARGES BY VOMITING AND STOOL. 131 discharged by vomiting, an almost immediate relief of all the unplea- sant symptoms induced by its presence in the stomach is experienced. Almost incessant vomiting, increased upon any thing being taken into the stomach, the discharges being decidedly acid, and often of a green colour, is a symptom of gastro-malacia, or that form of stoma- chic disease of children, terminating in a gelatiniform softening of the coats of the stomach. Vomiting occasionally attends the process of dentition; it very gene- rally ushers in an attack of scarlatina, and not unfrequently terminates the violent paroxysms of spasmodic cough, in severe cases of pertussis. Vomiting, attended with increased bilious discharges from the bowels, is common in infants during the heat of summer, particularly at the period of weaning, or during dentition:—when violent and protracted, and accompanied by repeated—almost constant—discharges of a yel- lowish or colourless fluid from the bowels, it constitutes the cholera infantum. Frequent vomiting, attended with gradual, sometimes rapid, ema- ciation, is common in infants who are deprived at an early period of the breast, and attempted to be reared upon other food. Vomiting is occasionally symptomatic of diseases of the brain, and is often one of the indications of incipient hydrocephalus. In early infancy, repeated evacuations from the bowels occur in the course of the day; and during the whole period of infancy and child- hood, the evacuations from the bowels are much more frequent than in after life. Increased evacuations, are then also, in general, much more readily produced from trifling errors in diet, and slight degrees of irri- tation of the intestinal mucous membrane. The period of teething is very generally accompanied by increased discharges of a thin mucous character from the bowels. Diarrhoea in children may arise from improper or too much food, the irritation of teething, irritation or inflammation of the intestinal canal, the action of cold, and from increased acid secretions in the sto- mach, the effect of functional derangement or disease of that organ. When profuse or long continued, it often proves fatal by the great exhaustion produced. Immediately after birth, the discharges from the bowels are of a very dark green or black colour—the meconium. During the early period of infancy, the discharges are of a soft, curdy consistence and appearance, occasionally tinged with bile and without fetor; during the remainder of infancy and childhood, they are more or less soft, and of a yellow or light brownish hue. Frothy, acid discharges from the bowels, of a light yellow or slightly green colour, indicate a disturbance of the digestive function; gene- rally from over-feeding or improper food. Discharges of slimy mucus occur in irritations of the bowels, from worms or teething; or in consequence of an increase of the mucous exhalation from the follicles of the intestines, caused by the impres- sion of cold upon the surface. Repeated discharges of viscid mucus, occasionally streaked with blood; or of a greenish fluid, mixed with small masses resembling the 132 SEMEIOLOGY OF INFANCY AND CHILDHOOD. curd of milk, are frequent in most of the inflammatory affections of the bowels. Profuse and frequent discharges of thin or frothy fluid, nearly co- lourless, and devoid of fetor, mark the occurrence of cholera infantum. A deepgreen colour of the stools, the discharges resembling chopped grass or spinage, is generally a symptom of serious disease of the sto- mach or intestines, and is a striking feature in gastro-malacia, and the more acute grades of gastro-intestinal inflammation. In chronic diarrhoea the stools are thin, dark brown, and often in- tolerably fetid. In cases of worms, and in certain cases of intestinal irritation from other causes, the discharges from the bowels consist occasionally of a slimy fluid of a whitish colour, resembling milk. Light brown or clay-coloured stools are, in general, the indication of hepatic disease, attended with a diminished secretion of bile. Worms are occasionally passed with the stools, during the latter period of infancy, and in childhood, without any symptoms having been present to indicate their existence. A diminution in the number of stools, when diarrhoea occurs as a symptom of the diseases of children, with a return to the ordinary healthy condition in the colour and consistence of the discharges, is a favourable symptom. The appearance of natural faeces in cases of dysentery, and of bile in the discharges in infantile cholera, is a favourable indication. Blood is occasionally observed in the discharges of children, in hy- persemia, irritation, and inflammation of the mucous membrane; it is generally mixed with mucus or with faecal matter, and never occurs in any great quantity. The passage from the bowels of the substance taken as food entirely unchanged, or but little altered, is an indication of excessive irrita- bility of the alimentary canal; it occurs occasionally in inflammations of the stomach and bowels, but more frequently in protracted cases of cholera infantum, and chronic diarrhoea. Constipation is not unfrequent in the early stages of infancy, and in many cases appears to be constitutional, and in others to depend upon the quality of the mother's milk. We have frequently known in a young infant several days to pass, and no evacuation by stool to take place without, apparently, any inconvenience resulting, but when, finally, the desire to discharge the contents of the bowels occurred, the violent straining, and the pain attendant upon the passage of dry, hardened masses of fasces, were particularly distressing to the little patient. Constipation should, therefore, never be overlooked, as it may be the means of inducing violent colic, invagination, or inflamma- tion of the intestines. Constipation often exists in the early period of many of the acute affections of infancy, particularly of the head and chest; it may arise, in some cases, from functional derangement or disease of the liver preventing the free secretion of bile. Constipation is, not unfre- quently, induced in infants and young children, by the imprudent use 01 opiates. r URINARY DISCHARGE — BONES. 133 In very young infants, the retention of the meconium occasionally gives rise to a deep comatose condition, terminating, if not speedily relieved, in asphyxia and death, while in other cases partial or general convulsions have been known to arise from this cause. 10—The Urinary Discharge. The condition of the urine, during infancy and childhood, affords but little important aid in the diagnosis of the seat or character of morbid action. In most of the acute febrile affections the urine is high-coloured and scanty, and its passage often attended with some degree of pain. It is often white in intestinal irritation from the pre- sence of worms, and in hydrocephalus. In irritation of the gastro-intestinal mucous membrane, it is fre- quently of a bright yellow or deep orange hue. Incontinence of urine is frequent in children at all ages. It may simply depend upon the extreme irritability which the mucous mem- brane of the bladder possesses during infancy; from an augmented se- cretion of serous urine, in consequence of a derangement of the renal function, or from neglect on the part of the child of the sensations in- cident to the natural call to urinate, in consequence of which, the com- mand of the will over the action of the bladder and its sphincter is lost. It occasionally results from irritations seated in the lower por- tion of the intestinal canal; and in some cases, from disease of the brain or spinal marrow. An excessive amount of limpid watery urine is often voided by in- fants and children, and is indicative of a disordered state of the di- gestive function from improper food; it often occurs at the period of weaning, and is occasionally attendant upon dentition. The increased flow of urine in children is said to be, occasionally, diabetic. When pain and difficulty are experienced in urinating, it is indica- tive of inflammation of the kidneys, neck of the bladder, or urethra; or of calculous concretions in the ureters, bladder, or urethra. It may originate, however, from irritations seated in the rectum, or of the di- gestive organs generally. In young children, scanty and painful urination occurs from disease of the kidneys, connected, most generally, with long-continued intes- tinal disease, or with some affection of the brain. In these cases, the urine is passed only in small quantities, and is usually high-coloured, and stains the linen yellow. Retention of urine is occasionally present during difficult dentition. In very young infants it is sometimes produced by some peculiarity of the mother's milk. We have known it, also, to be a symptom of worms in the rectum. Scanty urine occurring towards the decline of scarlatina, and other acute exanthemata, is in general connected with dropsical effusion within the abdomen or in the cellular tissue. 11— The Bones. A. premature, or very rapid development, in the longitudinal di- mension of the long bones, particularly, if, at the same time, there is not a correspondent but rather a deficient development in the dimen- 134 SEMEIOLOGY OF INFANCY AND CHILDHOOD. sions of the chest, very generally indicates a predisposition to tuber- cular disease of the lungs. A rapid increase of the osseous structure in length, is a very fre- quent occurrence towards the decline or immediately after fevers, especially the febrile exanthemata. With this direction of the nutri- tive process, the development of rachitis and tubercles, so generally consequent upon rapid growth, would seem to be connected. (Schill.) Curvatures of the long bones of the lower extremities are often the result of too early attempts to induce the child to walk; of a bending or imperfect fracture of the bones from violence; this occa- sionally occurs in the upper extremities, from imprudently lifting an infant by the arms. Curvature of the bones is also one of the symp- toms of rickets. Curvatures of the spinal column in young infants, are sometimes the result of placing them too early in the sitting posture; in children they may arise from debility of the spinal muscles, or disturbed equi- librium in their action, the result of improper positions of the body, too long continued, and of defective exercise. Curvature of the spine is, also, the effect of rickets, and of caries of the vertebras. Lengthening of one of the lower extremities, exists as a symptom of the second stage, and a shortening of the extremity, of the third stage of hip disease. Enlargement of the articular extremities of the long bones is com- mon in scrofula and rickets. Enlargements of the larger joints occur sometimes after the acute exanthemata, or upon the sudden repulsion of chronic eruptions. Excessive development of the skull, is a symptom of hypertrophy of the brain; it also takes place in chronic hydrocephalus, and apparently so in rickets. In idiocy there is commonly a very decided diminution in the development of the skull. A diminished development in the capacity of the chest, or a flatten- ing of the ribs at the sides, with undue projection of the sternum, is common in children predisposed to tubercular disease of the lungs. ON THE DISEASES OF CHILDREN. PART II. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. SECTION I. DISEASES OF THE DIGESTIVE ORGANS. CHAPTER I. DISEASES OF THE MOUTH. STOMATITIS.—INFLAMMATION OF THE MOUTH. 1.—Erythematic Stomatitis. Erythematic inflammation of the mucous membrane of the mouth is a common disease during infancy. The inflammation may be con- fined to the tongue, or to a portion of the parietes of the mouth; or it may be universally diffused over the entire cavity. It varies'in in- tensity in different cases—in some, being so slight as scarcely to at- tract the attention of the child's attendants, and disappearing promptly —while in others it assumes a considerable degree of severity, and causes intense suffering to the little patient for many days or weeks, and by extending to the oesophagus and stomach, or into the larynx and trachea, it may prove finally fatal. Simple erythematic inflammation of the mouth is characterized by increased heat and redness of the part or of the whole of the parietes of the mouth and surface of the tongue, accompanied with more or less dryness of the parts affected. The sensibility of the inflamed membrane is increased, and pain is experienced by the infant, when any part of the mouth is touched, and in the motions of the tongue and lips in the act of sucking. The first indications of the disease are, in general, the fretfulness and restlessness manifested by the infant; its suddenly quitting the nip- ple after sucking for a few moments—or, when fed by the hand, re- fusing its food, or crying when this is attempted to be forced upon it. When the inflammation extends over the whole surface of the mouth, it often spreads, also, to the lips, which tumefy, excoriate, and crack, and not unfrequently become affected with herpes. 138 DISEASES OF THE DIGESTIVE ORGANS. In very young infants, the disease is seldom attended with febrile reaction; but when it appears about the period of dentition, it is fre- quently accompanied by some degree of fever, and when of any du- ration, it is then often attended also by profuse ptyalism. Simple erythematic stomatitis may occur as an idiopathic affection, or it may be symptomatic of a diseased condition of the alimentary canal. In the first case it may be produced by exposure to cold, by too hot or stimulating food, by the violent exertions of the tongue and muscles of the mouth, in attempting to derive nourishment from an over-distended breast or from a too small or badly formed nipple, or, finally, it may result from the irritation of the mouth consequent upon dentition. In its simplest form, erythematic stomatitis is seldom a very violent or obstinate disease, and is very promptly relieved by simple emol- lient washes, as a solution of the pith of sassafras or of the inner bark of the slippery elm, in cold water. When marked by a greater de- gree of severity, it may be necessary to apply a leech or two at the angle of the jaws. In aggravated cases of the disease, we have de- rived advantage from washing the parts affected with a weak solu- tion of acetate of lead in wTater. (Three grains of the acetate of lead to one fluid ounce of water.) When the inflammation of the mouth is symptomatic of irritation or inflammation of the alimentary canal, it will, in general, yield to the operation of the remedies adapted for the removal of the latter. 2.—Erythematic Stomatitis with curd-like Exudation. A common result of erythematic stomatitis is the secretion of a white matter, which appears, usually, in the form of small points or patches, resembling minute portions of curd, adhering to the surface of the inflamed membrane; this is particularly the case in infants at the breast. It constitutes the muguet of the French writers, the thrush or children s sore mouth, of nurses; and the aphtha lactumina and aphthae infantiles of the older physicians. It is among the most common of the affections incident to the early stage of infancy, and many nurses are under the impression, that if it does not occur within the month, the infant is rendered liable at a later period to some other form of disease, which it might have escaped, had it gone through "the sore mouth," at the proper age. By most pathologists, the affection under consideration has been confounded with aphthae;—from the latter it differs, however, in many important particulars. In many cases it is preceded by no very striking symptoms. The infant is, however, generally peevish and fretful, and exhibits more or less pain and difficulty in sucking, and often abruptly quits its hold of the nipple, or cries when attempted to be applied to it, or to be fed with artificial food. Occasionally there is considerable languor, or even drowsiness, and not unfrequently, more or less disturbance of the sto- mach and bowels. If the mouth be now examined, the whole of its cavity will be found red, hot, and preternaturally dry. After a day or two, sometimes within a few hours, small white'points make their ap- ERYTHEMATIC STOMATITIS. 139 pearance at the extremity, or on the sides of the tongue, or at the angles and on the inner surface of the lips. These points have the appearance of minute fragments of curd adhering to the parts men- tioned, which latter are of a dark-red colour, hot and dry. In mild cases, the inflammation, in a short time, disappears; the par- ticles of white curdy matter become detached, and fall off, leaving the membrane beneath of a smooth and healthy appearance. Should the inflammation continue unabated, the points of curdy matter increase in number, and often extend over the whole surface of the tongue and mouth, or a number of the points unite together upon the tongue or inner surface of the lips and cheeks, in the form of patches, often of considerable thickness; these patches, sooner or later, become detached and fall off, and their place is quickly supplied by a new exudation; and this separation and renewal of the patches is re- peated so long as the inflammation continues. -In other instances, how- ever, the patches formed upon the tongue, and upon the inside of the lips and cheeks, coalesce, and the whole of these parts become covered with a whitish granulated crust, which often extends into the fauces, pharynx, and in some cases into the larynx. The general symptoms vary with the degree of intensity in the local disease. When the latter is slight, and of short duration, the child is fretful, or dull and peevish; he exhibits pain from the motions of the mouth in sucking, or in taking food, especially when this is warm or in the slightest degree stimulating. In general, the surface of the body is hot and dry, and the thirst is increased. In the more aggravated forms, there is often great restlessness, alter- nating with drowsiness, with disturbance of the stomach and bowels, and other symptoms dependent upon the affection of the alimentary canal, with which the inflammation of the mouth is very generally associated. The duration of the disease is various; in slight cases it terminates in a few days; in others, it may continue much longer, without pro- ducing any very severe or alarming symptoms. Excepting when com- plicated with inflammation of the alimentary canal, it is usually a trou- blesome, rather than a dangerous affection. In those cases in which large patches of exudation form upon the inside of the lips or cheeks, or upon the velum of the palate, the dis- ease, particularly in situations where a number of children are crowded together in ill-ventilated apartments—occasionally assumes a malig- nant character, and is then attended with very considerable danger. The patches of exudation acquire a dark colour—the breath becomes fetid—the submaxillary glands enlarge and become painful—and the face swollen, and of a dusky red. The lips and gums become tumid, and bleed upon the slightest touch—while a fetid sanious saliva flows constantly from the mouth—diarrhoea, also, often attends, the dis- charges being dark-coloured and highly offensive—the surface of the body becomes dry and hot, and the child sleepless and restless; finally, the patient sinks; death being occasionally preceded by a deep coma- tose condition. The usual causes of this form of stomatitis, are bad or improper food, a neglect of cleanliness, and confined and impure air. It is 140 DISEASES OF THE DIGESTIVE ORGANS. often produced by the bad quality of the mother's milk, or by feeding the child with food unadapted to the condition of its digestive or- gans; children prematurely weaned seldom escape an attack of it. It is very prevalent, also, in public institutions, where many infants are crowded together; especially in small, ill-ventilated rooms. By some writers it has been supposed to be communicated by con- tagion; we know of no facts, however, in support of such an opinion. Baron, Billard, Valleix, Trousseau, and Guersent, deny its conta- giousness excepting upon direct contact. Girelli states, that he has known healthy infants to become attacked by sucking from the same breast as those affected with the disease; and a similar statement is made by Marley. This fact may, however, be very readily explained by the deteriorated condition of the nurse's milk, without the necessity of admitting the communication of the disease by a contagious mat- ter, derived from an infected infant, and communicated by the nipple it has sucked. M. Guersent states that he has known the thrush to be communicated from the nursling to the breast of the mother. The true character of the disease appears not to be very generally understood. By the majority of medical writers, it has been con- founded, as we have already remarked, with aphthae,-in connexion with which it occasionally occurs. Breschet, Guersent, Veron, Lelnt, and Billard, have studied both diseases with great care, and it is evident, from the result of their observations, that, while aphthae are the result of follicular inflammation, the curd-like exudation, which takes place in the erythematic inflammation of the mouths of children, is the re- sult of an altered secretion from the inflamed mucous surface, in the form either of small white particles or flocculi, or, as in other diphthe- ritic inflammations, of large patches of a soft pseudo-membranous mat- ter, which Ldlut has attempted to show is analogous to, or identical with the false membrane of croup, while Billard terms it coagulated mucus, and Guyot, mucus rich in fibrine. Upon the separation of these morbid exudations, the membrane beneath is found to be smooth, and without solution of continuity; this fact we have tested in nume- rous examinations. According to Guersent, the morbid exudation is deposited beneath the epithelium, and its separation is consequent upon the rupture of the latter:—Plumbe is of a similar opinion. Guyot and Billard, however, never saw it in any case, excepting upon the surface of the epithelium, and this accords with our own observations. Recently, M. Gruby has attempted to show that thrush is invariably produced by the development upon the buccal mucous membrane, of a cryptogamic vegetable. According to the researches of this gentleman, the affection consists at first, of small, conical, whitish elevations, twenty-five millimetres in diameter, dispersed over the mucous membrane of the mouth. These elevations quickly augment in size, and extend rapidly over the adja- cent surface, until, finally, the whole of the mouth, fauces, and some- times the entire extent of the alimentary canal, appear to be covered with a pseudo-membranous layer, from two to three millimetres thick, and strongly adherent to the subjacent tissue. When a portion of this substance was examined under a microscope, M. Gruby found it to ERYTHEMATIC STOMATITIS. 141 be composed entirely of a collection of cryptogamic plants, the roots of which, of a cylindrical form, transparent, and about one-four hun- dred and eightieth part of a millimetre in diameter, arc implanted in the cellules of the epithelium. During their development, projections from these roots penetrate the entire series of cellules of which the epi- thelium is composed, to arrive at the free surface of the mucous mem- brane. According to M. Gruby, these cryptogamic plants have considera- ble analogy with the sporotrichium described by some botanists. Be- ing very fragile they become detached by the movements of the tongue and lips, and mixing with the food, are carried into the alimentary canal, a considerable portion of the mucous coat of which they subse- quently cover. Those children in whom this extension of the disease takes place to any great extent, fall into a state of marasmus, and soon die. M. Gruby, having never detected in the white matter of thrush, any thing else than the cryptogami just described, and the cellules of the epithelium,—there being, in no instance, any product of inflammation present,—considers himself authorized to conclude that the affection is nothing more nor Jess than a vegetation occurring upon the living mucous membrane. Views precisely similar to those of M. Gruby have been advanced by Dr. Berg, of Stockholm. Dr. Oesterlein has also submitted the matter of thrush to microsco- pic examination, and has been able to detect in it a vegetation similar to that described by the observers just named. This vegetation he has met with, however, only at the period of the fullest development of the disease, which latter he considers to be the product of an exu- dation resulting from an inflammatory condition of the mucous mem- brane; the production of the confervae being purely accidental. He attempted, repeatedly, to transplant them to other animal tissues or fluids, but without success. M. Bouchut states that he has had many opportunities of verifying the correctness of M. Gruby's observations. They are endorsed, also, by Berg, Robin, and Green. There is some dispute among medical writers as to how far this mor- bid exudation extends beyond the mouth and fauces. It is generally admitted that, in severe cases, it has been found in the oesophagus as far down as its cardiac orifice; but while some, including Billard and Valleix, have asserted that it has been observed throughout the whole tract of the alimentary canal, others, with Veron, maintain that it has, in no instance, been known to occur beyond the oesophagus—the curd- like crusts occasionally found in the stomach, being, in their opinion, conveyed thither from the mouth, by deglutition. Guyot, however, gives a case in which the disease was detected after death, throughout nearly the whole tract of the intestines. We have not had many op- portunities ourselves of examining after death the condition of the alimentary canal in infants affected with stomatitis with curd-like ex- udation ; but in the few we have examined, we were never able to trace the disease beyond the oesophagus:—a similar statement is made by both Dewees and Eberle. M. Aralleix maintains that the disease is 142 DISEASES OF THE DIGESTIVE ORGANS. almost invariably attended with softening of the gastric mucous mem- brane, often accompanied by redness and thickening. There can be little doubt that in the majority of the fatal cases, various morbid al- terations of the mucous membrane of the alimentary canal are present, but these alterations have evidently no necessary connexion with the disease of the mouth. The treatment will depend very much upon the extent of the local affection in each case, and of the morbid condition of the alimentary canal, with which it is accompanied. In the milder cases, the frequent application to the parts affected, of some emollient wash, as directed in simple erythematic inflammation, with proper attention to the food of the child, the daily use of the warm bath, and exposure to a dry and pure atmosphere of a proper temperature, will be sufficient to effect a cure. In the more severe and obstinate cases, Guersent advises a fourth part of chloride of soda to be added to the mucilaginous wash, and Billard a small quantity of alum; while Dr. Darling speaks in the highest terms of the solution of chlorate of soda. The application which we have found the simplest and most successful, is the borate of soda and white sugar—equal parts—rubbed together; a small por- tion of which, being occasionally sprinkled on the infant's tongue, soon becomes dissolved by the saliva, and applied to every part of the mouth; or the borate of soda may be mixed with honey, in the proportion of one part of the former to six or eight of the latter. By some practi- tioners a solution of borate of soda in water, with the addition of a fourth part of alcohol, sweetened with honey or sugar, is preferred. In many cases we have found the most decided good effects result from the weak solution of acetate of lead, noticed when speaking of simple erythematic stomatitis. Whatever washes are used, great care should be taken in their application, to avoid all harsh rubbing, or indeed, any degree of friction of the inflamed surface. When large patches of curdy exudation occur, these may be touched with a mixture of hydrochloric acid and honey, (one drachm of the acid to one ounce of honey,) and when'the exudation assumes a gan- grenous aspect, a wash of chloride of lime,1 or of a strong decoction of Peruvian bark with chloride of soda ;2 a mixture of creasote and mucilage,3 or of vinegar and alcohol,4 or a solution of nitrate of silver, (from two to four grains to the ounce of water,) may be employed, and repeated at shorter or longer intervals, according to circumstances. 1 R.— Mucilag. acacise, §j. s Creasot. gtt. iv. Calcis chlorin. gr. xv. ad xxx. Mucilag. G. acacise, gss. Syrup, cort. aurant gss.—M. (Angelot.) Aq. Camphors, gviij.—M. 2 Decoct, cinchonse, ^iij. * Aceti, zj. Syrup, cort. aurant. gj. Alcohol, giij. Sodae chlorin. ^j.—M. {Guersent.) Syrup, simpl. gj. Aquae, giij.—M. In even the mildest forms of the disease, acidity of the alimentary canal, with some degree of diarrhoea, are often present; for this occa- sional small doses of magnesia and rhubarb with ipecacuanha,1 will be found advantageous. In all the more severe cases, alterative doses of calomel, combined with magnesia or prepared chalk and ipecacuanha, FOLLICULAR STOMATITIS. 143 will be demanded;8 and in those in which the exudation in the mouth assumes a gangrenous aspect, quinia should be administered.3 When combined with disease of the alimentary canal, the latter is to be treated by its appropriate remedies. 1 Magnes. calcinat. ^j. 2 Calomel, gr. ij. ad iij. Rhei pulv. Qj. Magnes. calc. vel Cretse ppt. gr. xxxvj. Ipecacuanha; pulv. gr. j. ad "^ij. M. f. ch. No. iv. One to be given daily or Ipecacuanhae, gr. iij.—M. f. ch. No. oftener. xij. One to be given every two or three hours. 3 Aq. purse, ^iij. Sulph. quiniae, gr. viij. ad xij. Sulph. acid, dilut. gr. xv. ad xx. Syrup, simpl. gj.—M. A teaspoonful, every two or three hours. 3.—Follicular Stomatitis. APHTHiE. Follicular inflammation of the mouth is a frequent disease of infancy and childhood, and constitutes the affection ordinarily described as aphthae, by medical writers. It is more commonly observed about the period of dentition, than at an earlier age; and it is especially liable to occur in children in whom the lymphatic temperament predominates, or in whom haematosis is rendered imperfect, by improper or unnu- tritious food, a damp and cold, or an impure and stagnant atmosphere, exclusion from the light, and neglect of cleanliness. It is likewise a common occurrence in the course of most of the chronic affections of the intestinal canal. The disease usually commences by the appearance of a few small white specks on the inner surface of the lips and cheeks, and upon the sides and inferior surface of the tongue, and often over the greater part of the soft palate. These specks are slightly elevated, and usually surrounded by a red circle, more or less decided. They may be few in number, and irregularly dispersed over the angles and inner sur- face of the lips and cheeks; or they may occur in groups upon the lips, cheeks, and sides of the tongue; or they may cover every portion of the cavity of the mouth; extending, in some cases, into the oeso- phagus, and even throughout the alimentary canal; and in others pene- trating into the pharynx, and according to some writers, into the trachea also. The inflammation of the follicles will often continue, for some time, without making any further progress; or, as often happens, the disease may be arrested in its first stage and the mucous membrane of the mouth return to its natural condition. If, however, the inflammation continues, the specks enlarge, a whitish matter exudes from their centre, and ulceration taking place, a superficial ulcer is produced, with slightly elevated edges, and sur- rounded by a circle of inflammation. From these ulcers, there is often secreted a white curdy matter, adherent at first to their surfaces; but becoming subsequently detached, it is either swallowed, or ejected with the saliva of the infant. 144 DISEASES OF THE DIGESTIVE ORGANS. When the aphthous ulcerations are numerous, and in close contact, the curdy exudation spreads from one to the other, forming a layer, often of considerable thickness and extent. Occasionally, instead of a curdy excretion, there exudes from the ulcers a small portion of blood, which forms upon them a dark-coloured crust, that has not unfrequently been mistaken for a gangrenous slough. Upon the disappearance of the inflammation, the ulcerated follicles readily cicatrize without leaving any permanent scar. When the aphthous crusts, formed by the ulcerated follicles, be- come detached and fall off, they are often succeeded by others, which, in their turn, become also detached; and thus, in protracted cases, the crusts are detached and renewed, for several successive times; or only a portion of them are detached, while the general layer of curdy matter continues adherent for weeks. Follicular stomatitis is occasionally attended with scarcely any other than the local symptoms. The little patient is generally, however, fretful and peevish; his skin is dry, and its temperature increased; there is an augmentation of thirst; often some degree of diarrhoea; and an evident indication of pain and tenderness of the mouth, by the child, when sucking, suddenly leaving off and crying. Even when the disease of the mouth is more extensive, fever is seldom present, excepting towards its close, or when it occurs subsequent to the period of infancy; but even then, fever is absent in many cases. When the disease involves nearly the entire extent of the lining membrane of the mouth, the general symptoms are usually much more violent. There is then great restlessness; considerable pain is ex- perienced in the act of sucking; the infant seizes the nipple eagerly, but instantly relinquishes it and expresses its suffering by its cries. The mouth is dry and hot, but in the course of the disease there gene- rally occurs a profuse ptyalism, with painful intumescence of the salivary glands; the nipple of the nurse quickly experiences a sense of heat and irritation, and becomes excoriated and excessively tender. The child is troubled with frequent acid eructations, and repeated watery discharges from the bowels, of a green colour, and attended with severe griping. Vomiting is apt to occur from an early period of the disease, particularly upon anything being taken into the stomach. The surface of the body becomes pale; the countenance exhibits con- siderable peevishness or distress; emaciation quickly ensues, and is often extreme; the child is wakeful, and, occasionally, great restless- ness is alternated with dulness or some degree of stupor. In some cases the attack is ushered in by extreme drowsiness. As the disease advances, the discharges from the bowels increase in frequency, though diminished in quantity; the verge of the anus be- comes excoriated and inflamed; and in some instances we have known extensive erysipelatous inflammation of the nates to ensue. The abdo- men is generally swollen, and occasionally tympanitic; and there is more or less tenderness of the epigastrium. Gangrene of the mouth occurs in some cases; but, in general, the patient dies from exhaus- tion, or from inanition, in consequence of the entire suspension of the digestive functions of the stomach and bowels. FOLLICULAR STOMATITIS. 145 When the disease extends to the oesophagus, there is usually great difficulty of swallowing; and when propagated to the larynx, the cry of the infant becomes harsh and sibilant. Occasionally the ulcerations become gangrenous. This form of the disease is well described by Billard. The edges of the ulcers shrink, and assume a ragged, flabby appearance; a brownish-coloured slough forms in the centre, which, on separating, leaves a granulated surface, of a vermilion hue; or, in place of a slough, the ulcers become covered with a brown, creamy fluid, that exhales a very decided gangrenous odour. The parts surrounding the ulcers become tumid, soft and of a violet colour. From the half-open mouth of the child, is discharged a ropy—often fetid—saliva. The countenance becomes pale and puffy; the pulse is feeble; and the entire surface of the body, pallid, and de- ficient in sensibility. Frequent vomiting, profuse diarrhoea, and a tympanitic condition of the abdomen, generally occur; and occasion- ally hiccup, and frequent eructations; and the child finally dies without febrile reaction, or cerebral excitement. The termination of this form of the disease is very generally fatal. Follicular stomatitis most commonly occurs in infants of a relaxed habit, with predominance of the lymphatic system. It may be pro- duced in infants at the breast, whose nutrition is impaired from the want of an adequate supply of milk on the part of the nurse, or from the milk of the mother or nurse being deficient in its nutritious pro- perties, or otherwise of a bad quality. It more frequently occurs, however, in infants, who are attempted to be nourished upon other food than the milk of a healthy nurse; or who have been prematurely deprived of the breast. Improper or deteriorated food is, indeed, among its most common exciting causes. In infants at the breast, aphthre may result from their being at the same time imprudently fed on thick, farinaceous substances—pap; paste composed of flour boiled with milk; crackers soaked in milk—especially if these are over- sweetened with brown sugar or molasses. Children born before the full period, or of weakly women, are said by Dewees to be more liable to the disease than children born at the regular period, or of robust, healthy mothers. The infants of delicate females sometimes suffer considerably from this affection, by the mother's persisting in suckling them, even when assisted by what is sup- posed to be an adequate quantity of spoon victuals; while as soon as all attempts at suckling are abandoned, and the infant is confined en- tirely to appropriate and wholesome food, the disease disappears, and the general health rapidly improves. The tendency to the disease is increased by every thing that impairs the general health of the infant, and impedes haematosis; as a neglect of personal cleanliness, and to remove, daily, with a piece of soft linen and fresh water, the sordes which collect in the mouth; an im- pure and confined, or a cold, damp atmosphere; exclusion from the light; neglect of exercise; and, according to Underwood, by allowing the infant to sleep constantly with its face covered, and thus to breathe an air contaminated by its own respiration, and often by the emana- tions from its parent's or nurse's body. Follicular stomatitis is also 10 146 DISEASES OF THE DIGESTIVE ORGANS. a common occurrence in the course of nearly all the prolonged affec- tions of the alimentary canal, that occur during infancy and childhood. The severer forms of the disease are more liable to occur in low, damp situations. Van Sweiten, and subsequent writers, describe aphthae as prevailing to a considerable extent in various parts of Holland; and Hecher notices a severe form as very common in a part of Germany. The disease likewise prevails, in its more aggravated forms in many of the public institutions of Europe for the reception of infants. It is said, occasionally, to occur as an epidemic; and by many writers is supposed to be communicated by contagion. Frank declares this to be the case, when the matter is applied immediately to the mucous membrane of the mouth; and Girelli states, that in the foundling hos- pital of Brescia, he has known the disease to be communicated to healthy infants, who had been suckled at the same breast with one la- bouring under aphthae. Moss mentions the same fact, and Burns re- marks, that it would appear to be produced by sucking an excoriated nipple: this latter we have known to occur in numerous instances. There has existed not a little difference of opinion, as to the true character of aphthae. Many of the old writers describe them as a vesicular eruption. Among these are Aran Sweiten, Arnemann, Calli- sen, Plenck, Etmuller, and Pinel. Among the more recent writers who regard them as vesicular, are Ruyer, Bateman, Dendy, Girelli, and Evanson. Andral divides them into three species, the papular, vesicular, and pustular; Gardien describes them as tubercles; and Guersent, Billard, Guyot, Marley, and others, as an inflammation of the follicles of the mucous membrane of the mouth, presenting two stages; the first, consisting of small, white, miliary tumours; the se- cond, of superficial ulcers. This latter view of the disease, we are led, from our own observations, to believe to be the correct one. There can be little doubt, that the aphthous inflammation frequently extends into the pharynx, oesophagus, and even, in severe and protracted cases, through the entire extent of the alimentary canal. Numerous accurate observations attest this fact. The excoriation of the anus, which is usually adduced, to prove the extension of the disease to the lower portion of the intestinal tube^ affords, however, no evidence of such being the case: in the majority of the instances in which the ex- coriation occurs, it is evidently produced by the acid and irritating nature of the discharges; it is a frequent occurrence, also, in cases where no aphthae are present. Many writers speak of aphthae as never occurring again, after a first attack. This is unquestionably a mistake; and one which, in all pro- bability, has originated from confounding it with stomatitis with curd- like exudation, which is a disease seldom, if ever, met with, excepting in young infants:—follicular stomatitis we have known, in repeated instances, to recur more than once in the same individual. The treatment of the early stage, and milder forms of follicular sto- matitis, differs in nothing from that already recommended in simple erythematic inflammation of the mouth; namely, mild mucilaginous washes, frequently repeated. At the same time, it is all-important that the child should be placed in a pure, fresh, and dry atmosphere, FOLLICULAR STOMATITIS. 147 of a proper temperature. If at the breast, and any suspicion is enter- tained of the insufficiency or bad qualitities of the nutriment thence derived, the breast of a healthy nurse should be substituted for that of the mother; and if the infant be weaned, its food should consist, al- most exclusively, of barley or rice water, sweetened with loaf sugar. Care should be taken to preserve perfect cleanliness of the surface, and to promote the functions of the skin, by the daily use of the warm bath, followed by gentle friction. The thirst which generally attends the disease, should be allayed, by presenting to the child, frequently in the course of the day, a few spoonfuls of cold water, in which a small portion of gum acacia has been dissolved. This is peculiarly grateful and refreshing to the little patient; and by some it has been con- sidered, in conjunction with the daily washing of the mouth with cool, fresh water, as a very powerful means of preventing the occurrence of the disease. An occasional dose of magnesia, or of magnesia and rhu- barb, will, in general, be required, and will tend to remove, in part, the acid which generally abounds in the stomach and bowels. When the disease extends over a considerable portion of the mouth and is attended with great pain, as indicated by the uneasiness and cries of the child in the act of sucking, a few leeches should be applied to the angles of the jaw. Billard advises, in such cases, the addition of syrup of poppies to the mucilaginous washes, in the proportion of one or two drachms of the former, to two ounces of the mucilage;— we have derived much advantage from a weak solution in water, (three or four grains to the ounce,) of acetate of lead. Acetate of lead is re- commended by Stoll, as a local application, in cases of aphthae, on the authority of "certain English physicians," and by Latham, in what he terms Cachexia Aphthosa. Of the perfect safety with which it may be employed, in this manner, and of its good effects in allaying the pain and inflammation, our own experience has fully satisfied us. In cases attended with considerable stupor, according to Girelli, a blis- ter to the back of the neck, has been found beneficial. After ulcera- tion has occurred, a good—probably the best—local application, is the borate of soda and sugar, applied in the form of a powder, as directed for stomatitis with curd-like exudation. When the aphthae remain stationary, or become confluent, the addi- tion of a few drops of sulphuric or hydrochloric acid to the mucilagi- nous wash, will be often beneficial, or the mouth may be washed with the chloride of soda. Eberle recommends, as a wash, a solution of nitrate of silver, one grain to an ounce of water; and Lillard advises the ulcers to be touched with a piece of alum. We have seen the most ' decided good effects in obstinate cases, from the use of a weak solution of the sulphate of copper as a wash. When the ulcerations assume a gangrenous character, we should en- deavour to arrest the progress of the gangrene, by the application of the chloride of soda, or of creasote, by the internal use of quinia, and by a generous diet. Billard directs the application of a drop or two of sulphuric or hydrochloric acid, by means of a capillary tube, to the gangrenous ulcerations; and afterwards to touch the remaining gangrenous parts with a pencil of nitrate of silver, sharpened to a point. 148 DISEASES OF THE DIGESTIVE ORGANS. When the disease is attended with frequent watery discharges, and griping pains of the abdomen, it has been recommended by some of the German writers, to administer, internally, a solution of borate of soda. Pitshaft (Hufeland's Journal) declares, that in severe cases of aphthae, one of our most effectual remedies is the borate of soda, (two to four grains,) combined with the carbonate of magnesia, (five to six grains,) repeated two or three times in the twenty-four hours. We are in the habit of employing, in these cases, a combination of acetate of lead, calomel, ipecacuanha, and extract of hyoscyamus.1 Under the use of this combination, the irritation of the bowels is very often quickly diminished, the griping stools are suspended, and the general symptoms of the case improved. 1 Acetat. plumbi, gr. vj. ad xij. Calomel, gr. iij. Ipecacuanhas pulv. gr. ij. Ext. Hyoscyami, gr. iv. ad vj. M. f. Chart. No. xij. One to be given every three or four hours according to circumstances. When inflammation of the bowels is present, leeches to the epigas- trium, warm, emollient fomentations to the abdomen, and the other remedies applicable to such inflammation, are to be resorted to, in conjunction with the local treatment already recommended. Care should be taken throughout the disease to keep the parts about the anus perfectly clean. The diaper should be removed im- mediately after every stool, and the nates and orifice of the anus carefully washed with an infusion of the bark of slippery elm; and after being well dried, the parts which appear red and irritated may be smeared with a little perfectly fresh lard. When the irritation is considerable, the occasional use of a wash of a weak solution of ace- tate of lead, will be found advantageous. In cases attended with evident prostration of strength, without any acute disease of the alimentary canal, some light tonic, as the cold infusion of cinchona, or the sulphate of quinia, may be administered. In prolonged cases of aphthous ulceration, the use of iodine, and other alteratives, with change of air, and a well-regulated diet, will, in many instances, by restoring the nutrition of the system to a healthy condition, effect a cure. 4.—Ulcerative Stomatitis. Besides the aphthous ulcerations just described, the mouths of children are liable to be the seat of ulcers, resulting from acute phlegmonous inflammation. These may occur upon any part of the lining membrane of the mouth, but usually on the sides of the frae- num, along the inferior margin and edges of the tongue, on the gums, the inner surface of the cheeks, and the palatine arch. They are seldom seen upon the upper surface of the tongue. The disease usually commences with some degree of febrile excite- ment, indicated by increased heat and dryness of the surface, aug- mented thirst, lassitude, and restlessness. The infant becomes un- usually fretful—lets go the nipple when it has commenced sucking, and indicates the painful state of its mouth by its cries. On examining ULCERATIVE STOMATITIS. 149 the mouth, one or more small, inflamed, and slightly elevated points are perceived; the apex, or central portion of these, in the course of a day or two—often within a much shorter period—becomes softened, and of a yellowish hue, and, finally, a small ulcer is formed, at first superficial, but gradually becoming more deeply excavated, and often exhibiting an inflamed and elevated margin. The ulcerated surface is generally covered with an ash-coloured or yellowish matter, but it is occasionally bare, and readily bleeds. When the ulcers occur upon the upper surface of the tongue, they are in most cases superfi- cial, having the appearance, rather, of slight excoriations. After ulceration has taken place, there occurs, in general, a pro- fuse ptyalism, with a subsidence of the febrile excitement. The bowels are ordinarily costive at first, but become loose and often purged in the course of the disease. In some cases, but one or two ulcerations of no great extent, are present, which, after a short time, fill up with granulations, and rapidly cicatrize; in other cases, however, the ulcers are more numerous; sometimes thickly studding the inside of the cheeks, the gums, the arch of the palate, and both sides of the base of the tongue. In other cases, again, one or two ulcers will occur, which slowly extend in size and depth, and exhibit no disposition to heal; the little patient, at the same time, wasting away with a species of hectic fever, with exacerbations night and morning. Denis describes a species of ulceration, caused by a softening of the mucous membrane of the palate, and which invariably occupies its centre, either on the median line, or on the outside of this line. The mucous membrane is changed into a kind of pulp, of a red, inclining to a fawn colour. If the pulpy matter be removed, the edges of the ulceration are found to be perpendicular, with bone at the bottom of the ulcer, apparently in a healthy condition. This affection we have never observed. Ulcerative stomatitis frequently occurs during dentition, and is a common disease in children labouring under a disordered state of the digestive organs, with a costive or irregular state of the bowels, vari- able appetite, offensive breath, inertness of disposition, a pale puffy complexion, a hard tumid abdomen. "It may also occur in the course of other acute and chronic dis- eases, as pneumonia, eruptive fevers, &c, which entail constitutional injury. "It is endemic in certain wards of the Hopital des Enfans Trouves, according to M. Taupin, who also believes it to be contagious—that is, to be communicable by using the same spoon for feeding, &c. And occasionally, also, it would appear to prevail as an epidemic." (Churchill, Diseases of Infants and Children.) The treatment differs but little from that directed for aphthous ulceration. When unattended with serious derangement of the di- gestive organs, simple mucilaginous washes for the mouth, and when the bowels are confined or irregular, a small dose of calomel, followed, in the course of a few hours, by a dose of castor oil, with the tepid bath daily, and a plain, unirritating diet, will, in general, promptly 150 DISEASES OF THE DIGESTIVE ORGANS. effect a cure. If, however, the ulcers are tardy in healing, they may be washed with a solution of borax in water (15 grains to the ounce;) or with the chloride of lime, Or a weak solution of nitrate of silver (one grain to the ounce;) or of sulphate of copper (5 grains to the ounce.) According to Dr. Dewees, the following wash has never failed to quickly arrest the ulceration.1 1 R.— Sulph. Cupri, gr. x. Pulv. Cinchonas, r,Y\. " G. Acacias, 3J. Mellis, gij. Aq. puras, ^iij.—M. With this wash the ulcers are to be touched twice a day, with the point of a camel's hair pencil. M. Bonneau, physician to the Children's Hospital at Paris, re- commends the use of the chloride of lime, very dry and perfectly pulverized. The moistened finger charged with this powder is to be rubbed on the diseased parts. If necessary this operation should be repeated twice a day. It determines, he remarks, the detachment of the concretions which cover the ulcers, modifies their surface, and facili- tates their cicatrization. Immediately after the application of the chlo- ride, a mucilaginous fluid should be injected into the mouth, the head of the patient being tilted forward to prevent his swallowing the reme- dy. M. Bouchut prefers mixing the chloride of lime with honey, 45 grains of the latter to 6 drachms of the latter, and applying it by means of a camel's hair pencil. Dr. F. W. Mackenzie of London, in cases of ulcerative stomatitis, gives the preference to the following method of treatment. It con- sists in removing, in the first place, any apparent cause of irritation, such as a decayed tooth, should it exist, and in applying daily, the di- lute nitric acid of the pharmacopoeia, to the whole of the ulcerated sur- faces, by means of a sponge or camel's hair pencil, whilst, at the same time, the sesquicarbonate of ammonia is given in full doses, combined with citrate of iron. When the tongue is coated, and the alvine dis- charges are unhealthy, it is necessary to premise an emetic of ipeca- cuanha and squills, as well as a purgative of calomel and rhubarb. The patient should be well supported by a nutritious diet, and an adequate allowance of malt liquor or wine. The application of the dilute nitric acid, according to Dr. Mackenzie, has a remarkable influence in improving the character of the ulcera- tion and arresting its progress. Its usual sloughy, dirty, yellowish appearance, is soon changed into a florid, healthy, granulating surface, and this result would appear to depend upon the stimulating properties of the remedy being proportionate to the exhausted vital powers of the ulcerated tissues. When accompanied with extensive derangement of the alimentary canal, the proper remedies adapted to the removal of the latter will be demanded. In many cases, indeed, the ulcerations of the mouth will be found to resist every local application, until the digestive organs are restored to a healthy condition, and the nutrition of the system generally is improved. 5.—Gengivitis.—Inflammation of the Gums. The gums, from the period when dentition commences, until the com- GENGIVITIS. 151 plction of the first set of teeth, are liable to become inflamed, indepen- dently of the residue of the buccal cavity. In some cases the inflam- mation is but slight, and of short duration; but in others, particularly when it occurs in children whose general health has become impaired in consequence of a deranged state of the digestive organs, the inflam- mation is often severe, and productive of extensive ulceration, by which the alveola and teeth are frequently entirely destroyed. This disease has very commonly been confounded with scurvy of the gums. The gums become of a deep red or livid colour, swelled and painful; the tender state of the gums rendering mastication difficult, and often causing even spoon victuals to be refused. The child is, in general, very languid, with a hot and dry skin, a small and quick pulse, im- paired appetite, and considerable thirst. The tongue is usually covered with a thick yellowish fur. The patient's sleep is seldom much dis- turbed, and in some cases there is increased somnolency. When the inflammation occurs, as it frequently does, previously to the protrusion of the molar teeth, a small ulcer is liable to form upon the surface of the gum, immediately over the teeth about to protrude, and, quickly extending, often lays bare the alveola, and causes the destruction of the teeth. In other cases the ulceration takes place at the edge of the gum and extends rapidly downwards. In every case in which the ulceration is allowed to go on, the teeth become loose, black and carious, and are often reduced to a soft, pulpy state. M. Taupin, in his memoir on ulcerative stomatitis, describes the gums as becoming, when the seat of inflammation, first swollen, puffy, red, and full of blood, and then covered by a soft grayish layer. From the gums the inflammation extends to the inner surface of the lips and cheek, which become, here and there, covered with an exudation simi- lar to that upon the gum, beneath which the mucous membrane is ulcerated. The ulcerations are roundish in the mouth and longitudinal upon the gums and on the lips. If the disease is prolonged, the sub- mucous tissue becomes hardened at the seat of the ulcerations, and remains so for several days after cicatrization. When ulceration takes place, there is always a copious flow of fetid saliva, the breath becomes extremely offensive, and the counte- nance of the child assumes a pale, sallow hue; a bloody fluid oozes from the gums upon the least pressure, and often a very profuse diarrhoea ensues. This disease is very often produced by too much or improper food, particularly that which is of too stimulating a nature; and it is, very generally, attended with more or less—often with very extensive— derangement of the digestive organs. In its early stage, the proper remedies are, mild emollient washes to the gums, with, twice or thrice a day, a wash of a solution of ace- tate of lead, (five grains to an ounce of water,) applied by means of a soft sponge, or dossil of lint. If the inflammation is not promptly re- duced by these means, a few leeches should bo applied to the angles of the jaw, or to the gums themselves. Some writers advise the gums to be freelv scarified, and in many instances, when well timed, we have seen advantage to result from this procedure. The bowels should be freely opened by the administration of a few 152 DISEASES OF THE DIGESTIVE ORGANS. grains of calomel, combined with magnesia, and followed, after a few hours, by a dose of castor oil, or sulphas magnesiae; the tepid bath should be administered daily, and the child put upon a diet composed entirely of milk and farinaceous substances. When ulceration has taken place, and the inflammation of the gums is diminished, some light astringent wash will be beneficial; an infu- sion of oak bark, with alum,1 we have found peculiarly advantageous; the chloride of lime will, also, in many cases, speedily arrest the ulce- ration ; or, we may employ, as a wash, diluted hydrochloric acid.2 We have often found a solution of the sulphate of copper to succeed, how- ever, when other topical applications have failed. 1 R.—Corticis Querci, gj. 2 R.—Acid. Hydrochlor. gss. ad :jj. Aquas, Oss. Mellis, Boil to a pound and strain, then add Aquas Rosas, aa ^ j.—M. Sulph. Alumin. Qj. To be applied three or four times a day. To be applied to the ulcerated parts by means of a soft sponge or dossil of lint, several times a day. The child should be exposed to a fresh, pure air, and be supplied with a nourishing, easily digested, and perfectly unirritating diet. When the ulceration of the gums is very extensive, and the strength of the child is evidently impaired, the cold infusion of bark, or the sulphate of quinia may be administered, and will often very materially accelerate the healing of the gums. It is important that the teeth which have become destroyed by the disease be early removed. The disordered state of the alimentary canal will demand, of course, its appropriate remedies. 6.—Gangrene of the Mouth. (CANCRUM ORIS—GANGRJ3NOPSIS—CANKER OF THE MOUTH—WATER CANKER.) Gangrene of the mouth is a disease much less prevalent in this country, than it would appear to be in many parts of Europe; it, nevertheless, does frequently occur, and has, in more than one of our public institutions for the reception of infants, prevailed endemically. It may ensue in either of the forms of stomatitis already noticed; and, occasionally, in the follicular form, it becomes one of the most unmanageable and fatal of its terminations. It is, however, in cases of inflamed gums, occurring in children of lax and debilitated habits, of a strongly marked lymphatic tempera- ment, or the energies of whose organic functions have been impaired by previous disease, that gangrene of the mouth most frequently takes place. The patient is, in general, affected with great languor and listless- ness. He is indisposed to engage in play, or even to move about; is peevish and discontented, and unable to sleep; has no appetite for food, but usually his thirst is increased. The countenance becomes pale and dejected, and a peculiar puckering of the cheeks, about the corners of the mouth, is often observed. There is, in many cases, considerable emaciation, with nocturnal sweats. GANGRENE OF THE MOUTH. 153 In the course of one or two weeks, the patient begins to complain of sharp pains in his mouth and gums; his breath becomes more or less fetid, and there is an increased discharge of saliva. A sense of itching or pricking, and heat is experienced in the gums, which acquire a dark red or leaden hue, become swollen, and spongy, and bleed upon the slightest touch. The flow of saliva becomes more profuse, accom- panied often with a slight discharge of dark-coloured blood, and a tu- mid and painful condition of the salivary glands. The odour of the breath, and the appearance of the gums, at this stage of the disease, bear so strong a resemblance to those of a case of mercurial ptyalism, that we have known the disease to be mistaken for such by physicians of skill and experience. If the disease is not checked, the edges of the gums, most generally those of the inferior jaw, separate from the necks of the teeth, and present a ragged, flabby, and livid aspect. The teeth become loose, and often fall out of their sockets; or, if they remain, become covered with a thick coating of a dirty white or ash colour. Fever now generally sets in, at first towards evening, and attended often by an increase of the nocturnal sweats. The bowels are also often affected with diarrhoea. MM. Rilliet and Barthez state that, in the cases observed by them, the skin was always rather dry than hu- mid; a similar remark is made by MM. Baron and Destrees. The disease may continue in the state just described for many weeks or even months. Usually, however, in the course of a few days, a number of ash-coloured vesicles appear upon the gums, which rapidly enlarge in size, coalesce, and finally rupture; the denuded gum pre- senting a black and gangrenous appearance. When the dead portions of the gum separate, the ulcer which ensues assumes immediately a gangrenous appearance, and very rapidly the entire gum becomes de- stroyed, and the whole of the alveola, and sometimes the greater part of the inferior maxillary bone are laid bare;—the alveola are, generally, carious; portions of which, with the teeth, are separated and thrown off. From the gums, the gangrene, sooner or later, extends to the lips and cheeks, which become more and more swollen, as the disease in- creases in extent. At this stage, and sometimes much earlier, a difficulty is experienced in moving the lower jaw, in consequence of which, the mouth becomes occasionally firmly closed. This, Reimaun has erroneously considered to result from an actual tetanic affection; it is, evidently, the mere effect of the intumescence of the soft parts, and the pain which is con- sequent upon any effort to move the jaw. In the course of a few days, should the little patient not sink at an earlier period, which is generally the case, the whole of the soft parts surrounding the mouth, Avill become involved in the disease, assuming a dark livid colour, and discharging a putrid sanies, of a most offen- sive odour. The fever, which now often augments in intensity, presents a ner- vous or hectic character, and the child dies upon the eighth, or, at farthest, on the fourteenth day from the commencement of the gan- grene, his body presenting all the indications of a general colliquation. 154 DISEASES OF THE DIGESTIVE ORGANS. The disease just described is evidently a gangrene of the gums, extending thence to the surrounding soft parts, induced by acute in- flammation, occurring in children in whom the organic energy has been reduced, either by bad or deficient food, long-continued exposure to an impure and stagnant, or to a damp and chilly atmosphere, or by previously existing disease, particularly of the digestive organs. It is this form which, according to Richter, prevails endemically in the asylums and hospitals for children, and in low, damp situations bor- dering upon the sea. There is, however, another form of gangrene of the mouth, of less frequent occurrence than the former, and differing from it in many important particulars. It is not preceded by inflammation of the gums, but the disease, which commences in the soft parts surrounding the mouth, often at one of the angles of the lips, generally makes its appearance, as it were, abruptly: without, at least, any previous symptom indicative of its oc- currence. A hard, indolent tumour, about the size of an almond, is commonly first observed in some part of the lips or cheeks; the tumour is deeply seated, and accompanied by a slight degree of redness of the skin by which it is covered. Upon examining the mouth, nothing unusual is discoverable. For a few days, the tumour gradually aug- ments in size, and the skin becomes of a deeper red; the internal sur- face of the cheek, over the tumour, assumes a gangrenous appearance, and an extremely offensive odour is exhaled from the mouth. Exacer- bations of fever generally occur towards evening; the appetite and disposition of the child are seldom, however, much affected. In the progress of the disease, the external circumscribed redness of the lip or cheek soon becomes paler, livid, then of a grayish hue, and surrounded by a red areola, which rapidly extends. In a few hours, frequently, the gray sphacelated portion becomes completely black. Upon examining the mouth, it will now be found that in the imme- diate neighbourhood of that portion of the lip or cheek at which the disease commenced, the gums are in a state of gangrene; the teeth here become loose, covered with an ash-coloured mucus, and finally drop out. The affection of the gums is, in this form of the disease, secondary to that of the cheek or lip, occurring only after this has made consi- derable progress. Necrosis of the maxillary bone is seldom observed; death usually taking place from a general sinking of the powers of life, previously to any very extensive destruction of the soft parts. A much milder form of the disease is described by Richter, many cases of which have fallen under our notice. In this, circumscribed spots of gangrene, of a dark-brown colour, surrounded by a red mar- gin, and of various sizes, occur suddenly upon the lips, near to their angles, and upon the cheeks; the general system of the patient re- maining apparently unaffected. In some cases, the gangrenous spots are preceded, for one or two days, by a slight redness of the skin. The gangrene is always superficial, involving little more than the skin, and there is but little loss of substance when the sloughs separate; a GANGRENE OF THE MOUTH. 155 suppuration of a healthy character quickly ensues, followed by granu- lations and cicatrization. Occasionally, when the gangrene occurs at the commissure of the lips, it affects the entire thickness of the latter; the slight loss of substance which ensues is, however, speedily filled up by granulations, and little or no deformity ensues. These mild cases are usually observed subsequently to attacks of the acute exanthemata; according to Richter, Baron, Romberg, and others, more especially when these have run an irregular course, or have by any means been suddenly arrested during their evolution. We have seen it more frequently, however, in children who had laboured for some time under symptoms of irregular remittent fever, connected with chronic gastro-intestinal disease. In a third form of gangrene of the mouth, and the one which, next to that consequent upon acute gengivitis, we have the most frequently met with in private practice, the gangrene commences upon the centre of the internal surface of one of the cheeks. Its occurrence is, in general, like the last described variety, sudden. The patient becomes, all at once, unusually restless and peevish, and affected with slight accessions of fever. If closely observed, some intumescence of one side of the face will be detected. The disease is occasionally, however, ushered in by nausea, vomiting, or diarrhoea. One of the cheeks becomes quickly swollen, hard, dark red, and shining. As the external swelling augments in size, and the skin be- comes greatly distended, the centre of the tumour often assumes a perfectly white and shining appearance; the eyelids at the same time become oedematous, an increased flow of saliva takes place, and the breath acquires a very peculiar fetid odour. If the mouth be now examined, one or more grayish vesicles will be perceived upon the internal surface of the affected cheek, which, after some days, rupture, and form an ulcer of a dirty gray colour, of a rounded form, with red, distinctly circumscribed edges; and at the same time, a slight excoriation or fracture of the skin often occurs at the angle of the mouth on the affected side. The true character of the disease is not always immediately detected, and is occasionally entirely overlooked by those who are not familiar with it, the whole attention being directed.to the external swelling. There is, in fact, some difficulty in making an accurate examination of the inner surface of the cheek, from the inability the little patient often experiences in opening his mouth to a sufficient extent, after the external swelling has acquired any size. As the gangrenous ulceration within becomes deeper and more ex- tended, a livid spot, surrounded by a red areola, makes its appearance on the external surface, at the spot where the tumefaction is the great- est; this soon acquires a darker hue, and, augmenting in size, involves, in the course of from four to eight weeks, nearly the whole of the soft parts on that side of the face. Portions of it are soft, and of a gray or greenish hue, and present all the characteristics of humid gangrene, while other portions are completely mummified, hard, and of a deep black colour. On examination, the gums will now be found to be in a gangrenous con- 156 DISEASES OF THE DIGESTIVE ORGANS. dition, immediately opposite to where the gangrene commenced on the cheek, while in every other part they are apparently sound:—the af- fection of the gums being in this, as in the last variety, consequent upon the preceding mortification of the cheek; whereas, in the first variety, it is in the gums that the gangrene commences, the jaw being frequently destroyed previously to the cheek becoming affected. In the progress of the disease, the functions of the alimentary canal become deranged, the appetite is destroyed, and the thirst augmented; nausea and vomiting often occur; the diarrhoea becomes more copious, the discharges being thin, dark-coloured, and offensive; the skin of the body is dry and hot, while that of the extremities is colder than natu- ral; the abdomen becomes tympanitic; the patient falls finally into a soporose condition, and death speedily ensues. In our own practice, this variety of gangrene of the mouth has most usually occurred in children who had for some time been affected with disease of the gastro-intestinal mucous membrane, attended with fe- brile symptoms of a remittent character. In no one of the cases, how- ever, we have seen, did the gangrene involve the whole thickness of the cheek. In every instance, its progress was arrested before it had extended beyond the mucous membrane lining the cheek in which it commenced, and a small extent of the gums in the immediate neigh- bourhood. It is probable, however, that the cases we have met with, were, even in their earlier stages, of a much milder character than those described by the European writers. Gangrene of the mouth is an affection almost exclusively confined to the period of infancy. It may occur at any time between the' second and tenth years, but is most commonly observed between the second and fourth. By Rilliet and Barthez it was observed most fre- quently in children between the age of three and five years. Few, if any, cases have been met with in infants during the period of lacta- tion. The children in whom the disease most usually occurs, are those of delicate habits, of a lymphatic temperament, with soft and flaccid mus- cles and pale skin, and in whom the functions of assimilation and nu- trition have been depressed from a variety of morbific influences. It is hence seldom met with excepting among the children of the poor, who are imperfectly fed, or upon food of an improper quality; those who are exposed to the influence of a damp and chilly, or impure and confined atmosphere; in whom personal cleanliness is neglected, or who have become reduced by some severe acute affection, particularly of the skin, or have suffered from chronic disease of the stomach and bowels. It is of frequent occurrence in public institutions, where a number of children are crowded together in small, low, or illy ventilated apart- ments. Hence, in the asylums and hospitals destined for the reception of children, it frequently occurs as an endemic. In the Children's Asylum of Philadelphia, there was, at one period, among the two hun- dred and forty inmates of the institution, seventy affected with gan- grene of the mouth.—(B. H. Coates.) As the children of the poorer classes in Europe, who live upon the GANGRENE OF THE MOUTH. 157 borders of the sea, are exposed at one and the same time to most of the predisposing causes of gangrene of the mouth, it is, in consequence, an affection extremely prevalent in Holland, Sweden, Denmark, Nor- way, and in many parts of England, Ireland, and Scotland. The influence of long-continued exposure to a damp climate, and the constant use of unwholesome food, in the production of the disease, are sufficiently established by the report of the physicians attached to the French army which occupied Spain, they having to treat, fre- quently, a gangrenous inflammation of the mouth which occurred among the soldiers, and which received from the Spaniards the name of feg ar, or fegarite.—(Richter.) The disease is mentioned by more than one writer as having pre- vailed epidemically in the Netherlands, as a consequence of gastric fevers. In the majority of instances, it is no doubt intimately con- nected with gastro-intestinal disease. The causes which have been enumerated evidently predispose to the disease, by disturbing the healthy condition of the stomach and the other organs appropriated to diges- tion and assimilation, and to nutrition generally. In all of Poupail's cases, seventy-two, the disease followed an at- tack of intermittent or remittent fever; in nine of the cases reported by Dr. Jackson, formerly of Northumberland, it occurred in the course of, or subsequent to, an attack of remittent or bilious fever. Dr. Mar- shall Hall states that, in all the cases he has seen, the disease suc- ceeded to disorders of the digestive organs, typhus fever, or some in- flammatory affection. In the observations of Rilliet and Barthez, it , was in the lungs and intestines that disease was most frequently de- tected. The affections of the intestines were entero-colitis, either acute or chronic, or softening. In all the cases which have fallen under our notice, the affection of the mouth was preceded by more or less de- cided indications of gastro-intestinal disease; in the majority, the chil- dren had suffered for some time from the infantile remittent and inter- mittent fevers. Another fruitful cause of the disease would seem to be the acute ex- anthemata; an imperfect crisis, or sudden repulsion of the cutaneous eruption, appearing to favour, in an especial manner, the development of gangrene of the mouth. Dr. Willan notices its occurrence in scar- latina,^ d Dr. Marshall Hall, after variola, rubeola, and scarlatina. Dr. Cuming states that, in two cases which fell under his observation, the disease occurred as a sequela of measles; in another, in the ad- vanced sta<*e of dysentery; in a fourth, upon the termination of in- fantile remittent fever; and adds, that it is more generally observed at the close of the exanthemata, than of any other of the acute affec- • tions to which children are liable. Rilliet and Barthez state, that they have most frequently met with gangrene of the mouth in the course of an attack of measles; occasionally they have seen it in scarlatina, small-p«>\*, and pneumonia, and have also known it to follow intestinal affections, hooping-cough, scrofula, &c. In Dr. Duncan's cases, the disease appears to have most generally occurred in children labouring under some affection of the intestinal canal; in several of the cases, however, it followed an attack of measles. Of the six cases observed 158 DISEASES OF THE DIGESTIVE ORGANS. by Dr. West, of London, two succeeded to typhus fever, two to mea- sles, one occurred in a child whose health had been completely broken down by ague, and another in a tuberculous child, who had been af- fected for many weeks with ulcerative stomatitis of a severe form. By some of the writers on gangrene of the mouth, its propagation by contagion is asserted; but of this no well-authenticated instances have been recorded. In every case, however, as a prudent precau- tion, it will be proper to separate as much as possible the individuals affected from those in health, as well as from each other. A number of patients labouring under the disease, congregated in the same room cannot fail, even with every precaution in regard to cleanliness and ventilation, to render it more unmanageable than when the patients are placed in separate and distinct apartments. Few examinations of the lesions presented by the internal organs, in the children who have died of gangrene of the mouth, are upon re- cord; and of those which are reported, the majority appear to have been performed with very little accuracy, so that of the pathological anatomy of the disease we know but little. In the examinations we have made, which, however, have been very limited—for we have had the good fortune to lose but few of our pa- tients—the principal organs in which morbid appearances were pre- sent, were the stomach, intestines, and liver. In all the cases, the two former presented the indications of inflammation, of a more or less chronic character; the latter appeared to be affected with hyperaemia, rather than with any structural change. In the majority of cases the mesenteric glands were greatly enlarged. In the cases observed by Rilliet and Barthez, the internal organs were invariably found to be affected with indications of disease, which had existed anterior to that of the mouth, or was concomitant with or consecutive to it. The most frequent were acute affections of the lungs—entero-colitis, acute or chronic, and softening of the intestines; more rarely tubercles, which, however, were very abundant in one case. In a very few cases, gangrene of the pharynx and lungs was present, and in a still fewer number, pleurisy, pneumo-thorax, peri- tonitis, pharyngitis, and nephritis. MM. Baudeloque, Bouchut, and Taupin, notice the common occurrence of pneumonia as a complication of gangrene of the mouth. In the examinations made at the Children's Asylum, at Philadel- phia, between June 1st, 1827, and January 1st, 1880, the morbid ap- pearances exhibited, were enlargement and hardening of the mesen- teric glands; a scrofulous condition of the glands of the neck; and, in every instance, tubercles of the lungs. In general, the whole sub- stance of the lungs was thickly studded with tubercles, in various stages of development. The condition of the gastro-intestinal mucous mem- brane is not recorded. Richter remarks, that every physician who has had an opportunity of treating gangrene of the mouth in children, agrees, that if it be not entirely beyond the control of remedial agents, it speedily produces, in at least the majority of cases, the death of the patient; while Ril- liet and Barthez declare that death is the ordinary termination of the GANGRENE OF THE MOUTH. 159 disease. It is certainly true, that when the disease occurs in illy con- structed and crowded asylums for children, or in any situation in which the patients remain constantly exposed to a confined and impure or to a damp or chilly atmosphere, or when it occurs in children greatly ex- hausted by previous illness, the disease is one very generally fatal. When, too, its real character is misunderstood; when it is overlooked in its first stages, or treated by inert or improper remedies, death can very seldom be prevented. We have not found the disease, in any case in which we have been enabled to treat it in its early stages, so difficult to cure, however, as most of the European writers describe it to be. We have, indeed, seldom failed in arresting, very speedily, the progress of the gangrene. This is also the experience of Dr. B. H. Coates, who had the charge of the Children's Asylum of Philadelphia, previously to the year 1828, and of his successor in that institution; where, although the disease had frequently prevailed epidemically, it has been productive of a very small mortality. With a judicious treatment, early commenced, gan- grene of the mouth would appear to be even more manageable than many of the other severe affections of childhood. The period when the treatment is commenced, is, however, all-im- portant to insure its success. This, perhaps, more than almost any other circumstance, will determine, in the majority of cases, the greater or less mortality of the disease. When the physician has been enabled to detect it at the period of its development, he will, very generally, be able to arrest its further progress, and to save the life of his patient. It is remarked by many writers, that when the gangrene commences by a tumour or livid spot upon the cheek, it is very generally under the control of medicine. We have not, however, found the other forms of the disease to be less so. According to Richter, when it occurs subsequently to affections of the alimentary canal, it is of a less ma- lignant character than when it succeeds to diseases of the skin, or to fever in children of a scorbutic habit. Upon the true pathological character of gangrene of the mouth, much difference of opinion exists among the writers who treat upon it. That the first variety we have described is the result of inflammation of the gums, no one can doubt, who has examined the disease with care; and, according to Richter, the two other varieties, also, result from an inflammation of the parts in which they first occur—an opinion which we believe to be well founded. The disease has been ascribed to the inflammation of the lymphatics, by Bidloe, to a softening of the affected tissue, similar to what takes place in the stomach, uterus, brain, and other organs, by Klaatsch, Hesse, Weigand, and Boer; to a scrofulous affection, che'ilocace, by Lentin; to a scorbutic affection, by Van Sweiten, Seibert, and most of the older writers, and finally, to an induration of the cellular tissue from infiltration, similar to what occurs in new-born infants, by Fischer and Billard. In the majority of cases, the treatment of gangrene of the mouth consists simply in the application of remedies adapted to arrest the further progress of the local disease. When, however, we are called 160 DISEASES OF THE DIGESTIVE ORGANS. in previous to the occurrence of gangrene, in many cases much may be done to prevent its occurrence, by directing our remedies to the re- moval of the existing predisposition. Whenever it can be accomplished, the patient should be subjected to the influence of a dry and pure atmosphere: the strictest cleanli- ness of both person and clothing, should be enjoined, together with a diet perfectly unirritating, and easy of digestion, and adapted, in re- spect to the substances of which it is composed, to the actual condi- tion of the digestive organs in each case. If the gums are in a state of inflammation, the remedies directed in the section on that disease should be resorted to. In general, more or less disease of the alimentary canal, will be found to exist; this is to be treated by its appropriate remedies; re- collecting, however, that alterative doses of calomel, even when indi- cated by the symptoms present, are to be employed with the utmost caution, in every instance in which we have reason to apprehend the occurrence of gangrene of the mouth—for there can be no doubt that the disease has, in many cases, been developed by the incautious use of mercury. When judiciously prescribed, and their effects are care- fully watched, small doses of calomel will, nevertheless, often be pro- ductive of beneficial results. In a few instances, we have found the administration of the sulphate of quinia, and washing the gums repeatedly with a strong decoction of oak bark, to be beneficial in preventing gangrene of the mouth, in cases in which we had every reason to anticipate its speedy occurrence. In every case in which decided symptoms of local inflammation exist, leeches to the part will be proper. When tumefaction of the cheek occurs, blisters over the tumour have been, also, found beneficial by Dr. Jackson, formerly of Northumberland, now of Philadelphia. The remedies that have been applied locally, with a view of ar- resting the progress of the gangrene, are very numerous. All of them are reported to have succeeded in the hands of some physicians, while in those of others they have entirely failed. The wash or lotion which we have found by far the most successful, is a strong solution of sulphate of-copper, (thirty grains to the ounce of water,) applied very carefully twice a day, or oftener, to the full extent of the gangrenous ulceration. A solution of the sulphate of zinc, (one drachm to an ounce of water,) either alone or with the ad- dition of tincture of myrrh,1 will also be found, in many cases, an admirable remedy. Nitrate of silver was the only local remedy em- ployed in the cases that occurred in the Children's Asylum of Phila- delphia, from June 1st, 1827, to January 1st, 1830, the greater por- tion of which terminated favourably. As soon as the disease of the mouth was detected, the nitrate of silver, either in pencil or solution, was applied freely to the parts affected. 1 R.—Sulph. Zinci, sjj. Aquae, ^j. M. et solv. Dein adde Mellis, Tinct. Myrrh, a a gij.—M. Creasote, Dr. Dunglison informs us, was found to be an excellent GANGRENE OF THE MOUTH. 161 local application in the gangrene of the mouth, which occurred, as an epidemic in the Philadelphia Almshouse, in 1838, incisions being first made through the gangrenous sloughs. His prescription is creasote and alcohol, equal parts, to be applied by means of a pencil. In the Children's Hospital at Paris, cauterization of the gangrenous spots with hydrochloric acid, and afterwards covering them with powdered chloride of lime, with the use of tonics—generally the syrup of cinchona, given per anum,—is said, by Baudelocque, to have proved a very successful mode of treating the disease. The hydrochloric, sulphuric, and acetic acids, have all been highly recommended, as local applications. Van Sweiten employed the hy- drochloric acid, twenty drops to half an ounce of honey, or when the case was of an aggravated character, the acid alone, and invariably found the extension of the gangrene to be arrested, and the dead parts to separate in a short time: it was equally successful in the hands of Seibert, and is spoken of in terms of commendation by Bernstein, Richter, Jadelot, Boyer, Baron, and others. Heuter con- siders one of the best local applications to be a mixture of hydro- chloric and acetic acids. The nitric acid was employed by Dr. Baly, in a case which occurred in St. Bartholomew's Hospital, London. A single free application of the concentrated acid to the gangrenous part, completely arrested the morbid action. The application of sulphuric acid has succeeded in effectually ar- resting the disease, in the hands of Bruineman and Courcells; and the acetic acid, in the hands of Klaatsch and Reimann. To obtain from the acids any beneficial effects, their application should be re- peated every half hour, or, at furthest, every hour. They may be ap- plied either by pencil, or by covering the affected parts with lint moistened with them; their application being continued until the gan- grene ceases to spread, and granulations are formed. When thick firm sloughs occur, these should be freely scarified previously to the application of whatever wash is used. The actual cautery is recommended by Baron, the chloride of lime or soda, by others, and the tincture of iodine by Davies. Cases illus- trative of the good effects of the actual cautery, have recently been published by Henry Obree, Esq. When sloughs have formed upon the cheeks, some advantage may be derived from poultices, containing the chlorides of lime or soda, or the pyroligneous acid. The early extraction of the loosened teeth is of importance, and should never be neglected. The administration of internal remedies would appear to interfere but little with the progress of the disease. The diet of the patient should be light and nutritious; it may con- sist of beef tea, plain beef or mutton broth with rice; milk with rice; tapioca, sago, and the like farinaceous articles. Wine whey may be occasionally given with advantage; and we can conceive of cases, in which a moderate use of sound wine may be necessary, in order to sus- tain the sinking powers of the little patient. Such cases, however, have never fallen under our notice. 11 162 DISEASES OF THE DIGESTIVE ORGANS. From the administration of the sulphate of quinia in solution, or of the cold infusion of cinchona, we have, in many instances seen much good to result.1 1 R.—Quinias sulphat. gr. x. Or R.—Quiniae sulphat. gr. viij. Acid, sulph. dil. Tl^ x. Aq. chlorin. gj. vel Sacch. alb. ^iv. Acid, sulph. dil. nj/ v. Aq. cinnamon. 3;iv.—M. Syrup, limon. ^iv.—M. (Dunglison.) Dose, a teaspoonful every three hours. The chlorine water and the chloride of lime, or the chloride of soda, are said to prove advantageous internally administered.2 2 R.—Calcis chlorin. gr. x. vel. Liq. sodas, chlorin. ttjj viij. Syrup, zij. Aquas, 31 v.—M. (Dunglison.) Dose, a dessert-spoonful every three hours, for a child six years old. The free internal use of the chlorate of potassa—one to three scruples, in twelve hours, according to the age of the child, is strongly recommended by Hunt. The iodide of iron has also been suggested by Dr. Dunglison as a means of improving the condition of the nutritive function, which, in this disease, is evidently impaired. He gives it in Sherry wine, fifteen grains to an ounce, in doses of a teaspoonful four times a day. When a profuse diarrhoea occurs in the course of the disease, Ave have found it often to be very quickly arrested, by adding to the so- lution of sulphate of quinia two or three drachms of the tincture of kino. In some cases, we have given, with good effect, three or four grains of powdered galls, repeated every three or four hours; should these remedies fail, we may give the acetate of lead, in the following prescription.3 3 R.—Acetat. plumbi, gr. xvj. Cretas ppt. Qijss. Ipecacuanhas, gr. iv. Opii pulv. gr. ij.—M. To be divided into xvj. portions. One to be given every three or four hours. 7.—Difficult Dentition. Dentition is a purely physiological process, and in the healthy in- fant, with an organism in no part of which there exists any strong predisposition to morbid action, it is attended in general with little suffering or danger. It may, nevertheless, give rise to much suffer- ing, or even be the exciting cause of some violent and quickly fatal malady, whenever the irritability of the infant's system has become unduly augmented—when its energies have been impaired, and a ten- dency to disease in the alimentary canal, in the brain or in the respi- ratory organs, has been developed by bad nursing—or by an impure, heated, or confined air. It is usually between the fifth and seventh month, that dentition, in the ordinary acceptation of the term, commences. In different cases, however, the period when the teeth begin to protrude from the gums, will be found to vary—in some, the teeth appearing earlier, and, in others, not until some weeks or even months later. As soon as dentition commences, there is very generally an increased DENTITION. 163 redness, attended with considerable heat and tenderness of the gums, and an increased secretion of saliva. Occasionally, there is a slight febrile reaction—redness of the cheeks, watering of the eyes, and aug- mented thirst. The child is often fretful, and disturbed in its sleep. The discharges from the bowels are more frequent and fluid than usual, and occasionally of a greenish hue; and the stomach is morbidly irri- table, the matters discharged from it having often a strong acid smell. Occasionally, eruptions appear upon the skin, particularly upon the forehead and cheeks—in some cases erythematic inflammation and ulceration behind the ears, and not unfrequently a slight tumefaction of the salivary glands. As the advancing tooth approaches the sur- face of the gum, the fingers of the child are frequently held in his mouth; and he presses firmly between his gums the nipple in suck- ing, or any object which he can readily seize and convey to his mouth; this appears to ease some uneasy sensation experienced by the child, as does also pressing or rubbing the gum with a finger. In some children, however, the process is attended with such slight inconvenience, that the first two incisors are frequently cut without attracting the slightest attention, until their points are seen protruding beyond the gum. It is principally when there is a disproportion between the develop- ment of the teeth and jaw, as when dentition commences very early, or when a number of teeth are cut at the same time, that much pain or difficulty occurs. The molar teeth are, also, cut with more difficulty than the incisors. Even when the symptoms we have described above occur, all that is necessary is, to confine the child to the breast of a healthy nurse, and to supply him, occasionally, with moderate portions of fresh water, in which a small quantity of gum acaciae has been dissolved; or if he has been weaned, to restrict him to a diet composed chiefly of milk and farinaceous substances, and for his drink, to toast, barley, or rice water; animal food, all stimulating drinks, and every kind of spice being withheld. The child should be kept in a pure, fresh air, and not overheated either by too much clothing, or by too great a tempe- rature of the room he occupies. His head, in particular, should be kept cool, as well during the night as in the day. The daily use of the tepid or warm bath will be advantageous; and if the weather per- mit, daily exercise in the open air should not be neglected. Little attention need be paid to the diarrhoea that usually attends upon dentition—it is seldom very profuse. If accompanied with con- siderable griping, an injection of thin starch, or of a decoction of flax- seed, with the addition of a little sweet oil, will, in general, be sufficient; but if the griping still continue, a few grains of calomel may be given by the mouth, followed, in the course of four or five hours, by a dessert-spoonful of castor oil. If, as occasionally happens, the bowels, in place of being more free than usual, are constipated, a dose of magnesia, or of castor oil may be given. The eruptions which often appear about the face, and the inflammation and ulceration which occur behind the ears, demand no particular attention: the latter may be washed night and morning with some mild mucilaginous fluid, as 164 DISEASES OF THE DIGESTIVE ORGANS. water in which the pith of sassafras or the inner bark of the slippery elm has been infused. The eruptions and ulceration very commonly disappear when the teeth have protruded beyond the gums. As infants appear to derive relief from a slight degree of pressure upon the gums during dentition, something should be allowed them for that purpose. A substance that will yield to the pressure of the gums is to be preferred; an oblong piece of gum caoutchouc, two or three inches in length, and half an inch in breadth, will probably be the best; it should be suspended round the neck by a ribbon or tape. All hard, rough, or unyielding substances are positively injurious. A variety of washes for the mouth have been recommended, by differ- ent writers, to "soften, soothe and refresh the gums, during dentition." When composed of any simple mucilage, these washes will do no harm; they are unnecessary, however, if the child be supplied with cold mucilaginous drinks:—the good effects that have been attributed to them, in allaying the irritation of the gums, is referrible, we suspect, entirely to the gentle friction produced by the nurse's fingers, in their application. It is not always, however, that the process of dentition is accom- plished with so little inconvenience. In children of very irritable habits, in those who are gross and plethoric, or in whom there exists a strong tendency to disease in one or other of the organs, dentition may become the exciting cause of some of the most serious and fatal maladies incident to the period of childhood. In such cases inflam- mation of the mouth or gums, terminating in ulceration or gangrene —long-continued and extensive disease of the bowels, accompanied with frequent and vitiated discharges—spasmodic closure of the glottis —convulsions, often of a violent character—and hyperaemia, inflam- mation, or dropsy of the brain, are among the most common results of difficult dentition. In the children of the poor especially, who are exposed to the overheated, stagnant, and impure atmosphere of the confined streets, courts, and alleys, of our larger cities in the Middle and Southern States, dentition becomes, during the summer season, one of the most common exciting causes of the cholera of infants. Recently attention has been directed by Dr. Fliess, of Neusalt, to a paralytic condition of the limbs which sometimes occurs during dentition. {Journalfur Kinderkrankheiten, July and August, 1849.) It is much less frequent during the first, than during the second dentition. Its attacks are almost always sudden. The child is cheer- ful, as playful as usual, has a good appetite, and goes to bed in the evening apparently quite well. At first, perhaps, it sleeps very quietly; but it soon becomes disturbed, tosses about in a restless manner, groans and screams out in its sleep, grinds its teeth, is thirsty, has some heat of the head, and towards morning is rather feverish. On the next day, when perfectly awake, it is discovered that the child is unable to use one of its arms, or, in rare cases, an arm and leg. If the arm alone be paralyzed, it hangs down, useless, by its side; it is warm, but in consequence of the gravitation of the blood in the limb, the joints of the hand and the fingers are of a bluish red colour and swollen. The sensibility of the arm is either entirely lost, or is very DENTITION. 165 obtuse; and the excito-motory power can be but little, if at all, excited by strong stimulation. If the child, at last, complains of pain, it is only from the dragging of the muscles of the shoulder. The paralysis some- times extends to the leg of the same side,—the child is then unable to move it, and the sensation of the limb is lost, or at least impaired. More rarely, one arm and both legs, or both arms without the legs, are affected. The duration of the paralysis is very uncertain. In many cases, it lasts from a fortnight to three weeks, in others many months, and even, in some, many years, and then becomes incurable. Convulsions not unfrequently precede, or occasionally accompany the paralysis with- out any apparent exciting cause, or from a very slight one. If the child be in a passion, or annoyed about anything, the paralyzed limb sometimes becomes convulsed, and performs various movements which the child has not the power to restrain. The termination of the paralysis, under judicious treatment, is in most cases favourable; the limb regaining gradually its lost power, with a pricking sensation, or a feeling of formication. Not unfre- quently, however, the paralysis is obstinate, resisting the ordinary remedies, while other symptoms, indicative of an affection of the ner- vous centres and brain, make their appearance. The child is attacked with dyspnoea, palpitation, twitchings of the muscles of the eyes; it commences to squint, becomes dull, falls into a comatose state, and dies. The paralysis may become chronic; there are then no obvious indications of an affection of the nervous centres, but the affected limb remains paralyzed, and ultimately becomes atrophied; the individual may be, in other respects, in the most flourishing health, even active and strong. According to Dr. Fliess, in cases of dental paralysis, it is generally the molar teeth that are at fault; much more seldom the incisors; at least, in those cases which he has found recorded by various writers, where the situation of the teeth about protruding was given, the molars have almost always been mentioned as in progress of escaping from the gums. Much may be done by a judicious course of treatment, towards pre- venting the mischief which the process of dentition has a tendency t to develop. The child should, as far as possible, be removed from the influence of whatever morbific causes he may be surrounded with. He should be placed in a pure, fresh atmosphere. His diet should be mild, nourishing, and easy of digestion. If of a plethoric habit, every species of animal food should be withheld; while, if he be labouring under great exhaustion or debility, it may be necessary to allow him l beef, mutton or chicken broths, or even a portion of the meat of which these are prepared, plainly cooked, and in moderate quantities. The strictest cleanliness of person and clothing should be observed: the daily use of the warm bath, and frequent exposure to the open air, in suitable weather, with an amount of exercise adapted to his age and state of health, should be strictly enjoined. The condition of the gum should be daily and carefully examined ; and the moment it appears hard and swollen, and the teeth are evi- 166 DISEASES OF THE DIGESTIVE ORGANS. dently distending it, a free incision should be made with a lancet, at the points where they are about to protrude, so as completely to divide the tough membrane by which the tooth is enveloped, the distention of which by the advancing tooth, being the cause of much of the pain and irritation consequent upon difficult dentition. The lancet should, in every instance, be carried down until it reaches the tooth, and if it be one of the molar teeth that is about to protrude, a crucial incision will be necessary. This operation gives but little pain, and is rarely, when judiciously performed, attended with danger or inconvenience, while, in many cases, it is followed by immediate relief, and may be the means of preventing the occurrence of fever, convulsions, or fatal disease of the brain.1 Even subsequent to the occurrence of convul- sions, of spasmodic closure of the glottis, or of deep stupor from hy- peraemia of the brain, a free division of the gum over the advancing teeth has been known, in repeated instances, to be followed by an al- most immediate cessation of every alarming symptom. A curious case is related by M. Robert, in his Treatise on the Prin- cipal Objects of Medicine, illustrative, as well of one of the effects of difficult dentition, as of the division of the gum. We give it upon the authority of M. Carault, not having seen the work of M. Robert. A child, after having suffered greatly from difficult dentition, appa- rently died, and was laid out for interment. M. Lemonnier, having some business at the house of the nurse, with whom the child resided, after fulfilling the object of his visit, was desirous of ascertaining the condition of the alveola. He accordingly made a free incision through the gums; but, on preparing to pursue further his examination, he perceived the child to open its eyes, and give other indications of life. lie immediately called for assistance; the shroud was removed from the body, and by careful and persevering attention, the child's life was saved; the teeth in due time made their appearance, and its health was fully restored. When considerable redness and tenderness of the gums occur about the period when the process of dentition is expected to commence, without, however, either of the teeth having advanced sufficiently near to the surface of the gum to render an incision of the latter necessary, emollient washes should be frequently applied to the gum, and a leech or two to the angles of the jaw. If the bowels are costive, a purgative of calomel, followed by castor oil, may be admi- nistered. Should a considerable degree of febrile excitement be pre- sent—particularly if it be attended by heat and tenderness of the ab- 1 We have siid that the division of the gum over the protruding teeth, when performed at a proper time, and in a proper manner, is " rarely attended with danger or inconve- nience." It should be performed only when the gum is evidently raised by the advancing tooth, and the surrounding parts are red and painful. We have never seen the aplitlious or gangrenous ulceration which Billard apprehends may be produced by the incision. Were it to happen, in the majority of cases it would be a less troublesome and unmanage- able occurrence than that to prevent which the incision is made. In two instances, however, which fell under our notice, both occurring in children of a scrofulous habit, and who had suffered from long-continued chronic disease of the bowels, a constant oozing of blood took place from the incision, and which could not be arrested by any means that were resorted to, including the actual cautery. DENTITION. 167 domcn—a few leeches to the gums, and over the epigastrium, the tepid bath, and small doses of calomel and ipecacuanha,1 will be generally found advantageous. 1 ]£.—Calomel, gr. ij. ad iij. Magnes. calc. gr. xxiv. Ipecacuanhas, pulv. gr. ij. ad iij.—M. f. ch. No. xij. One to be given every three hours. When dentition is attended with frequent and copious discharges from the bowels, of a thin watery consistence, and accompanied with more or less griping—bland mucilaginous drinks, and the tepid bath, will, in general, afford relief; if, however, the diarrhoea continues un- abated or increases, we have found the best means of arresting it to be a solution of acetate of lead given by the mouth.2 2 R-—Acetat. plumbi, gr. viij. Acid. Acet. impur ttj; viij. Sacch. Alb. sy. Aq. puras, |j.—M. An ordinary-sized teaspoonful of which may be given as a dose, and repeated, three or four times a day, until the frequency of the discharges is abated. When there exist increased heat and redness, with turgescence of the vessels about the head—particularly if, at the same time, the child is unusually drowsy, or starts frequently from its sleep, with a wild, affrighted aspect—a few leeches should be applied behind the ears, and the head sponged frequently with cold water alone, or cold water, with the addition of one-fourth of proof-spirit; while the bowels should also be freely opened by calomel, followed by castor oil or Epsom salts. Where the tendency to disease of the brain is very decided, after the application of leeches, blisters behind the ears, repeated as they heal up, will often prove serviceable. The slightest indication of an ap- proaching attack of convulsions or spasms, should be carefully watched, and treated by its appropriate remedies. In the paralysis which occasionally attends dentition, Dr. Fliess re- commends scarification of the gums, repeated cupping in the neigh- bourhood of the origin of the brachial nerves, mild purgatives, and wrapping the affected limb in flannel. The application of stimulants to the paralyzed extremity, or even the use of electricity, he remarks, can produce no good effect. The dysuria, so common in cases of difficult dentition, is best as- suaged by the free exhibition of some mild demulcent drink. If the pain be considerable, and there is nothing present to forbid its use, an opiate may be administered.1 i R._Sulph. magnes. zij. ad 3iij. Solve in Or, R.-IIydrochlor. ammoniae, $. Aquas pur», gj. dein adde Pulv. ipecacuanha gr. iv. Spir. «ther. nitrici, ^j. Fulv. opn.gr. y. M.f. ch^oxv. Tinct. opii, ttr vij. ad xv. One to be given once or twice in the Dose-a teaspoonful, to be repeated accord- course of the day, according to cir- ing to circumstances. cumstances. 168 DISEASES OF THE DIGESTIVE ORGANS. CHAPTER II. DISEASES OF THE THROAT. 1—Tonsillitis. Inflammation of the tonsils and veil of the palate is a frequent disease of the latter stage of infancy, and during the entire period of childhood. It seldom, however, assumes the decidedly acute character so common in the tonsillitis of adults. From a very early age, the tonsils are liable to a subacute form of inflammation, producing, in many cases, a very considerable enlargement of these parts, which often continues for a long period, changing the tone of the patient's voice, and impeding his breathing, deglutition, and hearing. Tonsillitis usually commences with a sense of pain or uneasiness in the throat, a huskiness of the voice, and a sense of chilliness and languor, quickly followed by more or less febrile reaction. The pain in the throat increasing, deglutition becomes more difficult, and a sense of heat or burning is often complained of in the pharynx. There is often considerable nausea, and in children at the breast, re- gurgitation of the milk, shortly after it is swallowed; in children a few years old, there is a frequent hawking and rejection of tough mucus. The throat being examined, the velum palati and pharynx are found to be increased in redness, and tumid; both the redness and intumescence being, often, more considerable on one side than on the other, while one or both tonsils are found to be swollen, and generally covered with a coat of thick, tough mucus, often of a dirty white colour. In some cases, the soft palate and uvula present a dark red and oedematous appearance. The throat is tumid, and painful to the touch, externally. The tongue is covered with a white fur, through which the papillae, enlarged and of a bright red hue, project—a thick pellicle of transparent mucus being spread over the whole; when, as is occasionally the case, the inflammation of the throat is complicated with gastric disease, the tongue is generally covered with a yellowish fur, and a sense of pain or heaviness is experienced over the eyes. The swelling of the tonsils is often very considerable, impeding respiration, often entirely preventing deglutition, rendering the voice indistinct and whispering, and the hearing obtuse. The disease, when properly treated, commonly terminates by reso- lution. We never recollect to have seen an instance of extensive suppuration in a child. A substance, somewhat resembling pus, is, however, occasionally seen adhering to the surface of both tonsils; and, in some cases, a slight, circumscribed, diphtheritic exudation. Very frequently, the redness and tumefaction of the velum and pha- rynx subside, while the enlargement of the tonsils continues. TONSILLITIS. 169 More frequently the symptoms, from the commencement of the at- tack, are of a much less marked character. The child, if at the breast, exhibits a difficulty and pain in swallowing, and thfows up its milk soon after it is swallowed; the throat, externally, is somewhat Bwollen, and tender to the touch; and there is a peculiar huskiness of the cry. If the child is old enough, it complains of pain in the throat, increased at every attempt to swallow; and the swelling of the throat externally is often very considerable; there is a difficulty of breathing, and a frequent hawking up of a thick, tenacious mucus. On examining the throat, a slightly increased redness of the palate is observed, with considerable and irregular enlargement of the tonsils, which present a kind of lobulated appearance, their surface being covered with a thick coating of tough mucus. This form of the dis- ease is very generally complicated with disease of the alimentary canal; and is more common in children of a lymphatic, than in those of a sanguineous temperament and plethoric habit. The causes of tonsillitis are, in general, exposure to cold and damp- ness—sudden vicissitudes of atmospherical temperature—cold drinks, when the body is in a state of perspiration—and cold to the feet. It frequently exists simultaneously with the acute exanthemata. It is more prevalent in spring and the latter part of autumn, than in the middle of either summer or winter. The treatment of inflammation of the tonsils is very simple, and, if early commenced, a very prompt resolution of the inflammation may in general be effected. In slight cases, some rubefacient to the throat, externally,1 followed by an emollient poultice; a purgative of a few grains of calomel, with a moderate dose of the sulphate of magnesia a few hours subsequently, and a warm pediluvium at bed- time, will frequently be sufficient to arrest the inflammation. 1 R.—Ol. olivae, gj. Aq. ammoniae, s;ij. Sp. terebinth, gj.—M. When, however, the inflammation of the throat is more conside- rable, a few leeches should be applied to the neck or behind the ears; and, internally, minute doses of tartar emetic, either simply dissolved in water,2 or in a solution of sulphate of magnesia.3 2 Aquas puree, 31J. ad iv. s Sulph. magnes. £iv. Solve in Tart, antimon. gr. j.—M. Aq. puras, ^iv. dein adde Dose, a teaspoonful every two or Tart, antimon. gr. j.—M. three hours. Dose, the same. We have derived very great advantage, in cases of tonsillitis, from the use of a combination of the hydrochloride of ammonia, ipecacu- anha, and calomel.4 *Ammoniae hydrochlor. gr. xxxvj. ad. 3J. Ipecacuanha- pulv. gr. ij —iv. Calomel, gr. iij.—vj.—M. f. chart. No. xij. One of whichis to be given every three hours. The hydrochloride of ammonia, in inflammation of the throat in children, is a favourite prescription with many of the continental physicians. Loeffler recommends it in tonsillitis, to be given inter- 170 DISEASES OF THE DIGESTIVE ORGANS. nally, dissolved in water with the addition of the extract of liquo- rice. Blisters 'to the throat are directed by most writers, when the in- flammation of the tonsils is severe, and is not quickly arrested by the other remedies employed. We have seldom seen much good result from the application of blisters to the throat in young children; nor any instance in which they were required, in the disease under con- sideration. If resorted to, they should be kept on only so long as to redden the skin; and on their removal, the part to which they were applied should be covered with an emollient poultice. If the child be at the breast, it is better not to allow it to suck until the inflammation of the throat is subdued—it sucks in general with so much avidity that a large quantity of milk is carried to the throat at one time, which is almost immediately afterwards discharged by re- gurgitation or vomiting. Its thirst may be assuaged by a few spoon- fuls of water, rendered somewhat mucilaginous by an infusion of slip- pery elm bark or pith of sassafras, or by a mixture of milk and water, given occasionally. Older children should be debarred from all food, and allowed toast-water or some simple mucilaginous fluid as a drink. Patients affected with tonsillitis should be kept in a dry apartment, the air of which is of a moderate and equable temperature. When accompanied by disease of the alimentary canal, the latter should be treated by its appropriate remedies. The treatment of the subacute form of tonsillitis, which, according to our experience, is the one most frequently met with in children, differs in nothing from that of the acute form. Leeches to the throat will be occasionally required. The mixture of hydrochloride of am- monia, ipecacuanha, and calomel, will be found particularly advan- tageous. 2.—Hypertrophy of the Tonsils in Children. In young children the tonsils are subject to a chronic enlargement, the effects of which are far more serious than the entire neglect which the affection has met with from medical writers would lead us to sus- pect. In many cases there is no doubt that the enlargement is due to a subacute inflammation of the tonsils; in general, however, it would seem to be dependent simply upon the irritation of teething. It is commonly developed in children between six months and two years of age, thus coinciding with the most active period of dentition. In proof of the enlargement being due to the irritation of teething M. Robert, who has examined the subject with some care, (Bull. Gen. de Thera- peut., May, 1843) remarks, that he has seen the evolution of the dens sapientia in the adult attended with similar inflammation and hyper- trophy of the tonsils. The enlargement is always in both tonsils, and becomes in many cases very considerable. When of any extent it affects the voice, giving to it a peculiar nasal tone, and, by its pressure on the Eusta- chian tubes, impairs in a great degree the sense of hearing. By forcing up the velum palati, it also interferes with the freedom of re- spiration, hence those affected with it sleep with their mouths open. HYPERTROPHY OF THE TONSILS. 171 They are affected likewise with a constant troublesome dry cough; and the air in respiration being prevented from passing through the nares, causes the nose to remain undeveloped in breadth, which gives to the an- terior part of the face a thin and, as it were, pinched appearance. The most important result, however, of the enlargement of the tonsils is a flattening of the chest, to which Dupuytren first directed attention. This flattening M. Robert supposes to be produced by the enlarged ton- sils preventing a sufficient quantity of air being admitted at each in- spiration, fully to expand the chest, or to exert from within the lungs a pressure equivalent to that of the atmosphere without. The de- formity once established, it necessarily gives rise to dyspnoea, palpi- tation, and the usual results of interrupted respiration and circulation; hence the children in whom it exists are commonly pale, thin, and feeble. When enlargement is once established, the hypertrophied tonsils never diminish in size; their excision consequently is the only means by which the inconvenience and injury resulting from their presence are to be remedied. For diminishing the deformity of the chest, M. Robert suggests various plans and different forms of gymnastic exer- cises. Recently the application to the enlarged tonsils of the iodide of zinc, is said to have the effect of causing their rapid absorption. The arti- cle is prepared by placing a clean plate of zinc over a jar or vial, and sprinkling iodine over it. In a short time the iodide is deposited in the vessel, in the form of a semi-fluid deliquescent substance. This is to be applied pure, to the surface of the enlarged tonsil, by means of a camel's hair pencil, or "a piece of sponge, secured to a suitable handle. It is to be held on for a short time, and repeated every two or three days, until the object is accomplished. The application is followed by a pungent smarting, which lasts for twenty or thirty mi- nutes, but by no other inconvenience. Dr. Goddard, of this city, we are informed by Dr. Parrish, in his annual Report on Surgery to the College of Physicians, has used .the remedy extensively, and speaks very favourably of its effects. He has found it to possess the property of inducing a rapid absorption of the enlarged tonsil, by a sort of shrivelling process, without the formation of a slough. It does not, like the chloride of zinc, spread to the surrounding healthy structure, and hence, may be used without the fear of injury from being swal- lowed. (Summary of the Trans, of the College of Phys., of Phila- delphia, No. vii. page 191.) Professor Hess, of Copenhagen, states that he has employed com- pression, by means of the index finger applied to the indurated tonsils, with success. The pressure is to be repeated three or four times a dav, and as soon as the gland becomes softer and absorption com- mences, gargles may be used. Dr. Churchill, (Diseases of Children,) simL'-csts"that a fair trial should be given to an application of the caus- tic tincture of iodine to the enlarged tonsils, together with the ex- ternal use of the iodine ointment, which he has seen very successful in several cases. He very properly opposes strongly any attempt to remove the hypertrophied tonsils during childhood. The operation is by no means generally successful, and may be productive of conse- quences more troublesome than the disease. 172 DISEASES OF THE DIGESTIVE ORGANS. 3.—Pseudo-membranous, or Diphtheritic Inflammation of the Throat. This is one of the most common forms of inflammation of the throat in children, and is that which most generally accompanies scarlatina, when the latter prevails as an epidemic. Its most conspicuous cha- racter is the early excretion of a thin, pseudo-membranous pellicle, either continuous or in patches, and closely adherent to the surface of the inflamed mucous membrane, upon which it is produced. Pseudo-membranous inflammation of the throat commences often with symptoms of so mild a character, as to attract scarcely any at- tention until the local disease has made considerable progress. The deglutition is but little—or not at all—impeded; only a trifling sore- ness, or rather a sense of roughness in the fauces is experienced, while no febrile excitement is present. The child often continues to indulge in its ordinary sports, with, perhaps, a little more fretfulness and de- jection than usual, and becoming, apparentl}7, more quickly tired. In other cases there is, from the commencement of the attack, a sense of languor and general discomfort; a feeling of chilliness, alter- nating with flushes of heat; increased thirst; pain of the head; a sense of heat or burning in the throat; while the act of swallowing, and the slightest motion of the neck, cause more or less pain. The skin is hot and dry; the eyes are often red and watery; and the countenance flushed. Frequently, however, the countenance is tumid, pale, and expressive of sadness or dejection. When there exists any decided febrile excitement, an exacerbation generally occurs night and morn- ing. There is, in many cases, considerable nausea, and tenderness of the epigastrium. At first, there is usually a constipated state of the bowels:—diarrhoea, however, occasionally supervenes in the course of the disease, and in severe and protracted cases is often copious. From the very commencement of the attack, the mucous membrane of the fauces and tonsils is of a deepred colour, and becomes speedily covered with a layer of tenacious transparent mucus. The mucous membrane, particularly of the pharynx and soft palate, is in some cases infiltrated with blood, in the form of small disseminated points, having a linear arrangement; or of small, oblong ecchymoses, of a dark red colour. Occasionally, the mucous membrane presents a few dry, oblong, grayish spots, as though it had been, at these points, cau- terized with an acid. As the disease advances, the exudation becomes more abundant, and forms a firm pellicle, of a dirty yellow or grayish colour. It is usual- ly disposed, at first, in patches, more or less circumscribed, often slightly elevated in the centre, but thin and flocculent at the circum- ference. These patches increase in extent, more or less rapidly;— sometimes, in the course of a few hours the whole of the posterior fauces becomes covered with them. They are at first thin, but become increased in thickness, by successive depositions, and acquire, often, so much firmness, as to permit them to be detached entire from the mucous membrane, to which they adhere by numerous minute fila- ments that appear to penetrate the orifices of the mucous follicles. PSEUDO-MEMBRANOUS. 173 Their detachment is generally followed by more or less oozing of blood from the denuded membrane, which exhibits but little intumescence, and is of a dark red colour, often variegated with points or striae of a deeper hue. Between the pseudo-membranous patches, the submucous cellular tissue assumes, occasionally, an oedematous appearance; in conse- quence of which, the corresponding portion of the membrane is ele- vated, and causes the portions that are occupied by the pseudo-mem- brane to assume somewhat the appearance of ulcers, covered with a tenacious exudation. The patches, very generally, become soon con- fluent; so that, in many cases, the whole of the soft palate, the pharynx, and the inner surface of the cheeks, are lined by a continu- ous pseudo-membranous exudation, often of considerable consistence, which is rapidly renewed, as often as it is detached. In the commencement of the disease, the tongue is pointed, red at the edges, and covered on its surface with a thin layer of white mucus, through which the enlarged and florid papillae protrude. There is an increased secretion of saliva, which soon becomes dark-coloured, from the admixture of blood discharged from the mucous membrane as por- tions of the pseudo-membranous deposit are detached, and of an offen- sive odour, from the vitiated state of the secretions of the throat and mouth. In the course of the disease, the colour of the pseudo-membranous excretion changes to an ash-brown, and, finally, black colour, the mu- cous membrane beneath becoming of a dusky red hue. The tongue and mouth are often dry and dark-coloured, and the teeth more or less thickly covered with a dirty white, or blackish incrustation. If the affection of the throat is of any extent, and the inflammation is not early arrested, the submaxillary glands become enlarged and painful, and the surrounding cellular tissue infiltrated with serum, causing often a considerable intumescence of the neck. More or less tumefaction of the tonsils and soft palate, and occasionally of the tongue, takes place, frequently to such an extent as to interfere with the freedom of respiration; ulcers form along the edges of the tongue, the palate and upon the inner surface of the cheeks; and there is a con- stant oozing of blood from the mucous membrane of the mouth and fauces, which is increased upon the slightest irritation. The febrile excitement sometimes continues with but little abate- ment, until towards the close of the disease. The heat of the surface, however, in general abates—the skin assuming a dusky appearance, and doughy feel; profuse diarrhoea often occurs; the secretions, gene- rally, become vitiated, and either increased or diminished in quantity; the prostration of strength augments; and a state of torpor, or even decided coma, is not unfrequent. When the inflammation and pseudo-membranous deposit extend into the pharynx and commencement of the oesophagus, there is a sense of soreness and of heat in these parts, accompanied with increased diffi- culty of swallowing—every attempt at which is productive of severe pain. When the disease extends, through the posterior nares, to the mucous membrane of the nose, the patient is unable to respire through 174 DISEASES OF THE DIGESTIVE ORGANS. the nostrils; from these there takes place a discharge of a serous, yel- lowish and flocculent or bloody sanies, often of a very fetid odour, and which produces more or less inflammation and excoriation of the ex- ternal openings. When the disease extends to the Eustachian tube, pain is experienced in the ear, with more or less defect of hearing, often complete deafness, which, in consequence of the obliteration of the tube, is, occasionally, permanent. The pseudo-membranous inflammation is particularly liable to ex- tend into the larynx and trachea. This extension of the disease, in some cases, takes place almost immediately upon the first appearance of the patches in the fauces; in other instances the respiratory organs are not affected until about the second or third day, or even later. At whatever period the respiratory tube becomes affected, the symp- toms of croup—hoarseness, shrill cough, great difficulty of respiration, and more or less aphonia, are immediately developed, and, in the greater number of cases, the patient is rapidly destroyed. It is sup- posed by many pathologists, that croup is in every instance produced by an extension of the pseudo-membranous inflammation from the throat to the larynx and trachea: although we cannot admit that such is invariably the case, still we have reason to believe that croup is more frequently preceded by pseudo-membranous inflammation of the throat, than is generally supposed. Besides the extension of pseudo-membranous inflammation to the larynx and trachea, giving rise to the phenomena of croup, it is said by Guersent to be productive, also, in certain cases, of a species of pneumonia, extremely insidious in its commencement, and marked, in part, by the symptoms which are referrible to the disease of the throat. The cough, in this affection, is different from that of croup, and is un- attended with aphonia; the mucous expectoration is often streaked with blood, while auscultation and percussion give all the indications of a more or less extensive catarrhal engorgement of the lungs. Pseudo-membranous inflammation, likewise, often occurs upon re- mote parts of the body, particularly in situations covered by a mucous membrane, or from which the cuticle has been accidentally removed by a blister, or by ulceration. (Trousseau.) Thus, it is often observed upon the lips, the alae nasi, the concha, and external meatus of the ear, and the parts behind the external ear, upon the nipples, in the folds of the groin, around the contour of the anus, within the vulva, upon the surface of blisters, leech-bites, &c. In favourable cases, as the membranous exudation becomes detached from the mucous membrane, its place is quickly supplied by a new formation, and, after each separation, it becomes, in general, whiter, and much thinner. In other cases, the exudation, instead of being separated in fragments, becomes, in part, softened to a pulpy consis- tence, and is discharged from the mouth, mixed with bloody mucus. This separation and renewal of the pseudo-membranous deposit con- tinue, in most cases, for the space of eight or ten days; when, finally, it ceases to appear, leaving, most generally, the mucous tissue to which it had been attached perfectly sound throughout its whole extent, of a light red, uniform colour, and covered, usually, with a thick yellow mucus, more or less resembling pus. GANGRENE OF THE THROAT. 175 As the disease in the throat disappears, the glands of the neck, provided they are not in a state of suppuration, which very rarely occurs, diminish in volume, and are no longer painful or tender to the touch. The difficulty in deglutition disappears; the tongue loses its pointed appearance, and becomes clean and moist; the skin soft, moist, and of a more natural appearance; the countenance more ani- mated and cheerful; while the stomach and bowels gradually resume the regular performance of their functions, and the general strength and vigour of the patient become slowly reinstated. In severe and unfavourable cases, the disease is often more pro- longed; the whole of the symptoms become aggravated; the mouth, tongue, and throat become dry, and of a deep black colour; the diar- rhoea becomes profuse, and the strength of the patient more and more exhausted; general colliquation ensues, and death takes place, fre- quently preceded by deep coma, or, in children somewhat advanced in age, by violent delirium. When the disease is confined to the soft palate, isthmus of the fauces, and pharynx, it is seldom attended with much danger, and generally yields readily to an appropriate treatment; or, when the inflammation is of little extent, it may even disappear spontaneously in a few days. When, however, the disease extends to the larynx, it is very frequently fatal, by the occurrence of tracheitis, bronchitis, or pneumonia. The causes, nature, and treatment of pseudo-membranous inflam- mation will be noticed after we have described the gangrene of the throat. 4.—Gangrene of the Throat. Actual gangrene of the throat is of far less frequent occurrence than it was generally supposed to be by the older writers, or is still believed to be by many physicians of the present day. That form of anginose disease, to which the term putrid, malignant, or gangrenous, has been most commonly applied is, strictly speaking, unattended with either gangrene or sloughing of the throat; it is, in fact, a highly aggravated or malignant form of pseudo-membranous inflammation. Sloughing of the throat, or a species of gangrenous ulceration of this part may, however, occur in certain cases of epidemic pseudo-membranous an- gina, and particularly in the angina accompanying epidemics of scar- latina of a very malignant character. Malignant angina, in its commencement, differs but little from ordi- nary pseudo-membranous inflammation of the throat. The fauces pre- sent the same membraniform exudation: it is more generally confined, however, to the mucous membrane anterior to the larynx, over which it is more uniformly spread; it also assumes, at an earlier period, a dull ash-colour, quickly changing to dark brown or black. The disease seldom, if ever, extends to the trachea. The pain and tumefaction of the submaxillary glands are much more considerable than in the pre- ceding form of the disease; and they are, also, more liable to run into suppuration. The mucous membrane of the fauces is almost uni- formly injected with blood of a violet colour, and more or less swollen, 176 DISEASES OF THE DIGESTIVE ORGANS. but without the ecchymosed appearance noticed in the preceding va- riety; the tonsils, also, are more swollen, softer, and infiltrated with mucus and pus. The face exhibits a bloated, bronzed aspect; the eyes are heavy, dull, and watery. There is often extreme difficulty of deglutition; the voice is en- tirely guttural, and the power of articulation is occasionally sus- pended. In some instances, the respiration is rendered difficult from the excessive tumefaction of the tonsils and soft palate. In the commencement of the attack there is generally intense febrile excitement, with a dry, hot, burning skin, parched mouth, ur- gent thirst, and often considerable delirium. The fever is attended with an exacerbation towards evening. Nausea, vomiting, with ten- derness and oppression at the epigastrium, and diarrhoea, accompanied with thin, acrid, and intolerably offensive discharges, are often present from the commencement of the attack, or occur at an early period. A fetid, sanious discharge from the nostrils occurs often from the very commencement, and the patient discharges from the throat at first, a thin, bloody mucus, which becomes, subsequently, puriform, and mixed with shreds of a membranous appearance. In some cases, the discharge is dark-coloured, almost putrid, and highly offensive. In the milder cases of the disease, upon the separation of the pseudo- membranous exudation, the mucous surface beneath presents a moist, red appearance, without ulceration or loss of substance; the discharges from the mouth become of a less offensive character, and are dimi- nished in quantity; the tumefaction of the throat subsides; the tongue becomes cleaner and more moist; the febrile symptoms gradually abate, or entirely disappear; the dejections from the bowels diminish in frequency, and become more natural in appearance; a general amelioration of all the other symptoms ensues, and the patient by slow degrees acquires his accustomed strength and vigour. In cases of greater malignancy, the symptoms rapidly increase in intensity; the pseudo-membranous deposit in the throat assumes a dark colour, and separates in flocculi or shreds, of an intolerably fetid odour. The mucous membrane at first presents a dark red, and raw appearance, while from its surface there oozes a dark- coloured blood; but it speedily assumes a sloughy condition; the tongue becomes dry and parched, and coated with a dark brown or black crust; the teeth and gums are covered with dark-coloured sordes; and the gangrenous condition extends from the mucous membrane to the tonsils and soft palate. The accompanying fever assumes a low, typhoid character, and petechiae of the external surface are often observed. Dark-coloured vesicles occasionally occur about the. cor- ners of the mouth, and on the inner surface of the lips and cheeks, and occasionally upon the tongue, and, becoming ruptured, form gangrenous ulcers that quickly extend, and cause extensive destruc- tion of the surrounding soft parts. The diarrhoea increases in fre- quency, the discharges becoming more thin, acrid, and offensive; the strength of the patient becomes more and more prostrated; and stupor and insensibility ensue, which are quickly succeeded by death. The progress of gangrenous angina is ordinarily very rapid, the dis- GANGRENE OF THE THROAT. 177 ease often running through all its periods in the space of a week or twelve days. It generally attains its height in seven or eight days, after which period the febrile symptoms abate or disappear. It may destroy life in a very short period, but occasionally runs a protracted course of several weeks. When it terminates fatally, death usually takes place within the first week, either from extreme exhaustion of the vital powers, or in consequence of the occurence of extensive lesions of the digestive or other organs. When the disease occurs epidemically, it is often productive of a very great mortality. Under all circumstances it is a dangerous ma- lady, and one but little within the control of medicine. No little difference of opinion prevails, as to the pathological cha- racter of pseudo-membranous angina. Bretonneau, Guersent, and many other of the continental writers, denominate it a specific inflam- mation ; which, in fact, amounts to little more than a confession of their io-norance of its true character. Broussais maintains that the disease is, in fact, a gastro-enteritis; the affection of the throat being secondary to the inflammation of the digestive organs. Emmanguard also adopts this opinion. There can be no doubt, that, in numerous instances, the affection of the throat is preceded or accompanied by symptoms of more or less severe gastro-enteric disease; but it has been known to occur as frequently, perhaps, without any such symp- toms being present—at least in its early stages. Jolly refers the disease to a hemorrhagic inflammation, in which the colourless fibrine is exuded upon the surface of the mucous men- brane; and Naumann, with a few other German pathologists, supposes it to result from a separation and exudation of the albuminous portion of the blood, in consequence of a change in the condition of the latter, produced by an epidemic influence. Collineau regards the disease as one dependent upon a general and not upon a merely local af- fection; while according to the views of Andral, which appear to us to be the most correct, the disease consists in an acute hyperaemia of the mucous membrane of the fauces, with exudation of coagulable lymph. ... , c That pseudo-membranous angina consists in an intense erythema ot the mucous membrane, giving rise to an albuminous exudation, there can, we conceive, be little doubt. This exudation is a common occur- rence in the inflammations of the mucous tissue in children; and in them appears to be connected with a peculiar organization of this tissue, and a certain condition of the blood, difficult to be understood. Its gangrenous form is doubtless the result of defective organic power, and consequent impairment of the nutritive function. The causes of the disease have not been well made out. It is met with at all seasons, and in every variety of climate and locality. It may occur either sporadically, or as an epidemic. It is, however, most, prevalent during cold, wet, and damp seasons, and in low, damp, and marshy situations, especially during the spring and autumn. It is of most common occurrence, also, among the children of those classes bv whom personal and domestic cleanliness is neglected, and who, from J 12 178 DISEASES OF THE DIGESTIVE ORGANS. poverty or other causes, are deprived of a sufficient amount of whole- some nutriment. The disease is liable to occur endemically in situa- tions where a number of children are crowded together, and due atten- tion is not paid to preserve the air pure, and freely ventilated. It is, also, a common accompaniment of epidemic scarlatina. By nearly all the earlier writers, as well as by some of the more recent, the disease, especially its gangrenous form, is considered to be due to a specific contagion; or to be capable of being propagated by a contagious miasm, generated in situations where many persons are crowded together, without a proper attention being paid to clean- liness and free ventilation. In looking over the arguments by which this opinion is attempted to be established, we find them, however, altogether inconclusive. They are derived entirely from certain endemic or epidemic occurrences of the disease, and instead of proving its propagation from one or more foci of contagion, they merely show that a number of individuals had been exposed to the same local or general morbific cause, and that, while many wTere affected by it simultaneously, in some it produced the disease at an earlier, in others at a later period. That the disease has occurred sporadically, affecting only one member of a family, or a sin'gle individual of a community, is admitted by nearly all writers; but that it has ever been communicated directly from the sick to the well, we have not the slightest evidence. The treatment of pseudo-membranous inflammation of the throat will, in a great measure, depend upon the character of each case. In mild sporadic cases, the disease will generally yield to a very simple treatment; while in its more aggravated forms, and especially when it prevails as an endemic or epidemic, the most energetic remedies will be demanded from its very onset. In every instance in which there is no disease of the gastro-intes- tinal mucous membrane to counter-indicate its use, an emetic of ipeca- cuanha, administered in the commencement of the attack, will in ge- neral be found beneficial; and even at a later period mild emetics will very frequently do good, by expelling the tenacious excretions accumu- lated upon the fauces, and thus rendering the respiration freer, and deglutition more easy. Although the detraction of blood, either from the arm, or locally, by means of leeches, from the neighbourhood of the throat, is not so im- peratively demanded in pseudo-membranous inflammation, as in the other acute inflammatory affections of the throat in children, cases of the disease do, nevertheless, frequently occur, in which it is unques- tionably called for, and will be productive of the best effects. In robust children, particularly in those of a sanguineous temperament and plethoric habit, in whom the swelling and inflammation of the throat are considerable, and attended with symptoms of intense febrile excitement, general, as well as local bleeding, should be re- sorted to. Even when general bleeding may not be considered admis- sible, leeches to the throat, behind the ears, or to the angles of the jaws, will, in many cases, be found advantageous. Broussais, Emman- GANGRENE OF THE THROAT. 170 guard, and others, recommend, in all cases, leeches to the epigastrium; and whenever there exists tenderness, with increased heat at this part, their application should not be neglected. In cases attended with evident depression of the vital energies, with little febrile action, a cool skin, the fauces being of a dark colour, with considerable fetor of the breath, bleeding from the arm would be in- admissible, and even the application of leeches might be, under such circumstances, attended with danger. There can be no doubt of the beneficial effects of calomel, in many cases of the disease. In the earlier stages it forms our best purgative, and in those cases in which the larynx and trachea are implicated, it constitutes one of our most important remedies; it should be adminis- tered in large and repeated doses, either alone or combined with ipe- cacuanha.1 Even in the ordinary forms of the disease, occurring in patients possessed of some degree of vigour of constitution, calomel has been found advantageous,—relieving the throat of the membra- nous exudation and other vitiated excretions, and producing a marked amelioration of the symptoms generally. 1 R.—Calomel, gr. xxxvj. Ipecacuanhas, pulv. gr. iij. Magnes. calc. ^ss. M. f. ch. No. xij. One, to be repeated every three hours. The employment of calomel, at first with emetics, and subsequently by itself, in small, repeated doses, was a favourite practice with Dr. Rush, in malignant angina. In all cases the patient should be liberally supplied with diluent drinks. In the same class of cases in which active depletion has been recommended, the drinks should consist of iced water, iced lemonade, or cold water slightly acidulated with vinegar; even por- tions of powdered ice may be placed in the patient's mouth, and al- lowed gradually to dissolve. In other cases, cool drinks may be al- lowed; but where the powers of the patient are depressed, and the skin cool, the drinks should be given of a tepid, or even warm temperature. In cases attended with decided febrile reaction, the neutral or effer- vescing mixture may be advantageously administered. In the commencement of the attack, the tepid bath, with friction of the skin, will invariably be found productive of good effects; and when the heat of the surface is considerable, generally diffused, and steadily maintained, the surface should be sponged with cold water, or cold vinegar and water. In cases where the inflammation and swelling of the throat are considerable, warm pediluvia, with the addition of salt or mustard, will act beneficially as a revulsant. Where the powers of life are depressed, the pulse feeble, and the skin cool, the warm bath should be substituted for the sponging with cold fluids, as recommended above. Much difference of opinion exists as to the propriety of blisters to the throat in this disease. We confess that we are averse to blister- ing the throat in young children; and in the few instances in which we have applied them in pseudo-membranous angina, we have had reason to regret their use. In the early stage of the disease, the ru- 180 DISEASES OF THE DIGESTIVE ORGANS. befacients recommended under the head of tonsillitis, followed by warm emollient cataplasms, will occasionally be found useful. In cases of great violence, blisters may be applied to the back of the neck, with some active rubefacient to the throat. The diet should be regulated according to the leading symptoms of each case. Where the attack is one which calls for active depletion, little else should be allowed than barley water, rice water, or water gruel. Rennet whey and buttermilk we have, occasionally, found to be useful and refreshing articles of diet in this disease. When the in- flammation occurs in children of debilitated habits, or is attended with symptoms of exhaustion, beef tea, or plain mutton or beef broth, in moderate quantities, may be allowed. In the gangrenous form of the disease, with diminished heat of the skin, a feeble pulse, and other symptoms indicative of a depression of the vital energies, a discreet use of tonics and stimulants will frequently arrest the progress of the gangrene, and produce a favourable change in its leading symptoms. The cold infusion of cinchona, the sulphate of quinia, the mineral acids, an infusion of serpentaria, or the acetate or carbonate of ammonia, or wine whey, may be administered, ac- cording to the circumstances of the case. The acetate of ammonia, either alone, or combined with camphor; an infusion of serpentaria, or the cold infusion of cinchona, with some light aromatic, will be found among the most efficacious excitants and tonics in this disease. We have often combined with each dose of the bark a portion of the hydrochloric or sulphuric acid, with decided advantage. The use of these remedies should, however, be invariably resorted to with the greatest caution, and their effects upon the symptoms of the case care- fully wratched; if they produce dryness of the tongue, increased heat of the surface, inclination to stupor, or other unfavourable effects, their use should be discontinued. When we are unable to administer tonics by the mouth, a decoction of bark or of serpentaria may be given, in the form of enemata, and in many cases will, in this manner, produce a very beneficial result. When extensive tumefaction and tenderness of the glands of the neck occur, leeches may be applied upon the tumours or they may be kept constantly covered with cloths wet with cold water, or cold vine- gar and water, the effects of which are often peculiarly striking. Various local applications to the fauces, in the form of washes or gargles, have been proposed in the treatment of pseudo-membranous inflammation of the throat, and, by many, are considered to constitute the most efficient remedies for the disease. In the early stage, a wash or gargle of equal parts of good vinegar and water, is, perhaps, one of the best we can employ; diluted hydrochloric acid, or solutions of the chloride of soda or of lime, or a saturated solution of the borate of soda, also, in many cases, form an excellent wash for the throat. A solution of the acetate of lead may be employed for this purpose; it will be found, in general, in the commencement of the disease, very beneficial. A strong infusion of cinchona, or of oak bark, with the addition of alum, creasote diffused in water, or a saturated solution of the sulphate of copper, will also be found to constitute useful washes PAROTITIS. 181 for the throat, particularly when the occurrence of a gangrenous con- dition is apprehended. The application to the fauces, two or three times a day, of hydro- chloric acid, either pure, or combined with three parts of honey, has been highly extolled by many of the French and German physicians. Among the local applications, in favour of the beneficial effects of which we have the greatest amount of evidence, is that of the nitrate of silver, either in strong solution, from fifteen to twenty grains in an ounce of water, or in its solid form. It will not only cause the separation of the pseudo-membranous deposit, but also produce a more healthy action in the inflamed mucous membrane of the throat. It may be applied in the liquid form, by imbuing a portion of soft sponge, firmly attached to a whalebone, with the solution; great care being used to prevent any portion of it from entering the pharynx. Alum, reduced to a very fine powder, and blown into the throat through a tube, the end introduced into the patient's mouth, being de- fended by a piece of fine gauze, Is strongly recommended in this dis- ease, by Bretonneau, Guersent, Bourgeois, and other practitioners. The sulphate of copper has been employed in the same manner by Gmelin. We have never administered these remedies in the manner here described, from the apprehension that a portion of the powder should pass into the larynx, and excite violent coughing. A much better mode of applying them is in solution, as a wash, or by forming them into a stiff paste, by the addition of honey and water, which may be smeared upon the diseased surface by means of a sponge, brush, or small spatula. When the patient is unable to gargle, or when, from the extensive swelling of the throat, or the extreme restlessness of the child, it is found to be impossible to apply, effectually, any of the washes to the throat, by means of a sponge or swab, they may be injected into the mouth through a small syringe, the nostrils being closed, to prevent their immediate escape. Any of the local applications noticed above may be applied in this manner, with the exception of the nitrate of silver or the mineral acids. When the disease is attended with a profuse and exhausting diar- rhoea, we may employ the cretaceous mixture, with the addition of the tincture of kino,1 or—what we have found particularly beneficial in such cases—a combination of powdered galls, camphor, and ipecacu- anha,2 or the acetate of lead, in solution. i B._Mucil. G. Acacias, 5HJ. 2 R.—Pulv. Gallae, 3J. ("retas ppt. 3J. " Camphor, gr. iv. ad. vij. Tinct. Kino, 31*.— M. " Ipecacuanhas, gr. iij. ad. iv. A teaspoonful every two or three hours. M. f. chart. No. xij. One to be given every three hours. We need scarcely refer to the importance of keeping the apart- ments occupied by patients labouring under pseudo-membranous inflam- mation perfectly clean, and of a moderate, equable temperature, and freely ventilated. 5.—Parotitis.—Inflammation of the Parotids.—Mumps. Inflammation of the parotids generally occurs epidemically, and seldom attacks the same individual more than once. In the majority 182 DISEASES OF THE DIGESTIVE ORGANS. of cases it is a very trifling affection, subsiding spontaneously in a few days; while, occasionally, it is attended with very considerable swell- ing and pain, and febrile symptoms of some intensity. It is usually preceded by more or less chilliness, succeeded by in- creased heat of the skin, and a sense of pain, or uneasiness, in the re- gion of one or both parotids. A stiffness of the jaws, producing a difficulty in mastication, is very commonly present. Sooner or later, a tumefaction is observed behind the angle of one or both jaws, with, frequently, augmented heat and redness, and more or less severe pain, which is increased by the motions of the jaw, and by pressure. The swelling, in general, goes on increasing, producing a large, hard, movable tumour, sometimes on both sides of the neck. The skin covering the tumour is often unchanged in colour; and, occasionally, when the tumefaction is rather oedematous than inflammatory, the colour of the skin by which it is covered is even paler than natural. In severe cases, the swelling assumes a bright or deep red colour. The inflammation frequently extends from the parotids to the sub- maxillary glands, and is attended with symptoms of considerable feb- rile excitement, increased thirst, and constipated bowels. The tumefaction usually attains its height by the fourth or fifth day, when it begins gradually to diminish, and soon entirely disappears; the febrile and other symptoms declining and disappearing with the diminution and resolution of the swelling in the neck. It is extremely rare for the disease to terminate in suppuration, though a few instances of this are on record. A curious circumstance in connexion with this disease is, the lia- bility of the inflammation suddenly to disappear from the neck, and to be immediately followed by a painful swelling of the testicles in the male, and of the mammae in the female. The latter affection, under an appropriate treatment, in general terminates very promptly by re- solution; in males, it has been known, however, to produce an entire absorption of the testicle. In some instances, the inflammation sud- denly ceases in the testicles or mammae, and the pain and tumefac- tion of the parotids reappear. Instances occasionally occur, in which the sudden subsidence of the inflammation of the parotids has been succeeded by intense febrile symptoms, and more or less cerebral disease, indicated by deep coma, convulsions, or delirium. This occurrence has taken place even in cases in which the inflammation has ceased in the neck and been followed by inflammation of one of the mammae or testes. Parotitis generally occurs in children over five years of age; and, as we have already remarked, the occurrence of one attack usually pro- duces such a change in the parts affected, or in the organism generally, as to prevent a recurrence of the disease in future. Males are said to be more frequently attacked than females;—our own experience does not confirm the truth of this observation; we have certainly met with the disease as often in females as in males. Parotitis is evidently produced by some epidemico-endemic influence, it being, most generally, confined exclusively to certain localities; though it is probable, that with the predisposition produced by the ANGINA EXTERNA. 183 prevailing atmospherical influence, exposure to cold, or sudden transi- tions of temperature, may tend to bring on an attack. The disease prevails at all seasons, and in almost every variety of climate, but it is said to be much milder, and the so called metastasis less frequently to occur, when it prevails in warm and dry, than in cold and damp weather. We have found the disease, however, to be but little influenced by the state of the atmosphere. Parotitis is seldom either a severe or dangerous affection, and, in the majority of instances, spontaneously disappears, when the patient is kept within doors, and upon a mild, unirritating diet. It will be proper, in most cases, to administer a saline purgative; to keep the neck moderately warm, and to immerse the lower extremities in warm water, the child being, at the same time, kept at rest, and upon a plain farinaceous diet. Should the tumefaction of the neck be very extensive, and attended with considerable pain, heat, and fever, it will be prudent to apply leeches to the seat of the disease, in numbers proportioned to the ex- tent of the local symptoms; and, after the bowels are fully evacuated, by a mixture of sulphate of soda and magnesia, the following may be administered internally.1 1 R-—Sulph. magnesias, giv. Solve in Aq. puras, ^iv. et adde Tart. ant. gr. j. Spir. aether, nitrici, Sfiij. Sacch. alb. zvj.—M. Dose, a teaspoonful every three hours. Warm pediluvia will be found beneficial, and, in many cases, the tepid bath. When the testicles or mammae become affected, leeches may be applied to these parts, followed by emollient fomentations; purgatives, and antimonials, will likewise be proper, according to the nature and extent of the symptoms present. It has been generally recommended to attempt, by stimulating applications to the neck, "to bring back the inflammation to the parotids;" we do not, however, believe that any good can result from this practice; according to our experience, it is not calculated to effect the desired result; and, if it were so, no advantage will be gained; the inflammation of the testicles or mam- mae being as readily controlled by its appropriate remedies, as when the disease is seated in the parotids. When symptoms of cerebral disease manifest themselves, these should be promptly attacked by leeches to the temples, or behind the ears, active purgatives, warm sinapized pediluvia, cold applications to the scalp, and antimonials. 6.—Angina Externa. Under the name of phlegmone parotidea, Dr. Good describes a very common affection in children, consisting in an inflammatory tumour, occurring in the neighbourhood of the parotids, and proceeding slowly on to suppuration, forming, often, an extensive abscess. The same disease is described by James, in his "Observations on the general Principles, and on the particular Nature and Treatment of various 184 DISEASES OF THE DIGESTIVE ORGANS. species of Inflammation," as angina externa. Both names are founded upon erroneous pathology. The affection consists simply in an in- flammation of the cellular tissue surrounding the parotid or other glands of the throat, which is generally circumscribed, but occasion- ally diffused. The disease usually commences in the same manner as parotitis. The swelling is, however, more extensive, red, and painful; in many cases preventing deglutition, and rendering the respiration so difficult that the patient can scarcely sleep, from the sense of impending suffo- cation. There is, ordinarily, considerable febrile excitement. When the swelling is very great, extensive oedema of the face not unfre- quently occurs. Suppuration usually takes place, sometimes very early, but, in the majority of instances, very slowly. The swelling becomes more pro- minent at some part of its surface—the skin here becomes paler—a fluctuation is soon after detected, and sooner or later, the skin gives way and a discharge of healthy pus takes place. The tumour now gradually diminishes in size, cicatrization takes place, and all the symptoms of inflammation finally disappear. Often, however, some degree of hardness of the parts occupied by the inflammation remains for a considerable time, and only diminishes by very slow degrees. It occasionally happens that the inflammation and swelling are situ- ated immediately below the chin, and we have seen cases where the tumour occupied the whole of the front of the throat from ear to ear. Instead of a circumscribed inflammation and suppuration the in- flammation is, occasionally, deep-seated and diffused, and the pus, when it forms, is then liable to extend, under the angle of the jaw, to the pharynx, or downwards, into the upper part of the thorax, pro- ducing extensive destruction of the cellular membrane about the neck, and great distress to the patient. In this form of the disease, the ex- ternal swelling is less prominent and circumscribed, and there is less redness of the skin. When suppuration takes place, the swelling acquires a doughy feel, and an indistinct fluctuation may be observed at one or more points. The matter is slow in arriving at the surface, and in discharging itself externally. In some instances, distinct, deep-seated collections of matter form, and the pus, mixing with the dead cellular membrane, becomes putrid, and the evolution of gas thus produced, causes a kind of emphysematous condition of the parts. The febrile symptoms now assume a low typhoid character, the strength of the patient is rapidly exhausted, and death very gene- rally ensues; or if recovery takes place in these extreme cases, an extensive and unsightly cicatrix deforms the patient for life. Inflammation of the cellular tissue of the neck generally occurs in children of gross plethoric habits, particularly in those who are fed upon a diet consisting principally of rich animal food, in which they are allowed to indulge to excess. It is, very frequently, connected with more or less disease of the alimentary canal. We have seen the disease in children of almost every age; it is more common, however, subsequent to the period of dentition, than in infants at the breast. In perhaps the majority of cases, the inflammation is perfectly cir- OESOPHAGITIS. 185 cumscribed; and, if suppuration ensues, a simple circumscribed abscess results, the disease being rather troublesome and painful than danger- ous; but, when in children of an unhealthy habit, the inflammation is diffused, unless a free exit is given to the pus by early incisions, the affection is one attended with severe suffering, and very generally terminates fatally. In cases of simple phlegmonous inflammation, the treatment con- sists in the application of leeches to the neck, in numbers propor- tioned to the extent of the inflammation; and their repetition, after a short interval, if the local symptoms are not sufficiently reduced by the first application. After the leech-bites have ceased bleeding, the tumour should be covered with pledgets of linen, kept constantly wet with cold water, or with a solution of the acetate of lead. A dose of calomel should early be administered, followed by a sufficient dose of sulphate of magnesia to ensure its speedy operation. The patient should be restricted to a mild unirritating diet,—in severe cases, no other food being allowed than barley water or water gruel. In cases attended with considerable febrile excitement, the solution of sulphate of magnesia, with tartarized antimony, as directed in parotitis, will be beneficial. So soon as a disposition to suppuration is observed, the tumour should be covered with emollient poultices, frequently renewed; and, when a distinct fluctuation is observed, the abscess should be opened with the lancet, and a free exit given to the pus;—the appli- cation of the poultices being continued until cicatrization commences, when a dressing of simple cerate spread upon lint, may be substituted. When the inflammation is diffused, a similar treatment will be de- manded in the early stage; but, as soon as the swelling of the neck acquires a doughy feel, especially if there is great difficulty of swal- lowing, impeded respiration, or a constant dry cough, free incisions should be made, followed by the application of emollient poultices. If the patient's strength becomes depressed, a plain nourishing diet should be allowed; and, if necessary, moderate doses of the cold in- fusion of bark, or of a solution of the sulphate of quinia. The treat- ment of each case, must, however, be governed by the particular symp- toms present; the safety of the patient not unfrequently depending entirely upon the promptitude and judgment of the practitioner. CHAPTER III. OESOPHAGITIS—INFLAMMATION OF THE OESOPHAGUS. It is to Billard that we are indebted for our knowledge of the oesophagitis of infants;—he first pointed out its frequent occurrence in the first period of infancy, and described its diagnosis. From him, therefore, we shall be under the necessity of borrowing our account of the disease, it being one mentioned by no other writer, and in rela- tion to which our own observations have not furnished us with any ad- 186 DISEASES OF THE DIGESTIVE ORGANS. ditional facts. We have repeatedly recognised in infants the symptoms referred by Billard to inflammation of the oesophagus, but have not had an opportunity, as yet, of testing, by an examination after death, the accuracy of his diagnosis. The principal symptom of oesophagitis in infants is frequent vomit- ing, occurring almost immediately after the deglutition of drinks or aliments, which are discharged almost in the same state in which they were taken. The child refuses the breast, and fluids generally—but often swallows without much difficulty half solid aliments. The undi- gested food and drinks vomited by patients are, occasionally, mixed with matters secreted by the stomach, particularly if the latter be affected, at the same time, with inflammation. More or less pain is no doubt experienced along the whole track of the oesophagus, but at the age at which the disease occurs, we cannot determine its presence by any exterior sign; it is probable, however, that pressure upon the throat, in the direction of the oesophagus, may excite the cries of the child. Nutrition is interrupted, and emaciation rapidly ensues. Oeso- phagitis is seldom accompanied by any degree of febrile excitement. The disease may consist in a simple erythematic inflammation of the mucous membrane of the oesophagus, in inflammation, with altered secretion, or in gangrenous inflammation. As oesophagitis is almost invariably preceded by stomatitis, it is pro- bable, that according as the mouth is affected with inflammation at- tended with curd-like exudation, or with follicular inflammation, the inflammation of the oesophagus will also be attended with altered secre- tion, or with aphthous ulceration. It is, however, difficult to distin- guish the existence of ulcers or gangrene of the oesophagus, unless the matters vomited contain shreds, derived from the disorganization of the oesophageal mucous membrane. More extended observations, Bil- lard remarks, will probably enable us to form a more accurate diag- nosis of the several forms of the disease. The pathological changes detected after death are, vivid redness, with destruction of the epithelium of some portion of the mucous membrane of the oesophagus, especially at its upper part; aphthous ulceration; curd-like exudation, more or less extensively diffused; separation of the epithelium, often in large shreds; numerous red or dark-coloured striae, where the epithelium is not destroyed; large, irregular eschars of a black colour, with intervals of deep, bright red excoriations, and gela- tinous softening of nearly the entire thickness of the oesophagus. The pharynx, in general, exhibits considerable injection; the glottis is infiltrated and reddened. The stomach is often perfectly free from disease, but occasionally presents the various lesions incident to gas- tric inflammation. The hyperaemia of the mucous membrane of the oesophagus, which always exists in the early stage of infancy, is the chief cause of the frequency of oesophagitis at this period; its occasional causes are the same as those of stomatitis. It may be produced by too hot or stimu- lating food. When infants are fed with the spoon, if wine or spiced victuals, or if broth, milk, or panada of too high a temperature be given them, we can readily conceive that a very serious irritation may be INDIGESTION. 187 excited in an organ, already predisposed to disease, in consequence of its habitual state of hyperaemia. The treatment of oesophagitis is very simple. The child should be debarred from all stimulating and hot drinks; it should be supplied, at Bhort intervals, with small portions of some plain, mucilaginous fluid, as gum water, or an infusion of the pith of sassafras, or of the inner bark of the slippery elm; the throat, externally, should be covered with an emollient poultice, especially when the oesophagitis succeeds to stomatitis, and a few grains of calomel may be administered, fol- lowed by injections of milk with the addition of sugar. If necessary, the strength of the patient may be supported by injections of milk and broth, or of milk with rice flour, tapioca, or arrow-root. We have derived advantage, in cases presenting the symptoms of oesophagitis, from leeches along the sides of the neck, and internally a solution of acetate of lead. R.—Acetat. plumbi, gr. iv. Acid. acet. impur. m> iv. Aq. puras, gj.—M. Dose, a teaspoonful every three hours. CHAPTER IV. DISEASES OF THE STOMACH. 1.—Indigestion. We employ the term indigestion, to indicate an affection of the sto- mach, very common in children, in which the function of that organ is suspended or disturbed, and the food, either unchanged or im- perfectly digested, is discharged by vomiting or by stool, while no symptoms exist indicative of gastric inflammation, or of disease of other organs. Indigestion is invariably dependent upon too much, or improper articles of food, or upon some accidental circumstance interfering with the process of digestion. There can be no doubt that more or less disease of the mucous membrane of the stomach is present in every case, and that if the cause of the functional disturbance be continued, or repeated, inflammation of an acute or sub-acute character may be excited. . Nausea and vomiting are the most common symptoms of indiges- tion during infancy. Infants at the breast will repeatedly discharge from the stomach, immediately after sucking, by a species of regurgi- tation or by actual vomiting, a portion of the milk taken, without appearing to suffer any inconvenience. The vomiting in these cases arises, generally, from an overloaded state of the stomach, and is un- attended by either nausea or straining. The milk is usually returned unaltered; occasionally, however, it is coagulated in masses of greater or less size. 188 DISEASES OF THE DIGESTIVE ORGANS. This species of vomiting generally occurs in very young infants, of a robust habit, particularly, when suckled by a nurse in whom the sup- ply of milk is profuse, and flows with great freedom. It is rather salutary than injurious; preventing the effects of over-distention of the stomach; hence the common saying among nurses, that those infants who throw up their milk thrive the best. But as the cause is an habi- tual repletion of the stomach—more milk being taken than can be readily digested—it must be evident, that in every instance there is danger of a disturbance of the digestive function, or even more serious injury being, sooner or later, induced. The cause of the vomiting should therefore be removed by preventing the infant from sucking too much at a time, or too frequently in the course of the day. It should, as Dewees directs, be removed from the breast the moment it begins to dally with it, or as soon as it ceases to suck with avidity, as if it were gratifying a necessary and proper appetite. A common cause of vomiting from repletion of the stomach in in- fants is applying them to the breast whenever they are fretful, or with the view of lulling them to sleep, or allowing them to lie at the breast all night. There is in some infants, also, a disposition to eject the milk taken into the stomach, that is induced by dandling them in the arms or jolting them upon the knee, or walking them about soon after they have sucked, even when no undue quantity has been taken. As a general rule, therefore, but especially when vomiting is readily ex- cited, the infant should be allowed to remain perfectly quiet for a short time after its removal from the breast. A common error committed by nurses, is that of giving the breast to infants immediately after they have ejected the contents of the stomach. This should be avoided in every instance, it being calcu- lated to increase the irritability of the stomach and render the vo- miting more frequent. The more or less coagulated state of the milk discharged from the stomach, most generally arises from its having remained in that organ a short time before its ejection; the milk invariably under- going coagulation in the infant's stomach, previously to its digestion. In some cases, however, the coagulation of the milk, as well as the vomiting, appears to be due to the secretion in the stomach of an undue amount of acid. The breath of the infant, and the coagulated milk thrown up, have then a sour smell, and very often sour, curdy evacuations take place from the bowels, preceded by more or less griping. The cause of this acidity is very difficult to determine; whether it results from an irritation of the stomach, causing an excessive se- cretion of acid, or from the occurrence of acetous fermentation in the milk, we have been unable to satisfy ourselves. It is not uncommon for dense coagula of milk to form in the sto- mach of an infant, in some cases causing severe colicky pains, and in others, violent convulsions, which cease upon the rejection of the coagula. The retention of these coagula in the stomach appears to arise from the disturbance of the digestive process, independent of gastric in- flammation ; though some degree of this is liable to be induced, if the irritation of the dense coagula does not cause their speedy ejection by vomiting. INDIGESTION. 189 Not unfrequently, repeated vomiting occurs in children, attended with paleness, and other indications of considerable nausea; preceded, generally, by severe griping pains of the bowels, and followed by more or less diarrhoea. The matters vomited, whether milk or other articles of food are, usually, partially digested, and exhale an acid or rancid odour. Preceding the vomiting, the child exhibits, ordinarily, a con- siderable degree of uneasiness, and continues fretful and languid for some time after the spontaneous evacuation of the stomach and bowels. In such cases there exists a disturbance of the digestive function, at- tended with considerable irritation of the mucous membrane of the whole of the alimentary canal, but seldom any symptom of positive in- flammation. The mischief is almost invariably owing to improper or too much food. When the disease occurs in infants at the breast, its cause is, gene- rally, to be sought for in some condition of the mother's or nurse's milk, by which it is rendered either indigestible, too irritating to the stomach, or unadapted to the functional powers of the latter; or to the child being occasionally fed with improper kinds of artificial food. Even when the milk of the mother or nurse is perfectly healthy, adapted in all respects to the condition of the infant's digestive organs, and sufficient in quantity, indigestion may be produced by the prac- tice too commonly pursued, of giving to the child, occasionally, a por- tion of artificial food, often of the most indigestible quality. Pre- viously to the appearance of the first molar teeth, under ordinary cir- cumstances, no other nourishment is required than the breast-milk of the mother; and every kind of food which differs materially in its qualities from the latter, will produce serious disturbance of the diges- tive organs. We have seldom known an infant, to whom there was given, in addition to its mother's milk, any of the various compounds of bread and water, bread and milk, flour and milk, and the like "vile nursery compounds," who has not suffered from indigestion, and often from severe irritation or even inflammation of the stomach and intes- tines. Diseases of the alimentary canal being more certainly produced, in the generality of these cases, by the carminatives, antacids, and opiates, administered to relieve the vomiting, expel the wind, and allay the griping caused by the improper diet. Slight symptoms of indigestion are frequently attendant upon the process of dentition, in consequence of the irritation of the gums being extended to the digestive organs; they seldom, however, occur to any extent, unless when too much food, or food of too stimulating a quality is allowed at this period. Children too early weaned are especially liable to be troubled with indigestion, as well as those who, weaned at a proper period, are placed immediately upon a too rich and stimulating, or otherwise unfitting diet. Vomiting and diarrhoea—more or less griping pain of the bowels— and rapid emaciation, are the prominent symptoms induced. The matters vomited consist usually of the partially digested aliment, often of a decidedly sour or rancid smell:—the dejections from the bowels are similar in character. In some cases, however, the food taken into 190 DISEASES OF THE DIGESTIVE ORGANS. the stomach passes through the alimentary canal, and is discharged entirely unchanged, while little or no vomiting is present. The ap- petite often continues unabated, oris even increased; but, from the disturbance or suspension of the digestive process, the nutrition of the system ceases, and the child dies from inanition; in many cases, how- ever, the irritation of the alimentary canal is reflected upon the brain, and violent convulsions supervene; or a chronic inflammation of the mucous membrane of the stomach and bowels may occur. In children brought up by the hand, or improperly fed subsequently to weaning, indigestion occasionally occurs, attended by symptoms of considerable severity. There is generally loss of appetite, peevishness, restlessness and want of sleep; the tongue is covered with a layer of white or yellowish mucus; the breath is often sour, and, in some cases, aphthae appear upon the parietes of the mouth. There is constant diar- rhoea, intense thirst, and great emaciation and exhaustion. The diar- rhoea, after a time, frequently diminishes, or ceases entirely, but soon returns with increased violence—the discharges being a thin, serous fluid of a yellowish or greenish colour, and exhaling a strong acid smell. The face and extremities become cold; the pulse small and irregular; the respiration quick and short. The countenance becomes shrunken and pale. The child utters continually a low piteous moan, or lies upon his back, with the eyes fixed, glassy, and half closed. No pain or tenderness is indicated upon gentle pressure of the abdomen; the latter, however, is often greatly swollen and tympanitic. The child becomes more and more exhausted, and finally, expires quietly, and without convulsions. This appears to constitute that form of disease which is described by Camerer, Pomrner, Hergt, Romberg, Droste, and others, as gas- tromalacia; the stomach and intestines generally presenting, after death, a gelatinous softening of their parietes, to a greater or less extent, but without any indications of inflammation; the'softening appearing to depend upon a diminished cohesion of the tissues—the result of disordered or suspended nutrition. In older children, indigestion is usually the result of too much or improper food. Over-feeding is among the most common of its causes, and is often induced by parents supposing that the strength and growth of the body are best promoted by a large amount of animal food. Acid and unripe fruits, and the cakes and confectionery, with which children are so apt to overload their stomachs, very generally produce an attack of indigestion, attended with excessive nausea, a sense of weight and oppression about the praecordia, severe griping pains of the bowels, followed, sooner or later, by repeated vomiting and a copious diarrhoea; the attack being succeeded, in some cases, by long-continued loathing of food; and in others, by an augmented appetite; this difference depending, probably, upon the greater or less degree of irritation produced in the stomach. The affection of the stomach and bowels we have described as indi- gestion, is unattended with febrile excitement; it is essentially a dis- turbance or suspension of the functions of the digestive organs, in consequence of the food taken being too great in quantity, or un- INDIGESTION. 191 adapted in quality to undergo the changes necessary to its proper as- similation. We must, however, recollect, that in all cases, more or less disease of the mucous membrane of the alimentary canal is pro- duced, and that if the causes of the disease are continued, inflamma- tion of that tissue will be very liable to ensue; or, if this be not the case, from defective nutrition alone, softening of the stomach and bowels, or a disorganization of other organs may result. It is hardly necessary to enumerate the symptoms of indigestion, as it occurs during infancy and childhood, these having been already pointed out. They are, chiefly, uneasiness after eating, fretfulness and peevishness, nausea, griping or colicky pains, and frequent acid eructations, followed by vomiting, and generally by diarrhoea, the matters discharged by vomiting and stool being the food taken, par- tially or not at all altered, and exhaling a sour or rancid odour, and occasionally mixed with yellow or greenish bile; the absence of febrile symptoms and of tenderness of the epigastrium; more or less emacia- tion; with paleness of the surface, and, occasionally, flatulent disten- tion of the bowels. The appetite is often unimpaired or even in- creased. Not unfrequently the irritation is reflected from the bowels upon the brain, producing convulsions; or upon the nerves of the la- rynx, producing spasmodic constriction of the glottis; or inflamma- tion of the stomach and bowels may take place. In other cases, the vomiting or purging continuing unabated, extreme emaciation ensues, and the child dies from inanition. When indigestion is properly treated in its early stages, it is gene- rally a very manageable disease, and even at a later period it may often be remedied; but protracted cases, especially when we find it difficult to remove its cause, and when excessive marasmus has oc- curred, very generally terminate fatally. The dissections in cases of simple indigestion have been very rare; death seldom taking place excepting in protracted cases, or until structural changes have occurred in the alimentary canal or some other organ. Traces of inflammation are occasionally observed in the mucous membrane of the stomach or intestines; more commonly, however, there is a pale, anaemic condition of the membrane, with softening, sometimes in circumscribed patches, and in other cases in- volving a considerable portion of the mucous coat of the stomach or small intestines. This softening is evidently the effect of imperfect or suspended nutrition; it is also often met with in the brain and other organs. Portions of the intestinal tube are generally distended with gas, and have a transparent appearance, from the small amount of blood in the vessels, and the paleness of all the coats. A quantity of white frothy mucus is frequently found in the stomach and intes- tines. Invagination of the intestines is also a very common occur- rence. The treatment of infantile indigestion consists almost entirely in the removal of the cause by which the disturbance of the functions of the stomach has been produced. In young infants, when mere repletion of the stomach produces a regurgitation or vomiting of the milk, we have already pointed out 192 DISEASES OF THE DIGESTIVE ORGANS. the proper remedy; namely, preventing the infant from sucking too much at a time, and being careful not to place it too often at the breast; and when the irritability of the stomach is such as to cause the ejection of its contents upon the slightest motion communicated to the infant, being careful to allow it to remain at perfect rest for some time after it has been at the breast. A young infant is natu- rally inclined to perfect quietness, and generally to sleep, after suck- ing, and the interfering with this inclination is seldom unattended with injury. Rude dandling> jogging upon the knee or in the cradle, jolting in the arms, or even carrying a young infant rapidly up and down the room, is at all times improper, but particularly so imme- diately after taking it from the breast. Whenever the milk of the mother is found to disagree with the in- fant's stomach, if the cause of this be under the control of diet and regimen, it should be at once removed. When the cause cannot be traced to the condition of the mother's milk, it will, in general, be found to result from the injudicious over- loading of the infant's stomach with some kind of pap or panada,— articles which are invariably injurious, even when, from a deficient supply of milk on the part of the mother, additional aliment is re- quired. In addition to the proper regulation of the infant's diet, the func- tions of the skin should be promoted by the daily use of the warm bath, followed by gentle friction of the surface ; and when the weather will permit, the child should be carried into the open air daily. Riding short distances in an open carriage, or sailing in a boat, when practicable, will invariably be found advantageous. The body should be preserved of a proper and equable temperature, by appropriate clothing, and by rooms sufficiently heated in winter, and well venti- lated in summer. Medicine of any kind will seldom be required. When considerable nausea and retching occur without free vomiting, it may, however, be proper to unload the stomach by a gentle emetic of ipecacuanha. If considerable acidity of the stomach exists, a dose of calcined magnesia may be given; or, if the bowels are constipated, a dose of equal parts of magnesia and rhubarb; if diarrhoea be present, the simple creta- ceous mixture, or what we prefer, the prepared chalk in powder, com- bined with small doses of ipecacuanha, will be proper. R.—Cretas ppt. gj. Ipecacuanhas, pulv. gr. ij. ad iij.— M. f. ch. No. xij. One, to be repeated every three hours. Dr. Kuhn preferred, in all cases of acidity affecting the alimentary canal of children, and unattended with inflammation, the aqua ammo- nia, to either the magnesia or carbonate of lime. He prescribed it in the following formula. R.—Aq. puras, giij. Gum. acacias pulv. "^ij. Sacch. alb. puras, gij. Aq. cinnamom. simpl. vel, Aq. anisi, ^ss.—M. et adde Aquas ammoniae, nij xlviij.—lxxx. A teaspoonful to be given every one, two, or three hours; according to circumstances. INDIGESTION. 193 When the infant is troubled with severe griping pains, the warm bath, frictions with some anodyne liniment, followed by warm fomenta- tions to the abdomen, and the use of the aqua ammonia as directed by Dr. Kuhn, will be found in many cases to afford prompt relief. ' The remedy from which we have seen the best effects to result in the colic of children from indigestion, is a combination of magnesia, extract of hyoscyamus, calomel, and ipecacuhana.1 In some cases, a few drops of aq. camphora, or of the ethereal solution of camphor, will promptly allay the colicky pain.2 Three to five drops of spirits of turpentine, mixed with a little sweetened water, and repeated in the course of an hour, will, also, often produce a decidedly favourable effect. 1 R.—Magnesias calc. 9'jss. ad. ^j. 2 R.—Camphorae, 3J. solve in Ext. Hyoscyami, gr. viij. ad. xij. iEther. Sulphuric, ^j. Pulv. Ipecac, gr. iij. Add thirty drops of this solution to one Calomel, gr. iij.—M. f. chart. No. ounce of simple aniseed water, with xij. two drachms of refined sugar. The One to be given every two or three hours. dose is one or two teaspoonfuls, ac- cording to the age of the child. When, however, the pain is very intense, and is not promptly allayed by the remedies already enumerated, a dose of tincture of opium, adapted to the age of the child, may be given, in a little sweetened aniseed water, or it may be administered in the form of enema com- bined with thin starch. Great caution should, however, be observed in the employment of opiate enemata in the affections of infants— neither to resort to them unnecessarily, nor to repeat them too often. The opiate should be, also, in small doses, and its effects carefully watched, as very minute doses of the tincture of opium have, even when injected into the rectum, not unfrequently proved fatal to infants. In cases of indigestion attended with frequent and copious dis- charges from the bowels, it will, occasionally, be prudent to administer some slight astringent. The tincture of kino will, in general, very promptly suspend the diarrhoea; it may be given in combination with the cretaceous mixture. R.—Mucilag. G. acacias, ^ij. Sacch. alb. purae, gij. Aq. cinnamom. Jj. Cretas, ppt. 9'j. Tine. Kino, 3J. ad £ij.— M. A teaspoonful three times a day. In cases of indigestion from too early weaning, when practicable, the infant should be reapplied to the breast, or, if this cannot be effected, it should be confined entirely to milk and water, sweetened with loaf sugar, as directed in our section on the diet of infants. The indigestion occurring at the period of weaning is usually very readily managed by a proper attention to diet, the warm bath, daily exerefse in the open air, when the weather will permit, and the re- moval of any symptom of unusual severity that may occur by the re- medies already detailed. In the indigestion of older child»en, it will be proper, in most cases, to administer an emetic of ipecacuanha, followed, if the bowels are much disturbed, by a moderate dose of magnesia and rhubarb; after 13 194 DISEASES OF THE DIGESTIVE ORGANS. which, a proper regulation of the diet, as well in regard to quality as to quantity, will, in general, very speedily remove every unpleasant symptom, and restore the regularity and activity of the digestive func- tion. Confining the patient, for a short time, to a milk and farina- ceous diet alone, or with the occasional use of plain meat broths, with the addition of rice or crackers, will be proper. All species of pastry and confectionery, crude and acescent fruits, and flatulent vegetables, should be strictly proscribed. Every case of indigestion occurring in children should be carefully scrutinized and cautiously watched, and if any symptom indicative of the occurrence of even a slight degree of inflammation in any part of the gastro-intestinal mucous membrane be detected; if the skin be- comes dry and parched, the tongue red at its edges and extremity, and coated on its upper surface with a whitish mucus; or if increased heat of the epigastrium, with tenderness or pain upon pressure, are found to exist, leeches and fomentations to the abdomen, with cool mucilaginous drinks internally, will be demanded. In protracted cases, with entire suspension of the function of the stomach—the food and drinks passing through the bowels without change almost as soon as they are taken—but little can in general be done to prevent a fatal result. In some cases much benefit, however, has resulted from the use of a cold infusion of bark, with the addition of a few drops of hydrochloric acid; or of the tincture of the sesqui- chloride of iron, or chalybeate wine in small doses—one or two drops of the first, and from three to six of the latter, in a teaspoonful of water. We have occasionally seen good effects result from the carbonate of iron, combined with hyoscyamus and acetate of lead. R.—Ext. Hyoscyami, gr. vj. ad viij. Carb. Ferri, gr. xxiv. ad xxxvj. Acetat. plumbi, gr. xij.—M. f. chart. No. xij. One to be given every three hours. Friction along the spine with the weak liniment of ammonia, re- peated daily, and frequent exposure to the open air, by riding in a carriage, will, in genera], be found useful. The diet should consist exclusively of beef-tea or milk, with the addition of rice flour or arrowroot. What would be the effect of tannin, or of the pure sul- phate of alumina in these cases, we are not prepared to say—never having had an opportunity of making a trial of them. In that form of infantile indigestion in which softening of the sto- mach is most likely to occur, trial may be made of the hydrochloride of iron, which appears to have frequently succeeded in restoring the healthy functions of the stomach, in the hands of Pommer, Hergt, Camerer, Droste, and others. R.—Ferri bydrochlorid. gr. x. ad xv. Mucil. G. Acacias, giij. Sacch. alb. pur. gij.—M. A dessert-spoonful to be given every hour. Or, R.—Tinct. Ferri. sesquichlorid. Extract cinchonas, aa, Qss. Aq. flor. aurant. ^ij. Syrup, cort. aurant. £j.—M. A teaspoonful to be given every hour. INFLAMMATION OF THE STOMACH. 195 2.—Gastritis. Inflammation of the Stomach. Inflammation of the mucous coat of the stomach is of more frequent occurrence during infancy and childhood than is generally supposed. It varies in degree, in different cases, from a slight erythematic in- flammation, confined to a small portion of the gastric mucous mem- brane, and attended by symptoms so obscure as to cause its exist- ence, in its earlier stages, to be entirely overlooked; to an intense inflammation of the greater part of the stomach and bowels, accom- panied by symptoms of a very decided and violent character, and rapidly producing disorganization of the tissues in which it is seated. It is seldom that the stomach is alone affected; in the great majority of instances, the inflammation extends to the duodenum, and the other small intestines. The leading symptoms of gastritis in the infant are retching or vomiting; increased heat and tension of the epigastrium; shrinking and painful cries when this part is compressed; an expression of coun- tenance indicative of distress; a dry, parched skin; redness of the point and edges of the tongue; a coating of white mucus over its surface, through which the enlarged and florid papillae protrude; great restlessness; a small and contracted pulse, often greatly in- creased in frequency; augmented thirst, and generally, aversion from food. These symptoms vary in intensity, in different cases, and are often complicated with others, arising from disease of adjoining or remote organs, by which the gastritis has been preceded, or which became developed simultaneously with, or subsequently to its occur- rence. The most constant symptoms are, frequent vomiting, heat, tension, and pain upon pressure of the epigastrium, and an expression of countenance indicative of suffering. The vomiting is most liable to occur upon any drink or food being taken into the stomach, which is almost immediately rejected. The vomiting is occasionally attended with considerable retching, and is evidently, in severe cases, a cause of much suffering to the patient. The matters vomited are the food and drinks taken, or a thick, ropy, or frothy mucus, often mixed with yellow or greenish bilious matter;— brownish or dark brown, and even bloody discharges are occasion- ally observed. The matters vomited are not unfrequently decidedly acid. Some degree of heat and tension of the epigastrium is seldom absent. These symptoms are at first generally slight; but when the inflammation of the stomach is fully established, and of any degree of intensity, the heat and tension of the abdomen are usually very considerable; the heat of this part, in many cases, being the more marked, from the temperature of the surface generally not being augmented, while that of the lower extremities is perhaps reduced. The tenderness of the epigastrium may be detected only upon pres- sure ; by the patient starting and moaning, or crying out with the pecu- liar acute tone belonging to the cry from pain; or it may be to such an extent as to render the slightest touch a source of suffering, and to 196 DISEASES OF THE DIGESTIVE ORGANS. cause the patient to lie upon his back, with his knees drawn up. In these cases, the countenance, as well as the restlessness and constant cries of the infant, indicate the severity of its suffering. When the child is old enough to express his feelings, he, in general, complains of a burning pain in the stomach. When the gastric pain is severe, respiration is short and quick, and performed, almost exclusively, by the ribs. Diarrhoea is commonly present; the matters discharged from the bowels being at first faecal, but, subsequently, similar to those ejected by vomiting. Gastritis is occasionally, however, attended with con- stipation. The disease is often, especially in young infants, unattended, throughout, with any degree of febrile excitement; occasionally, how- ever, there is considerable fever, with a hot and burning skin, quick and frequent pulse, and delirium, or a tendency to coma. In general, the febrile symptoms are remittent, with exacerbations toward eve- ning or even later. Gastritis may terminate in resolution, ulceration, or gangrene, or in softening of the gastric mucous membrane, or of the whole of the coats of the stomach, causing a perforation of the organ. In violent cases, great prostration of strength, attended with profuse perspiration about the head and face, subsequently extending over the greater part of the body, hiccough, cold extremities, a sinking of the pulse, and often convulsions, early occur, and are, generally, speedily followed by death. The disease may become chronic, and continue for a length of time, with occasional vomiting—some degree of tenderness and tension of the epigastrium—irregular appetite—occasional diarrhoea, alternating with costiveness—a dry and harsh condition of the surface—febrile symptoms of a remittent character—and progressive emaciation. White softening of the stomach, with perforation, may occur in these cases; or, the brain may become affected, and effusion in that organ take place; or, tubercles becoming developed in the lungs, the patient may die with all the symptoms of tubercular phthisis. The causes of gastritis in children are, either irritating substances —improper or deteriorated articles of food, or some acrid or poisonous matter—introduced into the stomach; cold and moisture applied to some portion of the surface; sudden alternations of temperature; the sudden suppression of cutaneous eruptions, or of the discharge from ulcerations behind the ears. In many cases, particularly in young in- fants, the inflammation of the stomach is preceded by an attack of stomatitis; in others, the stomatitis occurs subsequently to gastritis. The disease would appear to prevail, occasionally, as an epidemic. Inflammation of the stomach, however, rarely occurs in children as a primary affection; in the great majority of cases, it becomes developed in the course of other diseases. The appearances observed after death, are injection and redness, with thickening, or a softened condition of the mucous membrane of the stomach. The redness may consist in simple injection of the blood-ves- sels, and present an arborescent arrangement:—this occurs chiefly in the INFLAMMATION OF THE STOMACH. 197 slighter cases of the disease:—when the inflammation is more intense, the redness is more or less diffuse; or it occurs in patches of a greater or less extent—or in irregular striae, which follow, generally, the course of the corrugations of the stomach, or in numerous, closely approxi- mated red points. (Billard.) The stomach often contains a quantity of thick, tenacious mucus. The papillae, or villosities of the mucous membrane, appear occasionally to be somewhat enlarged. In a few cases, large patches of curd-like exudation adhere to the mucous mem- brane ;—in others, the follicles of the stomach are morbidly developed, forming a number of small, rounded granulations, of a white colour, terminating in a black point; or the mucous membrane may be the seat of aphthous ulcerations, or of ulceration extending through the in- ner and middle coats. When the inflammation of the stomach terminates in gangrene, which is of exceedingly rare occurrence, (we have never met with a single case,) sloughs of various extent, implicating the whole of the coats of the stomach, occur, which, on becoming detached, give rise to perforations; or the mucous membrane alone may be reduced to a gangrenous condition. In cases of gelatinous softening of the stomach, the mucous mem- brane alone may be found reduced to a jelly-like consistence; or the softening may extend to all the tissues of the stomach, rendering them liable to be perforated by the slightest force; or a complete perfora- tion of the coats of the stomach may have occurred. All these conditions may exist in the same stomach at different points. These softenings, or perforations, occur especially at the great curvature, seldom extend- ing beyond the most depending parts. Some observers, however, de- scribe the softening as involving, occasionally, the greater part of the mucous membrane. Distinct traces of inflammation^ are frequently observed surrounding the softened parts; and the parietes of the sto- mach often present a serous infiltration. Rilliet and Barthez describe the softening as being, in some cases, to such an extent that by the slightest scraping the mucous membrane is reduced to a soft amorphous mass, leaving bare the submucous tis- sue. This degree of softening occurs only in very severe cases, and coincides almost always with a decided uniform redness of the stomach. In the ordinary run of cases, the mucous membrane, which still pre- serves a certain degree of consistence, gives way upon the slightest scratching, and is thus easily removed. (Maladies des Enfans, Tome lr> 444.) . . Many pathologists have denied the connexion, in any instance, ot softening of the stomach with inflammation, and maintain that, in the majority of cases, it is a cadaveric phenomenon, resulting from the action of the gastric juice upon the tissues of the organ; others, with Jaeger, Zeller, and Camerer, refer it to a paralysis of the nerves of the stomach, with increased acidity of the gastric fluid, by which the sto- mach is dissolved during the lifetime of the patient. A somewhat similar opinion is entertained by Laisnd, Chaussier, Desbarreaux, Ber- nard, and others. Dr. Messner gives a table of one hundred and seventeen cases, in 198 DISEASES OF THE DIGESTIVE ORGANS. which softening, either of the stomach, oesophagus or intestines, or of the lungs, or hemorrhagic erosion of the gastric mucous membrane ex- isted. From the facts developed by these he arrives at the following conclusions: "The so called softening of the alimentary canal and lungs is a result of the fermentative action which occurs primarily in cholera, and secondarily in the other affections of children. Softening can invade the mucous membrane during life; perforation of all the coats occurs first after death. It is rarely an object of diagnosis, never one of therapeutics." Herrich and Popp, (Der Plotzlichen Tod.,) give a table of one hun- dred and four cases, in which softening of the stomach was discovered after death, under various morbid conditions and in various ages. In no one of which cases were symptoms observed that would have enabled any one to declare during the lifetime of the patient, that softening would be found upon a post mortem examination. Without denying that the stomach may be dissolved after death, in consequence of the generation in its cavity of an excess of acid, and being well aware that a softening of the tissues of the stomach, and of other parts of the alimentary canal, may be produced by causes affect- ing the nutrition, and impairing the cohesion of the various tissues, altogether independent of inflammation, we are still convinced, from the result of our own observations, that the gelatinous softenings, so frequently observed in children who have died of acute gastritis, is in- variably the effect of intense inflammation of the mucous and other tissues of the stomach. Increased redness and softening of the gastric mucous membrane, remark MM. Rilliet and Barthez, when they occur together, are suffi- cient indications of inflammation, of the existence of which there can be no doubt, when to these is added a thickening of the mucous mem- brane. In general, the thickened parts project slightly above the healthy portions of the membrane, but without its limits being marked by a decided boundary. The thickening often occupies several very small portions of the membrane, very near to each other. It may be described as a swelling of the villi, rendering them projecting, firm, and enlarged. The surface of the mucous membrane is, in consequence, rendered rough or granulated like chagrin. This appearance coin- cides most frequently with a more general thickening of the mucous membrane, and indicates a violent inflammation. The subjacent tissues of the stomach are not involved in the thick- ening. Under certain circumstances, however, particularly when the inflammation is of a chronic character, the submucous tissue becomes somewhat hypertrophied, fibrous, hard, and resistant, the part feels heavy, and as if its substance were increased. The treatment of gastritis is that proper in cases of inflammation generally, modified somewhat by the seat of the disease, and by the age of the patient. Leeches should be applied to the epigastrium, in numbers proportionate to the violence of the symptoms; and if the attack be one of considerable intensity, occurring in a robust and plethoric child, and not too young to permit a vein to be opened in the arm, general bloodletting will be found of advantage. The necessity for a repetition of the leeches will depend upon the particular charac- INFLAMMATION OF THE STOMACH. 199 ter of the attack, and the effects produced by the first application. Should the tenderness and heat of the epigastrium continue with little abatement, after the first application of the leeches, it will be proper to renew them. In general, however, a less number will be required than at first. The leeches should be followed by warm fomentations, or by a soft emollient cataplasm over the epigastrium;—the fomen- tations and cataplasm being renewed at short intervals. The occa- sional use of pediluvia of warm water, with the addition of a small quantity of mustard, will, in general, be productive of good effects, and should not be neglected. The diet and drink of the child should be composed exclusively of some simple mucilage, as gum-water, or water in which the pith of sassafras or the slippery elm bark has been infused. These should be given cold, and in small portions at a time. The occasional adminis- tration of a spoonful of cold water, we have found to be peculiarly grateful to the patient, and often to remain upon the stomach, when everything else is instantly rejected. It is hardly necessary to say, that if the child is at the breast, it should not be allowed to suck so long as the inflammation of the stomach continues, excepting at long intervals, and for a very short period each time. A considerable difference of opinion exists, as to the propriety of administering remedies internally, in this disease;_ some proscribing them entirely, trusting the cure of the inflammation exclusively to external means; while others think it very necessary to administer, in the early stage of the attack, some mild purgative, especially if a costive Btate of the bowels exists. We have been in the habit, immediately after the application of leeches to the epigastrium, or the employment of general bleeding, when this has been indicated and admissible, to administer to the pa- tient calomel in small doses, repeated at short intervals—say from the sixth to the half of a grain every one or two hours. This we have known, in a large number of cases, to suspend, very promptly, the ir- ritability of the stomach, and to produce a favourable change in the symptoms generally. In cases attended with frequent thin, acid eva- cuations from the bowels, the calomel we have found very generally to arrest the diarrhoea, and render the stools of a more consistent and natural appearance. We ordinarily combine with each dose of the calomel a grain or two of calcined magnesia, and give it mixed in a little mucilage: but where there exists a very great irritability of the stomach we direct the calomel, combined with a few grains of pow- dered gum acacia, to be placed dry upon the tongue, the child being shortly afterwards given to drink a spoonful of thin mucilage. After the inflammation of the stomach is somewhat reduced, a blister to the epigastrium will often be found of essential service; when too early applied, blisters, however, have appeared to us to do more harm than good. The blister should be kept on only sufficiently long to pro- duce a redness of the skin, and then removed, and the epigastrium covered with a common bread-and-milk poultice. In young children great inconvenience, and often severe and protracted suffering have been the result of a blister being allowed to remain until vesication occurs. 200 DISEASES OF THE DIGESTIVE ORGANS. Inflammation of the stomach in its most acute form is often attended with a condition of the pulse and surface, and a degree of extreme pros- tration, which have induced the inexperienced practitioner to sup- pose that some remedy adapted to support the strength of the patient, was demanded; in every instance, however, its use will be found to aggravate the symptoms, and hurry on a fatal result. In these cases, of extreme prostration, with a cool skin, and small thready pulse, we have repeatedly seen the most beneficial results, from the use of the warm bath, repeated daily—in some instances, night and morning. The chronic form of gastritis is to be treated by a mild, unirritating diet, of some farinaceous preparation, with milk—by the warm bath— and blisters to the epigastrium, frequently repeated. In this form of the disease, we have derived great advantage from small doses of ca- lomel, combined with ipecacuanha and extract of hyoscyamus. R.—Calomel, gr. iij.—iv. Magnes. calc. gr. xxxvj. Ipecacuanhas, gr. ij.—iij. Ext. hyoscyami, gr. iv.—vj.—M. f. chart. No. xij. One to be given every three hours. If a frequent and troublesome diarrhoea is present, from half a grain to a grain of acetate of lead may be added to each dose. In that form of the disease which is attended with gelatinous soften- ing of the stomach—the occurrence of which, sooner or later, may be suspected, from the severity of the symptoms at the very commence- ment of the attack; the yellowish or greenish matters ejected from the stomach and bowels, the latter particularly being often extremely acid; the coldness of the extremities; the habitual expression of suffering which the countenance of the patient assumes, and the general state of prostration that early ensues—the most energetic treatment is de- manded, from the very onset of the disease. The remedies differ in nothing from those proper in other cases of acute gastritis. The early and judicious detraction of blood from the arm, or by leeches, to an extent commensurate with the violence of the disease, and the age of the patient, will often promptly abate the intensity of the inflamma- tion, and prevent the occurrence of disorganization of the stomach or limit its extent. In cases attended with repeated vomiting, or copious diarrhoea, and with a rapid depression of the powers of life—where there is every reason to fear a gelatiniform softening of the stomach,—Rilliet and Barthez recommend the administration of the gummy extract of opium either in a pill or dissolved in water, in doses of one centigramme every two hours, until three centigrammes (not quite half a grain) shall be taken during the day.—When no accident results, and when the age of the child will permit of it, they give the opium every hour in the same dose, stopping when five centigrammes (rather more than three- quarters of a grain) have been taken. When any obstacle exists to the administration of the remedy by the mouth, they recommend to sprinkle, twice a day, over a small blistered surface upon the epigas- trium, half a centigramme (about one twelfth of a grain) of the hydro- chlorate of morphia. ENTERALGIA— COLIC. 201 It is hardly necessary to say, that the hydrochloride of iron, recom- mended by Pommer, Hergt, and others in gelatinous softening of the stomach, is not adapted to the softening from acute gastritis; the cases in which it has reported to have been employed with advantage, were evidently those from defective or disturbed nutrition, unattended with inflammation. The utmost care should be paid to the diet and regimen of the patient, for a long period after his recovery from an attack of gastritis, as the disease is one very liable to relapse from slight causes, but par- ticularly from errors in diet. The food should consist, if not of the breast-milk of the mother or a healthy nurse, chiefly of milk and fari- naceous articles in moderate quantities. Gentle exercise, at first of a passive kind, should be taken daily, when the weather is fine, in the open air. The daily use of the warm bath should not be neg- lected. The surface should be preserved of a comfortable and equal temperature, by appropriate clothing, and by rooms properly warmed and ventilated in cold weather, and cooled by the admission of a current of air, and the exclusion of the sun's rays, during the heat of summer. We have said nothing of the treatment of gastritis from the acci- dental ingestion of poisonous substances into the stomach, which oc- casionally happens during infancy and childhood:—with the excep- tion of the administration of such articles as have been found to sus- pend the action of, pr to neutralize whatever poison has been taken, the same remedies precisely are demanded, as in the cases of ordinary gastritis. CHAPTER V. DISEASES OF THE INTESTINES. 1.—Enteralgia.— Colic. Intense pain of the bowels is of frequent occurrence during in- fancy. We have already noticed its connexion with indigestion, and the means best adapted for its relief, in such cases. Enteralgia, how- ever, often occurs during infancy, under circumstances where we have no reason to suspect, as its cause, any disturbance of the digestive function from the bad quality or undue quantity of the food. We have known it to occur daily, during the first month or two, and nearly at the same period of the day—generally towards the latter part of the afternoon. Dewees remarks that it generally occurs be- tween four and six o'clock, p. m. ; while others have noticed its oc- currence at a regular period, in the morning or forenoon. In most cases, this species of colic is attended with the formation of gas within the intestines, and, occasionally, the tumid and tympa- nitic state of the abdomen is very considerable. In other cases, howT- ever, little or no flatulence is perceptible, the paroxysms of pain oc- 202 DISEASES OF THE DIGESTIVE ORGANS. curring at irregular intervals, and being readily induced by the feet becoming cold or wet. We have not been able to examine the pathological condition of the alimentary canal in cases of simple enteralgia, never having known death to occur from it. In slight attacks of colic, the infant becomes suddenly very fretful, draws up its knees, cries for a few minutes, and then resumes its usual quiet state, as though nothing had occurred. These attacks may be repeated at shorter or longer intervals, and seldom cease permanently, or for any length of time, until a portion of gas is discharged by the mouth or per anum, or an evacuation of faeces, often thin and frothy, takes place. In more violent attacks, the infant commences, suddenly, to utter sharp, piercing screams, which are often long continued, or only inter- rupted by a few moments of quiet; the knees are forcibly drawn up, or the legs are drawn up and extended in rapid succession; the trunk of the body is occasionally forcibly extended, with the head thrown back, and the hands firmly clenched. The expression of the counte- nance indicates severe suffering; the face being occasionally flushed, or covered with large drops of perspiration. The abdomen is often distended, tense, and tympanitic, or presents an irregular or knotted surface. No pain is induced by pressure upon any part of the abdo- men ; gentle pressure and frictions appear, indeed, in most cases, to afford decided relief. Notwithstanding the severity of the paroxysms, in this form of colic, the child, immediately upon their cessation, becomes quiet, cheerful, and playful, and exhibits nothing in its appearance to indi- cate the severity of its recent sufferings. Its appetite is seldom im- paired, the digestive and nutritive functions are in no degree dis- turbed or interrupted, and the general health seems, often, actually to improve; as Dr. Dewees very correctly remarks, some of the fattest and healthiest children are those affected with it. It is a popular nursery opinion, that boys are more subject to this form of colic than girls; but we have not observed it to occur more frequently in one sex than in the other. Dr. Parrish has described a species of enteralgia which we have occasionally met with. The child often screams out suddenly, throws itself back and stiffens its body, as in cases of flatulent colic; the paroxysm ceases, generally, in a few moments, and is succeeded by a state of perfect ease. Even when the pain is less severe, the peculiar motions and complaints of the infant are such as experienced mothers and nurses immediately attribute to uneasiness in the cavity of the abdomen. Flatulent discharges by the mouth or anus are frequently productive of great relief. The formation of gas within the intestines is generally very abundant, producing, often, a tympanitic swelling of the abdomen. The peculiarity of this variety of enteralgia consists in its being ac- companied by a species of convulsion, resembling an epileptic fit; from which it differs, however, in the patient, immediately on its cessation, becoming quite sensible, and sometimes even playful. Occasionally, ENTERALGIA—COLIC. 203 two or more of these convulsive attacks will occur in quick succession, and then days and weeks will elapse before their return. If not arrested, however, they become more frequent and distressing; and at length the infant is almost constantly affected with severe spasms or partial convulsions, and finally sinks under the disease. It occurs usually in infants, between five and twelve months of age. According to the observations of Dr. Parrish, if the child survive the period of dentition, it is usually safe. In the only case in which a post-mortem examination was made, the greater portion of the small intestines were found irregularly contracted, being reduced, in some parts for more than an inch in extent, to the size of a goose-quill; in other parts, the caliber of the intestine was almost entirely obliterated, as if it had been tied with a thread. The omentum was folded up in the form of a thick twine or small rope, and lay upon the arch of the colon. The gall-bladder was filled with a light-coloured glairy fluid. No other indication of disease was de- tected in the cavity of the abdomen or thorax. The brain unfortu- nately was not examined. The peculiar phenomena of the species of enteralgia described by Dr. Parrish, evidently result from some degree of cerebral or spinal irritation being combined with the neurosthenic condition of the in- testines. The occasional causes of enteralgia are but little understood. A very attentive study of the disease has not enabled us to detect any particular circumstance under which it is most liable to occur. It may appear at any period between birth to the termination of the first dentition; but we have met with it, most frequently, within the first three or four months. It is very commonly attended with an habitu- ally constipated state of the bowels, and the paroxysms are often ex- cited by allowing the feet to become wet and cold. The disease is not necessarily connected with any degree of inflammation of the alimen- tary canal, though, in very severe cases, we have known enteritis to become developed at an early period. Dr. Parrish, who refers that form of enteralgia described by him to "intestinal spasms," remarks that "there can be no doubt that it is greatly aggravated by difficult dentition." The treatment of enteralgia may be divided into that proper during the paroxysms, in order to allay the violence of the pain, and that during the intervals, to prevent their recurrence. During the paroxysms, the warm bath and warm fomentations to the abdomen are among our most valuable remedies. We have found prompt relief often to be produced, by applying to the abdomen, after immersion in the warm bath, a cataplasm formed of hops steeped in warm water and enclosed in a thin gauze bag. The bowels should be opened by an injection of warm water, to which a few grains of assa- foetida, dissolved in milk, may be advantageously added. Internally we have occasionally administered, with prompt relief, a few drops of aqua camphora, or of spirits of turpentine rubbed up with sugar. Three to five drops of spirits of turpentine may be given to an infant, and repeated, every one, two, or three hours, according to the urgency of the case. 204 DISEASES OF THE DIGESTIVE ORGANS. When, however, the paroxysm is one of uncommon severity, and does not promptly yield to the means that have been enumerated, we have never hesitated to administer an opiate, either by injection or by the mouth, graduating the dose according to the age of the infant, and carefully watching its effects before venturing upon its repetition. We have been much pleased with the effects, in the colic of infants, of a watery infusion of opium. Five grains of opium may be infused, for three hours, in two fluid ounces of boiling water; the infusion being then filtered, ten grains of bicarbonate of soda are to be added; of this, ten drops may be given, with perfect safety, to a child within the month, in a little sweetened aniseed water—the same dose being repeated after an hour, if necessary. When the bowels are distended with gas, prompt relief may be occasionally obtained by the introduction into the rectum of a large gum elastic catheter, or a common enema syringe. In the species of enteralgia described by Dr. Parrish, he directs the bowels to be freely evacuated by castor oil, magnesia, or some other gentle cathartic; blood to be taken from the arm, or, by leeches from the abdomen; the child to be immersed in a warm bath, antispas- modics, particularly the assafoetida, to be given by the mouth, and as an enema. According to the age of the child, from two to five grains of assafoetida may be administered by the mouth every two hours in the form of emulsion, and from ten to twenty grains as an enema, repeated, more or less frequently, according to circumstances. If the assafoetida is not retained upon the stomach, or produces, when injected into the rectum, an unpleasant irritation, the rectified oil of amber, two to five drops, rubbed up with gum acacia, loaf sugar, and cinnamon water, may be substituted. If there should be intense pain, a few drops of lau- danum may be combined with the assafoetida or oil of amber, or from four to eight drops of laudanum may be injected into the rectum. Dr. Parrish likewise directs frictions along the spine with a liniment com- posed of oil of amber and laudanum, of each a teaspoonful, and olive oil and brandy, of each a table-spoonful; and, in severe cases, a large blister to the abdomen:—the distention of the bowels being at the same time relieved, by abstracting the accumulated gas by means of a syringe introduced per anum. In the few cases which we have seen of this form of enteralgia, we have succeeded in affording very speedy relief, by the use of the warm bath, followed by warm fomentations to the abdomen, injections com- posed of assafoetida dissolved in milk, and the administration of a few drops of aqua camphora, or of spirits of turpentine, in a spoonful of sweetened aniseed water. In severe cases, the application of a few leeches behind each of the ears, we have invariably found to produce a decidedly beneficial effect. From the evident tendency to cerebral disease in these cases, we have been deterred from the use of opium, and have never seen any advantage to result from the application of a blister or any stimulating embrocation to the abdomen. A cataplasm of hops steeped in hot water, or cloths wrung out of warm water, and then sprinkled freely with laudanum, has occasionally been followed with very decided relief. Frictions along the spine with the oil of amber, as directed ENTERALGIA—COLIC. 205 above, and the removal of the gas from the bowels by a tube or syringe, introduced into the anus, are unquestionably productive of good effects. In the intervals between the paroxysms of the usual form of ente- ralgia of young infants, we feel at a loss to say what ought to be done to prevent their recurrence. The child appears to enjoy perfect health; the functions of its organs generally are regularly performed; and in the majority of cases it is difficult to detect any cause to which the production of the disease can be referred. There is frequently, how- ever, an habitually inert condition of the bowels; this we should en- deavour to counteract by a proper regulation of the diet of the mother, which should be composed principally of articles of a laxative charac- ter, and the child should be immersed daily in a warm bath, followed by gentle frictions over the abdomen. The occasional use of laxative enemata will often be found beneficial; a very good one is that com- posed of milk and molasses, with a slight addition of chloride of so- dium; or a suppository, formed of the common resinous soap, about one inch long, and a quarter of an inch thick, shaped round, and slightly tapering to a point, may, after being dipped in water, be passed within the anus. The introduction of a large-sized urethra bougie a few inches up the rectum will generally cause an evacuation, and is attended with less irritation and inconvenience than either in- jections or suppositories. In some cases of habitual costiveness, according to Merriman, frictions over the abdomen, daily, with a mix- ture of one ounce of soap liniment and half an ounce of the compound tincture of aloes, have been found sufficient to maintain a regular state of the bowels. We have derived the best effects, as well in counteracting an habitu- ally costive habit in infants, as in preventing the recurrence of parox- ysms of colic, from the use of a combination of extract of hyoscyamus, ipecacuanha, and magnesia, in small doses. R.—Ext. hyoscyami, gr. iv. ad vj. Magnes. calc. gr. xxiv. ad xlviij. Ipecacuanhas, gr. ij. ad iij.—M. f. ch. No. xij. One to be given every three hours. Castor oil, which is usually given to obviate the inert state of the bowels in infants and young children, will in most cases be found to increase rather than to remove it. Care should be taken to keep the child's feet dry and warm, by pro- per clothing, and by changing the stockings or socks the moment they become we£ and thoroughly drying the feet before the fire or by gentle friction with a soft cloth, previously to putting others on. ^ Dr. Dewees, viewing the disease as one of a strictly periodical cha- racter, administered a decoction of bark, in many cases with the hap- piest effect; in others, however, no benefit resulted from its use. Dr. Eberle has seen good effects from the cyanuret of iron, in combination with powdered valerian, in the proportion of half a grain of the first to three grains of the latter, for a child between two and three months old; the dose to be repeated every three or four hours, during the intervals of the paroxysms. 206 DISEASES OF THE DIGESTIVE ORGANS. To prevent the recurrence of the convulsive form of enteralgia, Dr. Parrish directs a proper regulation of the diet of the child; attention to the state of the gums, which, if inflamed, are to be freely lanced, and the operation repeated whenever the incisions heal, so long as the continuance of the inflammation may render it advisable; with blisters behind the ears, kept open by some stimulating dressing; and, if there exist acidity of the stomach and bowels, the frequent administration of some alkaline remedy. Dr. Parrish directs the alkaline infusion of Physick, diluted to suit the palate of the infant, in doses of a tea- spoonful every two or three hours;—we should certainly prefer, in these cases, calcined magnesia, or carbonate of soda. The following will be found to be a very excellent prescription in most instances. R.—Mucil. G. Acacias, ^iij. Sacch. Alb. pur. giij. Spir. Terebinth, sy. Magnes. calc. gr. vij.—M. A teaspoonful to be given every three hours. In every case of severe colic occurring in children, the symptoms should be carefully scrutinized, and attentively watched; inflammation of the bowels being very apt to occur, which, the moment it is detected, should be met by its appropriate remedies. 2.—Diarrhoea. Notwithstanding that diarrhoea is one of the most common symp- toms of an inflammatory condition of the alimentary canal, it neverthe- less occurs in a large number of cases from a degree of irritation of the intestinal mucous membrane, which cannot be considered as amount- ing to actual inflammation; it would seem necessary, therefore, to consider it separately, as its treatment differs in many important par- ticulars from that proper in the diarrhoea attendant upon enteritis. In infancy, diarrhoea may be caused, independently of inflammation of some portion of the gastro-intestinal mucous membrane, by impro- per articles of diet, by excess in feeding, by cold and damp, by the irritation of teething, and by excessive heat, combined with an impure and stagnant state of the atmosphere. The excitable condition of the alimentary canal in infants renders them particularly liable to the occurrence of diarrhoea from slight causes; it is, consequently, an affection of far more frequent occur- rence during the early period of life, than at any subsequent age. It may last for only a few hours, and then cease spontaneously, or the evacuations may occur every few minutes, and continue, with little or no abatement, for a considerable length of time; exhausting the strength of the patient, and producing extreme emaciation, with- out, in many cases, the occurrence of inflammation. When, however, the diarrhoea assumes a protracted form, it will very generally be found to be dependent upon subacute inflammation of the intestinal mucous membrane. In the diarrhoea of infants, the discharges from the bowels may be more or less thin, of a dirty white or grayish colour, of a curdled ap- pearance, and of a decidedly acid odour, or they may be almost en- DIARRHC3A. 207 tirely fluid, of a bright yellow or greenish hue, and often mixed with blood. In older children, the discharges may be thin and feculent, yellow, green, or dark brown; or they may consist, at first, of portions of un- digested food, very acid, and often, when the diarrhoea has resulted from the use of crude acescent vegetables, in a state of fermentation. Occasionally the discharges are very thin and watery, without any de- cided smell, and nearly colourless; or they may be composed of a fluid mixed with bile, of a yellow or green colour. In many cases, par- ticularly during dentition, the stools consist, almost exclusively, of a thick, jelly-like, semi-transparent mucus. In the more prolonged forms of diarrhoea, the discharges are, in general, very thin, small in quantity, of a dark colour, and extremely offensive. Diarrhoea in children is usually attended with loss or irregularity of appetite, and often with more or less nausea and vomiting; in many instances, however, the stomach is not in the least degree affected, and the appetite remains unimpaired. Increased thirst commonly attends, and some degree of griping generally precedes and follows each dis- charge from the bowels. Occasionally, there is some degree of flatu- lence and severe paroxysms of colic. The skin is ordinarily dry, and the countenance pale and languid. The abdomen may be swollen, when the diarrhoea is connected with an over-loaded condition of the bowels, or when a development of gas takes place, but it is seldom tense or tender to the touch, nor is its temperature increased. Whenever pain is excited by moderate pressure upon the abdomen, especially when accompanied by tension, and increased heat of its sur- face, the diarrhoea will be found to be dependent upon enteritis. In such cases there is usually more or less heat of the surface generally, dryness, with a sense of heat or burning of the palms of the hands, and other symptoms of febrile excitement, with evident exacerbations towards evening. WThen the diarrhoea is prolonged, or assumes a chronic form, the skin becomes dry, harsh, and discoloured; great .emaciation ensues; the countenance becomes wrinkled, of a dirty yellow or brownish hue, and assumes the appearance of premature old age; while the discharges from the bowels are frequent, but small in quantity; occasionally they are suspended for a day or two. They vary in colour and appearance, but are generally very thin and dark-coloured, and are often intolerably Simple diarrhoea is not often a very troublesome or unmanageable complaint; with the removal of the cause by which it has been pro- duced, it will, in many cases, cease spontaneously, or may be readily controlled by appropriate remedies. Whenever, however, from any cause" the diarrhoea is prolonged, it may produce a great degree of ex- treme exhaustion and seriously interfere with the nutrition of the system. Or an acute or chronic inflammation, or extensive disorganization of the mucous membrane of the intestines may set in, and a fatal termi- nation rapidly ensue. # Death seldom occurs in cases of simple diarrhoea; and consequently, very few examinations have been made of the pathological condition 208 DISEASES OF THE DIGESTIVE ORGANS. of the intestines. In the more prolonged cases, the intestinal mucous membrane has often presented no marks of disease, with the exception, perhaps, of unusual paleness, and, occasionally, of softening to a greater or less extent. The parietes of the intestines have, in a few instances, been found of unusual thinness, almost transparent and easily torn. Legendre considers the morbid appearances in cases of simple diarrhoea to be the consequences of an excessive and prolonged secretion. (Sur quelques Malad. de VEnfance.) A contracted state of the tube at different parts, and its distention at others with gas, is a common occurrence. In children who die whilst labouring under serous or mucous diarrhoea unattended with symptoms of inflammation, the follicles of the intestines will be found greatly developed, studding the surface of the intestines, with small, white projections, or occurring in distinct clusters, or plexuses. The non-inflammatory character of these enlarged muciparous follicles is asserted by Billard, Friedle- ben and Fleisch, (Zeitschrift fur Rationelle Med., 1846,) whose ob- servations are based on the examination of fifteen infants, all under one year of age, and that were reared exclusively, or in a 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, state, that in the former cases, a condition of Peyer's glands, considered to be the result of chronic inflammation, was the chief morbid appearance; whilst in the latter cases, where death took place rapidly, an enlarged and congested condition of the same bodies, indicative, as they believe, of recent inflammation, was almost always present. They found that in all the cases there was comparatively slight disease of the colon, and that evidently secondary to the more prominent changes in the small intestines. In most cases of chronic diarrhoea, the mucous mem- brane is thickened, often softened or ulcerated, and, occasionally, pre- sents large patches of a livid or slate colour. The mucous glands are generally found enlarged, inflamed or ulcerated, or of a dark, nearly black colour. The mesenteric glands are often inflamed, enlarged, or indurated. The gall-bladder sometimes contains greenish bile, and the liver is occasionally more vascular than natural. (Brunner, Stark, Bang, Andral, Copland.) The most usual seat of the lesions in chronic diarrhoea, are the ileum, especially its lowest third, and the coecum. M. Legendre notices the occurrence of fatty degeneration of the liver in cases of prolonged diarrhoea. The organ is not increased in size, nor is its specific gravity diminished, but it is mottled with patches of a yellow colour. The most common form of diarrhoea in infants and young children, is that resulting from over-feeding, from the bad quality of the mother's or nurse's milk, or from some change produced in it by accidental causes or from improper articles of food. The foundation of diarrhoea is often laid during the first twenty-four hours after birth, by the reprehensible, but too common practice of gorging the infant's stomach with alimentary substances, often of the worst kind, previous to the secretion of its natural and congenial nourishment. Nurses are always fearful that the infant will suffer from the want of nourishment, previously to the appearance of the DIARRHC3A. 209 mother's milk, and, very generally, introduce into its stomach a quantity of food, which cannot fail to produce a degree of irritation, often resulting in an obstinate diarrhoea of some continuance. Ordi- narily no kind of nourishment is requisite until the child can be ap- plied to the breast. Should the secretion of milk, howrever, not take place for one or two days, as is occasionally the case, a little new milk, with the addition of about one-third warm water, sweetened with loaf sugar, may be given, and repeated if necessary. Infants who are partly nourished by artificial food, as well as those brought up by the hand, are particularly liable to attacks of diarrhoea, often of a very obstinate character. In these cases, the irritation of the alimentary canal is frequently produced, less by the improper cha- racter of the food employed, than from the stomach of the infant being habitually over-loaded, by the food being given to it in too great quan- tity, or at too short intervals. The quality of the mother's milk is often the cause of diarrhoea. Under the same circumstances as the breast-milk produces indigestion in the child that partakes of it, it will be liable, also, to cause an at- tack of diarrhoea. There i3 a curious circumstance in relation to the effects of parti- cular articles of food upon the stomach and bowels of infants and young children, which should be kept constantly in mind in directing their diet, in every case in which it becomes necessary to allow other food than the breast-milk;—it is that some infants are invariably purged by particular kinds of food, which agree perfectly well with others;— thus arrowroot, so generally recommended as an appropriate article of diet for infants, particularly when labouring under bowel complaints, we have so often found to produce purging, that we have almost en- tirely ceased from directing it. The diarrhoea which results, in infants, from improper or too much food, is generally attended with vomiting, the generation of an undue amount of acid in the stomach and intestines, colicky pains, paleness of the face, and general relaxation of the muscles. The discharges are thin, curdled, of a bright yellow or greenish colour, and often de- cidedly acid. The disorder of the bowels generally ceases spon- taneously in a short time, if the cause by which it has been produced is at once removed; but, if this be continued, the discharges become more frequent, thin and watery, often intensely green, the functions of the alimentary canal are imperfectly performed, or entirely sus- pended—the food and drinks taken pass through the bowels unchanged; great emaciation is produced, and the infant may, sooner or later, be destroyed by extreme exhaustion. The blood which is often mixed, sometimes in considerable quantity, with the discharges, in the diarrhoea of young infants, is the result of a true hemorrhagic effusion, caused by the state of hyperemia of the intestinal mucous membrane, which almost invariably exists for a short period after birth. Improper articles of food, or excess in eating, are among the most common causes of diarrhoea subsequent to the period of weaning. Unless the utmost attention is paid to the proper regulation of the in- fant's diet, for some time after it is taken from the breast, more or less 14 210 DISEASES OF TnE DIGESTIVE ORGANS. disorder of the bowels invariably results. Often an excessive diarrhoea occurs, the discharges being at first feculent, or faeces mixed with im- perfectly digested food, but speedily becoming composed of a serous fluid, of a dirty, or greenish yellow. Intestinal inflammation is early developed, or the diarrhoea assumes a chronic and peculiarly un- manageable form. It is this diarrhoea which is described by Cheyne as a new and peculiar form of disease, under the name of "atrophia ablactatorum." Errors in diet are a common cause of diarrhoea even in older children. In them the appetite is keen, and very liable to lead to excess in eating, and especially to an indulgence in rich food—pastry, fruits, and con- fectionery. An occasional excess may cause no further inconvenience than nausea, vomiting, and a rather profuse diarrhoea, ceasing spon- taneously soon after the offending substances are expelled. But when excess in eating, or improper food is habitually indulged in, a much more serious disorder of the alimentary canal ensues; the diarrhoea, often then becomes profuse, and, if not promptly and judiciously treated, inflammation of the bowels is liable to be produced, running, generally, into a chronic form, and producing death from marasmus; or disease of the brain is excited, terminating, most generally, in serous effusion. The application of cold to the surface of the body, especially ex- posure to cold or damp, or a sudden transition from a close and heated, to a chilly and humid atmosphere, will, in many cases, give rise, in children, to a more or less profuse diarrhoea, with mucous or thin watery discharges. These cases are often attended with more or less febrile excitement, and tenderness and heat of the abdomen, indicating the existence of some degree of intestinal inflammation. Slight ca- tarrhal symptoms are frequently present; and, in some cases, the latter precede the diarrhoea; hence the common observation of nurses, that "the cold is working itself off by the bowels." This form of diarrhoea, should its true character be overlooked, and it in consequence, impro- perly treated in its commencement, is very liable to become a serious disease, giving rise to extensive disorganization of the intestines, or early involving the brain. Some degree of diarrhoea is usually attendant upon the process of dentition. When moderate, its effects are salutary; but, when exces- sive, or of long continuance, particularly if the infant becomes ex- hausted, or considerable febrile excitement, with tension, heat and pain of the abdomen occurs, it should not be allowed to go on, but should be promptly arrested by an appropriate course of treatment. The discharges are, occasionally, faecal, of a bright yellow or green colour, and more or less acid, but more commonly they consist of thin mucus, often mixed with a portion of faeces or bile. It has been very correctly remarked by Billard, that the frequency of these thin mucous discharges about the period of dentition is in con- sequence of the rapid development and increased activity of the mu- ciparous follicles of the intestines, which takes place about the same time. The degree of irritation communicated to the digestive mucous membrane during the normal development of the teeth is sufficient, DIARRHG3A. 211 with the existing condition of the muciparous follicles, to cause an un- due amount of fluid to be poured into the intestines, which is still further augmented, if the cutting of the teeth be tedious, or attended with difficulty. Although this morbid development and activity of the muciparous follicles is not an inflammatory action, it is, nevertheless, one bordering closely upon it, and hence the propriety of always keeping children affected with mucous diarrhoea at the period of dentition, upon a strict regimen, and closely watching, lest inflammation should sud- denly occur. We have repeatedly seen cases of mucous diarrhoea, occasionally of a very severe and protracted character, ensue upon the sudden disappearance of cutaneous eruptions, or the drying up of the discharge from ulcerations behind the ears. These cases appear to be, in the majority of instances, accompanied with some degree of inflammation of the intestinal mucous membrane. Repeated mucous discharges are often accompanied with the pre- sence of intestinal worms; whether, however, they are in any instance attributable to an irritation produced by the latter is a question still in dispute. Of the existence of worms in the intestines, we have no positive evidence, excepting that derived from their appearance in the discharges. A superabundance of viscid mucus in the bowels, and its copious discharge by stool, being generally enumerated as leading indications of their presence, the latter is often inferred, merely from the fact, that a child is affected with mucous diarrhoea, particularly in its chronic form. We have, it is true, in numerous instances where worms have been discharged in great numbers from the intestines, observed the children to labour under a species of diarrhoea, attended with stools rather more frequent than usual, and composed entirely of a mass of thick, tenacious, diaphanous mucus, which appeared to come away at once, without straining, or any unusual effort. These discharges frequently alternate with regular, healthy stools, or those composed, in a great measure, of natural faeces. They are always unattended with febrile excitement or the slightest indication of inflammation. The children are generally pale, of a lymphatic temperament, with capricious ap- petites, and tumid, but soft abdomens; their breath has, generally, a sickly, disagreeable odour; their tongue is coated with a thin layer of slimy mucus; their urinary discharge is copious, and light-coloured, and in many cases more or less oedema of the feet, and about the eye- lids occurs. Atmospheric heat, particularly when combined with the influence of a confined and impure atmosphere, is a common cause of diarrhoea. During the summer months, in our large cities, few children escape a slight attack; and among the children of those who inhabit the eon- fined houses situated in narrow, ill-ventilated courts, lanes, and alleys, the disease prevails in a form of uncommon severity. It is of less frequent occurrence in high, elevated, and healthy situations in the country, but occasionally prevails to a considerable extent, in low, marshy, or what are usually termed miasmatic districts. The discharges are, at first, feculent, but soon become almost exclu- • 212 DISEASES OF THE DIGESTIVE ORGANS. sively composed of a thin mucus, mixed with bile, of a bright yellow, or green colour: they are extremely copious, and are generally attended with nausea, often with bilious vomiting, and more or less griping. This latter symptom is, however, absent in a large number of cases; the discharges taking place as it were involuntarily.^ In slight cases, occurring in children properly nursed, and resident in comparatively healthy localities, the disease often ceases in a short time spontaneously. In those who are exposed to the constant in- fluence of a heated and confined atmosphere, the diarrhoea will con- tinue, with occasional temporary cessations, for many days: the urine becoming tinged with bile, and the skin and whites of the eyes of a yellowish hue; or the discharges from the bowels are often attended with a sense of heat or scalding, and it is not uncommon for an exco- riation of the anus to take place. In such cases, symptoms of cholera infantum may quickly develop themselves, or, after a few days, and sometimes earlier, the bilious discharges may cease, and frequent copious evacuations occur, of a serous fluid, at first of a yellowish or greenish colour, but, subsequent- ly, almost colourless. At the same time, not unfrequently, the abdo- men becomes tense, hot, and painful upon pressure; the skin dry and harsh; the tongue red at the tip and edges, and covered on its surface with a dirty white or yellowish mucus; great thirst is experienced, and, whatever fluid is taken, is instantly expelled, and often with p;reat violence; aphthae frequently appear upon the parietes of the n.outh, and rapid emaciation ensues. The brain is, in some cases, early ai>ckd, and the patient expires with all the symptoms of hydroce- phalus; in other cases, the diarrhoea assumes a chronic form, and the child, after becoming reduced, literally, to "skin and bones," and to a state of extreme exhaustion, expires, apparently from inanition. The bilious diarrhoea of hot seasons, in its simplest form, appears to be produced by an undue secretion of bile, the result of the excessive stimulation of the skin by atmospheric heat; but in the more violent cases, the presence of acute inflammation of the mucous membrane of the stomach, and upper portion of the intestinal tube, or of the lower portion of the small intestines, is indicated, as well by the symptoms during life, as by the pathological changes observed after death. We have frequently detected in our autopsies, increased redness of the stomach and duodenum, occurring in points grouped together, in irregular strias, in large patches, or irregularly diffused, and presenting a kind of elevation from the thickening of the mucous membrane. Follicular inflammation was occasionally detected in the stomach, but more frequently in the ileum. Distinct ulcerations and softening of the mucous membrane were of common occurrence. In repeated instances, the follicles of the intestines were considerably enlarged, without appearing to be inflaiped. Contractions of different parts of the intestinal tube were frequently observed, and in a few instances, numerous invaginations. The small intestines were generally empty, while the mucous coat of the large intestines was frequently coated with a thick tenacious mucus, and often contained a frothy mucus, of a grayish or yellowish colour. The liver was usually in a state DIARRHOZA. 213 of hyperaemia, while the gall-bladder contained more or less thin and very light yellow or greenish bile. The marks of inflammation were, however, in a number of instances, particularly when the diar- rhoea had assumed a somewhat protracted or chronic form, by no means of so decided a character; and in a few cases, the only indica- tions of disease were unusual paleness of the mucous membrane, with enlargement of the muciparous follicles. The discharges, in some cases of diarrhoea, occurring during child- hood, are of a very white, opaque appearance, having some resem- blance to a mixture of chalk and water. This constitutes the chy- lous diarrhoea of many authors; chyle, however, never being present in the intestines, could scarcely be expelled by stool, especially in quantities sufficient to account for the copious, white, milk-like, evacuations we often observe to take place; neither do the physical appearances of the discharges bear any resemblance to those of chyle. It has appeared to us to be merely a variety of the mucous diarrhoea of children, the peculiar conditions of the stools arising from some morbid change in the intestinal secretion*. It hap been attributed to irritation, with altered secretion of the pancreatic gland. We have had no opportunity of observing the condition of the alimentary canal, and other abdominal organs in this form of diarrhoea, never having met with it in any case that terminated fatally; it is one, indeed, judging from our own experience, of not very frequent occurrence in this country. . From the preceding description of the several species of diarrhoea occurring in infants, it will be perceived how intimately all of them are connected with intestinal inflammation of an acute, subacute, or chronic character. It is true, as already remarked, that in its commencement diarrhoea may be the result simply of an increased peristaltic action of the intestines, with augmented secretion from the mucous membrane, and from the liver, without the slightest indication of inflammatory action. It may even continue for a long period, and finally produce the death of the patient by suspending the assimilative and nutritive functions, and still no indications of inflammation be present throughout the at- tack It must, nevertheless, be kept steadily in mind, that not untre- quently the diarrhoea may be dependent upon inflammation of the intestines, from its very commencement, and that there is a tendency to the development of inflammation of a more or less acute form in every case, unless the cause of the diarrhoea be early removed, and it be, in this manner, promptly suspended. Under whatever circumstances, therefore, diarrhoea occurs, a close scrutiny into, and careful analysis of all the accompanying symptoms, should be made, and if the case be a protracted or obstinate one, the state of the abdomen as to tension, heat, and tenderness upon pressure, should be cautiously examined;—and if intestinal inflammation be de- tected its removal by a judicious course of treatment is essential to the cure of the diarrhoea, and to secure the safety of the patient. In the treatment of every form of diarrhoea, the first and most mi- •oortant indication is, to remove the cause by which it has been pro- duced In that caused by improper food, or excessive feeding, the 214 DISEASES OF THE DIGESTIVE ORGANS. aliment should be at once improved in quality, or reduced in quantity. If the mother's milk be in fault, that of a healthy nurse should be substituted; or, if this be impracticable, the infant may be nourished upon diluted milk, with the addition of the best loaf sugar, by means of the sucking-bottle. If the infant be fed by the hand, in those in- stances in which the breast of the mother does not afford a sufficient supply of nourishment, the additional aliment should be the same as directed above; taking care that the child be not allowed to overload its stomach, by taking too much at a time, or being fed with it at too short intervals. When diarrhoea occurs at the period of weaning, the utmost atten- tion should be paid to the food of the patient, agreeably to the direc- tions given in our chapter on the diet of infants, care being taken, at the same time, to observe the effects of any particular article of diet, which although in itself perfectly wholesome, may from some peculiar idiosyncrasy in the child, disagree with its stomach, and cause more or less purging: whenever this is found to be the case, its use should at once be relinquished, and another kind of food substituted. We have known the bowels of infants, immediately after weaning, to be disordered by all the ordinary farinaceous preparations, and by milk, while meat broths, with the addition of rice or crackers, agreed perfectly well with them. In older children it will be proper, upon the occurrence of diarrhoea, to suspend every species of solid aliment, and to confine them entirely, for a short period, to moderate quantities of some preparation of rice with milk, to water gruel, or to crackers and milk. Fruits of every kind—pastry, confectionery, sweetmeats, and every species of fresh vegetables, should be entirely prohibited. For drink, cold water, or cold toast, rice or gum water, may be given in small quantities at a time. The proper regulation of the diet, with the use of the warm or tepid bath daily, and gentle exercise in the open air, will, in a large number of cases, be all that is necessary for the cure of this form of diarrhoea; and unless such regulation of diet be carried strictly into effect,—and in so doing, the physician will find himself constantly opposed by the prejudices and inattention of parents and nurses,—it is in vain to at- tempt its removal by the administration of medicine. The exhibition of some mild but active purgative, in the commence- ment of the attack, will be proper in most cases, to remove any irri- tating matters that may be retained in the alimentary canal. The repeated exhibition of active purgatives is, however, not only unneces- sary, but positively injurious, by increasing and prolonging the irri- tation by which the disordered action of the bowels is prodmied. If the diarrhoea is not quickly suspended by a proper regulation of the infant's diet, and the use of the warm bath—particularly if the stools are attended with griping—we have found a dose or two of a combination of calomel, prepared chalk, ipecacuanha, and extract of hyoscyamus, to be attended with the best effects. R.—Calomel, gr. ij. ad vj. Cretas ppt. gr. xviij. Ipecacuanhas pulv. gr. ij. Extract. Hyoscyami, gr. iij. advj.—M. f. chart. No. vj. One, to be repeated every two, three, or four hours, according to circumstances. DIARRHOEA. 215 Under the use of this combination, we have generally found the stools to become less frequent, more natural, and of greater consis- tence ; the digestion to be improved, and the irritability of the intes- tines diminished. It sometimes happens, in cases of simple diarrhoea from errors in diet, that a large amount of acid is generated in the stomach, which appears to keep up the discharges from the bowels. When this occurs, a few grains of carbonate of soda in solution; a teaspoonful or two, according to the age of the child, of the aqua calcis, combined with an equal portion of new milk, or a few grains of prepared chalk, combined with a quarter to a third of a grain of ipecacuanha, and the half of a grain to a grain of extract of hyoscyamus, may be given twice or thrice a day, with some slight astringent every three hours. The tincture of kino, or catechu, or either of these substances in powder, or the com- pound infusion of catechu, may be given. R.—Catechu pulv. gij. Cinnamom. contus. ^ss. Aq. bullient. (*f v. Macerate for an hour in a closely covered vessel, and strain. Dose.—A teaspoonful every two, three, or four hours, according to the age of the patient, or the nature of the case. With many American physicians, we prefer as an astringent, in cases of simple diarrhoea, a decoction of the root of the geranium maculatum, or the blackberry (rubus villosus,) especially the former, which, when the decoction is made with milk, is a very excellent and agreeable as- tringent, well adapted to relieve the irritable state of the bowels, by which, in many cases, the disease is liable to be kept up, after the original cause has been removed. The opiates generally recommended are seldom, if ever, required. If, however, in consequence of the sleep being disturbed by frequent evacuations occurring during the night-time, an opiate is indicated, an injection composed of thin starch and a few drops of laudanum, or a sm^Jl portion of opium combined with ipecacuanha, and carbonate of soda,1 by the mouth, may be given in the evening. But it is better, if possible, to dispense altogether with the use of opiates in every form. 1 R.—Opii pulv. gr. j. ipecac, pulv. gr. iij. ad iv. Carb. Sodas, "^j-—M. f. ch. No. xij. For a child over one year of age, the proportion of opium may be somewhat increased. The treatment of mild cases of mucous or serous diarrhoea will consist, principally, in the substitution of mild mucilaginous fluids, as rice water, gum water, or an infusion of slippery elm bark, for the or- dinary food and drink of the patient; in the use of the warm bath morning and evening, and the exhibition of a combination of ipecacu- anha and calomel, every two or three hours ;2 and, as soon as the dis- charges have become less frequent, and of a natural appearance, the administration of some light astringent, as directed above. It is all- important that every species of solid food be abstained from. In cases in which the diarrhoea is attended with thin mucous or serous dis- charges, even the mother's milk will, sometimes, be found to irritate the bowels, and increase the disease. Hence it is better to confine the patient always to simple mucilaginous fluids. 216 DISEASES OF THE DIGESTIVE ORGANS. 2 R.—Calomel, gr. j. ad ij. Ipecacuanhas, gr. ij. ad iij. Sacch. alb. J)ij.—M. f. ch. No. xij. One to be given every two or three hours, according to the age of the child. The warm bath will, in most cases, be found an admirable remedy, particularly if followed by gentle friction over the abdomen, and sur- face of the body generally. The common practice of administering frequent doses of castor oil in mucous diarrhoea, is one calculated to increase the irritation of the intestines, and in this manner render the disease more protracted and difficult to manage. When the discharges from the bowels are very profuse, and consist, principally, of a thin, often nearly colourless, serous fluid, the use of small doses of calomel, ipecacuanha, acetate of lead, and extract of hyoscyamus, will be found promptly to arre*st them.1 Ample expe- rience has taught us that the acetate of lead may be given with the most perfect safety to children: in the combination just stated, we know of no more effectual means of arresting the profuse serous dis- charges which often occur in the diarrhoea of infancy, which, if allowed to continue, will produce, in a very short time, a degree of exhaustion that is not unfrequently fatal. 1 R.—Calomel, gr. j. ad ij. Ipecacuanhas, gr. ij. ad iij. Acetat. plumbi, gr. vj. ad xij. Ext. Hyoscyami, gr. iv. ad vj.—M. f. ch. No. xij. One to be given every two or three hours. The proportion of the several ingredients and the frequency of repetition being regulated by the age of the patient. In every case of mucous diarrhoea, the liability to the development of intestinal inflammation should be kept constantly in mind; and the moment that tension, heat, and tenderness of the abdomen are de- tected, or distinct febrile excitement occurs, it will be proper to apply leeches to the abdomen, in numbers proportionate to the age of the patient and the urgency of the symptoms; followed by warm fomen- tations, or an emollient cataplasm. As soon as the inflammatory ac- tion is subdued, if the discharges from the bowels still continue to be frequent, and of a serous character, the combination of acetate of lead directed above, may be advantageously administered. In some cases, mucous diarrhoea assumes a kind of chronic form, the discharges being frequent, small in quantity, and attended with a good deal of straining. They consist, chiefly, of a transparent, occa- sionally jelly-like mucus, sometimes perfectly white, at others, of a dirty yellow, grayish, or green colour. The bowels are occasionally distended with gas, but the abdomen is seldom painful to the touch, or exhibits any increase of temperature. There is, generally, great emaciation, and sometimes diminished temperature of the surface of the body, or of the extremities. In these cases, we have found the calomel and ipecacuanha, as directed above, to produce an excellent effect. Mucilaginous injections, with a suitable addition of opium, or the combination of opium, ipecacuanha, and soda, noticed under the head of simple diarrhoea, will be required, to relieve the straining fre- quently attendant upon the discharges. Dr. Eberle recommends in this chronic form of the disease, from five to ten drops of balsam co- paiba, in the form of emulsion, with the addition of a few drops of DIARRHQSA. 217 tincture of opium, or given in conjunction with minute portions of Dover's powder; we have likewise administered the copaiba in many cases, and have often witnessed the best effects from its use. The form in which we have generally given it is as follows: R.—Bals. Copaibas, gj. Magnes. calc. gr. x. . Spir. aether, nitr. jiij. Sacch. alb. ^i'j. Aq. cinnamom. 5iij.—M. Dose.—One teaspoonful every two or three hours: each dose to be followed in the course of an hour by the fifth of a grain of Dover's powder. The frequent repetition of the warm bath will be found advantageous in these cases. The abdomen should be kept covered constantly with a broad flannel roller. Blisters to the abdomen have been recom- mended, but we have seldom seen much advantage from their use. The diet should consist chiefly of very thin preparations pf rice flour or tapioca, with milk and a small quantity of loaf sugar; in some in- stances, these will, however, be found to disagree with the patient, when probably, simple chicken water, with or without rice, may be advan- tageously substituted. When mucous diarrhoea proceeds from the sudden disappearance of cutaneous eruptions, or from the drying up of discharges from behind the ears, the treatment is the same as directed above. We have never seen any good effects result from attempts to renew,by stimulating applications, the irritation of the skin, or the ulceration behind the ears. The diarrhoea occurring during the process of dentition, is to be treated, when moderate in extent, by a careful regulation of diet. This should be restricted to preparations of the farinacea with milk- cool mucilaginous drinks. Attention should be paid to the gums—the protrusion of the teeth, if tardy, particularly if the gum covering them is hard, tense, and swollen, being promoted by incisions. The daily use of the warm bath will be proper. In children of a robust and plethoric habit, no attempt should be made to arrest the discharges, so long as they continue moderate in quantity, and unattended by any unusual symptom. When, however, they are profuse, when emaciation ensues, or the child is feeble and exsanguious, the diarrhoea demands immediate attention; it should then be treated m the same manner as though it had occurred independently of dentition. In the mucous diarrhoea so frequent in cases of intestinal worms, we have generally succeeded in restoring the natural condition of the stools, and removing the principal symptoms of the disease, by the administration of turpentine in emulsion, followed by light astringents, the use of the warm bath daily, and a careful regulation of the diet and regimen. "g.—Mucil. G. acaciae, 5iij. Sacch. alb. pur. gvj. Spir. asther. nitr. ^iij. Spir. terebinth. 3'j. Magnes. calc. gr. xiij. Lavend. spir. comp. 5'j.—"M. Dose a teaspoonful, repeated three times a day, or oftener, when the child is over two years of age. 218 DISEASES OF THE DIGESTIVE ORGANS. When the diarrhoea assumes an acute form, it should be treated by the means proper in that form of the disease, without reference to the presence of worms in the intestines:—the remedies usually employed for the destruction and expulsion of the latter would be calculated to increase the diarrhoea, or even to induce severe disease of the intesti- nal mucous membrane. In the treatment of bilious diarrhoea, the first indication is to remove the cause by which the morbid secretion of bile has been produced. As this is usually intense heat, with a stagnant and impure state of the atmosphere, the prompt removal of the child to a more free, and cooler atmosphere is essential to insure its recovery. When such a removal cannot be effected, domestic cleanliness and free ventilation should be enforced, as well as the free exposure of the child, in dry weather, to the external air, in the most healthy and open situations, in its immediate neighbourhood. It may be either carried out in the arms, in an open hand-carriage, or by riding in any open vehicle, or by sailing in an open boat, properly shaded from the sun, or in one of the steamboats, which, in most of our large cities, make repeated short trips in the course of the day. The diet and drinks of the patient should consist exclusively of gum water, rice water, or infusion of slippery elm bark—taken cold, and in small quantities at a time, but at short intervals. It should be immersed daily in a tepid or warm bath, according as the temperature of its surface is augmented or depressed, and its clothing should be light and loose, and so adapted, in the materials of which it is composed, as not unduly to augment the heat of the body, but, at the same time, to guard it fully from the effects of sudden transitions of temperature. This treatment will be sufficient in a large number of cases, in which the disease consists simply in an undue secretion of bile, to ar- rest the diarrhoea, and restore the discharges to their natural condition. If, however, these still continue with little or no abatement, and neither fever nor intestinal inflammation exists, small doses of calomel, cal- cined magnesia, ipecacuanha, and extract of hyoscyamus, will gene- rally produce the desired effect.1 Under the use of this combination, the discharges will generally assume, in a short time, a faecal charac- ter, and be diminished in quantity. If there exists irritability of sto- mach or vomiting, the calomel should be given alone. 1 R-—Calomel, gr. ij. ad iij. Magnesias calc. gr. xxiv. ad xxxvj. Ipecacuanhas, gr. ij. ad iij. Ext. hyoscyami, gr. iv. ad vj.—M. f. ch. No. xij. One to be given every two or three hours. Purgatives, opiates and astringents are seldom proper, unless the disease assumes a chronic form, unattended with inflammation. When the discharges lose their bilious character, and become thin and serous, if no tension, pain, or heat of the abdomen is observed, the acetate of lead, in the formula directed when speaking of the treatment of mucous diarrhoea, is the remedy which we have found the most frequently to succeed in arresting the disease. When the discharges are profuse, and the patient becomes rapidly exhausted, a DIARRHC3 A. 219 small portion of opium may be substituted for the extract of hyos- cyamus; and a solution of the acetate of lead, with such an addition of laudanum as is adapted to the age and condition of the patient, may be thrown into the rectum. As soon as the profuse serous dis- charges are suspended, the calomel in small doses, combined with ipecacuanha and extract of hyoscyamus, will, in general, complete the cure; or, if after the discharges assume a more natural appear- ance, they still continue thin and frequent, some of the astringents already mentioned, as the catechu, the geranium maculatum, or kino, will be proper, with a dose of Dover's powder at night. This form of diarrhoea occasionally assumes a chronic character, when the treatment will be the same as in the chronic stage of cholera infantum. In many cases, it is probable that the following prescrip- tion will be found advantageous:—it is recommended by Evanson as one of the most useful compounds in protracted cases of diarrhoea.1 We have ourselves never employed it, but have seen good effects re- sult from the administration, in these cases, of nitrous acid, in com- bination with aqua camphora and opium, or with hyoscyamus.2 1 R.—Infusi simaroubas, ^jss. Acidi nitrici dil. mjij. ad iv. Syrupi caryophyl. ^iv. Tinct. opii, m?vj.—M. One or two teaspoonful s, in a little barley water, to be repeated three or four times a day. * R,—Acid, nitros. ir^viij. ad xv. Or, R.—xlcid. nitros. tl^x. ad xv. Aquas camphor. 3J. Sacch. alb. ^iij. Tine, opii, irjjvj.— Ext. hyoscyami, gr. vj. A teaspoonful every three hours. Aq. cinnamom. gj.—M. Dose, the same. As we have already remarked, in a large number of cases, bilious diarrhoea is accompanied with evident symptoms of intestinal inflam- mation. The safety of the patient, as well as the cure of the diar- rhoea, will then depend upon a correct diagnosis being early made, and the appropriate remedies for the control of the inflammation promptly resorted to—plain mucilaginous drinks, leeches to the epi- gastrium, followed by warm fomentations or an emollient cataplasm, and warm sinapised pediluvia. When extreme irritability of the sto- mach or vomiting is present, we are in the habit of administering minute doses of calomel; placing them upon the tongue in a dry form, if they aTe quickly ejected from the stomach when administered in the usual manner. From an eighth to a sixth of a grain may be given, every half hour or every hour, according to circumstances; we have seldom been disappointed in quieting the stomach by this means in a few hours. After the inflammatory symptoms are subdued, the case may be treated as an ordinary attack of bilious diarrhoea; a careful watch being, however, kept upon the symptoms, lest intestinal inflammation be renewed; should this happen, the propriety of a re-application of leeches will depend upon the strength of the patient, and the urgency of the symptoms. It is probable, that, in most cases, a blister over the abdomen will be sufficient to remove the inflammation, without ahtha3, which also occasionally appear about the verge of the anus. Colitis may in its more intense forms terminate in death at an early period, but in general it runs a protracted course, and the patient .>inks finally from extreme prostration; or a state of coma ensues, and death is preceded by symptoms of encephalic effusion. The appearances upon dissection differ in nothing from those that occur in cases of enteritis, excepting in the seat; the mucous mem- brane of the colon and rectum is affected with red elevated patches or striae, and with friability or softening of the tissue, at the part where they are situated. The surface of the colon and rectum are occasion- ally covered with filaments, varying in size, of a curd-like matter. Enlargement, inflammation, and ulceration of the muciparous glands and follicles are very commonly met with; gangrenous ulceration is COLITIS. — DYSENTERY. 259 occasionally present, and, in chronic cases especially, thickening, with a dark purple or slate colour, of the mucous membrane of the colon or rectum, in patches of greater or less extent. Dr. Crampton has observed, in cases of children who died of dys- enteric symptoms, the mucous membrane of the intestines, in many places, to be highly vascular, and covered with granulations of a yellow, or dirty yellow colour, as if from a coating of wax; in several, ul- cerations had taken place; these ulcers were disposed in patches, with well-defined edges. In cases that terminated favourably, a quan- tity of yellowish, branny scales, were seen floating in the discharges from the bowels, like minute portions of wax from honey-comb. Dr. Mayne, in his account of an epidemic of dysentery which pre- vailed in Dublin, [Dublin Quart. Jour, of Med. Science, vol. vii., 1849,] states that in the majority of cases where death occurred within three weeks from the commencement of the attack, the morbid appearances were confined to the large intestine, pervading its entire tract, but most decidedly marked at its lower portion. There was also an undue degree of vascularity of the peritoneum covering the diseased portion of the canal; the absorbent glands along the same part were congested and enlarged. The walls of the intestine were thickened and indu- rated, while its mucous coat varied in colour from a bright red to green or purple, and was, in some cases, covered with a bran-like ex- udation, in others ulcerated. The ulcers were sometimes small and isolated, in others superficial and extensive, and in a third variety, large, irregular, ragged, and penetrating. The small intestines were generally healthy; the liver, in some cases, was much congested. Colitis would appear, in the majority of cases, to be the result of sudden transitions of atmospherical temperature, particularly the sudden change from warm and dry, to cold and damp weather. It is most prevalent during the latter part of summer, or the com- mencement of autumn, when the days are hot, but the nights chilly and damp. It is apt to prove endemic in unhealthy localities, espe- cially those favourable to the production of intermittent and remit- tent fevers, and often prevails epidemically with fevers of a catarrhal character. A few days of cool, rainy weather, occurring in the sum- mer, will often cause the prevailing bowel complaints of children to assume a dysenteric character. It may, however, be produced by the same causes which give rise to inflammation in other portions of the alimentary canal. In the treatment of colitis, the same general directions are applica- ble as in the other intestinal inflammations. All solid, stimulating, and indigestible food should be avoided. The patient may be allowed mild mucilaginous drinks; but even with these he should not be allowed to overload his stomach. The free use of fresh buttermilk has been found advantageous in many cases. The warm bath and warm fomen- tations or cataplasms to the abdomen, are equally beneficial, as in cases of enteritis. The patient should be kept at perfect rest in a recumbent posture, and not allowed to rise every time he feels an in- clination to evacuate his bowels; nor should he be permitted to sit for a long period, ineffectually straining, when, probably, only a drop or 260 DISEASESOF THE DIGESTIVE ORGANS. two of bloody mucus is discharged. Leeches should be applied, along the course of the colon, in numbers proportioned to the violence of the disease, and the strength and age of the patient, and repeated, if, after their first application, the symptoms remain without considerable abate- ment. By some practitioners leeches are directed to be applied to the verge of the anus. Occasionally, this will be found to produce a very favourable impression upon the symptoms of the case; but, as a general rule, we cannot recommend the application of leeches to this part in children; we have occasionally found the hemorrhage produced by them to continue for some time after their removal, and to be with difficulty controlled. In cases in which symptoms of gas- tritis are present, leeches should also be applied to the epigastrium. In robust children, over one year of age, when the disease is accom- panied by symptoms of any degree of intensity, blood may be taken from the arm. In regard to the use of internal remedies, there exists a very great diversity of opinion among practitioners. To the common practice of giving small and repeated doses of castor oil, either with or with- out an addition of laudanum, we are decidedly opposed; we have seen much injury result from it, and cannot understand the princi- ples upon which the treatment is founded. From the administration of small doses of calomel, in combination with ipecacuanha, we have derived the best effects, and believe that a small portion of extract of hyoscyamus, agreeably to the plan pursued by many of the Ger- man physicians, forms an admirable addition.1 The relief derived from this combination is often prompt and considerable, while a fa- vourable change is produced, in a very short time, in the character of the discharges. 1 R-—Calomel, gr. iv. ad xij. Ipecacuanhas, gr. iij.—iv. Ext. hyoscyami, gr. iv.—vj. Cretse ppt. gr. xxxvj.—M. f. pulv. No. xij. One to be given every three hours. When there is much tenderness of the abdomen, great relief will often be obtained from the use of the warm bath, followed by warm fomentations or the application of a soft emollient poultice. In protracted cases, the application of a blister over the abdomen, as directed in enteritis, we have repeatedly seen productive of very beneficial results. Injections into the rectum, of a solution of acetate of lead, with or without laudanum, are calculated to allay the tormina and tenes- mus, and may be repeated with advantage. We must recollect, how- ever, that much caution is to be observed in the use of opium and its preparations, in the form of enemata, in the diseases of children.— Experience early taught us, that very small portions of laudanum thrown into the rectum, will often produce a degree of narcotism which would be scarcely anticipated from a similar quantity given by the mouth; the same fact has been noticed by other practitioners. From an early period in the attack we are in the habit of giving every three hours the acetate of lead, in the dose of one grain, com- bined with from one to two or three grains of Dover's powder, ac- COLITIS. — DYSENTERY. 261 cording to the age of the patient and the urgency of the symptoms, and we have seldom been disappointed in the prompt relief which the patient experiences from the use of this prescription. The nitrate of silver, in from a sixth to a quarter of a grain doses, made into a pill with extract of gentian, and repeated every two or three hours, will often be found to produce prompt relief after the more acute symptoms of the disease have been subdued. If symptoms of exhaustion occur, stimulants will be needed, but much judgment is requisite as to the time when they should be commenced. No definite rule, as Dr. West remarks, can be laid down. "Each case must be treated for itself, and to be treated suc- cessfully it must be watched most closely. The necessity for stimulants may arise suddenly, or the need for their administration may be but temporary, while the infant's state in the morning affords in severe cases, no sure criterion to judge what its state will be at night.' "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 arrow-root with which it is fed, will often have the effect of arresting the sickness as well as of rally- ing the sunken energies of the system." When the brandy occasions pain in the stomach or nausea, Dr. West recommends the substitution of the compound tincture of bark, or the aromatic spirits of ammonia, or the two together, mixed with milk and sufficiently sweetened. When the child is weaned, instead of farinaceous articles of diet, or even milk, which latter often disagrees with the stomach, the child should be nourished on strong animal broths, given in small quantities at a time, at short intervals. In chronic cases of colitis, the same treatment is applicable as in chronic diarrhoea. The spirits of turpentine will, in such cases, be often found a very valuable remedy. Durino- convalescence, more especially from the more protracted and chronic forms of the disease, the vegetable astringents will be found advantageous, in restoring tone to the intestines, and facilitating the recovery of the patient's strength. In an epidemic of dysentery that occurred among children, in Washington county, New York, an infusion of white oak bark, black- berry root, and yarrow, in milk, with the addition of sugar,1 was found,1 according to Dr. Cogswell, to be productive of the best effects. The persesquinitrate of iron is also spoken of by Williams and others as a useful remedy, in cases of dysentery occurring in children. 1 B-—Cort. querci alb. Rad. Rub. villosi, aa. 3SS. Fol. achill. millefol. £iij. To be boiled in Oj. of milk. A dessert-spoonful to be given frequently. 262 DISEASES OF THE DIGESTIVE ORGANS. CHAPTER VI. PERITONITIS—INFLAMMATION OF THE PERITONEUM. Inflammation of the peritoneum may occur in children, even from the earliest periods after birth. In still-born infants, as well as in those who have died a few hours after birth, so frequently has there been found to exist redness and opacity of the peritoneum, with serous or puriform effusion; a coating of coagulable lymph, either in the form of flocculi or membranous shreds; adhesions between the intestinal convolutions and other abdominal viscera, some slight and recent, and others very firm and apparently of long continuance; or tubercular granulations of the peritoneum, that we are perhaps to include peri- tonitis among the most common and fatal of the diseases to which the foetus in utero or the child immediately after birth is liable. In its acute form peritonitis is by no means a very frequent dis- ease of children. It may, however, occur as a primary affection, but is more frequently developed in the course of some other disease. It is indicated by tension and pain of the abdomen, more or less acute, and invariably increased upon pressure; by restlessness, constipation, and a peculiar contracted and distressed expression of the face, with dryness, but seldom any great heat of the skin. The pain of the abdomen is constant, and often extremely acute, and the tenderness, in severe cases, is such as to cause the slightest pressure, even that of the clothes, or the coverings of the bed, to be insupportable. The child lies upon his back with his knees drawn up, and exhibits extreme restlessness;—his crie3 are often constant and acute. The abdomen is commonly tense and swollen, rising in a point towards the umbilicus. The tension is sometimes perfectly circum- scribed, and upon palpation a painful tumour is detected, without any change in the colour of the skin, and presenting a dull sound upon percussion. (Rilliet and Barthez.) The bowels are usually consti- pated, and the skin dry, but seldom hot. In children of two or three years of age, we have often seen the disease attended with very con- siderable febrile excitement. The pulse is generally very small and frequent, there is always great prostration, and not unfrequently con- siderable dyspnoea. As the disease advances, there is generally fre- quent eructation or vomiting—coldness of the surface, particularly at the extremities, and often a livid or dusky appearance of the face. Peritoneal inflammation, occurring in children, requires the closest attention and tact on the part of the physician, to distinguish it from inflammation of the intestinal tube, with w'hich it is often complicated. Peritonitis may be distinguished from pleurisy by the absence of the physical signs of the latter; and from severe paroxysms of colic, by the pain being continued, and increased upon pressure; while in cases PERITONITIS. 263 of colic, the pain is remittent, and is very generally diminished by pressure upon the abdomen. Acute peritonitis may terminate favourably by a gradual diminution, and final cessation of the symptoms. In severe cases, death often occurs at an early period, the patient appearing to sink from exhaus- tion. Often, however, peritonitis in children assumes a chronic form, when it constitutes probably one of the most insidious affections of early life, its real character being very often overlooked, and a most injudicious course of treatment pursued. M. Trousseau (Gaz. des Hopitaux, No. 100) describes^ a form of acute peritonitis terminating very promptly in serous effusions yrithin the cavity of the abdomen, which, according to his experience, is by no means rare. In a case described by him there was very slight pain in the abdomen, which was tense, and swollen by an amount of fluid, causing by its pressure upon the diaphragm considerable dys- pnoea. No fever was present, and the digestive organs continued in a normal condition. Chronic peritonitis is generally marked by pain in the abdomen, seldom severe or continued, but occurring, most commonly, in short pa- roxysms. More usually, however, there is only tenderness upon pres- sure—the patient shrinking or crying out upon being lifted or handled. The appetite is irregular, or but little affected; the bowels are generally costive, but occasionally there is more or less diarrhoea, alternating with constipation. The child is, in general, peevish, dull, and disin- clined to exercise; the pulse is small and quick; and the tongue covered with a whitish or yellowish mucus. The heat of the surface is often somewhat increased, and occasionally the disease is attended with fever of an intermittent form. The face is usually pale or sallow, and the expression of the countenance that of distress. The abdomen is generally more or less distended, and very often exhibits some degree of tympanites. The emaciation is always considerable, particularly in chil- dren over two years of age. In the early stage of chronic peritonitis, the symptoms are fre- quently so slight, and of so obscure a character, that but little attention is paid to them by the parents; or the child is supposed to be labouring under worms, the serious character of the disease being entirely un- suspected, and a few, often improper, domestic remedies, are all that is prescribed. The progress of the disease is generally marked by increasing, and often extreme emaciation and debility; with a small, frequent pulse; hectic fever; night sweats; often diarrhoea, with thin, dark-coloured, and offensive discharges, and the patient finally sinks from exhaustion. In other cases, a serous effusion takes place within the cavity of the abdomen; the effusion being entirely confined to the peritoneal cavity, and unattended with oedema of the extremities even in protracted cases. In these cases the tumefaction of the abdomen is at first sometimes so inconsiderable as to be overlooked, especially in young children, in whom there is naturally a considerable prominence of abdomen. The fluctuation of the effused fluid can always, however, be distinctly per- ceived by the usual means. 264 DISEASES OF THE DIGESTIVE ORGANS. The effusion increasing daily in extent, causes a gradual augmen- tation in the size of the abdomen. Every portion of the body, with the exception of the face, becomes, at the same time, more and more emaciated, Avhile the exhaustion of the patient rapidly increases. The appetite often, however, continues unimpaired, or is sometimes even increased. The bowels are variable; being at one time affected with diarrhoea, and at others, constipated, or at least seldom opened. A febrile excitement of an intermittent form now generally occurs, and the patient, in a state of extreme marasmus, sinks gradually into his grave. The appearances discovered after death, are redness and thickening of the peritoneum, particularly of that portion enveloping the intestines; the redness is occasionally confined to the larger omentum, or to the peritoneum covering the right iliac fossa (Rilliet and Barthez;) adhe- sions, more or less extensive, of the convolutions of the intestines to each other, or of these to the surface of the abdomen, or to the other viscera, are frequently present. The intestines are often coated with a layer of purulent, and at others of albuminous matter. Very ge- nerally the cavity of the abdomen contains more or less serum of a whitish or citrine colour, sometimes with small albuminous flocculi dif- fused throughout it. In chronic cases, circumscribed collections of puriform matter occasionally exist between the convolutions of the in- testines. The peritoneum is often studded with tubercles or tubercu- lar granulations. The mucous coat of the intestine presents frequently the indications of chronic inflammation, particularly ulcerations, to a greater or less extent. Peritonitis is usually the result of cold:—it may, however, particu- larly in its chronic form, supervene upon slight attacks of any of the acute affections of the alimentary canal, or upon other febrile diseases, as measles, or scarlatina. It may attack children of any age, but is more common after the fifth year than previously. An acute attack of peritonitis may be the result of perforation of the intestines, from disease of the alimentary canal. In the treatment of acute peritonitis, a careful regulation of the diet is all-important:—thin gruel, or any of the mucilaginous fluids directed in enteritis, may be allowed. As early as possible in the attack, leeches should be applied to the abdomen, especially in the neighbour- hood of the umbilicus, in numbers proportioned to the age of the pa- tient, and the extent and violence of the local symptoms; and if the first application does not effect the removal of the pain and tenderness of the abdomen, they should be repeated after a short interval. The warm bath and fomentations, or warm cataplasms to the abdomen, are remedies from which, if judiciously managed, and perseveringly em- ployed, the very best effects may be anticipated. Internally, it is generally proper to administer at the commence- ment of the attack, a full dose of calomel, followed in a few hours by a dose of castor oil, or some simple purgative enema; after the opera- tion of which, small doses of calomel, combined with ipecacuanha and extract of hyoscyamus, may be given every three hours. In children over two years of age, blood may be taken from the PERITONITIS. 265 arm, and if necessary followed by leeches to the abdomen. In most cases in which the symptoms are of any degree of violence, smapised pediluvia will be found advantageous. After leeching has been carried as far as is thought advisable, a blister over the abdomen, as directed in enteritis, will often cut short trip (liflPAflP On the subject of local depletion it will be proper to remark that the indications for its employment, and the extent to which it is to be carried, as well as for its repetition, are to be drawn chiefly from the intensity of the local symptoms: when there is pain or decided tender- ness of the abdomen, leeches should be applied in proportion to the surface over which it extends; and so long as it continues without any marked abatement, the repetition of the leeches should not be neglected. The frequent absence, in peritonitis, of febrile excitement, and the ex- haustion of the patient, will often mislead the inexperienced practi- tioner, and induce him to omit this important remedy, from the early and judicious employment of which more is to be expected than from any other. Even in the chronic form of the disease, pain and tender- ness of the abdomen call for the employment of leeches, which, if ap- plied in sufficient numbers, will often produce a very marked change in the character of the case. The warm bath, fomentations and blisters to the abdomen, are equally important in the chronic, as in the acute form, as is also the internal use of calomel, with ipecacupha and extract of hyoscyamus. In chronic cases, after effusion has taken place, we have derived the best effects from the addition to this prescription of minute doses of powdered digitalis. Wolff recommends, in such cases, the digitalis with the bitartrate of potass, in small doses, frequently repeated. Even when considerable diarrhoea is present, he states that he has observed, under the use of the remedy, a gradual abatement of all the symptoms of the disease to take place; and by following it with a course of mild bitters, in conjunction with digitalis, and an infusion of roasted acorns, he has, in a large number of instances, effected a perfect cure, even in cases that when first presented to him, he had almost despaired of being able by any means to conduct to a favour- able termination. During convalescence, whether from the acute or chronic form of the disease, it is all-important to place the patient upon a well-regu- lated, mild, and digestible diet, composed chiefly of farinaceous arti- cles and milk. Flannel should be worn next to the skin, and the arms and legs carefully protected from cold and damp. A change of air, particularly a change from a damp and chilly atmosphere to one that is mild and dry, will often expedite the patient's recovery. 266 DISEASES OF THE DIGESTIVE ORGANS. CHAPTER VII. THE REMITTENT OR GASTRIC FEVER OF INFANCY. The inflammatory affections of the alimentary canal, occurring in infants subsequent to dentition, are frequently accompanied by febrile symptoms, that usually assume a remittent form, with distinct exacer- bations towards evening. This constitutes the remittent fever of in- fancy, the worm fever of some writers, and the mesenteric fever of others. It is, in fact, in every instance, either a gastro-enteritis, an ileitis, or an entero-colitis, accompanied with febrile reaction. In many cases, however, the latter constitutes the most prominent cha- racteristic of the attack, and completely masks the local affection. Recent observations have rendered it extremely probable that, under the name of remittent fever of infancy, there have been confounded together diseases of an essentially different pathological character, one of w'hich, and this of not unfrequent occurrence, having a close affinity with the continued fever of the adult. The invasion of infantile remittent fever is occasionally very sudden. A child, apparently in good health, shortly after retiring to bed, is at- tacked with a severe febrile paroxysm: the skin becomes hot, the coun- tenance flushed, the eyes injected, and the pulse quick and frequent. The thirst is generally intense; the tongue dry, and often thickly coated on its surface with a layer of white mucus, but red at its point and edges. There is always great restlessness, and often transient delirium. The patient generally complains of pain over the eyes, and of pain or soreness of the abdomen, which is more or less tender to the touch, and hot. There is, not unfrequently, nausea, or vomiting of a yellow or greenish fluid, and of a sour and offensive smell. Towards morning these symptoms gradually abate; the skin be- comes cooler, the pulse less quick and frequent, and the tongue moister. There is still, however, dryness of the skin; the tongue continues coated; the pulse is quicker than natural; the child exhibits more or less languor and fretfulness, and is without appetite; the abdomen is still often painful or tender, and the urine scanty and high-coloured, often depositing a white sediment. In the course of the morning, the remaining symptoms abate or dis- appear, and the child becomes more lively and playful, but still exhi- bits a degree of languor and peevishness; these, in general, increase towards evening, when a febrile paroxysm occurs, as on the preceding night; and is again succeeded in the morning by a more or less per- fect remission. In this manner, with daily exacerbations and remis- sions, the disease, unless cut short by appropriate remedies, runs on for many days, and often assumes a chronic and very protracted form. The disease more generally, however, commences less suddenly. The child is observed, for several days, to be languid and fretful, with loss of appetite, augmented thirst, and some heat of skin. These THE REMITTENT FEVER OF INFANCY. 267 symptoms increase gradually in intensity, and towards evening, the heat and dryness of the skin become more marked; the thirst and rest- lessness greater; the breathing becomes somewhat hurried; the pulse more quick and frequent;—towards morning, the skin becomes again moist and cool, and the patient falls into a short, disturbed sleep. Each night the febrile paroxysm is more and more distinct, and of longer duration, and the morning remission less complete. In the commencement of the attack, the bowels are ordinarily con- stipated; in some cases, however, there is diarrhoea, or a frequent inclination to go to stool without much being passed. When evacua- tions from the bowels occur, they are always unnatural, and highly offensive; being dark-coloured, or clay-like, or of the appearance and consistence of tar; they are often mixed with mucus, and occasionally bloody. The vitiated secretions from the intestines, liver, and perhaps the pancreas are frequently accumulated in the bowels in large quan- tities, and constitute the morbid and offensive discharges which are so commonly produced by the action of purgatives. Not unfrequently there occur repeated evacuations from the bowels, accompanied with violent tormina and tenesmus—the evacuations consisting of little else than mucus, often mixed with blood. The symptoms of such cases are evidently dependent upon inflammation seated in the large intes- tines, and constitute the dysenteric fever of some writers. There is in most cases more or less pain or tenderness experienced upon pressure of the abdomen, which is also often hot to the touch, while the extremities are cool or cold—even during the febrile exacer- bations, when the face is flushed, and the residue of the body dry and parched. The patient usually lies upon his back, with his knees drawn Up—Cries frequently, and exhibits that peculiar expression of counte- nance indicative of abdominal distress. The breath, from an early period in the attack, has a peculiar sickly odour, and often becomes decidedly offensive. The stomach is gene- rally very irritable, and rejects, immediately, every thing taken into it. Frequent vomiting is not unusual. The tongue becomes, in the progress of the disease, more coated, dry, and pointed. The breathing is often quick and hurried, and a short, hacking cough is a very fre- quent symptom. In a few cases an eruption of rose-coloured lenticular Bpots occurs upon the abdomen or inner surface of the thighs, and oc- casionally sudamina appear upon the abdomen, or along the front and sides of the neck. Infantile remittent fever often assumes a chronic form; the exacer- bations being of longer duration, but marked by symptoms of less in- tensity than in the more acute form; the remissions are also less dis- tinct. The abdomen is usually tender and hot, and generally tympa- nitic; the bowels are often affected with diarrhoea, the dejections be- ing always abnormal in appearance, and fetid. The tongue is thickly coated upon its upper surface with a yellowish or brownish mucus, and red and dry at its point and edges; the teeth are often covered with sordes, and the lips parched and cracked; the urine is scanty and high-coloured, depositing a copious white sediment, particularly during the remissions; the skin is dry, harsh, and of a sallow or dirty hue; 268 DISEASES OF THE DIGESTIVE ORGANS. the countenance is contracted and wrinkled, presenting the appearance of premature old age. The appetite is occasionally unimpaired, and, in some cases, even voracious; in general, however, it is altogether lost. The child is very generally affected with a short, hacking, and frequent cough. Most commonly there is urgent thirst. There is al- ways more or less fretfulness, and the usual indications of suffering; and the patient exhibits a disposition to pick, almost constantly, at some portions of its face or body, or at the bed-clothes, or the face and arms of its attendants. If, as remarked by Locock, there be an acci- dental pimple on the skin, this will usually be picked until a sore is produced, the edges of which are still more eagerly attacked, so that the fingers are constantly stained with blood. This picking is, by many, considered as one of the diagnostic symptoms of infantile re- mittent fever;—it is, however, a common phenomenon in all the chronic affections of childhood, and is often observed when no positive disease is present. The emaciation and prostration of strength are usually very consi- derable. In the advanced stages, the child is sometimes affected with a species of stupor, in which he remains for hours, as in a doze, with half-closed eyelids; he is, however, readily aroused, but quickly falls into the same state again, when undisturbed. This condition is often mistaken for that resulting from effusion into the brain; there is, how- ever, no increased heat of the head, no affection of the pupil, nor any of the other symptoms characteristic of effusion within the cranium. Disease of the brain may, however, occur, either in the acute or chro- nic form of the fever, and give rise, if neglected, to tubercular menin- gitis, with serous effusion, or to acute meningitis. In other cases, the respiration, which has been hurried from the first, becomes laborious, a troublesome, short cough occurs, and very frequently, upon examination, a more or less extensive inflammation of the bronchial mucous membrane will be detected, and if the dis- ease be not subdued, wheezing, expectoration, and the other symptoms of bronchial inflammation, or of a tuberculous condition of the lungs, finally ensue. Occasionally the symptoms will appear to abate for a few weeks, and then suddenly recur; during these remissions, the patient will often gain flesh and strength, but the abdomen still remains tumid, and the bowels irregular; and these alternations of improvement and relapse may continue until the mesenteric glands become enlarged, or serous effusion takes place within the abdomen. The emaciation now increases; the exacerbations of fever are entirely confined to the night, and are followed, towards morning, by profuse perspiration, and a com- plete intermission; the appetite is occasionally voracious—the case, in fact, presenting all the symptoms of tabes mesenterica. The duration of the disease will depend, in a great measure, upon the character and extent of the lesions of the intestinal canal, by which it has been produced, the constitution of the patient, and the treatment pursued. In many cases, an appropriate treatment commenced at an early stage, will effect its entire removal in a few hours; in other in- stances, however, a cure is less easily effected; and in children of a THE REMITTENT FEVER OF INFANCY.. 269 strongly marked lymphatic temperament, in whom there is a tendency to the development of tubercles in the lungs, to a diseased condition of the mesenteric glands, or to tubercular meningitis or peritonitis, the termination of the fever is very generally fatal. Death may take place at an early period, from the extent of the in- testinal inflammation, or, in chronic cases, the child may sink from mere exhaustion. Often, however, even in the more protracted cases, attended with great emaciation and debility, a complete recovery may be effected by an appropriate treatment. Frequent relapses, which are liable to be produced by slight errors in diet, exposure to cold or damp, or over exertion during convalescence, produce ordinarily a chronic form of the disease, which is particularly unmanageable, and seldom permanently removed. The lesions discovered after death from infantile remittent fever vary, according to the longer or shorter duration of the disease. They are chiefly inflammation, more or less extended, of the digestive mucous membrane—in some instances, of the stomach and upper portion of the small intestines—most commonly of the ileum, at its lower part, and in some instances, of both the ileum and colon. The mucous mem- brane is either reddened in patches, points, or striae, and is generally thickened and softened, or ulcerated. The isolated muciparous folli- cles, as well as the follicular plexuses, are often found tumefied, red- dened and ulcerated. The mucous membrane is often covered with a thick layer of tenacious mucus. Dark, livid patches of the lining mem- brane of the small, but more commonly of the large intestines, are frequently met with, and occasionally gelatinous softening, with per- foration of all the coats. The mesenteric glands are very frequently enlarged—sometimes enormously so; occasionally in a state of sup- puration, but more commonly converted into a cheesy matter. Peri- toneal inflammation is sometimes present, and, in chronic cases, the peritoneum is not unfrequently thickly studded with tubercles. In some instances acute peritoneal inflammation seems to have been the immediate cause of death, and to have resulted from perforation of the intestines. The liver is usually enlarged and in a state of extreme hyper- aemia; sometimes changed in texture, and at other times, of a lighter colour than natural. In the brain there is often more or less effusion between the membranes, and into the ventricles, with opacity of the arachnoid membrane, and tubercles of the substance or meninges. In the thorax, the most common morbid appearance is increased redness of the bronchial mucous membrane, the bronchial ramifications and air-cells being filled with mucus. The lungs occasionally betray traces of inflammation; and in protracted cases, tubercles in the lungs, and upon the surface of the pleura, are frequently met with. Infantile remittent fever is, in every case, the result of inflamma- tion, most commonly subacute, of some portion of the digestive mu- cous membrane; the inflammation of other organs, so frequently met with, being a mere complication, occurring in the course of the disease. This is rendered evident by the phenomena which are described as constituting infantile remittent fever, all of which, upon a close analysis, will be found to point to the mucous surface as the original 270 DISEASES OF TnE DIGESTIVE ORGANS. seat of morbid action. The result of numerous autopsies have placed this fact beyond the possibility of doubt; it is therefore, chiefly to a morbid condition of the mucous membrane of the alimentary canal that we are to look for the pathology of the disease; and to the re- moval of this condition are our remedies to be primarily and mainly directed. When the stomach is the seat of inflammation, of a subacute charac- ter, theue will be pain on pressure at the epigastrium; a vivid redness of the point of the tongue, extending some distance round its edges' and generally a loathing of food; nausea, retching, or vomiting are sometimes observed. When the inflammation is seated in the mucous membrane of the small intestines, it is generally in the lower part of the ileum. We have then the same appearance of the tongue, with the papillae more prominent and distinct than natural. Pain will be excited by pressure lower down than when the inflammation is seated in the stomach; the discharges from the bowels will be more mucous than natural, often re- sembling thin oily paint, mixed occasionally with distinct masses of mucus. Nausea, retching or vomiting rarely occur; excepting when the stomach and upper portion of the small intestines are also affect- ed. ' When the inflammation extends to the large intestines, its seat is al- ways at the upper part of the colon. The tongue will then present the same appearance, and the same tenderness of the abdomen will be present, as in inflammation of the small intestines, and the dis- charges from the bowels will consist of a muddy, loose, offensive fecu- lent matter, or of a little mucus mixed with blood, the abdomen, in all these cases, being more or less tense and hot. Sometimes there i3 a torpid condition of the colon, with great distention, from retained fecal matter. When the liver is affected, we have pain or tenderness when pres- sure is made in the region of that viscus, and the discharges from the bowels will show a deficiency, or depraved state of the biliary secre- tion. From the sympathy which exists between the skin and mucous membrane of the digestive organs, an irritation is experienced either at the external termination of the mucous orifices, or upon some part of the surface, and it is to remove or abate this, that the child is prompted to pick incessantly at the nose, mouth, eyes, face, &c. The causes of infantile remittent fever are the same to which we have, in the preceding sections, referred the production of gastro-in- testinal inflammation. In perhaps the majority of instances, it is the result of too much, improper, or unwholesome food. Long habits of indulgence in the use of stimulating and indigestible articles of food, pastry, confectionery, crude fruits and vegetables, and various com- pound dishes—or swallowing food rapidly, and consequently without due mastication, are enumerated by writers upon the subject, as tho usual causes of the disease. According to the experience of Locock and Merriman, the acute form of gastric remittent fever is most pre- valent about the period of Christmas, when the rich and indigestible fare of the season is partaken of to excess by children, who are too THE REMITTENT FEVER OF INFANCY. 271 often encouraged in this by the foolishness of parents and friends.— The disease may likewise be produced by cold and damp, and hence it very frequently occurs towards the close of summer, and in the early part of autumn, when transitions of atmospherical temperature are most frequent, and when the system of the child is more liable to be af- fected by them, in consequence of the over-stimulation of the skin— and of the organs which sympathize most closely with it, by the heat of the preceding season, which often still continues during the middle portion of the day, and contrasts strongly with the coolness, often chilliness and dampness of the night. Teething and worms have been generally set down among the pro- ducing causes of infantile remittent fever; the first, which is usually attended with increased irritability of the digestive mucous membrane, ' particularly of its muciparous glands and follicles, no doubt often pre- disposes to inflammation of the alimentary canal, and of course to re- mittent fever; of the agency of the latter in its production, we have not, in any case, the slightest evidence. Among the more common causes of the disease are the neglect or mismanagement of the bowel affections of children generally; more especially the abuse of purgatives on the one hand, and of stimulating remedies and diet on the other. Infantile remittent fever is said to prevail occasionally as an epidemic, or, more properly speaking, as an endemic. Of this there can be little doubt. By some it is supposed, particularly in its low typhoid or chronic form, in other words, when connected with subacute inflam- mation and ulceration of the mucous glands and follicles of the intes- tines, to be propagated by contagion. The production of disease of the bowels in children by an impure and confined atmosphere, parti- cularly when combined with a neglect of personal cleanliness, and un- wholesome diet, has been too much overlooked. AVe have known nearly all the children of a family or neighbourhood, to become affected from this cause, with some of the worst forms of intestinal inflamma- tion, accompanied with the phenomena ascribed to the low or typhoid remittent fever, the progress of which could only be stayed by removal from the affected air in which it was generated, by an improved diet, and a strict enforcement of cleanliness of person and clothing. It is no doubt under such circumstances that the fever has been reputed contagious: in a strict sense, however, we do not believe that the dis- ease is ever propagated by contagion. Rilliet and Barthez, West, Willshire, and others of the continental and British physicians, believe that the disease usually described under the name of remittent fever of children is identical with the typhoid fever of the adult. Taylor (on Infantile Remittent Fever) recognises one of the forms of the disease as strictly typhoid—which character it may assume in the course of an acute attack, or from its very onset. He describes the characteristic symptoms of the typhoid form, as gra- dually augmenting debility—throughout the day drowsiness, approach- ing to stupor, from which the child is with difficulty roused—dryness of the tongue, which becomes of a brown colour, and glazed—fre- quently when diarrhoea is present, it is red and shining—the lips and 272 DISEASES OF THE DIGESTIVE ORGANS. teeth become covered with sordes—the pulse is quick and feeble, some- times small and thready—there is low muttering delirium and picking of the nose and lips. Diarrhoea is usually present, though not gene- rally severe—the evacuations have a yellow ochre colour—there is sometimes pain on pressure of the abdomen, more especially towards the right iliac region. When the stupor of the patient augments, and he seems unconscious, or nearly so, of what is occurring around him, the stools are passed involuntarily. The sensation of thirst, so dis- tressing in the early stages, seems then to be abolished. In some cases there is a rejection of all food, in others it is taken freely. Petechiae occur, and sometimes bullae are observed. A rose-coloured eruption is described by Rilliet and Barthez as appearing usually between the sixth and tenth days. In the greater number of cases it is extremely scanty. It remains visible often for only two or three days, and is not unfrequently absent altogether. Taylor has met with maculae, but very rarely. The duration of this typhoid form is from two to three weeks. Its termination is most commonly in re- covery ; the symptoms gradually improving, the bowels acting regularly, the stools becoming more natural, the tongue clean and moist, the mor- bid thirst disappearing, and the evening exacerbation of fever shorter and less severe. Convalescence is always slow, and relapses occur from very slight causes. Dr. J. L. Smith, of New York, in a paper published in the New York Journal of Med., (Jan., 1857,) has attempted to show that the remittent fever of infancy is always like the remittent fever of adults, a disease of miasmatic origin. That there is a form of fever of a re- mittent type produced in children by exposure to miasmatic influences, is admitted. Such a one is described by Bouchut and Taylor; it is, however, a very different disease from that known as infantile re- mittent fever. The latter would appear, indeed, to be of more fre- quent occurrence in non-miasmatic than in miasmatic regions. In many cases, in fact, it is produced by causes which are beyond our means of detection. Though generally appearing in isolated cases, it has, nevertheless, its seasons of epidemic prevalence. The treatment of infantile remittent fever will be readily under- stood from what has been advanced in relation to its pathology. De- pendent for its production and continuance upon inflammation, more or less extensive, and of an acute, subacute, or chronic character, of the mucous membrane of the alimentary canal—it is to the removal of this inflammation that our remedies must be directed; and just in pro- portion as they are adapted to effect this object, will be our success in the cure of the disease. A proper regulation of the patient's diet is all-important. In the more recent and acute cases, every species of food should be with- held; the child may be allowed, however, some cold mucilaginous fluid as a drink—any of those directed in gastro-enteric inflammation will be proper—but even of these, the patient should not be allowed to par- take so as to unduly distend the stomach; this is particularly necessary, if the case be attended with symptoms of gastric disease. In the more protracted and chronic forms of the fever, in addition to the mucilagi- nous drinks, a moderate portion of some plain farinaceous food, with THE REMITTENT FEVER OF INFANCY. 273 or without the addition of milk, may be allowed, at proper intervals. Occasionally, in very chronic cases, we have found beef tea, chicken water, or plain mutton broth with rice, to agree better with the sto- mach, and to produce a less amount of irritation than farinaceous pre- parations. On this point, of course, the judgment of the physician, guided by a knowledge of the pathology of the disease, and the par- ticular circumstances of each- case, must be exercised. The only ge- neral rule that can be given is, to prohibit every article of diet of a stimulating or indigestible character, as well as all solid food; and not to allow even that which is proper to be given at improper hours, or in too great quantity. In recent cases, the treatment may be commenced by the adminis- tration of a full dose of calomel, with magnesia, (five grains of each,) which should be followed, in the course of a few hours, by an appro- priate dose of castor oil, or a simple laxative enema. This will gene- rally bring away a large amount of undigested matter and vitiated se- cretions, with a manifest improvement in the condition of the patient. As to the propriety of repeating the purgative, this will depend upon the particular circumstances of the case. If the attack has been evi- dently the result of excess in eating, or improper food, the evacuation , of the undigested matter with which the intestines are, in such cases, often loaded, and which is a constant source of irritation to the mucous membrane, is all-important; if, therefore, pretty free discharges have not been produced by the first purgative, an additional dose of castor oil, or of magnesia and rhubarb, may be given on the succeeding day. The repeated administration of active purgatives, so generally recom- mended in this disease, and their continuance from day to day, until healthy stools are procured, is founded upon incorrect views of the pa- thology of the disease, and is rather calculated to augment than to re- move its more prominent and dangerous symptoms. We are persuaded, however, that the administration, at short intervals, of alterative doses of calomel, combined with chalk and ipecacuanha, is a practice from which, in the generality of cases, much good will result. A gentle laxa- tive action on the bowrels is kept up by this prescription; the discharges becoming more natural in appearance, the skin softer, the tongue more moist and clean, the pulse slower and more developed, the exacerbations of fever shorter, and the remissions more perfect. In the more pro- tracted and chronic cases, we are accustomed to add to each dose of the calomel and magnesia, a small portion of extract of hyoscyamus, which has the advantage of allaying irritation without binding the bowels. In every case in which the exacerbations of fever are marked by symptoms of any degree of intensity, the abstraction of a few ounces of blood from the arm, in children over five years of age, will be ad- visable; or, in younger subjects, leeches may be applied to the abdo- men, in numbers proportioned to the violence of the symptoms and age of the patient. The application of leeches will be demanded whenever there is pain or tenderness upon pressure, with tension and heat of the abdomen: when well timed, and in sufficient numbers to reduce the local inflammation, they are the remedy upon which most dependence is to be placed in the treatment of these cases. Even in 18 274 DISEASES OF THE DIGESTIVE ORGANS. the protracted and chronic forms of the disease, pain, heat, and ten- sion in the epigastric, umbilical, or hypogastric regions, or in either hypochondrium, should be the signal for their application, in numbers adapted to the circumstances of each case. The fact that the disease is one attended with so much exhaustion, and so liable to be protracted, has caused the abstraction of any amount of blood to be condemned by many; but an active treatment, judiciously pursued in its early stage, and in its more acute forms, is unquestionably the best adapted speedily to arrest the disease, and prevent the exhaustion consequent upon its more protracted forms. The intermissions will usually become more distinct, the tongue moister, the skin softer and more natural, and the evacuations more regular and of a better character, after the local abstraction of blood; and also at a later period, when the indi- cations for its use are present, it is often followed by an improvement in the pulse, the skin, and in the appearance of the stools, the very re- verse of those from increased depression. It has been suggested by Dr. Eberle, and with a good deal of plau- sibility, that the intestinal torpor that so frequently exists in the dis- ease, is often the result of hyperaemia of the brain; and hence it is that an efficient abstraction of blood almost always increases the sus- ceptibility of the bowels to the action of mild aperients. In every instance the tepid or warm bath is, as in the case of gas- tro-intestinal inflammations generally, a very valuable remedy. When the skin is hot and parched, sponging the entire surface frequently with tepid water will often produce a pleasant coolness and moisture, and relieve entirely the restlessness of the patient. In the intervals of the paroxysms, as well as in those cases in which the temperature of the surface is not increased or is actually reduced, the warm bath by immersion should be preferred. Fomentations to the abdomen, or warm emollient cataplasms, perseveringly employed, as well as warm or sinapised pediluvia, especially when there is a tendency to coldness of the extremities, or to irritation of the brain, will always be found to produce a decidedly beneficial effect. In protracted or chronic cases, blisters to the abdomen, as directed in enteritis, will be proper, and, in general, are followed by a marked improvement in the condi- tion of the bowels. When delirium, increased heat of the head, aversion from light, in- jection of the eyes, or a state of stupor ensues, a few leeches may be ap- plied behind the ears, and cold washes or lotions to the scalp, while at the same time, stimulating pediluvia or frictions to the lower extre- mities are employed. Cough, and hurried laborious respiration, will demand mucilaginous drinks, blisters to the thorax, and if the symp- toms of bronchial inflammation are distinctly marked, and of any de- gree of severity, leeches should be applied about the clavicles. In these cases, small doses of calomel, ipecacuanha, digitalis, and extract of hyoscyamus will be found a useful remedy. R.—Calomel, gr. iij. ad iv. Ipecac, pulv. gr. iij. Digitalis pulv. gr. iij. ad iv. Ext., hyoscyami, gr. iv. ad viij.—M. f. chart. No xij. One to be given every three hours. In the chronic form of infantile remittent fever, attended with tym- THE REMITTENT FEVER OF INFANCY. 275 panites, and vitiated, mucous, or dark offensive discharges, one of the remedies from which we have derived the most decidedly beneficial effects is the spirits of turpentine; it may be given in doses of from ten to fifteen drops, three or four times daily, in a little sugar, or in the form of a mixture, as recommended in cases of chronic diarrhoea, It has not only the effect of exciting the bowels to contract and expel the gas by which they are distended, but exerts a beneficial influence upon the morbid state of the intestinal mucous membrane, allaying irritation, and producing a decided improvement in the excretions. We have employed this remedy very extensively, in all the chronic affections of the bowels in children, and have always had occasion to be pleased with its operation. If there be evidences of serous effusion within the abdomen, with scanty secretion of urine, the same treatment should be pursued as di- rected in cases of chronic peritonitis. The treatment of cases attended with enlargement of the mesen- teric glands differs in nothing from that already laid down. As soon however, as the symptoms of intestinal inflammation are reduced, the administration of some of the milder preparations of iodine may be entered upon, with the inunction of the same, in the form of ointment about the groins and over the surface of the abdomen: the iodide of potassium is the preparation we have generally employed, and occa- sionally with very great advantage. In all cases, after the symptoms of the disease have subsided, the discharges from the bowels have become more regular and healthy in appearance, and the tongue cleaner and more moist, some light bitter, as a weak infusion of cinchona or calomba, may be given, in combi- nation with the sulphuric or hydrochloric acids, and, as convalescence advances, the sulphate of quinia, the tincture of the sesquichloride or the persesquinitrate of iron; the bowels, at the same time, being kept regularly open by gentle aperients, and the diet slowly and cautiously improved. By this course, aided by the tepid or warm bath, daily re- peated, and followed by friction of the surface, the functions of the digestive organs will be very rapidly improved, and the strength of the patient promptly restored. As soon as the patient is able to bear it, gentle exercise in the open air, at first passive, and subsequently of a more active kind, will confirm the cure. When the case has been of a protracted character, change of air will often produce the most beneficial effects. Great caution, however, must be observed, not to commence too early upon the use of tonics, or to improve too rapidly the diet of the patient. During the stage of convalescence the utmost circumspection should be observed, as well in regard to the quantity, as to the quality of the food that is allowed. A slight excess, a premature indulgence in solid food, or the use of that which is indigestible, or which has any tendency to oppress the stomach, will endanger a serious relapse. The surface of the body should be carefully guarded from the impression of cold or damp, by appropriate clothing and due precaution; and the proper temperature, dryness, and purity of the air of the apartment occupied by the convalescent, should be maintained by due ventilation, and by artificial heat when necessary. 276 DISEASES OF THE RESPIRATORY ORGANS. SECTION II. DISEASES OF THE RESPIRATORY ORGANS. 1. Asphyxia. Cases of still-born infants are very common; and although it may not be strictly correct to say that the infant is, in such cases, invaria- bly in a state of asphyxia, yet the term seems as little exceptionable as any other, provided it be employed only in its technical sense of suspended animation. Tanner, (Diseases of Infancy and Childhood, London, 1848,) suggests the term apnoea neonatorum, that is, absence of respiration in the new-born infant, as a much more appropriate one, almost suggesting the only appropriate remedy in such cases, the re- newal of respiration by artificial means. The absence of respiration in the new-born infant may arise either from the imperfect development or malformation of the heart and circulatory organs, of the lungs and respiratory apparatus, or of some portion of the nervous system; or from the extinction of life previous to, or during parturition, from con- genital disease, or from injuries inflicted upon the foetus in its passage through the pelvis. " In all these cases, as well as in those in which the powers of life are too feeble to carry on the functions of the or- ganism in the independent state of existence, no hopes, of course, can be entertained of resuscitation being effected, and the duration of life prolonged, by any course of treatment. In a large proportion of the cases in which the infant is apparently dead-born, there is, however, merely a suspension of the respiratory function, and by proper means, persevered in for a sufficient length of time, complete resuscitation may be effected.1 The most common causes of the suspension of respiration in new- born infants are: tedious and protracted labour, from defective uterine efforts, from rigidity of the os uteri, or from a disproportion between the size of the foetal head and the dimensions of the pelvis; the cord being twisted around the neck of the infant, or around some other part of its body; the cord, from its prolapsus, being subjected to pressure between the head of the infant and the walls of the pelvis; the pla- centa becoming partially or entirely detached before the expulsion of the infant; the os uteri or the constrictor muscle of the vagina being spasmodically contracted around the neck of the infant, as is liable to occur in a first labour, particularly when ergot is injudiciously admi- nistered to expedite delivery; the infant being born with the face in- 1 In the 10 years preceding 1845, of the 81,324 children born, 3,679, or about 4.5, were dead. How many of these latter were premature births, or to what particular cause the death of the foetus was owing, we have no means of ascertaining. The law requires that in every instance in which the foetus has arrived at the term of six months, or at the termination of the full period of utero-gestation, and is born dead, it shall be reported as a case of still-birth. ASPHYXIA. 277 vested with the membranes; the mouth and fauces being filled with viscid mucus, or, as sometimes happens, the tongue falling backwards, and closing up the fauces; or, finally, the infant being exceedingly feeble or exhausted. A suspension of respiration is likewise occasion- ally observed in cases of very rapid delivery, where the infant is pro- truded by a quick succession of severe uterine contractions. Asphyxia may occur immediately after birth, and even after the infant has breathed and uttered some feeble cries, when, from the ig- norance, or the wilful neglect of the practitioner or attendants, the necessary measures are not pursued for the preservation of its life; and occasionally, from causes the nature and operation of which it is very difficult to understand. In some cases the infant, when born, is pallid, with open and flaccid mouth, relaxed limbs, and only a feeble, obscure pulsation, sometimes none at all, at the heart or in the cord; in other cases the face is swollen, livid or purple, with or without pulsation of the heart or of the cord; occasionally, however, the cord is tense and pulsates strongly, while the pulsation at the heart is slow and feeble. The state of asphyxia may be more or less complete. The foetus may neither cry nor respire, and present no appreciable motion of the umbilical arteries or heart, being, to all appearances, actually dead; or, while no effort at respiration occurs, the heart and cord may pulsate with mure or less vigour, or, again, a few ineffectual respiratory efforts may be made, and even faint cries uttered, and then a complete state of asphyxia ensue. All the causes to which the suspension of respiration in the new-born infant is to be immediately referred, have not been investigated with sufficient accuracy. Some are, it is true, very evident, being those which directly impede the passage of the air into the lungs, as the ex- istence of a quantity of thick, tenacious mucus in the mouth, fauces, or windpipe; or which prevent the dilatation of the chest and other respiratory movements, by suspending innervation—as an apoplectic condition of the brain. In those cases, howTever, of not unfrequent oc- currence, in which there exists no impediment to the entrance of air into the lungs, and no undue distention of the vessels of the brain, it is difficult to assign the real cause for the non-establishment of respi- ration. Some have supposed it, in these cases, to arise from a state of extreme debility; others from anaemia, or from the functions of the placenta having become suspended a short time previous to delivery, in consequence of which the blood is rendered unfit to produce that degree of stimulation of the brain and other organs, which is essential to the proper performance of their functions, and, hence, the death of the infant must necessarily ensue unless respiration be promptly esta- blished by artificial means, and the due vitalization of the blood is in this manner effected. The latter opinion, which is that of Velpeau, seems to us the most plausible. When a new-born infant opens its eyes, moves its limbs, and exhi- bits a few imperfect respiratory efforts, a smart slap upon the buttocks, or a few drops of cold water sprinkled upon the chest and abdomen, will very generally cause it instantly to breathe, and to cry out lustily. 278 DISEASES OF THE RESPIRATORY ORGANS. In all cases, immediate attention should be paid to remove at once any viscid mucus which may exist in the mouth and throat. This may be readily done with the finger, surrounded with a piece of soft linen. The infant should be subsequently placed upon its side, in such a po- sition that, should any of the mucus remain, it may flow from the mouth, while at the same time its entrance into the trachea is prevented. The practice of turning the child upon its face, slapping it between the shoulders, and gently shaking it, as recommended by a few highly respectable writers, " with the view of disengaging any mucus that may be lodged in the trachea," is one that we cannot believe to be either safe or useful. In all cases in which the suspension of respiration is unaccompanied with symptoms of cerebral congestion—a puffy and dark purple or livid appearance of the face—it is not proper to tie and divide the umbilical cord, until its pulsation has ceased, or become quite feeble. The pre- mature application of a ligature to the cord has, we believe, in many instances, given rise to asphyxia. The dashing of a little cold water or spirits upon the chest and ab- domen will, in many cases, almost immediately excite the respiratory action,—with loud and vigorous cries,—when the cord may be divided, and the infant suffered to remain quiet, until its strength is, in some degree, recruited. The plan pursued by Velpeau, in imitation of Desormeaux, is a very excellent means of rousing the infant from a state of asphyxia. A portion of some spirituous liquor being held for a moment or two in the mouth, is then spirted with force, in the form of a douche, upon the breast of the child. Immersion in the warm bath is also in many cases a very successful means of inducing respiration in the still-born infant. The use of the bath in these cases, however, requires some little management, to de- rive from it any advantage. The object of the bath is to excite the action of the heart and respiratory muscles; if, however, within a very short time after immersion, neither respiration nor circulation ensues, the child should be taken out, as the effect of the bath is then decidedly injurious. Even when respiration sets in, as it often will, soon after immersion, continuance in the bath should not exceed a few minutes; or we run the risk by raising the temperature of the infant, of rendering it less capable of enduring the state of asphyxia, while, at the same time, the action of the atmospheric air on the surface of the body, which always exerts a very powerful vivifying influence, is prevented. When the child is removed from the bath, gentle friction should be applied to the surface of its body with a warm dry flannel cloth. Cold affusion has been resorted to, in cases of suspended respiration in new-born infants, and when judiciously managed, there is no doubt it will often prove a very powerful and successful means of resuscita- tion. In two cases, related by Dr. Patterson, of Dublin, in which the infant was placed in a tub, and three quarts of water, at a temperature of about 60°, were twice dashed over it, strong friction being at the same time applied to the parietes of the chest, active respiration was ASPHYXIA. 279 quickly established; the infant was then removed from the tub, well dried, and wrapt in flannel; in both cases, an entire recovery was ef- fected. In the Journal fiir Kinderkrankheiten, it is stated by Dr. Tott, that he has often succeeded in restoring life in cases of asphyxia asthenica in- fantum, after the failure of the usual means, by causing a person stand- ing on a table to pour cold water from the spout of a tea kettle on the pit of the infant's stomach. In this way, it is added, Professor Has- selberg has saved many lives. But of all the means that have been employed in cases of suspended respiration in new-born infants, inflation of the lungs is the one upon which, experience has taught us, the most confidence is to be placed, if early resorted to, judiciously practised, and persevered in for a suf- ficient length of time. The inflation is best effected by the mouth of the operator applied to the mouth of the infant, the latter being first covered with a silk handkerchief, or soft napkin; the child's nostrils should be closed with one hand, while the other is applied upon its thorax. By a moderate but uniform force of insufflation, the lungs will be readily filled with air, when the mouth of the operator is to be withdrawn, and gentle pressure made upon the chest, so as to expel the air which has been introduced; in this manner, artificial respiration should be kept up for some time. If the cord be examined, at a short distance from the ab- domen, it will be often found to pulsate soon after the commencement of the operation, or the heart may be felt to beat beneath the ribs. The first symptom of returning life, is, generally, a tremulous motion of the respiratory organs; the infant next makes a feeble attempt to inspire, and the cheeks begin to redden: when these phenomena occur, if the inflation is suspended, the infant will frequently be found to make a spontaneous effort at respiration; a deep sigh is the first breath it draws, and in a few seconds it often breathes freely. If now, on sus- pending artificial respiration, the heart continues to beat vigorously, the cord to pulsate, and the breathing to augment in frequency and depth, it need not be resumed; but should the pulsation stop in the heart and cord, and the breathing cease, or become more feeble, arti- ficial respiration must be immediately resumed, and this repeatedly, as the case requires—at one time, the natural powers of the infant to carry on respiration being tested, at another, the respiration being sup- ported by artificial means. As the efforts at spontaneous respiration increase, ammonia, or Cologne water rubbed upon the hand, and held over the mouth of the infant during inspiration, will materially assist the recovery, and has a better effect than introducing stimulants into the stomach. A few smart slaps on the gluteal muscles will now ge- nerally complete the recovery. In favour of the efficacy of artificial respiration, in cases of asphyxia occurring at or soon after birth, we have the most incontestable testi- mony. Blundell trusted to it alone, with the aid of the warm bath. Toogood declares that he never found any other means necessary, and believes that, if actively employed, and steadily persevered in, it will. in the majority of cases, be successful. We may add our own expe- 280 DISEASES OF THE RESPIRATORY ORGANS. rience, which is decidedly in favour of this means of resuscitation. But, to be generally successful, it must be persevered in until the na- tural action of the respiratory organs is fully established, or until the recovery of the infant is shown to be impossible, by unequivocal signs. Toogood continued it for forty-five'minutes, in several cases, before respiration was fully established; and in a communication of Sir James Eyre, in the London Medical Gazette, March, 1840, a case is referred to in which the artificial means were persevered in for from thirty to forty minutes, and to two cases in which they were continued by Mr. Terry of Northampton—in one for one hour and a half, and in the other for two hours and a half, with complete success. Blundell recommends artificial respiration to be practised by means of a tube introduced into the trachea. We have never had any diffi- culty in effecting it by the mouth alone; this is also the experience of Mr. Toogood; and in the communication of Sir James Eyre, already referred to, he remarks, "I uniformly inflate with my own breath; in this matter, I perfectly agree with Dr. Cape, in a sensible letter of his which appeared in the Medical Gazette of October 7, 1837." In the cases of suspended respiration, occurring in new-born infants, from a congested state of the brain, a somewhat different practice is to be pursued. This form of asphyxia is usually met with in large, robust, plethoric infants, after tedious and difficult labours, where the child has remained for several hours under the direct influence of the uterine contractions, subsequent to the discharge of the waters; where a loop of the cord strictures the neck or thorax; or where the cord is itself compressed by any means during labour. Its immediate cause is the engorgement or compression of the brain; though in all proba- bility it may also frequently result, like the preceding variety, from the want of proper revivification of the blood. It is, in many cases, produced by the too early and injudicious use of ergot. In the apoplectic form of asphyxia, the countenance, and often the scalp and neck, present a dark red or livid, and bloated appearance, the lips are swollen and purple, the eyes prominent, and the surface of the body warm, red, and somewhat tense. When an infant is born in this condition, no time is to be lost. The umbilical cord should be immediately divided, and more or less blood, according to circumstances, allowed to flow from it. If the pulsation in the cord has not already ceased, as the blood flows from its cut ex- tremity, very generally, the lividity and turgid state of the face and neck will disappear, and respiration be very promptly established. When the pulsation of the cord is slow and feeble, inflation of the lungs should be resorted to, in addition to the abstraction of blood. The infant may, at the same time, be immersed in a.warm bath to the hips, while cold water is applied to its scalp. In those cases in which the child is born without any indications of life—its face swollen and livid, its body flaccid, and no pulsation is perceptible in the cord, or at the heart—notwithstanding there is but little hope that resuscitation can be effected, it is nevertheless proper that suitable efforts should be made and persevered in during a reason- able time, for the establishment of respiration. CORYZA. 281 It is seldom that a sufficient quantity of blood can in these cases be procured from the cord upon its division. We have often, however, found the blood to commence flowing, when the infant is immersed in a warm bath, as directed above, its head being at the same time washed with brandy and water, and its lungs properly inflated. It has been suggested by Dr. Eberle, with the view of soliciting the flow of blood from the cord, to cut the latter short, and apply over the navel a wide- mouthed cupping-glass, furnished with an exhausting syringe. It is sup- posed that by exhausting the cup, a flow of blood may sometimes be obtained from the divided cord, even after the heart has ceased to act. The suggestion is a very plausible one, and worth a trial. When it is im- possible to obtain blood from the cord, Velpeau directs leeches to be applied behind the ear. In cases of asphyxia in new-born infants we are in no instance has- tily to pronounce success impossible. Many a foetus, Dr. Blundell remarks, has been laid aside as dead, which by a diligent use of proper means might, in all probability, have been saved. It is, indeed, amazing the length of time that new-born infants can survive without breathing; not merely for half an hour or an hour, but, as Dr. Maschka has shown (Viertel-Jahrschrift f. Prakt. Heilkunde, 1854) for a much longer period, even under circumstances the most unfavourable; a series of cases in proof of this are collected in the Ga- zette Hebdomadaire for December 1, 1854. It often happens that after we have succeeded in establishing respi- ration, the infant remains for many hours in a feeble condition; the slightest fatigue or agitation being sufficient to extinguish life. It is of the utmost importance, therefore, in all cases in which resuscitation has been effected, that the infant be allowed to remain upon the bed properly wrapped up, in a state of perfect repose, for several hours before any attempt is made to dress it. 2.—Coryza. Simple catarrh, or inflammation of the mucous membrane of the nares, as it occurs in infants, has received various appellations. It is usually described, however, by medical waiters under the denomination of coryza, gravedo, or snuffles, to which occasionally, the terms malig- nant; or morbid, have been added to distinguish the more aggravated form of the disease, or that in which the Schneiderian membrane be- comes covered with a diphtheritic exudation. Coryza, though always troublesome, is in many cases a disease of little importance, disappearing spontaneously after a few days; it is occasionally, however, productive of considerable suffering and danger. The younger the infant is, in whom it occurs, the more severe and dangerous it in general proves. The mucous membrane of the nares is particularly susceptible of irritation in the early period of life; and inflammation is excited in it often by very slight causes. It is not uncommon to hear an infant sneeze soon after birth, or even immediately on the air coming in con- tact with the membrane. There often occurs, also, at a very early period, an abundant secretion of mucus, which, in some infants flows 282 DISEASES OF THE RESPIRATORY ORGANS. constantly from the nose, apparently without being attended by any degree of inflammation. Coryza may be simple, or complicated with the more or less rapid formation of a pellicular exudation throughout the whole extent of the nasal fossae; or, it may assume a chronic character, and occasion the death of the patient, by the disorganization which ensues. The first indication of the disease is frequent sneezing; the inner surface of the nostril soon after becomes red, dry, and swollen; and the cry of the infant is altered, from the impediment to the free pas- sage of the air through the nose; a watery, or thin muculent fluid soon begins to flow from the nostrils; in a short time the discharge assumes a thick, white, opaque appearance, subsequently changing to a yellow, and becoming finally purulent, exhaling frequently a pecu- liar fetid odour. The child sleeps with its mouth open; the respi- ration is difficult and noisy; and instead of the usual rale, a whistling sound occurs in the nasal fossae: this becomes greater, and the diffi- culty of respiration increases, in proportion as the discharge from the nose becomes thicker and more abundant: the nose acquires a red ap- pearance externally, and is somewhat swollen, while the central por- tion of the upper lip, constantly irritated by the discharges from the nostrils, becomes frequently red, swollen, and excoriated. Often it is covered with a false membrane. In severe cases the child experiences great difficulty in sucking, from its inability to breathe through the nose, in consequence of the diminution of the nasal cavities, caused by the submucous infiltration, the result of the inflammation of their lining membrane; and as the discharge, by drying at the orifices of the nostrils, often completely closes them, every attempt to take the breast is attended with the utmost anxiety; the countenance of the infant becomes flushed, and it is obliged instantly to quit the nipple to prevent suffocation. Its restlessness and cries, as well as the expression of its face, indicate the utmost distress and suffering; which are increased by its sense of hunger, and the impossibility it experiences of satisfying it. Worn down by fatigue, pain, and deficient nourishment, the infant may perish from inanition; or the brain becoming affected, extreme prostration and drowsiness may ensue, and sooner or later terminate in death; or death may be preceded by convulsions or acute menin- gitis, quickly terminating in effusion. In the more prolonged, or chronic form of the disease, the mucous membrane of the nares may become softened and destroyed, or the seat of an extensive ill-con- ditioned ulceration. Dr. C. D. Meigs believes that the chief danger to the young infant affected with coryza results from one of two causes; of which the first and the most common is the filling up of the nostrils with a plug of dried viscid mucus, and the other, the submucous infiltration, causing the sides of the cavity to collapse. Now as the nostrils are the prin- cipal—Dr. Meigs considers them to be the only—instinctive respira- tory orifices in the young infant, it is evident, that so long as their obstruction from either of the above causes continues, the aeration of blood in the lungs must be imperfectly performed. As a necessary CORYZA. 283 consequence, the vitality of every tissue must become impaired, and the functions of the several organs impeded or deranged. The difficulty of respiration is always greatest in those cases in which the inflammation of the nasal mucous membrane gives rise to a pseudo-membranous exudation; in such cases, also, the tonsils and fauces occasionally present a swollen and dark red appearance, their surface being covered with ash-coloured specks, terminating, in some cases, in extensive ulcerations. In violent cases, death may occur in three or four days, while in other instances, the symptoms are mild from the commencement, the inflammation very rapidly abates, the secretion gradually lessens in quantity and consistence, and the respiration improves in proportion, and in a few days every symptom of the disease disappears. The danger is always in proportion to the degree of tumefaction of the mucous membrane of the nares, and the abundance and tena- city of the excreted fluid. When the inflammation is slight, and the mucus of the nose is only a little more abundant and ropy than natu- ral, the difficulty of respiration is but slight, and the infant is able to suck without much difficulty. All other things being the same, coryza is, as already remarked, always more serious and dangerous, in proportion to the tender age of the patient. The appearances discovered after death, in those who have fallen victims to this disease, are increased redness, with thickening and softening of the mucous membrane throughout the whole extent of the nasal fossae, the membrane being generally thickly coated with pus or an opaque tenacious mucus. In some cases, small patches of a pseudo-membranous exudation are scattered over its surface. In other instances the exudation covers the whole interior surface of the nares, and extends from the superior part of the glottis, upwards, towards the sinus and cornua of the nasal cavity; the mucous mem- brane beneath, to which it firmly adheres, being much tumefied, and of a vivid red colour; softening of the mucous membrane and exten- sive ulceration are frequently present. In chronic cases, various mor- bific affections of the alimentary canal, lungs, and brain, are frequently met with. The disease, when it occurs as a primary affection, is usually the result of exposure to a cold or damp atmosphere, or of neglect in changing the diaper and clothing of the infant when these become wet with the urine. Billard enumerates among its common causes, exposure to a strong fire, and particularly to the light and heat of the solar rays. When children are taken out, he remarks, for the benefit of the air, on the return of spring, it is almost always ob- served that they sneeze, and are affected with a discharge from the nose. We apprehend, however, that the exposure to an atmosphere many degrees colder than that to which the child has been accustomed, has more to do in the production of coryza in children, on their first being taken out in the spring, than the action of the sun's rays. In light attacks, little treatment is necessary beyond the avoidance of the occasional causes of the disease, with proper clothing, and con- finement to rooms of a warm, equable temperature. The use of the 284 DISEASES OF THE RESPIRATORY ORGANS. warm bath, daily, will be proper, however, in most cases, with the occasional use of some mild aperient, as castor oil, or magnesia and rhubarb. In more violent cases, the application of a few leeches to the root of the nose will be advisable, with some gentle diaphoretic.1 In some instances we have found the administration of a few grains of calomel, followed by a dose of castor oil, highly advantageous. A small blister to the nape of the neck will, also, often produce very considerable relief. In all cases great benefit will be derived from anointing occasionally the inner surface of the nostrils by means of a camel's hair pencil, with a few drops of glycerine, or the oil of sweet almonds. 1 R.—Hydrochlor. ammoniae, gr. xxvj. ad. xxxvj. Pulv. ipecacuanhse, gr. ij.—iij. Ext. Hyoscyami, gr. iij.—M. f. chart. No. xij. One to be given every three hours, mixed in a little sugar and water. Dr. C. D. Meigs' plan of treating coryza is to keep the interior of the nostrils, after they have been carefully freed from mucus, con- stantly anointed with some of the finer animal oils, or what he be- lieves well adapted to the case, the cucumber ointment. The effect of this application will be, Dr. Meigs remarks, to cover the lower part of the aperture with a thin glazing of oil, upon which the viscosities will not rest and dry, but fall outwards upon the lip, whence they may be readily wiped away, whereas upon the dry epithelial surface of the orifice, they are liable to adhere, and becoming inspissated, form hard, dry, and solid crusts or scabs. Dr. Meigs also directs that a light flannel cap, fitting closely to the infant's head, should be applied and worn until the coryza disappears. This he has found to be alone sufficient, in a large number of in- stances, to cure the malady. There can be little doubt that in the ma- jority of cases of simple coryza, occurring in young infants, the plan of treatment here recommended will be all that is necessary. The infant should not be put to the breast during the stoppage of the nostrils, but the nurse's milk should be given with a spoon, or fresh cow's milk diluted with barley or rice water, or with rennet whey, may be substituted. If, after the inflammation is reduced, there should be formed any pellicular concretions in the nasal fossae, Billard directs some fine ca- lomel, or a mixture of sugar and alum finely powdered, to be gently blown into the nostrils. In cases attended with pseudo-membranous exudation, the nitrate of silver in solution constitutes the most efficacious local application. Five to ten or fifteen grains may be dissolved in an ounce of water— and applied to the interior of the nostrils by means of a camel's-hair pencil, several times a day, according to the severity of the case. In chronic cases, alterative doses of calomel, with ipecacuanha, prepared chalk, and extract of hyoscyamus,1 if conjoined with a proper diet, the daily use of the warm bath, and some light tonic, will, in general, effect a cure. A decoction of oak bark has been highly recommended when the disease has continued for many weeks, and the infant becomes pallid and very feeble. Underwood states that he BRONCHITIS. 285 has known it to remove promptly the snuffling, and to give vigour to the patient in the course of a few days. A weak infusion of bark, the sulphate of quinia, or the persesquinitrate of iron, will, however, in most cases be found a better tonic than the oak bark. lB-—Calomel, gr. iij. Ipecac, pulv. gr. iij. Cretse ppt. gr. xxxvj. Ext. Hyoscyami, gr. iv.—M. f. chart. No. xij. One to be given every three hours. When, in the course of the disease, symptoms of cerebral conges- tion or irritation, or convulsions occur, these are to be combated by their appropriate remedies—leeches behind the ears, or to the tem- ples, warm sinapised pediluvia, cold applications to the scalp, blisters to the nape of the neck, and purgative doses of calomel, followed by castor oil, the sulphate of magnesia, or purgative enemata. During convalescence from the more chronic cases, the restoration of the patient's strength is to be promoted by. a well-regulated diet— gentle daily exercise in the open air, and appropriate clothing. 3.—Bronchitis. Bronchial inflammation, varying in extent and intensity, is a very common disease throughout every period of infancy and childhood. Its leading symptoms are cough, hoarseness, difficulty of respiration, and more or less febrile excitement. To these symptoms, in many cases, are conjoined soreness of the throat, running at the nose, sneezing, and a red and watery appearance of the eyes. The disease commences, in general, with a slight degree of chilli- ness, or a complete chill, and some degree of languor, depression, and drowsiness; followed, after a short period, by more or less febrile re- action. The patient, if old enough, now complains of dull, aching pains in the head, back, and extremities; the pulse becomes frequent, full, and somewhat tense; the face is slightly flushed; the surface is dry and harsh, but is seldom much increased in temperature; the bowels are, in general, constipated, and the urine is small in quantity and high-coloured. The eyes are often red and suffused, and a thin transparent mucus is discharged from the nostrils, attended with fre- quent sneezing. Cough and some degree of hoarseness, with soreness or a sense of roughness in the throat, are usually present from the commencement of the attack. Frequently, however, the cough is not developed until the second or third day, and while its violence is al- ways in proportion to the extent and intensity of the inflammation, it generally becomes more frequent and severe as the disease advances. In some cases the cough is attended with pain of the thorax, or at the base of the sternum. The respiration is, in general, more or less short, difficult, and oppressed, from an early period of the attack, and is attended with a wheezing or rattling sound, heard first in the throat and extending, subsequently, over the upper portion, and finally, over the whole of the chest. The respiration in mild cases is but little ac- celerated, but when the inflammation is intense and extended, it is al- ways frequent, amounting, sometimes, to one hundred in a minute; 286 DISEASES OF THE RESPIRATORY ORGANS. the act of inspiration, in severe cases, being attended with a dilata- tion of the nostrils, and a heaving motion of the chest. The respi- ration becomes always more frequent in the progress of the disease. During the first period of the attack, the infant at the breast sucks without much difficulty; but subsequently, although it seizes the nip- ple with avidity, it can only suck for ten or fifteen seconds, when it will suddenly quit the breast, and throw its head backwards and continue in this position for some time, even after the cough has produced an expulsion of mucus. The cough is at first dry, frequent, and distressing, but, in the course of the disease, is attended with an expectoration of mucus, at first scanty, but subsequently more free and copious. The expectora- tion consists, at first, of a thin, transparent sero-mucous fluid, or of a yellowish frothy mucus, but subsequently of masses of a viscid, opaque, muco-purulent matter, of a yellowish or greenish colour. In young children, the matter brought up from the lungs is most generally swallowed, or retained for some time in the fauces. In some few cases, the matter expectorated is found to contain thin, white, soft fragments of a membranous appearance. The difficulty of respiration is not uniform throughout the attack; the breathing being, occasionally, for a short period, tolerably easy, and then becoming suddenly extremely oppressed. The cough, like- wise, often occurs in occasional fits, at irregular, and generally short intervals. As the expectoration becomes more copious, each fit of coughing is often attended by a paroxysm of suffocation, ending in vomiting. The cough, difficulty of respiration, and febrile excitement, gene- rally increase towards evening, and, at the commencement of the dis- ease, there is a distinct remission of the fever in the morning, though usually of very short duration. Upon percussion, in the early stage of the attack, the chest will usually be found sonorous throughout; but, at a later period, a circum- scribed dulness may often be detected at some part. When the child is old enough to describe its sensations, a feeling of weight, tightness, and soreness of the chest is generally complained of, but seldom any positive pain. When the paroxysms of cough are severe, infants are often known to scream, as if from pain, and the in- spirations are, occasionally, suddenly arrested, and attended with an expression of suffering in the countenance, probably from an accom- panying pleuritic inflammation. The countenance, in the milder cases, does not exhibit any particular change—the cheeks are generally slightly flushed; in the progress of the disease, however, the eyes be- come surrounded with a dark circle, the countenance assumes an anxious, suffering expression, and the nostrils are dry and crusted—the lips are pale, but at intervals acquire a violet hue, especially after a violent paroxysm of coughing. Delirium occasionally occurs, particularly towards the close of the day, and at night. As the disease advances, the cough and difficulty of respiration in- crease ; the physical signs, resulting from the impediment to the free passage of the air through the bronchial ramifications, in consequence BRONCHITIS. 287 of the amount of mucus by which they are filled, become extensive and evident; the child is unable to assume the recumbent posture without an increase of suffering; he becomes drowsy, his face acquires a pale or livid hue, and the expression of his countenance is that of the ut- most anxiety and distress. Death finally occurs, often preceded by a state of complete coma, or by convulsions. In young children, a certain amount of drowsiness or stupor is pre- sent from the commencement of the attack, and by preventing the pa- tient from complaining or coughing is apt to mask the disease of the chest, which is thus rendered peculiarly insidious and dangerous. A close attention will, however, detect an augmented frequency in the breathing, and on applying the ear to the thorax, the universal rhonchi, sibilant and mucous, at once declare the true nature of the case. The physical signs of simple acute bronchitis are, in very young subjects, a combination of mucous and sibilant rhonchi—slight, and of short duration; in older children these sounds are more decided and continuous, with a predominance of the mucous rhonchi. In cases of greater intensity there is a combination of loud or sibilant rhonchi and mucous rhonchi. In some cases the rhonchi are sub-crepitant. In infants, the epigastrium and right hypochondrium become, occa- sionally, tumid, tense, and tender upon pressure; the discharges from the bowels being, generally, small in quantity, and whitish or clay- coloured at first, but subsequently containing a large amount of light green or dark-coloured bile. In some cases, the evacuations from the bowels become thin and muddy or reddish, and contain more or less mucous flocculi, the abdomen, at the same time, being greatly swollen and tympanitic. This complication is evidently the result of gastro- enteric inflammation, attended with an engorged and torpid state of the liver. It is to this form of bronchitis that the term catarrhal fever has been generally applied. When the inflammation extends to the more minute ramifications of the bronchi, giving rise, not unfrequently, to a pseudo-membranous exudation, and constituting the capillary bronchitis of many writers, the general symptoms are of a much more severe character than in the simple acute form of the disease. There is a greater degree of rest- lessness and irritability; more decided febrile symptoms, and a fuller and more frequent pulse. The face is flushed, the surface dry and hot, the thirst urgent, and the appetite entirely deficient. The respi- ration is short and quick, the cough occurs in frequent short parox- ysms, and is, occasionally, attended by a decided stridulous or croupy sound, and hence, the disease is denominated by some authors bron- chial croup. The cough is not unfrequently painful, and, although at first very generally dry, it is usually attended, after a few days, by an expectoration of a tough, yellowish matter, containing, occasionally, fragments of a pseudo-membranous appearance. If the disease is protracted, and increases in intensity, the respira- tion becomes still more oppressed, frequent and irregular, and attended with a violent action of the alae nasi; the pulse increases in frequency and becomes small and irregular. The face assumes a leaden or a 288 DISEASES OF THE RESPIRATORY ORGANS. more or less decidedly livid hue, while the temperature of the entire surface of the body is reduced. The paroxysms of coughing are fre- quent and distressing, and the expectoration scanty and difficult. The patient cannot assume the recumbent position without causing an in- crease of the difficulty of respiration. In the still more protracted cases, there occasionally occur irregular and deceptive remissions of the leading symptoms, but finally, the difficulty of respiration augments, the pulse becomes almost impercep- tible, the countenance assumes a peculiar anxious expression—the ex- tremities become cold—while the patient is in a constant state of jacti- tation or falls into a soporose condition, and death very quickly ensues. The duration of capillary bronchitis is various. When severe and occurring in very young infants, it may terminate fatally within a few hours. In children at the breast, its usual duration is from two to six days; in older children it may continue from one to three weeks. Capillary pseudo-membranous bronchitis presents symptoms very simi- lar to those of croup. Valleix presents the following as the distinctive phenomena of the two diseases. CROUP. CAPILLARY BRONCHITIS. Dyspnoea in more or less marked parox- Continuous intense dyspnoea. Inspiration ysms. Whistling inspiration; respiration somewhat stertorous, respiration very laboured. short, rapid, and panting. Voice almost extinct. Voice not altered. Expectoration of false membrane in the Expectoration of ramified false membrane. form of a large tube, but more frequently This, however, does not often occur, but in shreds or patches. when it does, it is decisive. On auscultation, whistling or hissing re- On auscultation we have mucous and sono- spiration, with a weak respiratory mur- rous rales, often extending over a large mur is detected. part of the chest. Bronchitis in young children not unfrequently gives rise to that peculiar condition of the lungs, at their lower and posterior portions, to which the denomination of lobular pneumonia has of late been ap- plied ; the correct pathology of which will be considered in the chapter on pneumonia. Rilliet and Barthez state that the anatomical characters of acute bronchitis are rarely met with in children under five years of age, without at the same time traces of pneumonia being present—the latter being sometimes a secondary, at others a primitive or concomi- tant disease. Hence the value of the sub-crepitant rhonchus, as a diagnostic sign of bronchitis, differs with the age of the child. If, in those under five years of age, the sound is heard on one or both sides of the chest, there is danger that the bronchitis is complicated with lobular pneumonia—whilst, in older children, there is less probability that such is the case, though from the tendency even then to pneu- monia, its presence may still be suspected. When the crepitant rhon- chus is heard, Rilliet and Barthez have invariably found, with one ex- ception, that portions of the lungs were affected with pneumonia. In young children it will be found, however, that, in the majority, if not in all cases, the condition of lung which is supposed to result from hepatization of the lobules, the product of preceding inflammation, is, in fact, a collapse of the air cells, caused by a clogging up of one or more of the smaller bronchial tubes by a portion of adhesive mucus. BRONCHITIS. 289 The bronchitis of children occasionally assumes a chronic form, at- tended with copious perspiration and hectic fever, the exacerbations occurring in the evening, when its symptoms closely resemble those of phthisis. A very common and dangerous form of bronchitis, which is referred by Mackintosh to a subacute inflammation of the bronchial mucous membrane throughout both lungs, is of common occurrence in young children. The cough and dyspnoea are but slight, and attract but little attention, so long as the expectoration is free, and the excreted matter is discharged with ease; but if, from any cause, the secretion of mucus in the bronchi is increased, and the cough arrested, speedy death from suffocation inevitably results, unless the air-passages can be freed from the accumulated mucus, by the administration of an emetic. An unfavourable change in these cases is often produced by accidental exposure to cold. This form of the disease we have repeatedly met with; it is one often neglected by parents in its early stage, and even the practitioner will be apt to be misled in his prognosis in regard to it, unless he early makes himself acquainted with its true character, by an attention to the physical signs to be derived from a careful ex- amination of the chest. The prognosis in cases of bronchitis is to be drawn from a careful estimate of the general and local symptoms; the age and condition of the child in whom it occurs, and the hygienic circumstances under which it is placed. In many cases the inflammation is slight, and of little extent, and readily yields to an appropriate treatment. In at- tacks of greater intensity, however, the disease is often more pro- tracted—even when the termination is favourable. The respiration becoming less frequent and laborious; the febrile symptoms abating; the skin becoming softer and moist; the cough less frequent, pro- longed, and suffocative, and attended with a free expectoration, are the general indications of the decline of the disease. The occurrence of convulsions, and of a great somnolency or drowsiness, with increased difficulty of respiration, accompanied with a feeling of suffocation, and with lividity of the cheeks and lips, and coldness of the extremities, are all unfavourable symptoms, that are but too generally quickly fol- lowed by a fatal termination. From the facility with which the inflammation extends to the whole of the bronchial tubes, even to the minutest ramifications, and the danger of its becoming complicated with lobular or lobar pneumonia, bronchitis is always to be considered a serious affection which requires to be carefully watched and promptly treated. Capillary Bronchitis, or that form of the disease in which from the commencement of the attack, the entire extent of the bronchi are inflamed, even to their smallest ramifications, is invariably attended with very considerable danger. When there is intense fever, great acceleration of the respi- ration, and severe dyspnoea, with a copious purulent or pseudo-mem- branous secretion, it is an extremely unmanageable affection. Under such circumstances, according to the experience of MM. Rilliet and Barthez, as well as that of M. Fauvel, its termination is very gene- rally in death. 19 290 DISEASES OF THE RESPIRATORY ORGANS. The appearances discovered after death from bronchitis, are a bright redness of the bronchial mucous membrane, either in patches, and partial in extent, or more diffused, and of a brownish or violet shade, with more or less thickening and roughness of the membrane, and occasionally, softening. The bronchial ramifications are generally filled with a quantity of frothy viscid mucus, sometimes transparent, at others opaque and yellow, and occasionally sanguinolent, or with a muco-purulent fluid, the presence of which, by preventing the escape of the air from the lungs, is the reason why these, in many cases of bronchitis, do not collapse when the thorax is opened. In some cases, the more minute ramifications of the bronchi are lined with a pseudo-membranous concretion, very soft, and slightly adherent; of a white colour, and of variable thickness. This occurs, in some cases, only at certain portions of the bronchial tubes, while in others it occupies the whole of the bronchial ramifications. Be- neath these membranous concretions, the mucous tissue is occasion- ally firm, and remarkably pale: at other times it is red, softened, and rugous. It is in the bronchi of the inferior lobes that the fluid products of inflammation are ordinarily most abundant. The bronchi are in many cases dilated, either in some portion of their branches or at their extremities. The dilatation is occasionally very con- siderable. This dilatation, which is met with only in cases of long stand- ing, is very readily accounted for on physical principles. It is supposed, and with reason, that in consequence of an accumulation of mucus in the bronchial tubes, a considerable obstacle is presented to the escape of air, which is in consequence retained in the pulmonary cells. At each inspiration a fresh portion of air is added to that already pre- sent ; there must in consequence be a continual pressure made by the im- prisoned air upon the parietes of the tubes, giving rise to more or less dilatation of their extremities. Such is the rational hypothesis expla- natory of the production of bronchial dilatation in cases of bronchitis, and which has for its support the authority of Rilliet and Barthez, Barrier, Fauvel, and Grisolle. \Bouchut, Diseases of Children.^ When the bronchi are dilated at their extremities, a section of the lung presents an areolated surface, formed by the presence of a num- ber of small rounded cavities, communicating with each other, and with the bronchi of which they appear to be the continuation. The most part of these cavities are central; some of them however exist at the surface of the lungs, and are formed by the pleura, lined by the thinned membranes of the dilated bronchi. These produce upon the exterior of the lung slight rounded transparent projections, which col- lapse when punctured, and simulate emphysema. The interior of these cavities contain the same fluid as is found in the bronchi; their parietes are smooth and thin, and they are lined by a continuation of the lining membrane of the bronchi. In cases of vesicular bronchitis, the lungs are flaccid and soft at their surface, and more or less shrunken, according to the extent of the dis- ease. A section presents a large number of granulations about the ize of a millet seed, of a grayish colour, inclining slightly to yellow. BRONCHITIS. 291 These may at first view be readily mistaken for miliary tubercles; from these, however, they are readily distinguished by their giving dis- charge to a drop of purulent liquid, and becoming immediately ef- faced, when punctured by the point of the scalpel, leaving in their centre a small depressed point, which is sometimes, however, difficult to detect. Often a very narrow canal wTith smooth parietes may be traced for some lines, being no doubt a small bronchial tube, the ter- mination of which is at the central depression of the granulation. In these cases it is probable that the inflammation is seated only in the extremities of the bronchial tubes, and that a certain number of pulmonary vesicles, separately inflamed, have become filled with a puriform fluid and dilated, without the surrounding cellular tissue being involved in the disease. If several neighbouring vesicles become inflamed, the inflammation may extend also to the tissue by which they are united, and there will then result a small induration, of the size sometimes of a lentil, the section of which presents, after the discharge of a fluid, a number of granulations or of depressed points. This constitutes lobular pneumo- nia, which forms the connecting link between bronchitis and the latter disease. (Rilliet and Barthez, vol. i. p. 21.) When the disease succeeds to the pustular exanthemata, the lining membrane of the bronchi often presents traces of follicular inflamma- tion—often ulceration. In severe and protracted cases it is not un- common to meet with distinct patches of red hepatization, particularly at the lower and posterior portion of the lungs. Bronchitis is generally produced by exposure to cold and damp; it is hence most liable to occur during the raw, variable, and humid weather that so frequently prevails late in autumn, or in the com- mencement of spring; it is common, also, in winter, from accidental exposure, more especially when the season is mild and damp. It often occurs, likewise, during the summer in consequence of the sud- den occurrence of rain, or of damp cloudy weather, attended with a reduction of the atmospherical temperature, after a long continuance of intense heat and dryness. It may result, also, from the applica- tion of cold and damp to the surface of the child's body, by wet clo- thing, or exposure to a draft of air while in a state of profuse perspi- ration; it is an almost constant symptom in measles, and probably in pertussis, and it not unfrequently supervenes on variola and scarlatina, and occasionally, upon gastro-enteric inflammation. It sometimes pre- vails epidemically, affecting as well children as adults, or confined, in a great measure, to the former. The treatment of bronchitis will differ somewhat according to the violence of the disease, and in its different stages. In mild cases, an emetic administered in the commencement of the attack, particularly if followed by a warm pediluvium, will very often be sufficient to arrest the disease. In all cases of bronchitis in children, an emetic given upon its first occurrence will be found decidedly beneficial; and even at a later period, when great oppression at the chest, with severe dys- pnoea occurs, from the clogging up of the bronchial tubes with mucus, nothing will be found to afford more prompt relief. In infants and 202 DISEASES OF THE RESPIRATORY ORGANS. young children we invariably prefer the ipecacuanha as an emetic, to the tartarized antimony; the effects of the latter being, in early life, often peculiarly prejudicial. The powdered ipecacuanha, mixed with sugar and water, or the wine or syrup, may be employed; the dose being proportioned to the age of the patient. Whenever bronchial inflammation is attended with symptoms of any degree of severity, more especially when it occurs in robust, plethoric infants, blood-letting by cups or leeches is the remedy upon which alone our chief reliance should be placed. It should be resorted to as soon after the inflammation is developed as possible; if it be delayed until a copious secretion from the lining membrane of the bronchi has taken place, it is always far less efficacious, while in some cases its effects will be even decidedly prejudicial. In children, over two years of age, particularly when the pulse is full and active, and the disease is attended with considerable accele- ration of respiration, a dry, hard cough, dyspnoea, and much febrile ex- citement, blood should be taken from the arm to an extent proportioned to the condition of the child, and the violence of the case; and sub- sequently, if rendered necessary by the continuance of the inflamma- tion, leeches may be applied upon the fore part of the chest, or cups between the shoulders. It is better, however, in most cases, to carry our first bleeding to a sufficient extent to make a decided impression upon the action of the heart:—we shall be much more likely, in this manner, to cut short the disease, than by a repetition of the bleeding from the arm, or by the application of leeches. Although, as a general rule, bleeding is not advisable in the ad- vanced stages of bronchitis, still there occasionally takes place a sud- den recurrence of inflammatory symptoms, or a congested condition of the lungs, in which a prompt and judicious application of leeches or cups to the chest, will be productive of the very best effects. In some cases, where any amount of direct depletion would appear inadmissible, the application of a few dry cups to the parietes of the chest will generally be found advantageous. The employment, extent, and repetition of blood-letting in cases of bronchitis, whether by the lancet or by local means, demand the utmost judgment on the part of the practitioner. Whilst in severe attacks, the safety of the patient can only be certainly secured by the abstraction of blood in the early stage of the disease, numerous cases unquestionably occur in children in which no amount of blood-letting is absolutely de- manded, whilst in others again it would be certainly injudicious if not absolutely prejudicial. In those instances in which the disease is complicated with gastro- intestinal inflammation, the application of a few leeches to the epigas- trium will always be found highly beneficial. By most writers, tartarized antimony is recommended as being, next to blood-letting, the most efficacious remedy in the bronchitis of chil- dren. It is probable that, in severe cases, after the immediate effects of blood-letting have subsided, should the fever and dyspnoea not be materially relieved, a twelfth to an eighth of a grain of tartarized an- timony, according to the age of the patient, given every few hours BRONCHITIS. 293 until vomiting or faintness is produced, may render a repetition of the bleeding unnecessary; but it is under these circumstances alone, that we should be inclined to recommend the employment of tartar emetic in infantile bronchitis; experience having taught us that it is a remedy, the operation of which is borne with great difficulty in the early periods of life. In the generality of cases we prefer the administration of small doses of ipecacuanha. After the first bleeding, we are accustomed to direct from a fourth to half a grain, in combination with a quarter of a grain of calomel, and from four to five grains of hydrochlorate of ammonia, and have always found it to produce a very decided impres- sion upon the symptoms of the disease. When the cough continues dry, and the surface hot, with quickness and frequency of pulse, we have repeatedly added to this prescription a quarter of a grain of powdered digitalis; and notwithstanding its general condemnation, we are persuaded that, under the circumstances just referred to, it will in most cases be found a highly useful remedy. After the occurrence of expectoration also, the ipecacuanha may bo employed, combined with extract of hyoscyamus, which latter, while it has a tendency to relieve irritation, is unattended with any of the dis- agreeable effects that so frequently result from the employment of opiates in the diseases of young children. The warm bath, especially when confined to the lower extremities, the child being immersed only to the hips, is, in all cases of bronchitis, productive of the best effects. In mild cases it may be employed at the very commencement of the attack, subsequent to the operation of an emetic; but in cases of considerable severity, it should invariably be preceded by bleeding, or the application of leeches. After bleeding, either general or local, has been carried as far as is thought advisable, there is, perhaps, no remedy from which more de- cided relief will be derived, than a blister applied to the upper part of the chest, or between the shoulders: it should be allowed to remain on only so long as is necessary to render the skin uniformly red, and then be replaced by a large emollient cataplasm. In the generality of cases, the bowels are constipated, or at least in- active, although occasionally, when the disease is accompanied with in- testinal inflammation, there is more or less diarrhoea, with vitiated dis- charges. In the commencement it will be proper to administer some purgative, and perhaps the best is a full dose of calomel, followed by a portion of castor oil. The use of the combination of ipecacuanha and calomel, already recommended, will render the repetition of pur- gatives unnecessary. The administration of expectorants will seldom be found of any be- nefit in the first stages of the disease, but in the latter period, after the inflammatory symptoms have been reduced, and a copious secretion has taken place in the bronchi, they are occasionally of advantage; the mel seillse compositum of the United States Pharmacopoeia may be employed, or the following combination.1 When, however, the oppres- sion of the chest is very considerable, from the amount of mucus filling the bronchial tubes, an occasional emetic will produce far more prompt and decided relief than will be derived from any other expectorant. 294 DISEASES OF THE RESPIRATORY ORGANS. 1 R—Infus. polygalse, ^iv. Vin. ipecacuanha?, :jij. Oxy. scillae, giij. Tinct. hyoscyami, gj.—M. A teaspoonful to be given every three hours. M. Valleix, (L' Union Mtdicale, No. 48,) directs attention to the importance of mechanically removing the mucus from the throat of the patient, in the suffocative paroxysms that occur in the generalized bronchitis so fatal to young children. As soon as the infant's counte- nance assumes a violaceous aspect, and the suffocation seems imminent, the little finger should be passed along the back of the tongue. The child will close its jaws and resist violently, but the finger should be gradually advanced. When it reaches the isthmus, the child opens its mouth, and we should then pass on the finger behind the epiglottis, so as to bring its pulp several times over the orifice of the larynx. This produces efforts at coughing and vomiting, and the mucus is expelled from the air passages, a part being drawn out by the finger, and the rest swallowed. The child appears, after the operation, much flushed and agitated, and almost suffocated, but soon becomes calm, until re- newed signs of asphyxia call for a repetition of the procedure. In a case related by M. Valleix, apparent death, after one of these parox- ysms, was successfully treated by artificial respiration, the employment of which he strongly recommends in similar cases. When there is much prostration, with a small and feeble pulse, and a degree of drowsiness, the carbonate of ammonia will often produce considerable relief.2 In such cases, wine whey, in small quantities, judiciously administered, will be occasionally serviceable; the patient being sometimes so weak and languid that he cannot make any volun- tary efforts to cough, upon which, perhaps, his life depends. Hoffmann and some other of the German practitioners, speak very favourably of a combination of benzoin and camphor,3 in cases attended with great debility; it is said to have produced complete relief, under circum- stances to all appearances hopeless. 2 R-—Carb. ammonias, J")ij. Or, R.—Assafoetidse, sjss. Ext. glycyrrh. 3'j. Liq. ammoniae acetat. Aquas, ^iv. Aquae menth. aa ^ij.—M. Oxymel scillae, giv.—M. A teaspoonful to be given every three A teaspoonful to be given every two or hours. three hours. 8 R-—Flor. benjoin. gr. iij. ad iv. Camphor, gr. iv. ad vj. Sacch. alb. ^ss.—M. f. chart. No. xij. One to be given every two or three hours. The diet, throughout the early stages of the disease, should be mild and unirritating. Infants at the breast may be allowed, occasionally, fresh whey, or gum or barley water sweetened with loaf sugar, and they should be prevented from sucking more than once or twice in the course of the day; the diet of older children may consist of thin water gruel, barley or rice water, or fresh whey; and as a drink, cold toast water or weak lemonade. During convalescence, the diet should be gradually and cautiously improved; milk and preparations of the usual farinaceous substances must, however, constitute the chief food of the PNEUMONIA. 295 patient, for a considerable period after the disease has been removed. The child should be carefully guarded from exposure to cold or dampness, and from any sudden alternations of temperature; the air of the apart- ment he occupies should be kept perfectly pure, by attention to strict cleanliness and free ventilation. As soon as he is sufficiently recovered, much benefit will be derived from gentle exercise in the open air, during dry mild weather, the patient's body being protected by appropriate clothing. During convalescence, the same directions are applicable as were given when treating of coryza. 4. Pneumonia. Inflammation of the substance of the lung ranks among the most frequent diseases of children; as a primitive or secondary affection, it may occur at any period, from birth upwards, differing greatly in its extent and violence in different cases. It may be confined to a very small portion of one lung, or involve nearly the whole of one or both. In youug children, or those under six years of age, the disease would appear, in a large number of cases, to be the consequence of extensive bronchial inflammation, and is probably, in these, very generally pro- duced by the extension of inflammation from the extreme ramifications of the bronchi to the substance of the lungs: in very many instances, however, the inflammation of the bronchi and of the lungs is unques- tionably simultaneous. In older children, the disease more commonly commences in the lung, and the circumscribed bronchial, inflammation, which so generally attends it, is, in all probability, a secondary affec- tion. The general symptoms of pneumonia, in very young children, are often extremely obscure in the onset of the disease, and even when most strongly marked, they differ but little from those of bronchitis. There is invariably more or less cough, some degree of dyspnoea, in- creased frequency of respiration, and fever. There is seldom any very decided pain of the thorax. The attack, which is most generally preceded, in infants, by symp- toms of a slight bronchitis, usually commences with a chill, more or less severe and prolonged, followed by increased heat and dryness of the skin, increased frequency of pulse, accelerated respiration, dyspnoea, and a slight dry cough; which symptoms very quickly increase in in- tensity: often at the very onset of the disease there is vomiting, and in young children diarrhoea. Many cases are attended with conside- rable agitation and anxiety, or drowsiness, more rarely with convul- sions. According to the observations of Rilliet and Barthez, it is in pneumonia occurring at the summit of the lungs, in young infants, that the attack commences with convulsions, which are sometimes vio- lent and repeated, and followed often by loss of consciousness. The lips are usually of a bright red, the tongue of a florid hue, somewhat dry, and frequently coated along its centre with a thick white fur. Dr. West describes a peculiarity in the mode of sucking and respi- ration, which, in the early stage of the disease, when it occurs in in- fants at the breast, affords a valuable indication of its true character. 296 DISEASES OF THE RESPIRATORY ORGANS. So soon, he remarks, as the lungs become affected, even when no other symptom exists than general febrile disturbance, and perhaps vomit- ing, the infant will be seen no longer to breathe solely through the nose, as in health, but to lie with the mouth partly open, and drawing in air through it. This imparts to the tongue its preternatural dry- ness, and the same inability to respire through the nares causes the child to suck by starts. The infant seizes the breast eagerly, sucks for a few moments with greediness, and then suddenly drops the nip- ple, and in many instances begins to cry. The respiration in pneumonia is invariably accelerated, the number of inspirations being generally upwards of thirty, and sometimes be- yond seventy, in a minute; there is also a peculiar abruptness in the inspiration, it occurring suddenly, before the expiratory movement is completed; the nostrils during the act of inspiration being more or less dilated. The acceleration of respiration does not always corre- spond in extent with the violence of the disease, nor does it in all cases progressively increase from the onset of the attack to its fatal termi- nation. It is often absent or very slight in the pneumonia that fre- quently occurs in the course of chronic enteritis, and it may be masked by the symptoms of abdominal or cerebral disease. Acceleration of respiration is often strongly marked in cases of broncho-pneumonia, the dyspnoea being so great in some cases as to threaten suffocation. This symptom follows ordinarily the same course as the pulse, in- creasing with it, and diminishing at the period when it diminishes. . In cases of primitive pneumonia, the acceleration of the pulse and respiration obtain their greatest intensity generally by the end of the fourth or fifth day. By the seventh, or at the furthest by the ninth day, in favourable cases, the heat of the skin and frequency of the pulse diminish, the inspiratory movements become less frequent and unattended with dilatation of the nostrils; and the cough more free and moist: the fever now quickly disappears, the face becomes paler, and the expression of the countenance more natural. The respiration assumes, finally, its normal rhythm, the appetite returns, the cough rapidly diminishes, and in a few days convalescence is fully established. In all the cases, except one, which fell under the notice of Rilliet and Barthez, and terminated favourably, the earliest period at which the acceleration of respiration disappeared was the sixth day, and the latest the twelfth; the general period of its disappearance being the seventh, eighth, or ninth. In pneumonia of the summit of the lungs, occurring in infants, ac- cording to the last-mentioned authors, there is an inequality to be ob- served in the respiration, it being effected by short, abrupt, broken ef- forts. There is always more or less dyspnoea, which is proportionate to the violence and extent of the pulmonary affection, and goes on increasing with the progress of the disease, and is often attended with great anxiety, and, in severe cases, with a sense of impending suffocation, rendering a recumbent position insupportable. The cough, which is at first frequent, short, dry, and painful, soon becomes moist; the expectoration, when it occurs, which is seldom the PNEUMONIA. 297 case in young children, is at first slight, and consists of a whitish, viscid mucus, but becomes subsequently reddish; it is rarely, however, rust-coloured. Pain of the chest is not invariably present; when it occurs it is generally acute, though sometimes dull; it is commonly felt, according to Dr. Gerhard, at the anterior margin of the axillae; it is augmented by the cough, and often declines long before the other symptoms disappear. There is generally a diminution or entire loss of appetite, and in- creased thirst. The bowels are commonly torpid; though, occasionally, when the disease is complicated with intestinal inflammation, profuse diarrhoea may be present throughout the disease. There is often an anxious expression of the countenance. In cases occurring in the course of chronic enteritis, the skin becomes, occasionally, covered with furunculi or ecchymoses, while the parts to which blisters have been applied are liable to become ulcerated. When the pneumonia is severe and extensive, the patient exhibits considerable dulness or drowsiness, often amounting to complete stupor. Delirium is not of- ten observed, and when it is, we have generally found it to be an un- favourable symptom. The cough varies greatly in violence and frequency, according to the extent and intensity of the pulmonary inflammation, the stage of the disease, and various concomitant circumstances. It usually aug- ments from the first day, but as it becomes more moist, in favourable ca|es, it gradually declines in violence, until towards the eighth or ninth day, when it diminishes rapidly, and finally disappears. Should, however, the pneumonia become more diffused, or occur in the course of some acute affection, and in children not much debilitated, the cough is very frequent and intense, and is rarely attended with a free expec- toration. In some cases, in which the inflammation of the lungs is extensive, there is a sense of suffocation, with a dark violet hue of the lips and tongue, analogous to what is observed in capillary bronchitis. In the attacks of pneumonia that so frequently occur in the course of chro- nic enteritis, there is seldom much cough; occasionally, indeed, it is en- tirely absent: the skin in these cases is pale and cool, the pulse small, and the face.and extremities cedematous. The disease, in fact, is often so destitute of leading symptoms, that its existence might be overlooked, were it not for the physical signs revealed by auscultation. The peculiarities which distinguish that form of pneumonia which is preceded by bronchitis, are very accurately sketched by Dr. West of London. The disease often comes on insidiously, and develops itself gradually without its being possible for us, in most cases, to fix the exact date of its attack. Occasionally, however, there is a well- marked accession of fever and dyspnoea, and an aggravation of all the symptoms, sufficient to mark the time when the pneumonia super- venes. The fever and heat of the skin are less than in other forms of the disease, but the dyspnoea and distress are usually greater, and the face presents, from the first, a more livid hue. The cough is less hard, but often comes on in paroxysms, which greatly distress the patient; the respiration is more hurried and more irregular; the irregularity 298 DISEASES OF THE RESPIRATORY ORGANS. coming on at an earlier stage of the disease. Head symptoms are more frequent; the patient's sleep is disturbed, and he often mutters in his sleep, and has far more restlessness and jactitation when awake. Convulsions and coma more frequently precede death, and death oc- curs at an earlier period than in the other forms of pneumonia. It is almost exclusively from the physical condition of the chest, that our diagnosis is to be derived in this disease. The physical signs are the same as in the pneumonia of adults, crepitant rhonchus, bron- chial'respiration, and a flat sound upon percussion. Fine, crepitant rhonchus is seldom, if ever, present without bronchial respiration;— while these, with diminished sonorosity of the chest, are always at- tended with bronchophony. The crepitus is generally larger in chil- dren; and if, for a short time, it is not heard, it may be generally re- produced, by causing the child to cough, when it is again distin- guished, in the strong inspiration that succeeds the cough, giving rise to a sound like the cracking of a whip. (Gerhard.) In cases of simple primitive pneumonia, if of the lobar form, even from the very onset of the disease, crepitant or subcrepitant rhonphi may be detected, and often bronchial respiration on one side of the thorax towards its base. In the lobular form, the subcrepitant rhonchi are more generally diffused, while the bronchial respiration is rarely heard; the extent of the latter increases with the increase of the dis- ease, while the rhonchi decrease. By the time the acceleration of the respiration and of the pulse has attained its maximum the bran- chial respiration becomes intense, and is accompanied with broncho- phony, or with a ringing sound of the voice, and extensive dulness of the chest. As the symptoms diminish in intensity, and the cough be- comes more moist, the subcrepitant rhonchi are very abundant, the ringing sound of the voice is heard over a greater space, the bron- chial expiration continues, but the dulness of the chest is much less marked. Even after convalescence has been established, a slight pro- longation of the expiration is still to be detected, as well as a diffused ringing sound of the voice. The respiration continues feeble for se- veral days, and does not for a long time recover its proper vesicular tones. When the inflammation is of a still more violent character from the first, humid rhonchi are heard throughout the chest, intermixed with others of a drier character, or with bronchial expiration and a diffused ringing of the voice. Bronchial respiration, as Dr. West has remarked, must always be regarded as a very grave sign. In eleven out of twenty cases of pneumonia in children where it was detected by that gentleman, the disease had a fatal termination. The mucous rhonchus is heard in most cases of broncho-pneumonia, and in cases of lobar pneumonia, in the neighbourhood of the subcre- pitant rhonchus, and, occasionally, where distinct bronchial respiration exists, and it often persists for a long time after every other sign of disease has disappeared. The physicial signs of lobular pneumonia, as it usually occurs in young children, are at first limited to the mucous and subcrepitant rhonchus, dependent upon the secretion of mucus in the bronchi. The PNEUMONIA. 299 subcrepitant rhonchus is frequently continued throughout the disease, being often the only stethoscopic symptom present: it is rarely re- placed by the fine crepitant rhonchus, as in the pneumonia of adults. When induration has extended to a considerable portion of the paren- chyma of the lung, bronchial respiration becomes developed, chiefly at the upper and middle portions of the posterior part; it is rarely heard in the lower lobe, from the comparative smallness of the bronchi, and their early obliteration by the progress of the disease. The respira- tory sounds are very peculiar; the inspiratory murmur, instead of being full and expansive, as in a healthy child, is short, obscure, and almost without the vesicular murmur, and may or may not be accompanied with the mucous or subcrepitant rhonchus; the expiration is rarely dis- tinct, unless the bronchial respiration is fully developed, when it is usually louder than the inspiration. The signs indicative of inflam- mation of the parenchyma of the lung are often entirely obscured by the mucous rhonchi of bronchitis. (Gerhard.) When lobular inflammation of the lungs i3 more generally diffused, upon percussion, the sound, on both sides of the chest, posteriorly, will be dull, compared with that of a healthy child; more or less so, ac- cording to the extent of the induration. The duration of pneumonia in children will, in a great measure, de- pend upon the severity of the attack; the extent of the inflammation; the nature of the treatment, and the period at which it is commenced. In very violent attacks, the disease implicating a considerable portion of the lung, death may take place very promptly; in other cases, the fatal termination may occur at a much later period, from extensive disorganization of the lungs. We have seen the disease, in what were evidently very severe attacks, promptly cut short, by appropriate re- medies; but in general, even in cases where recovery takes place, the disease is of some continuance. In the case reported by Dr. Gerhard in which the commencement and termination of the symptoms were ascertained, the mean duration of the pneumonia was nearly fifteen days. In the more severe and unfavourable cases the dyspnoea is very in- tense from the onset of the disease—the pulse is extremely small, the face pallid, with a violet tinge of the lips, and at the summit of the cheeks. The general symptoms augment with the progress of the local disease, and death may occur upon the third or fourth day. In other cases, after the fifth or sixth days, the symptoms exhibit no far- ther increase, but remain stationary; or, more generally, while the ac- celeration of the pulse, and a frequent, difficult, and painful cough, with loss of appetite and some degree of thirst continue, the fever abates, the face becomes pale, a wasting diarrhoea sets in, the child becomes rapidly emaciated, and, in a state of the utmost debility, at the termi- nation of perhaps three or four weeks, expires. The fatal termination may be hastened by the occurrence of pleurisy, measles, gangrene of the mouth, &c. Acute pneumonia, occurring in the course of some other acute dis- ease, was found by Rilliet and Barthez to seldom continue beyond the twenty-fifth day. The progress of chronic pneumonia is very gene- 300 DISEASES OF THE RESPIRATORY ORGANS. rally slow; the disease may continue for three or four weeks, or even longer. Occasionally in depressed constitutions pneumonia has been known to terminate in gangrene. Such a termination is, however, very rare in children. Rilliet and Barthez met with eleven cases, and Dr. West with but one. Unless the gangrenous portion of the lungs be extremely small, death will be the inevitable result. The pathological anatomy of pneumonia in children has of late years attracted much attention. Among those who have investigated it with the greatest care are to be ranked, Rufz, Valleix, Lanoix, La Berge, Barrier, Becquerel, Billard, Rilliet and Barthez, Bailly and Legendre, of France, West, Gairdner, and Hewitt, of England, Albers, Jorg, Fuchs, and Succow, of Germany, and Dr. Gerhard, of Philadelphia. The anatomical lesions differ very materially, according as the pneu- monia is lobular or lobar, and according to the period of the disease when death takes place. The lung affected with lobular pneumonia is generally soft and flaccid; externally it presents a mottled appearance; portions of a deep red or violet colour being interspersed in the midst of others having the natural grayish-red tint. The dark red or violet patches are usually distinctly circumscribed, and of a circular or oval form, slightly projecting, and hard to the touch. They are most commonly situated at the inferior edge of the lung, but may occur at other portions of its surface. The part occupied by them does not collapse upon the chest being opened. In some cases the marbled appearance of the lung is absent, but spots of induration, more or less deeply seated, may be detected by the finger, the lung having an uneven or knotted feel. A section of the diseased lung presents the same marbled appear- ance as the exterior. In the first stage of the disease, the dark red or violet portions are more or less accurately circumscribed; they are somewhat firmer than the surrounding parts, swim when thrown into water, crepitate beneath the finger, and however carefully separated from the sound portions of the lung, they yield, upon pressure, a red- dish fluid intimately mixed with air. In the second stage, the dark red portions form nodules of a firmer and more compact consistence. Their cut surface is smooth, and when carefully detached from the surrounding parts, they crepitate none or but slightly, and sink rapidly when placed in water. When the central portion alone of the nodule is subjected to pressure, a red sanious fluid escapes, without any ad- mixture of air. It is comparatively rare that single lobules are found affected, the indurated portions usually comprising four or five, which together form a mass of the size of a nut or almond. If the patient lives for some time, the intervening substance usually becomes affected, and the lobular is thus converted into lobar pneumonia. This change does not appear to take place from the gradual extension of disease, from each inflamed lobule, as from so many distinct centres; but sooner or later, the whole intervening pulmonary substance seems at once to become the seat of inflammatory action, which runs its course, as in ordinary lobar pneumonia. PNEUMONIA. 301 In the third stage of the disease, the section of the lung presents a grayish colour, inclining more or less to yellow, in different cases. The pulmonary tissue is very friable, and when pressed gives discharge to a purulent fluid, its tissue being infiltrated with pus. If the in- flamed portions of lung are attentively examined, it will be seen that some of the lobules are more projecting than others, and that here the vesicles are not compressed as in the surrounding parts. When the,lobules are pressed, they give discharge to a purulent fluid. Rilliet and Barthez describe two forms, or rather varieties of lobu- lar pneumonia, the mammelonnated and the partial. In the first, there exists a nodule of hepatization, differing but little in colour or appearance from the surrounding tissue. Its limits are clearly cir- cumscribed, even when the neighbouring tissue is engorged. It is sometimes completely surrounded by a layer of about half a line in thickness, white, firm, and of a fibrous appearance. The hepatized nodule slightly projects above the surface of the incised lung, from the collapse of the surrounding air-cells. The nodule varies in size from that of a hemp seed to that of a pigeon's egg. It is spheroidal in form, and has usually a regular surface. There may exist but a sin- gle nodule in one lung, or they may amount to twenty, thirty, or more. This form of lobular pneumonia results, according to Rilliet and Barthez, from the inflammation being confined to one or more lobules. They have found invariably the hepatized nodules to be surrounded by a circle of pulmonary tissue in a state of engorgement. The dis- ease very generally runs on to the third stage, and terminates in the formation of an abscess. In the same lung there may be detected cir- cumscribed nodules of hepatization in the first and second stages, and, also, rounded masses of a straw-colour, very humid when Cut into. At a more advanced stage, the pus, which was at first deposited in the interstices of the pulmonary tissues, becomes collected in the cen- tre of the nodule. This minute collection of pus is surrounded by two concentric zones, the internal one yellow—hepatization of the third degree; the external one red—hepatization of the second degree. At a later period, the exterior zone passes into suppuration, and the size of the central cavity is increased at the expense of the inner zone. At a later period, an incision through the diseased part reveals cavi- ties varying in size from a few lines to four or six. They are, in ge- neral, round, more rarely oval, and contain usually a thick tenacious yellow or greenish pus, perfectly free from any admixture of air. Sometimes small coagula of blood are mixed with the pus. At first, these cavities are formed by a layer of hepatized pulmo- nary tissue, lined with a layer of concrete pus, or, in some cases, with a false membrane, yellow, soft, and readily detached. Subsequently this membrane becomes changed into a thin, smooth, polished tissue, analogous to a serous membrane. The abscesses sometimes freely communicate with each other, and at the point where the bronchus penetrates their cavity, its mucous membrane presents a true solution of continuity. When the inflammation invades, separately, several neighbouring nodules, the cavity of the abscess is multilocular, each 302 DISEASES OF THE RESPIRATORY ORGANS. cell being isolated by a lamina of hepatized pulmonary tissue, upon the rupture of which the different abscesses communicate with each other. These abscesses may occur in different parts of the lung; they have generally, however, a tendency to approach the surface. It often hap- pens that an adhesion takes place between the opposing surfaces of the pleura, or the pleura of the lung becomes gradually thinned, and finally perforated, giving rise to a true pneumo-thorax. In a single case, Rilliet and Barthez have seen an adhesion take place between the base of the left lung and the diaphragm, and the abscess of the lung communicating by a perforation of the diaphragm, with the peritoneal cavity. The pulmonary abscesses are often completely isolated, and, with the exception of a thin layer of hepatized parenchyma, in their immediate vicinity, surrounded by perfectly healthy pulmonary tissue. Occasionally, however, the greater portion of the whole of one of the lobes may have been invaded by the inflammation. The number of abscesses is very variable; sometimes there is but one; at others, but very rarely, they are so numerous that we cannot count them. Their size is usually in inverse proportion to their num- bers. They are, in far the greater number of cases, confined to a sin- gle lung; and they more frequently occur in the left than in the right. They are met with most commonly in subjects under six years of age. Partial lobular pneumonia is much less circumscribed than the pre- ceding variety. There is no distinct limit between the healthy and diseased portions. In extent, the disease very generally exceeds the mammelonnated. Its form is not always regular. The diseased por- tions may throughout have reached the second stage, or at the centre alone, the circumference being still in the first stage. In the last case, the circumference may be in contact with several other parts of the lung in a diseased condition, so that nearly the whole of an entire lobe may present an intermixture of the characteristics of pneumonia in the first and second stages. This Rilliet and Barthez denominate generalized lobular pneumonia, which, when it has reached the third degree, is strictly lobar. There is, according to the observations of Rilliet and Barthez, a difference between lobar pneumonia, and generalized partial pneumo- nia. Although in both there is a union of the several stages, yet they are differently disposed. Thus, in ordinary lobar pneumonia, when the inflammation commences at the base, it successively invades the superior portions of the lung, and while the base passes to the second stage, the superior portions are in the first, and when these last have arrived at the second, the first have attained the third: in the case of generalized partial pneumonia, many lobules, indiscriminately disseminated, become inflamed and finally unite. Sometimes, how- ever, the partial pneumonia, in becoming general, does not pass to the third stage. But even here we find ordinarily in the same lung, or in that of the opposite side, lobules in the second stage of inflam- mation, the remains of well-marked lobular pneumonia. The lobular pneumonia is of much more frequent occurrence than lobar pneumonia; partial and generalized lobular pneumonia is more PNEUMONIA. 303 frequent than the mammelonnated form; partial pneumonia is more common than generalized pneumonia. In the great majority of cases lobular pneumonia is double. Fre- quently the pneumonia is much more extensive on one side than the other. Thus it is partial in one lung, generalized lobular in the other. A union of the three forms of pneumonia—mammelonnated, partial, and general—is often found in the same patient. Mammelonnated pneumonia is equally frequent in every portion of both lungs, while generalized pneumonia is far more frequent in the inferior than the superior lobes. Partial pneumonia is often disseminated through all the three lobes: it is more frequently met with, however, in the infe- rior. Mammelonnated pneumonia is ordinarily equally diffused in both the right and left lung, while generalized pneumonia predomi- nates in the left. Mammelonnated pneumonia is of much more rare occurrence beyond the sixth year than partial pneumonia, while ge- neralized pneumonia is still more rare than the former between the sixth and fifteenth years. [Maladies des Enfans, T. i. p. 61.] It has been doubted whether all the -changes in the texture of the lungs described as characteristic of lobular pneumonia are really the result of inflammation. Hasse, in his Pathological Anatomy, refers many of these changes to the persistence of the foetal state of the lung subsequent to birth; a condition which Jorg has described under the name of atelectasis pulmonum, and has pointed out the distinction be- tween the latter, and the changes in the pulmonary tissue produced by inflammation. In atelectasis, the colour of the diseased portion of the lung always approaches more to a violet, their exterior appearing smooth and shining, contrasting thus with the dull, brown-red surface of inflamma- tion. In inflammation, again, the diseased portions are preternaturally distended, whilst in atelectasis they are collapsed, and inferior in vo- lume even to the healthy texture, but susceptible, provided the condi- tion has not lasted too long, of artificial inflation, and in this manner, of acquiring a perfectly natural appearance. In inflammation, the pul- monary tissue is softened; in atelectasis it is hard, and the cut surface is smooth, not granular. In short, we have nothing like pneumonia, excepting the solid, non-crepitant mass, which has been confounded with red hepatization. Views similar to those of Hasse are adopted by Dr. West in his very excellent monograph on the pneumonia of children. More re- cently, the subject has been more minutely investigated by MM. Bailly and Legendre, the results of whose observations are published in the Archives Gen. de Med. for February and March, 1844. These gentlemen deny the inflammatory nature of what has been termed lobular pneumonia, and refer it in every instance, to a peculiar state of condensation of the lung, similar to that of the foetal state. It consists, they suppose, in an occlusion of the pulmonary vesicles, which may result from the mere contractility of the tissues, or may depend on congestion of the vascular network exterior to the vesicles. The former is the simple, the latter the congestive form of this affec- tion. The congestive form is usually met with along the posterior 304 DISEASES OF THE RESPIRATORY ORGANS. border of the lungs, and generally accompanies catarrhal inflammation of the vesicles. In either of these forms of the foetal lung, insufflation reproduces, more or less completely, the natural condition of the lobules. Though occasionally met with unassociated with inflam- mation, yet, in by far the majority of cases, this condition becomes developed under the influence of catarrh and catarrhal pneumonia. When unattended with catarrh, and involving only isolated lobules, it cannot be detected until after death, but in the new-born infant it usually assumes the lobar form, is attended by the physical signs of deficient respiration, and associated with the absence of all signs of constitutional reaction. Lobular pneumonia has, they maintain, strictly speaking, no existence; the action of inflammation never being confined to a single lobule. Partial pneumonia would therefore be a fitter term. Insufflation does not modify the patches of true he- patization, and the bronchi leading to such hepatized nodules arc exempt from catarrh; two characters which distinguish partial pneu- monia from the lobular engorgements of partial broncho-pneumonia. .True partial pneumonia, according to MM. Bailly and Legendre, is by no means common in children, though when hepatization does occur in those under five years of age, it almost always affects the partial form. The statements, therefore, that have been made with reference to the variety of lobar pneumonia in infancy are correct; but almost all that has been said about the extreme frequency of lobular pneu- monia at that age, must be taken as referring to the foetal state of the lung. Broncho-pneumonia may affect healthy lobules, or those in the foetal state. In the latter case it gives rise to appearances which have led to the supposition that these lobules were the seat of a parenchy- matous inflammation. Dr. West has repeated the experiments of MM. Bailly and Legendre on many occasions, and fully substantiates the correctness of their statements. Dr. Fuchs, in his very excellent monograph on the Bronchitis of Children, published at Leipzig, in 1849, denies that, in children under five years of age he has ever met with an instance of true pneumonic (inflammatory) condensation, and adduces conclusive evidence of the connexion of what has been denominated lobular pneumonia with bron- chitis, and of its relation to bronchial obstruction. This connexion and relation has also been ably illustrated in a treatise On the Patho- logical Anatomy of Bronchitis, and the Diseases of the Lung con- nected with Bronchial Obstruction, by Dr. W. T. Gairdner, of Edin- burgh, (Edinburgh, 1850,) who has indicated the manner in which, in the course of a case of bronchitis, a collapse of the air-cells may occur, and give rise to the lobular condensation so frequently met with in the lungs of children who have suffered from what has been termed broncho-pneumonia. The general results to which Dr. Gairdner, has been led from a careful series of observations are, 1st, that in all cases of collapse of the lung, as well in the adult as in children, not caused by external pressure, the bronchi have presented unequivocal appearances of ob- struction ; 2d, that in most, if not all, the instances of severe and fatal bronchitis, especially if the secretions had become ropy or inspissated, PNEUMONIA. 305 more or less collapse of the pulmonary texture has also been present— that under peculiar circumstances, a much less amount of obstruction may be attended with collapse of the pulmonary texture, the symptoms in such cases probably attracting little attention. In reference to the mechanism and causes of pulmonary collapse he considers it to be clear, from experiment, as well as from pathological observation, that the most usual and most direct effect of obstruction, or of diminished caliber of the bronchi, however caused, is not accu- mulation, but diminution in quantity, of the air beyond the obstructed point. This is probably due in part to the comparative weakness of the inspiratory power; out there is also another mechanical condition which comes into play in producing collapse from obstruction, especially in the case of a viscid plug of mucus, which is most commonly, in bronchitis, the source of this affection. This condition is found in the form of the tubes. "The bronchi are a series of gradually diminishing cylinders, di- viding, for the most part, dichotomously. If a plug of any kind, but especially one closely adapted to the form of the tube, and possessing considerable tenacity, be lodged in any portion of such a cylinder, it will move with much more difficulty towards the smaller end, and in doing so will close up the tapering tube much more tightly against the passage of air, than when moved in the opposite direction into a wider space." "The consequence of this mechanical arrangement must inevitably be, that at every expiration a portion of air will be expelled, which in inspiration is not restored, partly owing to the com- parative weakness of the inspiratory force, and in part to the valvular action of the plug. If cough supervene, the plug may be entirely dis- lodged from its position, or expectorated, the air of course returning freely into the obstructed part; but if the expiratory force is only sufficient slightly to displace the plug, so as to allow of the outward passage of air, the inspiration will again bring it back to its former position, and the repetition of this process must, after a time, end in perfect collapse of the portion of lung usually fed with air by the ob- structed bronchus." Considered as a whole, the causes which tend to produce pulmonary collapse, would seem to resolve themselves into the following: firstly, the existence of mucus in the bronchi, which is more liable to produce obstruction in proportion to its tenacious and viscid character; secondly, weakness or inefficiency of the inspiratory power, however caused; thirdly, inability to cough and expectorate, and in this manner to remove the obstructing mucus. Of these conditions, the first, according to Dr. Gairdner, must be considered as the imme- diate exciting cause, the others, as predisposing causes, co-operating with the first, but incapable, without it, of producing collapse. He considers that the circumstances which produce inefficiency of the in- spiratory act are weakness of the muscles of inspiration, usually con- curring with general debility; distention of the abdomen, impeding the descent of the diaphragm ; and, finally, which is one of the greatest importance in relation to this subject, want of due resistance on the part of the thoracic parietes. The full dilatation of the lungs is only effected when the depression of the diaphragm is accompanied by the 306 DISEASES OF THE RESPIRATORY ORGANS. elevation of the ribs and widening of the thorax; and if the bones of the latter be very yielding, the external muscles of inspiration cannot, of course, act effectively under an obstruction. This is obviously the reason of the greater tendency in children to collapse of the lung as a consequence of bronchitis. The respiration of the child is at all times, even in health, more diaphragmatic than that of the adult; and the observations of Rilliet and Barthez afford satisfactory evidence of the comparatively small dilatation of the thorax in children, particularly of its lower part. When any obstruction exists to the entrance of air into the chest, even this small dilatation ceases, and collapse of the lung very readily takes place. Under such circumstances, Dr. Rees (on Atelectasis Pulmonum, London, 1850) has pointed out that in very young children the motions of the chest are absolutely reversed, and instead of the descent of the diaphragm being accompanied by ex- pansion of the chest, the ribs give way beneath the exhaustion caused by it within the thoracic cavity, and bend inwards to accommodate themselves to the collapsed lung in inspiration. This altered movement of the chest in infants is regarded by Dr. Rees as pathognomonic of atelectasis. It is also a prolific source of that permanent deformity of the chest which, in the early years of life, is often ascribed, with too little discrimination, to rickets.1 The origin of the minute abscesses which so often occur in the por- tions of lung supposed to be in a state of hepatization from lobular pneumonia, Dr. Gairdner thus explains: When pus accumulates in the central bronchi of a collapsed lobule, the evacuation of that pus is pre- vented from occurring, firstly, in consequence of the absence of the ex- piratory vis a tergo; and secondly, from the resistance opposed by the thickened mucous membrane and its secretion, closing up the bronchus in front. The coats of the ultimate bronchi, therefore, softened and injured by disease, gradually give way to ulceration, and the pus, which thus accumulates in still larger quantity, may at first scarcely be circumscribed, but soon begins to be surrounded by a false mem- brane exactly similar to that of an abscess in any other part of the body. The continuity of the membrane with that of the original bron- chus may be either maintained from its first formation, or it may be secondarily established. It is asserted by M. Bouchut, that even time hepatization may be removed by insufflation: in this, however, he is decidedly wrong. The hepatized portion may sometimes be made to assume a brighter colour, but not to resume the texture of healthy lung, as is the case with lung in the foetal state. Dr. Gairdner remarks, however, that he does not believe that inflation alone is applicable to the determi- nation of the presence or absence of true hepatization in those mixed cases in which alone there is any difficulty. For he has observed that while the partially hepatized lung may be inflated when the affection is recent; in the uncomplicated forms of pulmonary collapse, complete inflation is often very difficult or impossible after the collapsed state has been of some duration. In fact, the lung then begins to undergo gairdner, op. cit., pp. 33, 34. PNEUMONIA. 307 a modification in its nutrition and structure, which ultimately leads to permanent atrophy. The anatomical characters of the lobar pneumonia of children are identical with those of the same disease in adults; it is unnecessary for us, therefore, to detail them here. We meet with the evidences of inflammation in the stage of engorgement and hepatization, both red and gray, these lesions proceeding ordinarily from the base to the summit. The termination in abscess is rarely met with. The disease is most generally confined to one lung, and occurs more frequently in the right than in the left. It is most generally accompanied with pleuritis, to a greater or less extent. Beside the lesions already described, there are others which occa- sionally occur in the lungs of those who die of pneumonia. Portions of the surface of the lung are found to be without crepitation, de- pressed, soft, and flaccid. Their colour is violet, or pale red, marked by white lines disposed in lozenges or squares, which designate the lobes. Their section presents a smooth surface, of a red colour, and somewhat firm texture, resembling a portion of muscle. When pressed they give discharge to a serous, bloody fluid, without any mixture of air. The carnified portion is often found around the lower edge of one of the lungs, or it may occupy a considerable portion of one lobe, or the individual lobules. It is as frequent in one lung as in the other, and is very generally confined to one. There is some difference of opinion as to the exact character of this lesion; the supposed carnification is no doubt, in many cases, merely portions of persisting foetal lung. True carnification Rilliet and Bar- thez refer to the effects of inflammation, and in this opinion Dr. West would seem to coincide, and, we believe, very properly. Inflammation of the bronchi, from a simple injection with increased mucous secretion, to a dilatation of the bronchi with purulent effusion or the formation of false membrane, is a common complication of pneumonia. It is very generally confined to the smaller bronchial ramifications. Pleurisy is also a frequent complication of pneumonia, and is often of a very intense degree. Emphysema of the lung is not unfrequent- ly met with; its extent is in direct proportion with the extent of the pneumonic and bronchial affections, their violence, and the amount of dyspnoea with which they are attended. It generally occupies the summit of the organ, or its sharp edge. It is commonly double; when on one side only it is confined to the inflamed lung, and is here al- ways most considerable. By a few writers, lobular pneumonia was supposed to be peculiar to children under five years of age; but by the investigations of Dr. West, Rilliet and Barthez, and others, it has been shown that al- though more frequent, perhaps, in young children, lobular pneumonia may, nevertheless, occur at any period of childhood; a fact which our own observations very fully confirm. It has been asserted that pneu- monia in children under five years is invariably preceded by bronchi- tis. The result of the more recent researches of Rilliet and Barthez has convinced them that lobar pneumonia, without bronchitis, occurs 308 DISEASES OF THE RESPIRATORY ORGANS. more frequently in children under five years than they supposed in 1838, the date"of their first publication; that lobular broncho-pneu- monia is much more frequent than simple lobular pneumonia; but that it is incontestable that lobular pneumonia, mammelonnated, partial or generalized, may exist in children without bronchitis; and, finally, that inflammation of the bronchi and of the lungs is, in some cases, simultaneous. The lobular form of pneumonia, including under this term the cases of pulmonary collapse consequent upon bronchitic inflammation, is not only the most frequent during childhood, but it is also the most seri- ous. Lobar pneumonia, when it occupies only one lung, and occurs in children between six and fifteen years, whose health has not been impaired by previous disease, unless complicated by some secondary affection, is not a very fatal disease, if a judicious course of treatment be commenced with in its early stages. Its serious character is great- ly enhanced by its being complicated with certain other diseases. The most common of these are measles, hooping-cough, chronic ente- ritis, and small-pox. The most fatal of its complications is that with measles, and perhaps with chronic inflammation of the bowels, and with small-pox. Pneumonia in children may be produced by any of the causes which ordinarily give rise to bronchitis. It is consequently, most prevalent during spring, autumn, and winter—and among the children of those classes who are most liable to be exposed to cold or to sudden alterna- tions of temperature. Cases, however, occur at all seasons of the year, but comparatively seldom during those months the temperature of wThich is mild and equable. The disease occurs in both sexes, but most frequently in boys. Of 245 cases which are noticed by Rilliet and Barthez, 150 occurred in boys and 95 in girls; in 118 observed by Dr. West, 65 were in boys, and 53 in girls; and in 184 cases, of which an accurate account has been kept by ourselves, 96 were in boys and 88 in girls. In Phila- delphia, during the ten years preceding 1845, of sixteen hundred and fifteen deaths from pneumonia, 872 were in boys, and 743 in girls. Pneumonia is very liable to recur in the same child, after a shorter or longer interval. Of seventy-eight children who came under the care of Dr. West, with inflammation of the lungs, 31 are reported to have had previous attacks, namely, 21, once; 4 twice; 2 four times; and 4 several times, the exact number of attacks not being mentioned. The treatment of pneumonia in children must be, in a great mea- sure, governed by the particular circumstances of each case. The employment of blood-letting, particularly by cups or leeches, will very generally be found beneficial; and in children over three years of age, in the commencement of the disease, when carried to a proper extent, it will not only greatly and promptly relieve the dyspnoea and cough, but have a tendency to materially shorten the duration of the attack. In young children leeches or cups to the anterior parietes of the chest, or between the scapulae, in numbers proportioned to the violence of the symptoms, and the age and strength of the patient, will, in ge- neral, suffice; but in older children, whenever it can be effected, we PNEUMONIA. 309 should prefer, in severe cases of pneumonia, bleeding from the arm, which has always appeared to us to produce a more decided impres- sion upon the disease, than the more gradual abstraction of blood by leeches or cups. The propriety of repeating the bleeding must be left entirely to the judgment of the practitioner: when the first bleed- ing has been well-timed, and carried to a sufficient extent, a second will not generally be required. Whenever, however, the leading symptoms, particularly the dyspnoea, continue with little abatement, we should never hesitate to repeat the bleeding, either from the arm, or by leeches or cups, according to the violence of the remaining symptoms, the age of the patient and the amount of strength remain- ing. It is, however, in the early period of the attack alone, that we are to expect any very decided advantage from blood-letting; in the more advanced stages of the disease, it is seldom beneficial or admis- sible ; though we have occasionally met with cases that had existed several days, in which the cautious application of cups between the shoulders has been attended with very marked relief. In all cases the exhibition of some mucilaginous drink, in small portions, and at short intervals, will be found to abate, very sensibly, the cough, and relieve the dryness of the fauces, which, in the early stage of the disease, is often a harassing symptom. A solution of gum, or the mucilage of the slippery-elm bark, or pith of sassafras sweetened, will be the best we can employ. By many physicians, the employment of tartarized antimony, in large doses, has been recommended in the treatment of pneumonia oc- curring in children, as in that of adults, either in conjunction with blood-letting, or as the sole remedy; and cases have been published by Guersent and others in proof of its efficacy. M. Herard, in a paper published in L' Union tittdicale, Nos. 127, 131, considers that tartar emetic, in large doses, should be regarded as almost the exclusive re- medy in children over two years of age; although, in exceptional cases, one or two emissions of blood or a blister may be required. He does not believe that the injurious effects upon the alimentary canal, which are said to result from the continued administration of tartar emetic to young children, are of so common occurrence as has been supposed. In thirty-one cases of pneumonia in children treated exclusively by large doses of tartar emetic by MM. Baudelocque and Blache, in the Hospital for Infants in Paris, seven died; of these, two fell victims to tubercular pneumonia, and in the other five, lobular pneumonia was very extensive. This form of pneumonia Dr. Herard considers as far less amenable to tartar emetic than the lobar, while cases of broncho- pneumonia, occurring in children under two years of age, are gene- rally far more efficaciously treated by emetics than by antimony given in contra-stimulant doses. The rapidity with which convalescence takes place, is, he remarks, one of the most striking and advantageous results of the use of antimony. Given as an emetic, in the commence- ment of severe cases, we have often derived advantage from the em- ployment of tartarized antimony; and the same appears to have been the experience of others. In young infants, we have never employed the remedy in any form, believing it to be, at best, one of doubtful 310 DISEASES OF THE RESPIRATORY ORGANS. propriety at this period of life; but in the pneumonia of older children, we have repeatedly given it in divided doses, subsequently to bleeding, and often with very great benefit. In the cases occurring in infants under three years of age, small doses of ipecacuanha, combined with calomel, may be given; it is a remedy, with the effects of which we have had cause to be much pleased. In numerous instances, we have combined with it a small portion of powdered digitalis, and we think not without very decided advantage.1 In many cases, we may add to the mucilaginous drinks of the patient a small quantity of the wine of ipecacuanha, and of the tincture of hyoscyamus.2 This will often be found, after blood-letting, to aid very materially in allaying the cough, dyspnoea, and general restlessness. If the calomel should purge, as is sometimes the case, this may be ob- viated by combining it with a portion of Dover's powder. XR-—Calomel, gr. iv. ad vj. 2 R.—Mucil. G. acaciae, §iv. Ipecac, gr. iij.—iv. Vin. ipecac, %j. Pulv. digitalis, gr. iij.—iv.—M. Tinct. hyoscyami, gj. f. chart. No. xij. Sacch. alb. pur. giij.—M. One to be given every three hours. A teaspoonful to be given every two, three or four hours, according to the age of the infant. In the commencement of pneumonia, if the bowels of the child are costive or torpid, it is proper to administer a full dose of calomel, to be followed, in a few hours, by a dose of castor oil; or, in robust chil- dren, over three years of age, by a dose of equal parts of magnesia and sulphate' of magnesia. Subsequently, the bowels should be preserved regularly open by enemata, or occasional doses of some mild purga- tive; a grain of calomel, with half a grain each of ipecacuanha and extract of hyoscyamus, administered twice or three times a day, will usually effect this object. Costiveness is not, however, very common in the pneumonia of children; an opposite condition of the bowels is a more frequent and troublesome symptom. Blisters are remedies from which much advantage will be derived in most of the cases of pneumonia occurring in children. In violent cases, or in those attended with much febrile excitement, they should not be applied until the violence of the symptoms has been abated by direct depletion, and they should never be allowed to remain on longer than is necessary to produce a general redness of the skin: when re- moved, they should be immediately replaced by an emollient cataplasm. In slight cases, a weak sinapism may be employed, instead of a blister: a very good one consists of a thick slice of bread, dipped in vinegar, and lightly sprinkled with powdered mustard. AVarm pediluvia, with the addition of mustard, or sinapised hip baths, produce always a favourable revulsion from the lungs, and should not be overlooked in the treatment of the pneumonia of children. After the violence of the disease has been somewhat abated, we have found great advantage from the administration of small doses of calomel, ipecacuanha, and extract of hyoscyamus, every three hours. Under the same circumstances, the compound honey of squill may be administered; given in divided doses throughout the day, it forms an excellent expectorant in cases of children. PNEUMONIA. 311 Dr. West speaks highly of mercurial inunction in stubborn cases. Under its employment, he has seen recovery to take place even where circumstances had seemed to warrant a most unfavourable prognosis. It is especially, he remarks, in cases of neglected pneumonia, where the time for depletion has long gone by, the patient having become ex- hausted, and the employment of calomel is forbidden by the presence of diarrhoea, that the full value of mercurial inunction is seen. Dr. West employs it in the proportion of one drachm, rubbed into the thighs and axilla every four hours, for children of four years of age. He has never observed salivation to be induced by it, but he has seen the symptoms of the disease gradually diminish in severity during its em- ployment, and the solid lung become once more permeable to air. Dr. Hewitt, (Med. Times and Gaz., 1856,) in cases of broncho- pneumonia occurring in young children, deprecates the continued ad- ministration of debilitating remedies, or the employment of such thera- peutic agents as depress the strength of the patient, among which he enumerates direct depletion to any great extent, and the use of tartar emetic, etc. He advises attention to the diet and regimen of the child; an emetic of ipecacuanha to promote expectoration and dislodge mucus from the lungs, with sinapisms to the chest, with small doses of the wine of ipecacuanha at stated intervals, regulated by the urgency of the symptoms, together with frictions over the surface of the chesf; with olive oil frequently repeated, with a view to promote the expan- sion and movements of the thorax, in order to the complete distention of the pulmonary cells with air, and the removal of mucus from the bronchial ramifications. Stimulants, as the carbonate of ammonia, etc., may in certain cases be indicated. To the efficacy of this treat- ment, Dr. Hewitt bears testimony from the results of an ample expe- rience. In many cases, however, at the onset of the disease, cups, either scarified or dry, will be found advantageous. The warm bath is also an excellent remedy, and blisters to the chest, kept on only long enough to produce redness of the skin, will, also, be often pro- ductive of beneficial effects. In chronic cases, our chief dependence is upon revulsives, applied either upon the chest, or upon the surface generally, and perhaps upon a judicious mercurial course, particularly by inunction. When in the advanced stage of the disease, there is great exhaus- tion, with symptoms of impending suffocation, the use of carbonate of ammonia has been strongly recommended;1 but, under such circum- stances, there can be but little hope of the patient's recovery. JR.—Decoct. Senegae, 5";iij. Carb. ammoniae, 3J. ad ^jss. Sacch. alb. 3'j.—M. A teaspoonful to be given every three or four hours. It must be evident, that in severe cases, our chief hopes of a favour- able termination must be founded upon an early detection of the true character and extent of the disease, and the judicious employment, in the commencement of the attack, of bleeding, and the other antiphlo- g;stic remedies adapted to the age of the patient, and the violence of the symptoms. After a change has occurred in the texture of the 312 DISEASES OF THE RESPIRATORY ORGANS. lungs, we can do but little beyond moderating the more pressing symptoms. The diet of the patient, in the early period of the more acute cases, should be confined, almost exclusively, to plain mucilaginous fluids, or whey; in the more prolonged cases, however, after the violence of the disease has been subdued, plain water gruel, arrow-root, or tapioca, may be allowed. When the disease occurs in infants, they should be always taken from the breast, and the mother's milk given to them in moderate quantities by means of a spoon, as well to prevent their stomach from being overloaded, as to guard against the mischievous effects of the violent exertion of the respiratory function in sucking. The apartment occupied by the patient should be kept of a comfort- able, uniform temperature, and, at the same time, the purity of the air should be secured by proper ventilation, and a strict attention to cleanliness. The patient should be placed always in a half-recum- bent posture, in order to render the respiration more easy, and to prevent the injurious consequences resulting from the stasis of fluids in the posterior portions of the lungs. Dr. West has given another very important precaution that should never be neglected, which is, when the disease has reached an ad- vanced stage, or involves a considerable extent of the lungs, to move the little patient with the greatest care and gentleness, lest convulsions should be brought on. He has known instances in which children have been seized with convulsions immediately on being lifted some- what hastily from bed, and placed in a sitting posture. After convalescence is fully established, gentle exercise in the open air, in mild dry weather, may be taken with great propriety, but for a long period, the utmost care should be observed, by appropriate clothing, and other precautionary measures, to guard the patient from exposure to cold and damp; and while a gradual improvement is made in his diet, rich, indigestible, and irritating food must be avoided, as well as excess in the use of the articles which are allowed. Having alluded, in the foregoing section, to that condition of the lung which has been denominated by Jorg, Atelectasis Pulmonum, it may be proper to give a short notice of the disease, for the informa- tion of such of our readers as may not have met with that gentleman's work, Die Fotuslunge in gebornen kinde. The disease consists in a compression or obliteration, to a greater or less extent, of the pulmonary cells, but especially the inferior lobes of one or both lungs, and the posterior half of the remaining lobes. It is usually most extensive in the right lung. The portion of the lung in which the obliteration of the cells exists, is depressed below the level of the surrounding tissue, of a dark red or violet hue, and neither by incision nor pressure is any crepitation produced. It presents, when incised, a smooth red surface, from which a bloody serum may be squeezed, but in which no air bubbles can be detected; when separated from the sound tissue, and placed in water, it sinks to the bottom. When the diseased portions are artificially inflated, the cells become dilated, and they assume the same condition as the PLEURITIS. 313 surrounding parts. This condensation of the tissue of the lung, from compression of the air-cells, is not produced by either inflammation or effusion, but is the result of imperfect respiration, which prevents the air from penetrating and distending all the cells of the lungs; the parts affected, consequently, retain the colour and density of the foetal lung, and sink when placed in water. In infants who had died of atelectasis, Jorg invariably found the foramen ovale of the heart still open: this fact is confirmed by Hasse, who, however, very cor- rectly remarks, that the patulence of the foramen is not uncommon at the age at which death from atelectasis occurs. The causes assigned for this affection are, a very rapid and easy delivery, or too strong compression of the head of the child during parturition;—both of which circumstances are common causes of as- phyxia in new-born infants;—or, when respiration does take place, they prevent it from being sufficiently full to dilate the whole of the texture of the lungs, and, hence, give rise to the disease under con- sideration. The affection is especially characterized by an imperfect, short, anxious, and sometimes scarcely perceptible or intermittent respira- tion; a feeble, plaintive cry, difficulty of sucking, an imperfect eleva- tion of the ribs and sternum, often a livid or blue colour, with cold- ness, of the surface, a weak, languid pulse, and symptoms of general prostration. In consequence of the imperfect respiration, and im- peded circulation, nutrition is always impaired, and hence, if the child survive, it becomes emaciated, and cannot bear the slightest motion or exercise. In some cases congestion of the brain is produced, and convulsions; or, from the violence of the respiratory efforts, inflamma- tion of the bronchi and lungs. The endeavour of the obstetrician should be, as early after delivery as possible to induce in the infant a deep, full, vigorous inspiration; for, if the respiration be allowed to continue weak, and the lungs to be but imperfectly expanded, the infant seldom survives for any length of time. The mouth of the infant should, therefore, be cleared of any mucus that may be present in it; and by smart slaps upon the glutei muscles, or upon the palms of the hands and feet, respiration will often be fully established, or we may proceed as directed in the section on asphyxia. Rubbing the chest and back with sulphuric ether, and intro- ducing it into the nostrils and mouth, immersion in an aromatic warm bath, and repeated clysters and emetics are recommended by Jorg, all of which, however, arc of doubtful propriety. Emetics, and all means which tend to increase the engorgement of the vessels of the brain, are, indeed, strongly contraindicated when the brain has been injured during labour; in these cases a few grains of calomel, and stimulants to the lower extremities, cool lotions to the head, and even leeches to the latter, will often be found of advantage. 5.—Pleuritis. Inflammation of the pleura is not an unfrequent disease of infancy and childhood. It may occur at any period, from birth upwards; but it is more frequently met with in children over two years of age. Ac- 314 DISEASES OF THE RESPIRATORY ORGANS. cording to Rilliet and Barthez the primitive acute form of the disease is very rarely seen in children under six years of age. In younger children, pleurisy is most generally a complication of severe bronchitis or pneumonia, though it may occasionally occur as an independent disease. Mr. Crisp, in a paper read before the South London Medical So- ciety, (Lancet, January, 1847,) has shown, however, that pleurisy is by no means of so rare occurrence in infants as is generally believed. In forty-one post-mortem examinations made by him, of children un- der two years of age—the greater number under one year—six cases of inflammation of the pleura were detected. In five it was combined with pneumonia; in one it was complicated with pericarditis; in another with peritonitis and hydrocephalus; in one case only did the pleura alone appear to be affected. Although in some instances the disease is more difficult of detec- tion in young children than in the adult, and is especially liable to escape observation in infantile life, where many valuable signs, ob- tainable in patients of a more advanced age, are wanting; still, when the inflammation is confined chiefly to the pleura, he believes it may be easily recognised: even when complicated with pneumonia, atten- tion to the auscultatory signs will enable us to ascertain its existence. The symptoms observed by Mr. Crisp in infantile pleurisy were: great restlessness, violent screaming at the onset of the attack, very qui'ck pulse, hot and dry skin, glassy eye, dry, unfrequent cough; the head thrown back, and great apparent pain on placing the child erect. On auscultation a dry, rubbing sound was heard. Many of these symptoms may be present in other diseases, as in pneumonia, thus in- creasing the difficulty of the diagnosis; but when the dry, rubbing sound is heard, with frequent screaming, and an apparent increase of pain on elevating the head, he considers the existence of pleurisy to be pretty clearly indicated. If, in addition, mucous and crepitating rhonchi are heard, and only a small portion of the serous membrane is inflamed, the diagnosis is more obscure; but the disease may still be recognised by careful investigation. In older children the symptoms of pleurisy are more marked and characteristic. The disease generally commences with a chill, in some cases slight, in others more severe, which is soon succeeded by more or less febrile reaction; the skin being usually dry and hot, the face flushed, and the pulse frequent, full and strong. To these symp- toms cough, dyspnoea, and acute pain of some portion of the chest are soon added. In many cases there is vomiting of Bilious matter, and sometimes pain of the head. The respiration is short, quick, and somewhat oppressed; the oppression being aggravated when the pa- tient is in a recumbent posture. Breathing is performed chiefly by the action of the abdominal mus- cles and diaphragm; the motion of the chest being instinctively re- strained by the patient, in consequence of the pain attendant upon the elevation of the ribs; sometimes each inspiration gives rise to a sharp cry or moan, and an expression of countenance indicative of suffering. The cough is at first short, dry, and stifled; it is generally increased PLEURITIS. 315 when the child is lying down, and more so when lying on one side than on the other. When both pleurae are affected the only position in which ease can be obtained is upon the back, with the head and shoulders elevated. Pain is generally complained of, and usually referred to one side or other of the thorax—sometimes to both. The pain is increased by the cough and on inspiration; and when intense, gives to the coun- tenance that peculiar contraction which is the common expression of suffering in young children. If the disease is arrested in its first stages, the pain and dyspnoea generally abate; the last, as well as the fever, often entirely disap- pearing. The cough, in the course of the disease, becomes more moist, and a little viscid mucus is often raised by it: expectoration, however, seldom attends upon pleurisy, unless when this is complicated with bronchitis or pneumonia. When pleurisy occurs in the course of some acute disease in young infants, its onset is occasionally marked by an attack of convulsions or of suffocation, and in older children, by acute pain of the thorax. The dyspnoea and acceleration of pulse are often very considerable. The duration of the disease when properly treated at its onset, is generally short, and its termination favourable. When accompanied with bronchial or pneumonic inflammation, it is somewhat difficult to ascertain, with precision, either its commencement or termination. In such cases it is usually very acute, and terminates much more prctopt- ly than when it occurs alone. Pleurisy may assume a very chronic form, and is then marked, at first, with very obscure symptoms. There is some degree of pain in the side—often a slight fever, with evening exacerbations. A copious effusion in the pleural cavity takes place, and the form of the chest becomes, in consequence, changed. The patient loses his appetite, be- comes pale, languid, and emaciated; evening exacerbations of fever, and copious night-sweats ensue, and after being reduced, in the course of one or several months, to a state of extreme marasmus, expires; or, in more favourable cases, the fluid effused into the chest is absorbed, or being evacuated by a surgical operation, the patient may recover his ordinary health. The physical signs of pleuritis in infants are extremely equivocal. According, however, to the observations of Rilliet and Barthez, the disease, whatever is the age of the patient, is marked from its very onset by the presence of bronchial respiration. It is heard at first du- ring very strong inspirations, superficial or profound, and having a peculiar metallic tone. It is usually detected in the posterior part of the chest on a single side; at first at the superior portion of the chest, subsequently only in the neighbourhood of the inferior angle of the scapula, or between the scapulae. It may disappear on the first, se- cond, or third day, or it may continue for a longer period, when it is heard in both the movements of respiration, or only during expiration or inspiration. Rilliet and Barthez have known it to continue until the twenty-seventh day. In favourable cases, most generally, the bronchial inspiration is replaced, at variable periods, by a feebleness of the respiratory murmur, more rarely by the friction sound, and 316 DISEASES OF THE RESPIRATORY ORGANS. sometimes by the normal respiration. It is in the more acute cases, in which effusion probably occurs very promptly, that the bronchial ex- piration is most decided; when, on the contrary, the inflammation is slow in its progress, and the effusion takes place gradually, it has been entirely absent. Bronchial respiration is often accompanied with aegophony, heard at the posterior part of the chest, below the inter- scapular space, and at the inferior dorsal region. It may be detected as late as the fourth day of the disease; it sometimes disappears and again returns. It is present only in cases attended with serous effu- sion, when this is very abundant, or when thick false membranes are formed. It is often present in infants of two or three years, but is more distinct in older children. In cases of subacute or chronic pleurisy, when the effusion takes place gradually, and, as it collects, forces upwards the lung, or in cases occurring in debilitated subjects, with little reaction and tardy respiratory movements, the respiratory murmur becomes gradually ob- scured, at first at the base of the chest, and then higher and higher; the obscuration extending, finally, over the whole of one side of the thorax, and at length being lost entirely. In very acute cases the absence of the respiratory murmur may occur at the very onset of the attack, and over a large portion of one side of the chest, and very soon the respiration can be heard only at the interscapular region. The obscurity of the respiratory sound in these cases disappears early; in tRe more chronic cases it may persist in some part of the chest for several months. In very acute cases, upon percussion, the chest is tolerably sono- rous. When the disease is prolonged or is of a chronic form, the dull sound of the chest becomes more and more considerable, following in its march and in its extent the obscuration of the respiratory murmur. In very acute cases the dulness will disappear, sometimes very sud- denly, at the same time that the respiratory sound becomes perfectly free. When the chest is inspected the ribs of the side on which the effu- sion has taken place will be found to be confined in their movements, while the intercostal spaces are enlarged. When the effusion is very considerable the chest on that side is more or less dilated. Rilliet and Barthez lay it down as a principle that when a pleuritic attack occurs in a child labouring under hepatization of the posterior part of the lung, all the abnormal sounds that were perceived at the level of the diseased point become considerably exaggerated, and the sonorosity disappears. This occurs, however, only in cases sufficiently extensive and profound, to prevent the lung from collapsing. Thus it may be inferred, that if an entire absence of the respiratory murmur succeeds the symptoms of a well-determined pneumonia, the hepatiza- tion was of slight extent, and but little profound; whilst, on the other hand, if the bronchial expiration, the resonance of the voice, and the dulness of the chest are suddenly increased, the pneumonia, to which the pleuritic effusion has just been added, occupies a large ex- tent both in depth and surface. (Maladies des Enfans, T. i. 118.) Upon examination, after death, the appearances discovered are: ad- PLEURITIS. 317 hesions of the pleura, more or less recent; the pleura covered, to a greater or less extent, with yellowish lymph, forming, in some cases, a coating of considerable thickness; effusions into the cavity of the pleura of a serous or sero-purulent fluid, or of serum mixed with nu- merous small flakes of lymph. The serum is, sometimes, perfectly transparent, but at others is troubled and more or less opaque. The fluid secretions usually occupy the most depending portions of the pleural cavity; they are occasionally collected in separate cavities formed by recent false membranes or adhesions of the pleura. The most common lesion met with after death from pleurisy is unquestionably false membranes; they usually cover the costal pleura, often the pul- monary, and frequently both. In some instances the pleura is stud- ded with numerous small red points, arising from ecchymoses beneath the membrane; we have observed this occasionally upon the costal pleura, but more frequently upon that of the lungs. The pleura is not unfrequently thickly studded with minute tubercles, the lungs generally being in a similar condition: we have met with tubercles of the pleura, however, where none existed in the lungs. The inflammation is most commonly confined to one side of the chest, but may affect both. It is more frequent on the right than on the left side. According to the observations of Rilliet and Barthez, when the pleurisy complicates pneumonia it is, however, more fre- quently on the left than on the right. As a primitive disease, it occurs more frequently in boys thafi in girls. It is a common complication of pneumonia; often, however, it is in such cases of little intensity, though in others it assumes as seri- ous a character as the accompanying pulmonary inflammation. It is a frequent complication of rheumatism, scarlatina, and Bright's disease. It is of more frequent occurrence in spring, autumn, and winter, than in summer, or seasons of moderate, equable temperature. Pleurisy is not, of itself, a very fatal disease, and is readily con- trolled by an appropriate treatment. We have never seen a case in which the disease terminated fatally in its acute stage. Even when extensive effusion has taken place in the cavity of the chest, this will often be entirely absorbed, if it consists chiefly of serum; but when purulent, it frequently produces considerable uneasiness and suffering, and, sooner or later, causes the death of the patient. When extensive adhesions occur between the pleura costalis and pulmonalis, in chronic cases, a very marked contraction of the chest takes place, on the side on which the adhesions exist, productive, when of any extent, of de- cided deformity. In cases where copious effusion into the cavity of the pleura has taken place, the lung is more or less pressed upwards, and its functions im- peded. If, after this has existed for some time, a rapid absorption of the effused fluid takes place, the lung not expanding with sufficient ce- lerity to fill the chest, the ribs will consequently contract upon the compressed lung, and more or less contraction of the chest will be pro- duced. This deformity often disappears during the growth of the child—though occasionally it may exist, to a certain extent, throughout life. Of the treatment of pleurisy but little need be said, as it differs in 318 DISEASES OF THE RESPIRATORY ORGANS. no important particular from that proper in cases of bronchitis and pneumonia. The remedy upon which the chief dependence is to be placed is blood-letting, early employed, and carried to a sufficient ex- tent to produce a decided impression upon the symptoms of the disease. Precisely the same remarks that were made in relation to the employ- ment of this remedy in cases of pneumonia, are applicable to the dis- ease before us. In young children, a few leeches to the chest, followed by soft warm cataplasms, will often produce a very decided abatement of the disease. In the commencement of the attack, the bowels should be freely opened by a purgative of calomel, followed by castor oil, or sulphate of magnesia, and kept in a regular condition by small doses of ipecacuanha and calomel repeated daily. In the latter period of childhood, when pleurisy is most apt to occur independently of inflammation of the lungs, the tartarized antimony, either alone or combined with nitre, will often be found a powerful auxiliary to blood-letting, in arresting the progress of the disease.1 The tartarized antimony, combined with nitre and calomel,2 is parti- cularly advantageous in those cases in which, after blood-letting, the skin remains hot and dry, and the cough short and frequent. Under the same circumstances, the warm hip-bath and warm pediluvia act be- neficially. 1 R-—Nitrat. potassae, gj. 2 R.—Nitrat. potassae, 3J. Tart. ant. gr. ij. Tart. ant. gr. j. . Aquae, ^iv. Calomel, gr. iv.—M. f. chart. No. xij. Sacch. alb. 3'j.—M. One to be given, mixed in sugar and A teaspoonful to be given every two or three water, every three hours. hours, according to the age of the patient. As soon as the violence of the disease has been subdued by direct depletion, a blister to the chest, as directed in cases of pneumonia, will, often, very promptly relieve the cough, pain, and dyspnoea. Un- der the same circumstances that blisters become proper, considerable benefit will be derived from small doses of the compound powder of ipecacuanha, particularly in the evening; when well-timed, nothing will be found more effectually to relieve the cough and restlessness, and promote the healthy action of the cutaneous exhalants, particularly if, at the same time, a warm pediluvium be employed. When effusion to any extent has occurred within the chest, and the fluid is not speedily removed, after the inflammation of the pleura has been subdued, its presence being indicated by auscultation as well as by the inability of the child to assume a recumbent posture without experiencing more or less dyspnoea and cough, small doses of calomel, squill, and digitalis,3 given every three or four hours, will often cause the effused fluid to be absorbed. In some cases a combination of di- gitalis and bi-tartrate of potassa,* or a mixture of the syrup and oxymel of squill,5 with sweet spirits of nitre, will prove highly efficacious. 3 R.—Pulv. scillae, gr. iij. ad. iv. 4 R.—Bi-tart. potass, sjiij. Calomel, gr. iij. Pulv. digitalis, gr. iv.—M. f. chart. No. xij. Digitalis, gr. iij.—M. f. chart. No. xij. One to be given every three or four hours. 5 R-—Syrup, scillae, ^vj. Oxy. scillae, ^ij. Spir. aeth. nitr. gvj.—M. Dose, twenty-five drops, three or four times a day. CROUP. 319 The same rules are to be observed in regard to the diet of the pa- tient as were directed in pneumonia. In chronic pleuritis, our chief remedies are a mild unirritating diet, composed principally of the farinacea and milk, counter-irritants to the parietes of the chest, and internally, calomel in small doses, combined with some of the diuretics, of which, perhaps, digitalis and squill are the best, though occasionally the tincture of Sanguinaria Canadensis will be found a very valuable remedy in these cases, in the dose of from two to ten drops, according to the age of the child, repeated three times a day. In some cases mercurial inunction, employed in the same manner as was directed in pneumonia, will produce a beneficial effect. The bowels should be kept open by mild laxatives, or purgative ene- mata. Iodine, both internally and externally, may, in some cases, be productive of benefit. When effusion of pus has taken place in the pleura, the case, as we have already remarked, is generally hopeless; nevertheless, we are assured by Ilerpin, that by an operation, the pus has been evacuated, even in a child only seven years of age, and entire recovery has en- sued, with the exception of a slight contraction of the chest on the af- fected side. The operation has been performed several times with success, by Heyfelder, in children of from six to eight years of age. M. Trousseau has also insisted upon the utility of the operation in children. Dr. Hughes, (Guy's Hospital Reports, 1844,) states, that of twenty-five cases in which it was performed, in some repeatedly, thirteen may be fairly said to have recovered. The colleague of Dr. Hughes, Dr. Ad- dison, considers, however, the operation to be one of the worst and most deceiving in general practice. (Lancet, Nov., 1855.) Dr. Henry Bennett, (Lancet, Dec, 1843,) records six successful cases out of nine, in which the operation was performed by Dr. Davies, and several in the practice also of Dr. Hamilton Roe. During convalescence from chronic pleuritis, change of air will often be advisable, especially the removal from a cold, damp, and variable climate, to one warmer and more equable. 6.—Tracheitis.—Croup. CYNANCHE TRACHEALIK— ANGINA POLTrOSA VEL MEMBRANACEA--LARTXGEO-TRACHEITIS. If we take into consideration its frequency, the rapidity of its pro- gress, the distressing and painful symptoms by which it is accompanied, and the amount of mortality produced by it, tracheitis or croup must be regarded as one of the most formidable of the diseases peculiar to infancy and childhood. In Philadelphia, during the ten years pre- ceding 1845, there occurred 1150 deaths from croup, being an average of 115 per annum; in London, during the five years from 1845 to 1849, both inclusive, the deaths from this disease amounted to 1543, being an average of 306 nearly, per annum. In 1840 the deaths from croup throughout the whole of England, were 4,336. In Paris, the deaths from croup for three years, from 1838 to 1840 inclusive, were 79!I, being an average of 266 per annum. The croup is, strictly speaking, an inflammation of the mucous mem- 320 DISEASES OF THE RESPIRATORY ORGANS. brane of the larynx and trachea, the former being, in the great majo- rity of cases, the part first affected. The peculiarity of the disease consists in the early occurrence of an exudation upon the surface of the inflamed surfaces, forming, in many cases, a pseudo-membrane, which extends often from the larynx throughout the larger, and even sometimes into the smaller divisions of the bronchi. It has been sup- posed by Blaud, Duge's, and others, that in certain mild cases, of fre- quent occurrence, unattended with fever, and. readily cured by simple means, the pseudo-membranous exudation does not take place. These cases of simple laryngeo-tracheitis have been denominated by Guer- sent and Bertin spurious, and by others catarrhal croup; they are evidently cases of spasmodic laryngitis. The distinguishing symptoms of croup are; dyspnoea, a peculiar hoarseness of the voice, a loud ringing cough, sibilant inspiration, and fever. In the majority of cases the disease is preceded by symptoms of catarrh or bronchitis. The patient is affected with more or less chilli- ness, succeeded by increased heat of the surface, lassitude, loss of ap- petite, and cough. These symptoms vary in intensity and duration; in some cases presenting simply the characteristics of a slight catarrh for several days; while in others, the tendency to croup is exhibited from the commencement of the attack. It is usually during the night that the proper symptoms of the dis- ease are developed. The child, after retiring to rest, suddenly awakes from his sleep with difficult and wheezing respiration, and frequent paroxysms of a loud, ringing cough; his skin is intensely hot, his face flushed, and his voice hoarse and indistinct. Frequently he complains of a sense of constriction in the throat, and sometimes of pain about the larynx. In general, these symptoms, after a short period, gradu- ally abate, the respiration becomes more free, the patient falls again into sleep, and on awaking in the morning, with the exception of some degree of hoarseness and a slight cough, presents no symptoms of any serious disease:—the pulse, however, will, in general, still be found to be more frequent than natural, and the cough more hoarse and re- sonant. On the ensuing evening the respiration becomes again suddenly dif- ficult, loud, and wheezing, and the cough convulsive and ringing; the patient experiences a sensation of impending suffocation, and often carries his hand to his throat, as if to remove the cause of his suffering. His face becomes swollen and flushed, his pulse hard and frequent, and his voice hoarse and almost inaudible. The cough is unattended with expectoration, or causes the discharge of only a small amount of glairy mucus, streaked with blood. The violence of the foregoing symptoms may, after a time, moderate; but if so, soon again increase in violence, and usually continue, with slight remissions, and exacerbations of augmented severity, during the night. Sleep appears to favour their return; or if the patient remains awake, they are excited by his cries, or by the slightest paroxysms of coughing. Unless the disease be arrested by an appropriate treatment, the symptoms constantly augment in intensity, and the remissions become CROUP. 321 slighter and of shorter duration; the cough loses, however, its acute ringing sound, while the loud wheezing respiration of the patient is heard even beyond the apartment he occupies. The dyspnoea be- comes excessive, the patient is in a constant state of agitation, his face swollen and livid, his lips purple, and his forehead covered with large drops of perspiration. The skin becomes cool, and the pulse small, feeble, and extremely rapid. The thirst is often excessive, and not the least difficulty is experienced in swallowing the fluids presented. There is often expelled by the cough, or by vomiting, at this period, a quantity of thick, ropy mucus, sometimes mixed with fragments of a membranous appearance. These symptoms may continue for a longer or shorter period accord- ing to their intensity. The voice, however, soon becomes extinct, the respiration short and convulsive, and the patient is every moment in danger of suffocation; his face becomes pale or livid, his eyes dull and inanimate, and his head, face and neck are bathed in a cold, clammy sweat. There is now but little, if any cough or expectoration, the pulse is feeble, irregular, and intermittent, and the patient at length ceases to breathe,—the intellect, being, in general, unaffected through- out the attack. In other cases, however, the disease commences much more ab- ruptly, and proceeds with greater rapidity and violence. The patient, who retired to bed apparently in perfect health, is suddenly awoke from his sleep with a violent fit of loud, ringing cough; his respiration is loud, wheezing, and oppressed, and attended with a feeling of im- mediate suffocation; there is the utmost anxiety and restlessness; the face is tumid, and of a dark red colour, the eyes injected and pro- truding, and the pulse frequent and hard. These symptoms present not the slightest remission, but increase in intensity, and the patient, in the midst of the most frightful agony, perishes as though from ac- tual strangulation. In these extreme cases, death may occur in a few hours, or the attack may be prolonged for one or more days. Between the two forms of the disease we have described—that in which it is gradually developed and of some duration, and that in which it occurs suddenly, with symptoms of the utmost severity, and runs a rapid course—croup may present very various shades of intensity. Its duration will vary in different cases, according to the intensity of the disease, the age and constitution of the patient, and the nature of the treatment pursued. When attacked in its early stages by ap- propriate remedies, even in the more violent cases, the disease will oc- casionally be removed within a short period. The ordinary duration of the disease is from one to three or four days, though cases have been related in which it has been protracted until the twelfth day from its invasion; or the disease assuming a chronic character, it may, it is asserted, continue for two or three weeks. We very much doubt, however, the correctness of the diagnosis in these latter cases. The disease is usually described as one peculiarly liable to recur in the same individual, after a longer or shorter interval: this statement is made by nearly every writer upon the disease; it has, according to Jurine and Albers, been known to recur seven, and even nine times in 21 322 DISEASES OF THE RESPIRATORY ORGANS. the same individual. The subsequent attacks are described as vary- ing in intensity in different cases; an infant, it is said, may promptly recover from one, two, or three consecutive attacks, and finally be destroyed by a fourth, exceeding in intensity either of the preceding. We suspect, however, that many of the cases reported to have been repeated attacks of genuine croup, were in fact cases of the false or spasmodic form of the disease. The diagnostic symptoms of croup are: the hoarseness of the voice, the peculiar deep ringing cough, and the loud wheezing or sibilant in- spiration. The hoarseness of the voice is generally among the first symptoms that occur; even, in many cases, being observed previous to the dys- pnoea, cough, or febrile reaction. It is at first slight, but becomes more marked in the progress of the disease; not unfrequently, in the second and third stages, amounting to an entire extinction of the voice. In the cases that are preceded for some days by simple catarrhal symp- toms, the peculiar hoarseness of the voice will early warn the observing physician of the true character of the attack. The roughness or hoarseness of the voice, to a certain extent at least, often continues for some time after the disease has been entirely removed, and only slowly disappears. It is extremely difficult to present a correct description of the pe- culiar croupal cough. In cases preceded by catarrhal symptoms, a cough is present from the onset of the disease, differing in nothing from the ordinary cough of bronchitis; but from the moment that inflamma- tion of the larynx is developed, the cough becomes deep and hoarse, and with the first accession of the phenomena dependent upon the laryngeo-tracheitis, it assumes the characteristic loud ringing sound, constituting the proper croupal cough. This sound has been compared to the crowing of a young cock, to the barking of a hound, or to a cough heard through a brazen trumpet: these comparisons, however, but illy characterize its deep, ringing resonance. It must be heard, to form a correct idea of it; and, when once heard, it will scarcely be possible afterwards to confound it with any other. During the paroxysms of the disease, the cough occurs by fits, more or less violent and prolonged: during the intervals the cough still retains its croupal sound, but is less violent. Towards the close of the dis- ease, when the natural functions of the respiratory tube have become nearly destroyed, the cough is always entirely suppressed, and loses its peculiar characteristics. In the event of a favourable termination, the cough very frequently disappears entirely; or, as is more commonly the case, resumes its catarrhal character, and continues to recur for a longer or shorter period. The paroxysms of coughing are excited by the most trifling cause, as the act of drinking, speaking, crying, and the like. The respiration is more or less short and hurried from the com- mencement of the attack, and the dyspnoea augments in intensity with the progress of the disease, being sometimes so great as to threaten, every moment, strangulation. During the paroxysms, inspiration is prolonged, and attended with a loud wheezing, in some cases, amount- CROUP. 323 ing almost to a low, lengthened whistle. This wheezing inspiration continues throughout the attack, being less intense, however, during the intervals, and disappearing entirely with the disappearance of the disease. The hoarseness of the voice, the peculiar croupal cough, and the loud wheezing, and prolonged respiration, are evidently dependent, in a great measure, upon the diminished capacity of the rima glottidis and upper portion of the trachea, in consequence, in the first instance, of the thickening of the inflamed mucous membrane of these parts, and subsequently, of the pseudo-membranous exudation with which they become covered. But the circumstance of these symptoms, in many cases, becoming aggravated at irregular intervals, divided by distinct remissions, thus constituting, as it were, paroxysms, that commence suddenly, and decline with equal abruptness, has induced many to suppose that the peculiar symptoms of croup are, to a certain extent, due to a spasmodic constriction of the muscles of the larynx and glottis. It is probable, however, that it is chiefly the extreme dyspnoea of croup that is the result of this spasm, and which gives to the disease its ap- parent paroxysmal character. In the more violent attacks of croup, the dyspnoea commences with' the very onset of the disease, and continues, with little abatement, until its close. When, however, the attack is preceded for some days by catarrhal symptoms, the dyspnoea does not occur until somewhat later, and attains its peculiar character only in the second stage, when, during the paroxysms, it is only by the utmost efforts that the child appears to be capable of effecting the respiratory movements. The muscles of the face, neck, shoulders, chest, and abdomen, are thrown into violent, almost convulsive action; the mouth and nostrils dilate, the larynx ascends and descends rapidly; the entire thorax is elevated, and the shoulders are drawn up at every inspiration. In most cases, the dyspnoea is increased by the horizontal position, and the patient, in a state of the most violent agitation, throws his body successively in every position to obtain ease. Very generally the head is bent backwards, as it were to augment the size of the larynx, and thus to give to the air a more free passage into the lungs: this, however, is not invariably the case, and hence, as Royer-Collard very properly remarks, cannot be considered as one of the diagnostic phenomena of the disease. In the final stage of croup, the dyspnoea is equally intense; but res- piration is effected almost entirely by the action of the diaphragm, the contractions of which are violent and convulsive; the cartilages of the ribs and the abdominal muscles, are, at one moment, drawn inwards, towards the spine, and at the next, return suddenly to their former position. Ordinarily, inspiration is long and almost continuous, en- dangering, every instant, the suffocation of the patient. In the se- cond, and even at the commencement of the third stage, the dyspnoea may present very distinct remissions. These remissions occasionally are so complete, that the disease appears to be suddenly suspended, and the parents have rejoiced in the speedy recovery of the child: nothing, however, is more insidious than this sudden occurrence of a deceitful calm. 324 DISEASES OF THE RESPIRATORY ORGANS. Fever is very generally present in croup; it is in some cases strongly marked, commences with the disease, and continues until its closing stage; in other cases the febrile excitement is less intense; and again, in what have been termed spurious croups, the laryngeo-bronchial va- riety of Duges, there are often, especially in young children, no symp- toms whatever of fever. In the more violent attacks of croup, there is frequently pain of the larynx and trachea, in general of an obtuse rather than an acute character, and increased upon external pressure; in slight cases, how- ever, this symptom may be wanting. By some writers, a swelling of the neck, at the upper part of the trachea, has been described as frequently occurring. The swelling is represented as varying in size in different cases, of an oedematous cha- racter, and disappearing immediately upon the recovery or death of the patient: it must, however, be of very rare occurrence, as we have never had an opportunity of observing it. Vomiting occasionally occurs on the accession of the disease, but is not an invariable symptom, as has been supposed by Albers and others, even in the more violent cases. The fact is, that in these lat- ter cases vomiting is with difficulty excited, even by the administration of the most active emetics. Occasionally, however, vomiting will be provoked by the violent fits of coughing which occur during the height of the disease. The matters vomited in these cases are usually a thick, viscid mucus, or muco-purulent matter, mixed with shreds of false membrane, sometimes in the form of tubes, or portions of tubes. The discharge of these matters, when copious, is followed by a very marked relief of the dyspnoea and cough, which, however, is never of long duration. The condition of the bowels is various; but in the majority of cases, according to our experience, they arc more or less torpid. The urine is sometimes clear, pale, and abundant, and at others, small in quan- tity, thick, and deep-coloured; it is very often whitish and turbid, par- ticularly towards the close of the second period. This condition of the urine, however, is neither diagnostic of the disease, nor critical. There is often a disposition to somnolency in the commencement of the disease, which, in some cases, amounts to complete stupor, arising, probably, from a slight congestion of the brain; drowsiness or stupor, however, is by no means an invariable—we should think not even a frequent—attendant upon croup, as has been supposed, especially in its first and second stages. Some, with Cailleau, have described the senses, as well as the intellectual powers of the patient," to be increased in activity: although we have seldom seen the mental powers much impaired throughout an attack of croup, we cannot say that we have ever observed any augmentation of their activity. The pathological changes observed in those who have fallen victims to croup are principally confined to the larynx, trachea, bronchi, and lungs. One or other, or all of these, invariably present traces of dis- ease, differing, somewhat, according to the intensity exhibited by the symptoms during the life of the subject, and the period at which death has taken place. The lesion most commonly observed is a pseudo- CROUP. 325 membranous exudation, covering some portion of the mucous membrane of the respiratory tube, and an effusion of mucus or muco-purulent matter, filling the larger and sometimes the smaller bronchial ramifi- cations. In cases that have terminated rapidly in death, the exuda- tion is found only in the larynx and upper portion of the trachea, or is confined to the latter situation: when death has occurred at a later period, it is in the trachea alone, or in the trachea and bronchi that it is detected; it never exists in cases of genuine croup in the bronchi alone. In the larynx, the exudation is often in the form of a thin coating, extending over the whole of its internal surface, but more frequently it is disposed in membraniform patches, or is found upon the inferior surface of the epiglottis alone. In the trachea, it often lines the whole of the tube, and varies in consistence and thickness; or it occurs in detached patches, or in the form of soft concretions, resembling polypi, attached to the posterior surface of the tube; or the trachea is filled with a mucuform fluid, containing small masses of a more solid consis- tence. These same appearances are occasionally present in the upper part of the bronchi; but more frequently in the bronchial tubes there is only found a viscid mucus, more or less fluid, and containing often albuminous flocculi. In those cases in which the invasion of the disease has been sudden and violent, and its termination in death rapid, it is rare, according to Martinet, to find the exudation assuming a pseudo-membranous ap- pearance, the respiratory tubes in such cases containing only mucus, somewhat more abundant and viscid than natural. The larynx and trachea have, however, been found, according to Blaud, lined with a pseudo-membranous concretion, in cases in which the entire duration of the disease did not exceed twenty-four hours. When the fatal termination occurs towards the close of the second stage, the pseudo-membranous exudation very frequently lines the whole of the trachea, and sometimes even the larynx and upper por- tion of the bronchi, and presents, throughout nearly the whole of their extent, considerable firmness. In cases in which death occurs at a still later period, there is seldom found any thing in the upper portion of the trachea but a quantity of viscid mucus, which becomes more consistent at the lower part of the tube, and here often assuming a more or less complete membrani- form appearance, separated from the mucous membrane by an abun- dant layer of fluid matter. In the bronchi it becomes much softer, and soon loses entirely its membraniform character, the bronchi be- ing filled in their final ramifications with a thick, ropy mucus. (Royer- Collard.) The colour of the membraniform exudation is either whitish, yel- lowish, or gray; the part applied to the surface of the respiratory tubes is often marked by slight bloody striae or points. It is sometimes very closely adherent to the mucous membrane; but in other cases, there is interposed between it and the surface of the tube a layer of mucus or puriform fluid. It is in some cases soft, and readily torn, while in others it has considerable firmness; it is, in general, most thick and firm in the trachea, particularly at its posterior part. 326 DISEASES OF THE RESPIRATORY ORGANS. Vanbergher, Bohmer, and a few other writers on the disease, have described the pseudo-membrane of croup as an organized substance, possessing minute fibres and blood-vessels; a supposition which is con- tradicted by the most conclusive testimony. That in some cases, after the cessation of the disease, a portion of the membrane intimately attached to the mucous membrane of the trachea, may remain, and become organized, has, however, been placed beyond doubt. The chemical composition of the pseudo-membranous exudation of croup is the same as that of the diphtheritic inflammation generally, and of the pseudo-membranes of serous surfaces, it being composed chiefly of albumen. According to Dr. Seitz, upon a microscopic ex- amination of a portion of the pseudo-membranous exudation of croup, of about half a line in thickness, and of slight consistence, it was found to be composed almost entirely of pus globules, mixed with inflamma- tion corpuscles, and a species of cell double the size of the pus glo- bule, but in other respects similar to it. When the pseudo-membranous exudation, and the viscid mucus are removed from the surface of the respiratory tubes, the mucous mem- brane of the larynx, trachea, and bronchi is generally found to be in a state of inflammation throughout the greater part of its extent, though in many cases it has been found free from any mark of dis- ease. When death takes place in the early stage of the more violent cases, the larynx and upper portion of the trachea are of a deep red colour and more or less thickened, and sometimes more or less softened. When the disease has continued for a longer period, the redness is less intense; the blood-vessels of the mucous membrane are however, strongly developed, and when the mucus is scraped from its surface by the scalpel, is of a reddish colour. At a still later period of the disease, traces of inflammation are less perceptible, and often en- tirely absent. The affection of the bronchi is in proportion to the extent and duration of the disease; the earlier in the attack the death of the patient occurs, the less marks of disease are presented by them; the later in the disease the fatal termination takes place, the more ex- tensively do they appear to be involved. Cases not unfrequently occur in which their minutest ramifications are filled with a pulpy matter. Pneumonia is not an unfrequent complication of croup; portions of the lungs being in a state of inflammatory engorgement and hepatiza- tion ; pleuritic inflammation is also occasionally met with, as well as interlobular and sub-pleural emphysema. The physical signs of croup are not of a very positive character. In the early period of the disease, it is said that the stridulous respiration may be detected by the stethoscope, applied to the trachea, before it i8 otherwise distinct. According to Barth, when the stethoscope is ap- plied upon the trachea, there is perceived a kind of tremulous vibra- tion, as though a thin, movable partition was agitated by the air. This indicates the presence of floating portions of false membrane, and when confined to the larynx, is not an unfavourable symptom; if, on the contrary, it extends to the trachea and bronchial tubes, it indicates that the false membranes occupy the greater portion of these tubes. So long as the disease is confined to the larynx and trachea, upon per- CROUP. 327 cussion, no dulness will be found to exist. When bronchitis or pneu- monia is present, it will be indicated by its appropriate signs; these, however, may in a great measure be obscured by the loud sound of the tracheal respiration. In the early stage of the disease, or after vomiting, the tracheal sound being less, the sonorous breathing and rhouchi of bronchitis, and the crepitation of pneumonia, may be de- tected, if present. (Stokes.) When the pseudo-membrane in the tra- chea is partially detached, it is said by Maunsel, that we may have a clapper or valve-like sound, upon inspiration, when the upper, and upon expiration, when the lower extremity is the one detached and moved by the passage of the air through the larynx. We have never, ourselves, observed this sound. It is unnecessary to enter into an examination of the various hy- potheses that have been emitted in reference to the nature of croup. The investigations of modern pathologists have shown that the disease is simply an inflammation of the mucous membrane, and probably, ac- cording to Ryland, of the submucous cellular tissue of the larynx and trachea, and in many cases of the bronchi also; the inflammation in the early stage of the disease being, in most cases, confined to the larynx and upper portion of the trachea, but extending subsequently to the bronchi, often throughout their ramifications, and to the tissue of the lung itself. It gives rise, more or less rapidly, to the exuda- tion of an albuminous fluid, which most generally forms a pseudo-mem- branous coating upon the larynx, trachea, and commencement of the bronchi. The collapse or adynamic symptoms of the third stage, re- sult from the interruption to the function of respiration, and the con- sequent imperfect haematosis, caused by the presence of the exudation, and the congestion of the lungs. As we have already remarked, nearly all the characteristic phenomena of croup indicate that there also exists a spasmodic affection of the glottis, which, however, is the result of the increased irritability of the parts labouring under inflam- mation, and probably of the irritation of the morbid secretion, and not, as some pathologists have supposed, the chief cause of the promi- nent symptoms of the disease. In a very excellent monograph on The Pathology of Infantile La- ryngeo- Tracheitis, or Croup, Dr. E. R. Peaslee, of New York, has very clearly shown that the idea of the inflammation in croup having a pe- culiar or specific character is one altogether erroneous. The object of Dr. Peaslee is to prove that the disease is simply a laryngeo-tracheitis, and as such, stands in intimate relationship to, or rather, is identical with, this form of inflammation, whether it occur in the adult or in- fant—whether it run its course to a favourable or unfavourable termi- nation, or with or without the production of a false membrane. On this particular point the general conclusions of the author are as fol- lows:— "1st. An inflammation of the larynx, extending into the trachea, occurs, offering in its essential nature nothing different from any other case of inflammation of the same parts, either in the infant or the adult. It is generally preceded, in both infants and adults, by congestion and irritation, and therefore, by catarrh. 328 DISEASES OF THE RESPIRATORY ORGANS. "2d. An exudation of plasma occurs on the inflamed surface, as in the adult; this being most abundant in the trachea on the posterior wall, for reasons already given. "3d. This exudation may be disposed of, in at least two ways, pro- vided it is not at once removed, as it generally is, in adults, but not in infants, by coughing; reabsorption probably very seldom occurring in this disease, though it is not impossible, a. It may become degene- rated into pus—purulent matter—and thus, of course, at once be de- tached, which is the most common result, b. It may become organ- ized into false membrane. This is more probable if the blood is rich in fibrin, as in a plethoric child; if there is but little cough, an adult generally expelling it thus; and if time is allowed for its development, less being required in the child than the adult. "4th. Croup is, therefore, merely a laryngeo-tracheitis in infants and children, and offers nothing essentially different from the same inflam- mation in adults. The exudation in the case of adults is, however, usually at once ejected by coughing, or in the form of purulent mat- ter, while the liability to its organization in infants is greater, though, after all, a comparatively rare result, considering the whole number of cases, for the reasons before mentioned. "5th. Practically, therefore, as well as pathologically, we cannot say with Bouchut, '•without a false membrane, croup does not exist.' This membrane never exists till the inflammation—the essential element of the disease as we believe—has preceded, and has produced the exuda- tion of plasma, as before shown. No sooner does the catarrhal irrita- tion merge into inflammation, than the plastic lymph is thrown out, and this inflammation and its accompanying exudation are the ele- ments always present in croup." We, therefore, need not for any practical purpose, admit, Dr. Peas- lee maintains, an 'inflammatory and membranous' croup, as some writers have done, any more than we should make the same distinction in regard to pleuritis or peritonitis. All croup is inflammatory, and a few cases are accompanied by the formation of a false membrane. But the latter should not affect the treatment of the disease as an in- flammation, but merely from its mechanical effects; its occurrence cannot be predicted in any case until it is actually seen, and this is not possible in most cases even when it is developed at the very onset of the disease. Finally, Dr. Peaslee would drop the word croup en- tirely, and use the term laryngeo-tracheitis instead. He would call particular attention to the fact that a false membrane is formed in about one-sixth of all the cases, while in adults, it is of very rare oc- currence. But he would not make an accident the distinguishing fea- ture of this disease, any more than in the case of any other, nor allow it to enter into either the name or the definition of it. "So far as laryngismus enters into any particular case—and it does into all cases of true laryngitis to some extent—the case is, of course, spasmodic, but this term must not be applied to the exclusion of the idea of inflammation. Genuine spasmodic croup is a mere laryngismus. There is more or less spasm in all cases of bronchitis, and still more in hooping-cough, in the latter case in the larynx also, CROUP. 329 so that infantile laryngitis does not present any peculiarity in this re- spect. " Diphtherite, or the 'croup of adults,' differs not pathologically from infantile laryngeo-tracheitis. Generally, however, it is an asthenic form of laryngeo-tracheitis, since it usually attacks persons already de- bilitated by other diseases." Various divisions of croup have been attempted by different writers. By Blaud, it has been divided into three forms, dependent upon the intensity of the inflammation, and the character of the secretion from the inflamed mucous surfaces. The first being a mild form, with the secretion of a moderate quantity of thin, limpid, frothy mucus; the second, a more aggravated form, but still comparatively mild in its progress, and favourable in its termination, with opaque and puriform secretion; and the third, the most aggravated form, with pseudo-mem- branous exudation. This division, which is of little benefit in a practi- cal point of view, even were it well founded, is not borne out by the re- sults obtained from autopsical examinations. By others, croup has been divided into the laryngeal, laryngeo-tracheal, and laryngeo-bron- chial, according as the inflammation is confined to, or predominates in the larynx, trachea, or bronchi; this division is a much more accurate one than the preceding. It is probable, that in many cases, the bron- chi are the part originally affected; in the great majority, however, the disease commences in the larynx, and we suspect there are few, if any cases, in which it is confined to the trachea alone. Jurine has attempted to show, that in the ordinary form of croup, the disease is, in its first stages, a tracheitis alone, and that in the more violent form, (suffo- cating croup,) it is simply a laryngitis. Although this is not correct in fact, yet our observations have taught us, that in cases attended with violent symptoms, sudden in their onset, and rapid in their progress, there exists, most generally, considerable inflammation, with pseudo- membranous exudation, about the larynx, and in the immediate neigh- bourhood of the glottis, to a much greater extent, certainly, than* in cases in which the disease is marked by symptoms of less violence, and pursues a more protracted course. Another division of croup is into the sthenic and asthenic. The first occurring in robust and plethoric children, and attended with decided febrile reaction, firm pulse, pain in the larynx, and other indications of severe inflammation; the disease usually occurring as a primary af- fection. The second form, occurring in debilitated and cachectic chil- dren, or those reduced by previous disease, and attended with a low, obscure fever, feeble pulse, early collapse, and other indications of as- thenia. The first, or sthenic form, corresponds very nearly with the primary croup, and the second, or asthenic form, with the secondary croup of medical writers—the second, very generally, resulting from the extension of pseudo-membranous inflammation from the fauces into the larynx and air-tubes. Upon the termination of the symptoms characteristic of croup, the patient is frequently perfectly convalescent within a very short period; more commonly, however, they are succeeded by those of a mild bron- chitis, which continues for many days; in other cases the bronchitis 330 DISEASES OF THE RESPIRATORY ORGANS. becomes chronic, and occasionally terminates finally in tubercular dis- ease of the lungs. Age is evidently the chief predisposing cause of croup; the disease being principally confined to children under ten years of age, seldom occurring beyond that period as a primary affection. It is rare in the first months of life, but is met with most frequently in children between one and seven years old. By numerous writers, the occurrence of croup previously to the seventh month, has been denied. Others, how- ever, declare that they have met with it repeatedly, as a primary dis- ease in children at the breast. In Philadelphia, during the ten years preceding 1845, 475 deaths are reported from croup, in infants between 2 and 5 years; 238 in those between 1 and 2 years; 319 in those un- der one year; 112 in those between 5 and 10 years; and 6 in children over 10 years of age. In 1852, 429 deaths occurred from croup in the state of Massachusetts, 357 were under five years of age, 71 be- tween five and ten years, and one upwards of twenty years of age. Of 330 cases of croup, presented in a tabular form, by Andral, 141 oc- curred in infants between 2 and 5 years old; 71 between 5 and 8; 61 between 1 and 2; 36 over 8; and 21 under one year of age. The earlier the children are weaned, the more liable, according to Home, they are to attacks of the disease. Judging from our own experience, we should say that the croup oc- curs more frequently between the tenth month and fifth year from birth, than at any other period. This is the period of childhood when there exists a peculiar tendency to the formation of pseudo-membraniform exudations in all the inflammations of the mucous surfaces, especially those of the respiratory organs, which readily assume, in particular constitutions, the croupal character, rendered still more marked and dangerous by the imperfect development in early life of the larynx and trachea, and the small size of the glottis. Boys would appear to be more frequently affected with the disease tha'n girls. Of 543 cases of true and false croup, collected by Guer- sent, 325 occurred in males, and 218 in females; of the 1150 fatal cases of croup reported to the Health Office at Philadelphia, during the ten years preceding 1845, 612 occurred in boys, and 538 in girls. Of the 429 deaths from croup in Massachusetts during 1852, 243 were in boys, and 178 in girls. The deaths from croup in the London Hos- pitals during 1840, were, in the male sex 3, to 1 in the female. Children of a sanguineous temperament, of a florid complexion, in- clined to fat, and apparently in the enjoyment of perfect health, are those in whom the croup is most liable to occur as a primary disease, and hence we find of those families in which this temperament prevails, almost every infant attacked with the disease, as it reaches its first or second year. Children are rendered more liable to an attack of croup, when, by the improper fashion of their dress, their neck, shoul- ders, upper portion of their breast, and the greater part of their arms, are left entirely bare, or only slightly covered. The chief exciting cause of croup is, unquestionably, the impression upon the body of a cold and damp atmosphere, or sudden transitions of temperature; hence, we find the disease most prevalent during the CROUP. 331 variable, damp, and chilly weather which prevails in the commence- ment of spring and close of autumn. It is also of much more frequent occurrence, in situations naturally abounding in moisture, than in those of an opposite character. It may be considered as, to a certain ex- tent, endemic in valleys surrounded by high mountains, and in the vicinity of lakes and large rivers. It may be produced, however, at any season of the year, by sudden alternations of temperature. Sitting or lying down on a damp grass-plat, or in a current of air, after the body has been heated by exercise, or a sudden chilling of the body from any other cause, is very apt to induce the disease. It is also par- ticularly apt to occur, in the course of, or immediately subsequent to, an attack of measles or of pneumonia. Of the frequent prevalence of croup as an epidemic, Berge, Can- statt, Fleury, Valleix, Wunderlich, and others, furnish incontestable evidence. An epidemic of the disease is recorded as having extended over the greater portion of Central Europe during the period between 1805 and 1807, and one of more circumscribed limits by Terrand in his Thesis on Membranous Angina, published in 1827, during which, in a district of very small extent, there occurred no less than sixty cases of croup, all terminating fatally. In many of the instances, however, in which the disease is said to have prevailed epidemically, we suspect that it was not the primary, but the secondary form of the disease, consequent upon pseudo-mem- branous angina. The latter differs, in some degree, from primary croup. Independently of the inflammation of the larynx and trachea, being secondary to disease of the pharynx and throat, and its occur- ring always in the course of some other affection, the symptoms are usually of an asthenic character; the deglutition is more or less difficult, the breath fetid, and instead of a tendency appearing in the course of the attack to acute pneumonic inflammation, it is disease of the mucous membrane of the stomach and bowels, with which, in cases of second- ary croup, the laryngeo-tracheitis is most commonly complicated. Stokes enumerates other points of difference, which we do not recog- nise, as, for instance, the contagiousness of secondary croup, and its chiefly affecting adults. Under no circumstances, do we believe croup to be contagious;—even when it accompanies or succeeds to small-pox, measles, or scarlatina, it is scarcely correct to refer it to contagion, merely because the affection which it accidentally complicates is in this manner propagated. Almost the only disease with which croup can be confounded is laryngismus stridulus, or false croup. True croup always, however, commences gradually, the severe paroxysms never occurring until the disease has lasted for at least some short time; while in laryngismus, the attacks of stridulous and almost suspended respiration occur sud- denly, generally without the slightest premonitory symptom, and in the greater number of cases at night, they are also marked by intervals, often of some duration, during which the child has every appearance of being free from disease of any kind. In croup there are no true remissions or intermissions. After each paroxysm of laryngismus the natural tone of the voice is speedily regained, but such is not the case 332 DISEASES OF THE RESPIRATORY ORGANS. in croup; the voice retaining its hoarse rough sound for some time even after the entire removal of the disease. True croup never relapses, whereas in laryngismus relapses are common and frequent. There is another affection of not unfrequent occurrence, to which attention has been recently directed by Dr. Behrend (Jour, der Kin- derkrankheiten,) the attacks of which have no doubt been frequently mistaken for those of croup. It is a spasmodic cough of a peculiar character, to which children are liable, and which is said to occur only during the night. This affection is most generally observed in spring and winter; it, however, also frequently occurs during the autumn, and but rarely in summer. It is seldom, if ever, observed in infants at the breast, but occurs at every subsequent period of childhood, and more frequently in boys than girls. There is no cough whatever during the day, not the slightest catarrhal symptoms, and, when put to bed, the child falls into a sound quiet sleep at the usual hour. In the course of a few minutes, however, it becomes restless, and before awaking, coughs violently. It now commences to cry, and the cough becomes more and more severe, until, in some cases, it produces vomiting; after one or two hours of suffering, the child again falls asleep, and passes the remainder of the night quietly. The cough returns at the same hour the following night, and continues sometimes for weeks and even months; finally, it begins to diminish in violence, the fits become of shorter duration, and occur at a more advanced period of the night, so that the length of the sleep enjoyed previously to its coming on, is gradually prolonged:—at length the cough disappears entirely and spontaneously. The subjects of this affection are pale, readily fatigued, and troubled with a coldness of the feet towards evening; they eat and play, however, as usual, and appear otherwise to enjoy good health. The nocturnal cough has frequently a catarrhal character, and is ge- nerally accompanied with a mucous rattle; sometimes, the cough is dry, croupy, and whistling; the kinks are short, isolated, and uniform, and may recur every five minutes, or extend only to one or two. This nocturnal periodic cough cannot be confounded with genuine croup, by such as have carefully studied the characteristics of the latter disease; and it may be distinguished from spasmodic laryngitis by the complete intermission which follows the paroxysms, by its not being preceded by any catarrhal symptoms, and by the entire freedom from fever throughout the attack. It may be distinguished from hooping- cough from the latter being almost always epidemic, and occurring as well during the day as during the night, and always accompanied with a peculiar dyspnoea. In the nocturnal periodic cough there is no true appearance of suffocation; the children do not awake suddenly, as in a fit of asthma or spasm of the glottis, but they awake slowly, after having coughed several times during sleep. It most nearly resembles the cough of catarrh or bronchitis, but it is distinguished from those by the entire absence of the physical signs, and by the nocturnal pe- riodicity of the fits, which are followed by complete remission.1 1 Dr. Behrend considers the cough above described to be a purely nervous affection, and bases this opinion chiefly on the symptoms, and on the circumstance of its having CROUP. 333 The treatment of croup varies somewhat, according to the stage of the disease, and the violence of the attack. In mild cases, or in the early, or forming stage, an active emetic, followed by immersion in the warm bath, and subsequently the exhibition of small doses of antimony combined with calomel, will, in many instances, put a stop to its fur- ther progress. Nearly every writer upon the disease has spoken of the good effects of emetics, administered in the cases and at the period noticed: much discrepancy of opinion, however, exists as to the best emetic to be employed; by the majority of physicians, the tartarized antimony is preferred. Some, however, ascribe a peculiar efficacy to the sulphate of copper; while others, again, prefer the sulphate of zinc. Many of the American practitioners esteem the Sanguinaria Cana- densis, in infusion, as almost a specific, while a few prefer the Lobelia inflata. Dr. Meigs considers alum in powder, from the certainty and speediness of its operation, to form the best emetic in cases of croup, while Dr. Hubbard, of Maine, recommends the turpeth mineral, the yellow sulphate of mercury, as an emetic in this disease, in consequence of its promptness and certainty, and its never producing catharsis, or being followed by the prostration caused by tartar emetic. It is upon these latter considerations that the sulphate of copper has been considered the article best adapted to produce emesis in croup. By many of the continental physicians, it is held to be superior to all others. It is recommended by Berignier and Trousseau, in two or three grain doses, but by the latter in doses of five grains, to be re- peated after a short interval, should the first fail to produce vomiting. Dr. Hornerkopff, in a paper published in 1855, (Journ. fiir Kinder- krankheiten,) states that he has employed the sulphate of copper in 99 cases of croup, of which 77 recovered. He gave the salt in solution. 6 to 8 grains to one ounce of water of this from a tea to a table spoon- ful was given, more or less frequently, according to the age of the pa- tient and the extent of emesis produced. He continues the use of the remedy so as to keep up vomiting or decided nausea until convalescence has been fully established. Dr. J. Samter, of Posen, (Giinsburg Zeits- chrift, 1855,) has employed the sulphate of copper very much in the manner recommended by Dr. Hornerkopff, and speaks of it in equally favourable terms. Dr. Luzinsky (Schmidt's Jahrbuch, 1855,) gives a decided preference to sulphate of copper in croup. He administers it in solution, (two to frequently appeared after an epidemic of hooping-cough, and whilst intermittent fever3 were very prevalent among adults. This latter remark has been made by several phy- sicians whose attention was drawn to this cough by Dr. Behrend. The prognosis, we are told, is always favourable. In one case the periodic cough was followed by bronchitis, but this was probably merely accidental. In another case there was repeated epistaxis. The disease, upon the whole, is said to be generally more troublesome than serious, and to demand no active treatment. Gentle purgatives, as manna with the tincture of rhubarb, given in the evening, with attention to diet and regimen, are recommended. A drachm or two of the liq. acetatis ammoniae, in a little sugar, may also be given, before putting the child to bed. One physician found small doses of quinia, given at bed-time, of great service; another found slight irritation of the skin, chiefly by means of pediluvia, and friction of the soles of the feet with roasted onions, and even envelop- ing the limbs, after the manner of Preissnitz, beneficial. 334 DISEASES OF THE RESPIRATORY ORGANS. four or more grains in two and a half ounces of fluid,) of which the dose is a teaspoonful every fifteen minutes. The great objects to be kept in view, in our choice of an emetic in croup, are the promptness, certainty, and activity of its operations; and these properties being combined in the tartarized antimony, we have invariably preferred it in the commencement of the attack. In many of the milder cases, the compound honey of squill, given in a sufficient quantity to operate freely as an emetic, and continued sub- sequently in nauseating doses, will, very effectually, cut short the dis- ease. The only writer whom we have met with, that condemns emetics in the treatment of croup, is Goodlad. In cases of greater violence, or in which the emetic given in the forming stage, has failed to arrest the disease, our most effectual re- medy is, unquestionably, blood-letting. In many cases, the application of leeches to the throat will be sufficient, but in every instance in which the disease is marked by symptoms of considerable severity, or the pa- tient is robust and plethoric, the pulse hard and full, and the dyspnoea very considerable, blood should be drawn from the arm to an extent sufficient to make a decided impression upon the symptoms, but never, if possible, to the extent of inducing syncope; and if the symptoms should again recur with any degree of violence, the bleeding should be repeated, or leeches should be applied around the throat in numbers proportioned to the age and strength of the patient, and the intensity of the disease. The repetition of the bleeding must be governed by circumstances; in some cases, one bleeding, in the early period of the attack, will most effectually control the symptoms; but in others, when the system reacts with force, the pulse continues firm, the skin warm, and the dyspnoea considerable, a repetition of the bleeding will be proper. There is certainly no disease, in which bleeding, when well timed, and carried to a sufficient extent, is calculated to produce more bene- ficial effects than in croup. The practitioner, who, in violent cases, neglects this important measure, and places his hopes on any other remedy, or combination of remedies, will have but little reason to flatter himself upon his success in the management of the disease. This as- sertion is based upon a tolerably extended personal experience, as well as upon the recorded experience of nearly every American practitioner, and a majority of the most authoritative of the practitioners of Europe. But, it must be recollected, that it is only in the first stages of the sthenic form of the disease the beneficial effects of blood-letting are to be obtained: if it be then neglected, or timidly practised, the time for its employment will have passed, and in those cases in which it is strongly indicated, there will then be but little hopes of arresting the fatal termination by whatever other remedial measures may be resorted to. From the difficulty often experienced in obtaining blood from the arm, in young children, it has been recommended by Cheyne and Goodlad, to open one of the jugular veins; others, however, have ob- jected to the operation, from the difficulty of measuring the quantity of blood drawn, and of arresting the bleeding when a sufficiency has CROUP. 335 been obtained. We have repeatedly drawn blood from the jugular veins, in violent cases of croup, and with very decided advantage; the promptness of the relief has occasionally been very striking. We have never experienced any difficulty in performing the operation, or in arresting the hemorrhage; and as to the extent of the bleeding, this being measured not by the number of ounces of blood drawn, but solely by its effects upon the disease, we have had no more trouble in judging of this when the jugular vein was opened, than when the bleeding has been performed from a vein in the arm, back of the hand, or foot. Immediately after the first bleeding, the exhibition of an emetic and immersion in the warm bath will prove powerful auxiliaries. It often happens that an emetic, exhibited upon the accession of the dis- ease, will not operate, sometimes not even excite nausea, until the pa- tient is bled and the warm bath employed, when immediately copious vomiting will occur, and render the repetition of the emetic unneces- sary. After the patient is removed from the warm bath, he should be placed in bed, and enveloped in blankets, the perspiration induced by the bath and emetic being encouraged by the employment of divided doses of tartarized antimony. We generally combine the antimony with calomel and hydrochlorate of ammonia. R.—Calomel, ^ss. ad gj. Tart. ant. gr. j. Hydrochlor. ammon. 9'jss.—M. f. chart. No. xij. One to be given every two hours. The employment of nauseating doses of antimony in croup, subse- quently to full vomiting and sufficient depletion by the lancet, has the sanction of the best writers upon the disease. Cheyne declares that he has found no other remedy worthy of confidence in the second stage, an assertion which we consider, judging from the result of our own experience, scarcely too strong. Stokes places it even above blood-letting. Steinmitz trusted to it alone in the second stage, as also did Jadelot, who combined the tartarized antimony with ipecac- uanha, squill and senega.1 Cheyne also speaks highly of the efficacy of the tartarized antimony, both as an emetic, and in nauseating doses throughout the first and second stages of croup. A recent writer (C. Wilson) gives the tartarized antimony throughout the disease, at first in doses of a quarter or a third of a grain every hour, until a decided impression is produced upon the symptoms, and subsequently every two hours. Combining the article with calomel, we have certainly found to increase very materially its efficacy. "-R.—Infus. senegae, i|iv. Syrup, ipecac. 33. Oxy. scillae, giij. Tart ant. gr jss. — M. A teaspoonful every ten minutes. Of the good effects of calomel in croup, we have abundant testi- mony. Given in large doses and at short intervals, it is the remedy upon which many physicians have almost exclusively depended for the 336 DISEASES OF THE RESPIRATORY ORGANS. cure of the disease; while in somewhat smaller doses, after bleeding, an emetic, and the warm bath, it is strongly recommended by a host of authorities. By some practitioners calomel is directed in enor- mous doses, far greater than we should be inclined to prescribe; we nevertheless believe that the good effects of the remedy, in a disease of such rapid progress as croup, can be obtained only from its free administration. After the first bleeding, the operation of an emetic, and immersion in the warm bath, from two to five grains of calomel may be pre- scribed every two hours, so long as the symptoms of the disease con- tinue with any degree of violence; as these subside, the dose of the remedy may be reduced, or it may be exhibited at longer intervals. We have generally found, however, that when the use of the calomel produces, at an early period, deep green discharges from the bowels, it is better to reduce the dose; or if frequent green discharges still occur under its use, to discontinue it entirely. We have in no instance seen any bad effects from the employment of calomel in this manner, but often the most decided benefit. Its tendency is to reduce the laryngeo-tracheal inflammation, and thus to counteract the pseudo- membranous exudation. The hydrochlorate of ammonia appears to us to be a remedy well adapted to nearly all the inflammations attended with diphtheritic ef- fusions; we have employed it pretty extensively for many years in croup, and have always been pleased with its effects. Chamerlat re- commends it as almost a specific, when employed as a wash or gargle. We usually prescribe it in combination with calomel, tartar emetic and extract of hyoscyamus. Three or four grains to one or two of the calomel, an eighth of a grain of the tartar emetic, and from a quarter to half a grain of the hyoscyamus every two or three hours according to the age of the patient and the urgency of the symptoms. In the early stage of those cases of croup in which the disease is preceded by pseudo-membranous angina, M. Guersent, Jr., (Gazette des Hdpitaux, Nos. 48, 52,) strongly recommends the local applica- tion of the nitrate of silver. In the cases referred to, the symptoms are at first but little urgent; and a physician who is not accustomed to treat children, will often neglect to examine the throat. M. Guersent lays it down as an invariable rule to make such examination whenever a child manifests any febrile reaction ; and in this manner he has fre- quently been enabled to detect the approaching disease, the presence of which would not, otherwise, have been suspected. At first, and while the tonsils alone are covered with the plastic exudation, although the symptoms, as already remarked, are not severe—it is, neverthe- less, according to M. Guersent, a precious moment for the physician, as he may now frequently arrest a disease, which, if allowed to go on is usually fatal. While employing the solid caustic, M. Guersent directs the child to be held by a strong assistant, the tongue to be depressed by a broad instrument, as a very large spatula, or the handle of a large spoon, or what M. G. prefers, a large wooden tongue depressor. For fear of accident, the caustic should project only very slightly from its case. CROUP. 337 Many practitioners prefer the caustic in solution. In the earliest stage of the disease a weak solution, applied three times a day, will suffice. but in serious cases the solution must be very strong—1 part to 3 or 4 of water—and need, then, be used only once a day. It may be ap- plied by means of a sponge fixed to the end of a piece of whalebone by sealing wax. To prevent the extension of the false membrane, the caustic should be applied beyond its margin as well as upon it. The application, M. Guersent remarks, frequently dissipates the exu- dation from the tonsils, and yet it may extend to the epiglottis. The caustic is still our best remedy. A larger sponge is now re- quired, which must be fixed upon a strong whalebone, bent at an ob- tuse angle. The operator places himself on one side, and, introducing the sponge directly to the base of the tongue, executes some semi-rotary movements. Sometimes the epiglottis is raised, and the fragments of false membrane are detached from its inferior surface, which may be known by the paroxysm of dyspnoea this gives rise to. The caus- tic, in these cases, requires to be repeated three or four times in the twenty-four hours. A number of cases are recorded in the European and American Journals, where the treatment here recommended was pursued with en- tire success in all cases of membranous croup. In those instances in which the pseudo-membranous exudation is still confined to the pharynx, it is certainly deserving of a fair trial. Blisters to the throat are strongly recommended by many practi- tioners in the treatment of croup. Mackintosh confines their appli- cation to the first stage, after the violence of the disease has been re- duced by bleeding and leeching. Dewees doubts their utility; and Goodlad, Stokes, and Porter, condemn them entirely. We have occa- sionally employed them, but cannot say that we have perceived any benefit to result from their use. Rubefacients, however, followed by warm fomentations or emollient cataplasms to the throat, will, in the forming stage of the disease, be often productive of the best effects. As a rubefacient, the spirits of turpentine is the one we have generally employed: its action upon the skin is prompt and sufficiently powerful: a strip of flannel wet with turpentine should be applied around the neck, and kept on for ten or fifteen minutes; it may be reapplied at short intervals, from time to time, if necessary. In very violent cases, in the incipient stage of the disease, even rubefacients should not be resorted to un- til after blood-letting. A German physician, Dr. Willige, states (Schmidt's Jahrbiicher, 1847,) that he has derived marked success in the treatment of severe cases of croup from the external application of iodine to the upper part of the neck. He applies, by means of a feather, the tincture of iodine over the front portion of the neck, corresponding to the region of the larynx and trachea, and repeats the application at intervals of about four hours, until redness and irritation of the skin are produced. This, he declares, is followed in most cases, by a subsidence of the difficulty of respiration, the spasmodic affection of the glottis, and of the other distressing symptoms. 338 DISEASES OF THE RESPIRATORY ORGANS. The internal use of the iodide of potassium has been suggested as a means, adapted in the first stage of croup, to modify the disposition to membraniform deposition in the larynx. It was first used in a case of the disease by Dr. Purefoy of Dublin, who gave it in one grain doses, combined with a grain of hydrarg. c. creta, every two hours, with much benefit, (Dublin Journal, 1846.) Dr. J. D. Griscom, of this city, pre- scribed it also in a case of the disease with apparently the most fa- vourable results: it has since been employed by others, who speak of it in terms that should encourage us to a fair trial of it, in order that its true value as an antiplastic in croup may be ascertained. Dr. Griscom gave the remedy in doses of two and a half grains every three hours. Bromine or the bromide of potassium, in doses of from one to ten grains a day, is regarded by M. Ozanam as almost a specific in all pseudo-membranous affections. (Med. Times, 1857.) As a means of reducing the plasticity of the blood, and thus dimi- nishing the tendency to the formation of false membrane in croup, the vegetable alkalies have been strongly recommended by several of the continental physicians. Eggert considers the carbonate of potass, after an experience of its effects in about two hundred and fifty cases, to be almost a specific in croup; and Luzinsky speaks of it in the most favourable terms. (Schmidt's Jahrbilcher, 1855.) The latter states that it may be given advantageously in doses of from half a drachm to two drachms, daily. In mild cases the carbonate of soda may be employed, but in the more severe, the carbonate of potass is alone to be relied on. Mr. Hird speaks also in praise of the alkalies as a means of allay- ing the spasmodic paroxysms, and promoting the removal of the exuda- tion in croup. He gives from ten to fifteen drops of the liquor potassa every four hours. (London Lancet, 1846.) When the disease persists after the use of the lancet, leeches, eme- tics, and calomel, very great advantage will often be derived from a tobacco cataplasm, composed of the moistened leaves of tobacco, mixed with the crumb of stale bread or ground flaxseed, and applied around the throat. The effects of the cataplasm should be carefully watched, lest its depressing effects be carried too far. After the pseudo-membranous exudation has occurred, our chief dependence is to be placed on the use of calomel and tartrate of anti- mony; the latter being occasionally carried to a sufficient extent to ex- cite vomiting. The administration of repeated emetics in this stage, was the practice pursued by Jadelot, Steinmitz, Cheyne, and Currie, and the result of their experience is certainly decidedly in its favour. Tartrate of antimony was the article employed by these physicians, and Cheyne states, that the only cases he saw recover from the second stage of the disease, were those in which the patient was kept under its effects for two or three days. Fielitz, Hoffman, and Droste em- ployed the sulphate of copper, in the dose of one-fourth to one-half of a grain every two hours. It is in this stage that the tincture of lo- belia will often be found advantageous; or, perhaps, the infusion of the sanguinaria Canadensis.1 We know nothing of the latter remedy from our own experience; it comes to us, however, very highly re- commended by respectable practitioners. CROUP. 339 It often happens, from the impediment to haeraatosis, produced by the effusion within the respiratory tubes, and the deficient innervation from the venous congestion of the brain, that emesis is with difficulty produced, even by very considerable doses of antimony; it has under these circumstances been recommended to employ the sulphate of zinc or of copper in solution, alone,2 or combined with ipecacuanha. 1 R.—Rad. sanguinar. Canadensis, pulv. Qj. 2 R-—Sulph. zinci vel cupri, spj. Aquae calidae. 3; iij. — M. Aquae, ijj.—M. Dose.—A teaspoonful every half hour. Dose.—A teaspoonful every 20 minutes. In conjunction with emetics, either in full or nauseating doses, and calomel, the frequent use of warm sinapised pediluvia will generally be found advantageous. After the violence of the disease has been to a considerable extent reduced, or the case has assumed a somewhat chronic character— when a dry, hoarse cough, with oppressed breathing, increased at in- tervals, but with little febrile excitement or tenseness of pulse, remains, a strong decoction of senega will be often found a useful auxiliary to the other remedies. R.—Rad. polygalae senegas, 2jj. Aq. bullient. Oj. Simmer to % xij. then add mellis, Jjiij. Dose.—One, two, or three teaspo mfuls, every one or two hours; according to the age of the patient, and the urgency of the symptoms. In the third stage of the disease, blisters may be applied upon the upper part of the chest, or between the shoulders; sinapisms, or cloths wet with hot turpentine, or the decoction of turpentine and cantharides, may at the same time be applied to the extremities, and internally a strong decoction of senega, with the addition of camphor and assa- foetida, may be resorted to; and if there is great and increasing ex- haustion, it will be proper to support the patient's strength by am- monia or wine whey. Occasionally, even under apparently the most desperate circumstances, recovery will ensue; but seldom, when the disease has reached this stage, will its fatal termination be arrested by any course of treatment. Of the good effects of musk, given in large doses, from twelve to twenty-four grains in the course of the twenty-four hours, in the latter stage of croup, we have certainly very strong testimony. Assafoetida, likewise, has been extolled, given as well by the mouth, as by injec- tion into the rectum, to the extent of half a drachm to a drachm a day. By some of the European physicians, the employment of cold affu- sions upon the back, from the occiput to the sacrum, has been strongly recommended as beneficial in cases where every other remedy has failed to afford relief. The immediate effects ascribed to the cold affusion, are certainly surprising, but the result of the practice is not such as strongly to press it upon our attention. The operation of tracheotomy has been suggested by some as a last resource in cases of croup, and by others as a measure that should only be resorted to before effusion has taken place in the trachea. Among the advocates of the operation are Home, Huxham, Caron, 340 DISEASES OF THE RESPIRATORY ORGANS. Maingault, Hosack, Farre, Maslhieurat, Berard, Petel, Trousseau, Valleix; while it is opposed by Crawford, Ferriar, Cheyne, Vieusseux, Double, Albers, Jurine, Royer-Collard, Porter, Bricheteau, Becquerel, Boudet, and others. In the cases in which tracheotomy was performed by Guersent and the Hospital Internes, in the Parisian Hospital for Children, during the year 1841, the operation, while it was of no advantage whatever when the pseudo-membranous exudation extended into the bronchi, appeared, in many cases, to accelerate the fatal termination, by in- ducing severe bronchitis or an excessive secretion of mucus in the bron- chi, pneumonia, or convulsions; while in many cases the patient died im- mediately after the operation, without any local lesion existing, to which the fatal termination could be referred. The subject of tracheotomy in croup is certainly one of considerable interest. That it may, in many cases, when timely performed, save the life of the patient, we have the most unquestionable evidence. In a statement of Trousseau of the result of the operation in two hundred and fifteen cases, the patients recovered in forty-seven, and M. Val- leix gives seventeen cases of recovery out of fifty-four, of unques- tionable pseudo-membranous croup, in which the operation was per- formed. In the case of his own child, three weeks old, published by Dr. Scoutetten, the operation was performed on the third day of the disease, under circumstances apparently the most desperate, with com- plete success—the infant recovering in a short time from the effects of the operation, as well as from every symptom of the croup. A somewhat similar case was related by Dr. C. D. Meigs, to the College of Physicians of Philadelphia.—(Summary of Transactions, vol. ii. page 275.) By the operation, M. Bretonneau has saved six out of twenty of his cases; M. Leclerc, of Tours, one out of two; M. Velpeau, two out of ten; M. Petel, (de Chateau-Cambre'sis,) three out of six; M. Bouchut, forty-five out of one hundred and sixty. Thus out of one hundied and ninety- eight operations of tracheotomy, leaving out those of Trousseau, Val- leix, and others, fifty-seven were successful, or a little more than one- fourth. It is very certain, however, that tracheotomy in croup has not been attended with the same beneficial results in the practice of the phy- sicians of Great Britain and this country as it is asserted to have been in that of Bretonneau, Trousseau, and other French practitioners. This has been supposed by some to result, so far as it concerns Great Britain, at least, in a difference between the pathological character of the disease as it occurs in that country and in prance. It being in the latter confined pretty much to the larynx and upper portion of the trachea, whilst in Great Britain, the trachea in its entire length is in- volved, and partially obstructed by false membrane of more or less density. This difference in the pathology of croup in the two countries is noticed by Dr. West in his work on the diseases of children. "In France," he remarks, "croupal symptoms are, in the majority of cases, induced by the extension to the larynx of false membrane originally deposited on the fauces and soft palate, whilst the wind-pipe itself is comparatively seldom in a state of active inflammation, often alto- gether unaffected, and the bronchitis and pneumonia, which in this CROUP. 341 country so often and so seriously complicate the disease, are there of less common occurrence." The class of cases, and the period and particular circumstances of the disease in which the operation is most likely to afford relief, are ques- tions of no little importance, and it is more than probable that much of the want of success experienced from the operation, is to be attributed to its having been resorted to under improper circumstances. M. Trousseau, whose experience on this subject has been somewhat ex- tensive, has presented the following as a summary of the prognosis of tracheotomy in croup. 1st. If the commencement of the attack dates several days back, the disease having advanced slowly—whatever may be the extent of the false membranes in the trachea and bronchi, the child either recovers, or, at least, lives several days after the operation. 2d. If the child has been subject to chronic catarrhs, and when he has been suffering from a cold for some time before the attack of croup, the operation is more successful. 3d. So long as the respiration is silent, or the noise is only occa- sioned by the displacement of mucosity, there is nothing to fear; but when the respiration is attended with a sound like that produced by the sawing of stone, death is certain. 4th. If the croup supervene upon-measles, scarlatina, small-pox, or pertussis—tracheotomy does not succeed. 5th. There is no reason to despair of the patient, even if an attack of pneumonia or pleurisy should supervene. 6th. When the disease has been very rapid, even though at the time of the operation the false membranes do not extend beyond the larynx, the child dies very quickly. 7th. When, previously to the operation, the false membranes have extended to the nares, or if they cover the blistered surfaces—when the child is pale and somewhat bloated, without having taken mercury or been bled—or when he has lost much blood, there is little to be expect- ed from the operation. 8th. When, previously to the operation, the pulse is moderately fre- quent ; and if, after it, the pulse remains calm, hopes may be enter- tained. 9th. The more deeply the false membranes have extended, the greater, caeteris paribus, the danger. 10th. It is a bad sign, if, immediately after the operation, the respi- ration becomes very frequent, without or with very little cough; even when all is going on favourably, the occurrence of a very great fre- quency of respiration is a bad sign. 11th. More boys than girls recover after the operation; but children under two and over six years of age seldom recover. 12th. The more rapid and energetic the inflammation which attacks the wounds in the trachea, the more are the chances of success: a sud- den sinking of the wound is a mortal sign. 13th. Should the wound become covered with false membranes; if after withdrawing the canula, it remains gaping for a long time, or if, after having become completely cicatrized, it reopens largely, the child is in danger. 342 DISEASES OF THE RESPIRATORY ORGANS. 14th. Agitation and sleeplessness are bad signs, so is also the oc- currence of convulsions. The younger the patients, and the more blood they have lost before or during the operation, the more liable are convulsions to supervene. 15th. The sooner after the operation the larynx is disembarrassed, the sooner may the canula be removed, and the more rapid and cer- tain the cure. 16th. If the expectoration becomes mucous and catarrhal by the third day after the operation, the child will recover. If there is no expectoration, or it is serous, or like half-dried portions of gum Arabic, he will die. 17th. If the patient reacts vigorously under the injections into the trachea, of warm water or a solution of nitrate of silver, and the sponging out of the trachea, we should not despair, however unfavour- able the other symptoms. 18th. When, after the tenth day, the drinks pass almost entirely from the pharynx into the larynx and trachea, even if they are readily rejected, the child most generally dies. 19th. The increase of the fever after the fourth day, agitation, sink- ing of the wound, dryness of the trachea, frequency of the respiratory movements, and attempts to cough, announce the invasion of pneumo- nia, which, at first lobular, becomes sometimes pseudo-lobar, and is to be treated by the same means as are employed in the pneumonia of children: we should, however, exclude blisters, because they too often become covered with false membranes. We have said nothing, as yet, on the subject of diet in croup. During the forming stage, the diet should be the same as in violent cases of bronchitis: during the height of the disease, little or nothing else should be allowed, than some mild, mucilaginous fluid in small portions at a time; while after the disease has been subdued, and throughout the period of convalescence, the child should be allowed the mildest and most unirritating articles of food, care being taken that even in regard to these, no excess be committed. For a long time after recovery, there is very considerable danger of a relapse, upon the slightest exposure to cold or moisture, or to the most trifling transitions of temperature; from these, therefore, the child who has recently recovered from an attack of croup, should be care- fully guarded, by appropriate clothing, and every other judicious pre- caution. The daily use of the warm bath, and daily exercise in the open air, during mild and dry weather, should never be neglected. 7.—Spasmodic Croup. Millar's asthma.—spasmodic laryngitis.—false croup.—catarrhal croup. There is a form of disease of frequent occurrence during childhood, which has very generally been confounded with croup, to which it bears a strong resemblance in some of its features, but differs from it, never- theless, in its less serious character, and the absence of any tendency to the formation of a false membrane, in the air passages. The dis- ease to which we allude has been variously named by different writers. SPASMODIC CROUP. 343 Millar, who was the first that directed attention to it, denominated it Asthma, which name was retained by Wickmann and others; Breton- neau named it Stridulous Angina, Guersent, Laryngismus Stridu- lus, while Rilliet and Barthez prefer the denomination Spasmodic La- ryngitis, as indicating what they believe to be the true character of the disease. The attack of spasmodic croup is usually preceded, for a day or two, by slight catarrhal symptoms; coryza, watering at the eyes, a sense of chilliness followed by flushes of heat; slight hoarseness, and cough. The paroxysm usually occurs during the night, though it occasionally takes place during the day. The child is, generally, suddenly awoke from sleep by a sense of impending suffocation. He starts up in a sitting posture, or throws himself upon his knees, with the body bent forward. He cries out that he is suffocating, tears away every cover- ing from his throat, and pushes away those who surround, or offer to assist him. The face becomes congested, and of a red or violet hue, the eyes projecting and humid, and the expression of the countenance anxious in the extreme. The respiration has a peculiar prolonged hiss- ing sound, which is occasionally so loud that it may be heard in a neighbouring apartment. There is at the same time a frequent hoarse cough. The voice is constrained, but seldom whispering or abolished. There is great quickness of pulse and heat of the skin. After conti- nuing for a short time, the paroxysm ceases suddenly, and the child falls asleep. The disease may be confined to a single attack, or a second attack may succeed upon the same night; more usually, the child continues during the ensuing day tolerably well, though in many cases affected with hoarseness and a frequent, short, barking cough, with or without expectoration, and during the night following is again attacked with a paroxysm of suffocation. The disease may continue in this manner for several days, and then the paroxysms cease to recur, and the cough and remaining symptoms speedily disappear. In a case detailed by Jurine, a decided alteration of the voice continued for a long time after the cessation of the disease. In some cases, the paroxysms continue to recur, and at the same time to augment in intensity, and death finally takes place from asphyxia. In other instances, after one or more paroxysms have taken place, the patient becomes affected with the utmost inquietude, constant nausea, repeated vomiting, with great exhaustion, and a small frequent pulse, and soon sinks. Usually, how- ever, the disease is one readily managed, and having very seldom a fatal termination. Spasmodic croup is one very liable to return. According to Rilliet and Barthez, its recurrence may take place at the end of six months, or of one or two years. In a case reported by Vidal, the first attack occurred when the child was two years old, the second when it was five, and then, in the space of three months, it had three attacks. We have seen it more frequently recur at intervals of nine ajid twelve months than at shorter periods; we have known it, however, to attack three times within the same year. The prognosis in spasmodic croup is to be drawn chiefly from the 344 DISEASES OF THE RESPIRATORY ORGANS. progressive violence of the paroxysms, and the short intervals at which they recur. When they do not continue to recur beyond the second or third day—and gradually decrease in intensity—when the voice is but little affected—the cough moist—and the febrile reaction slight— a favourable termination may be anticipated. When, on the contrary, the paroxysms are protracted beyond the third day, and gradually in- crease in violence; and particularly, when the paroxyms are succeeded by a state of great restlessness, nausea, and vomiting; when the pulse continues soft and feeble, when a suffocative cough remains, and when the patient's strength gradually diminishes, an unfavourable termina- tion is to be apprehended. The true pathology of this affection has not yet been very accu- rately made out. Millar, and after him most of the German physi- cians, have considered it to be a purely spasmodic disease, somewhat resembling hooping-cough, while Desruelles and Bricheteau believe it to be merely the first stage, or a very mild form of croup. Guersent supposes it to consist in a transient inflammation of the mucous mem- brane of the larynx: Bretonneau considers the local affection to consist in a mere congestion of short continuance; a simple, transient intumes- cence of the rima glottidis. Rilliet and Barthez believe that the dis- ease consists in an actual inflammation of the larynx, and they found their opinion upon the fact of the attack generally resulting from the sudden exposure to cold; the disease being usually preceded by coryza, watering of the eyes, oppression, &c, and attended by some degree of febrile excitement: in connexion with this mild laryngitis, they pre- sume that there occurs a spasmodic affection of the glottis, by which the sudden paroxysms of suffocation which characterize the disease, and which are excited by the slightest causes, are produced. The correctness of this opinion is borne out by our own observations. That the disease is connected with some degree of laryngeal inflam- mation is proved by the result of post-mortem examinations. For al- though these have been but few in number,—the disease rarely termi- nating in death—yet, not unfrequently, traces, more or less decided, of inflammation of the mucous membrane of the larynx, are to be detected: even when no increased redness of this part exists, its secretion will generally be found augmented, and of an opaque, yellowish or reddish colour. When death takes place with great suddenness, it is probable that it is the result of the spasmodic closure of the glottis, and the consequent asphyxia. The spasmodic croup is essentially a disease of children ; according to Guersent it occurs most frequently between two and seven years, and according to Rilliet and Barthez between three and eight. We have met with it in children of nine or ten months, but less frequently than in those between two and eight years. There is unquestionably, in many instances, a peculiar predisposi- tion to the attacks of spasmodic croup in the children of the same family; we have.known families in which all the children when they attained the age of between two and three years were successively affected with it. This predisposition is said, in many instances, to bo hereditary. The disease occurs more frequently in boys than in girls. SPASMODIC CROUP. 345 Though generally sporadic, it occasionally prevails as an epidemic. Jurine describes an epidemic of spasmodic croup which occurred in Geneva in 1808. Its occasional cause is, almost exclusively, exposure to cold, or a sudden alteration in the temperature of the atmosphere. After an attack has happened, the occurrence of any sudden or violent mental emotion is liable to excite a paroxysm. The disease with which spasmodic croup may most readily be con- founded, is tracheitis or genuine croup. The following comparative diagnostic peculiarities, borrowed partly from Valleix, and partly from Rilliet and Barthez, will enable the two diseases very readily to be distinguished. In Genuine Croup. The disease commences with fever of variable intensity, and, most generally, pseudo-membranous angina, and slight hoarseness. There is a gradual increase of the hoarseness, to which, sooner or later, there is added a hoarse ringing cough. The fever does not remit; the cough becomes hollow and feeble, and the voice faint or extinct. There is occasionally an expectoration of false membrane. The dyspnoea constantly increases in intensity—the croupal sound continues during the intervals of the paroxysms—finally, the voice and cough become extinct. In Spasmodic Croup. The symptoms of invasion are slight—there is generally a slight catarrh, and a cough somewhat hoarse—the throat is unaffected—sometimes there are no prodroma. The paroxysms attack suddenly—usually at night. Between the paroxysms the patient appears tolerably well—the fever disappears or declines—the voice may be hoarse, but never becomes extinct. There is an expectoration of mucus. The paroxysms gradually decrease in violence. The remedies to be employed in a case of spasmodic croup will de- pend pretty much upon the violence of the attack, and on the age and condition of the patient. When the indications of laryngeal inflam- mation are strongly marked, and when the spasmodic paroxysms are very violent and prolonged, the application of leeches to the throat, in numbers proportioned to the age and strength of the child, will be de- manded. When the patient is over five years of age, and of a robust habit, a bleeding from the arm will often be attended with the best effects. In no case, however, should the amount of blood drawn from the arm or by leeches be considerable, nor the operation repeated at short intervals, or too late in the disease. The warm bath is always an important remedy; it may be employed in the commencement of the attack, or subsequent to bleeding. Lehmann advises, at the very onset of the paroxysm, the application of a sponge of the size of the fist, dipped in very hot water, and then carefully squeezed in the hand, to the fore part of the neck; it being left a moment in contact with the skin and its application renewed at short intervals. This produces a redness of the neck, and a gene- 346 DISEASES OF THE RESPIRATORY ORGANS. ral perspiration, which is to be promoted by the exhibition of the in- fusion of elder and chamomile. By this means, we are told, the parox- ysm is cut short, and all the leading symptoms of the disease quickly removed. When the paroxysm is very violent and long-continued, and there is danger of asphyxia occurring unless immediate relief be obtained, the operation of tracheotomy should be performed without delay. An emetic given on the first accession of the disease will often, when followed by the warm bath and sinapisms to the extremities, have the effect of abating the violence of the paroxysm and shorten- ing its continuance. When considerable hoarseness of the voice and a short barking cough continue during the intermissions, the exhibi- tion of an emetic will be found advantageous—generally removing very promptly the remaining.symptoms, and preventing the recurrence of a paroxysm. We have usually preferred, in the cases occurring in young chil- dren, the ipecacuanha to the emetic tartar—excepting where this, as is often the case, fails to produce a prompt and full operation; under these circumstances, as well as in older children, we have never hesi- tated to prescribe the tartarized antimony. We are in the habit of giving the ipecacuanha in small nauseating doses, every two or three hours, either alone or combined with extract of hyoscyamus, in the intervals of the paroxysms, and have invariably been much pleased with its effects. In mild cases, small repeated doses of the mel scillae compositum of the United States Pharmacopoeia, may be advantage- ously substituted for the ipecacuanha. ** Blisters upon the chest or between the shoulders are recommended by some writers—when employed, they should be allowed to remain on only long enough to redden the skin, when the parts occupied by them should be covered by a soft emollient poultice. We have seldom, how- ever, seen much good result from the application of blisters in cases of spasmodic croup. Covering the breast, however, with a hemlock or assafoetida plaster, has appeared to us very generally to have a de- cidedly beneficial effect. Purgatives are only required in those cases in which their use is indicated by a costive or torpid state of the bowels. Hence a dose of calomel, followed by castor oil or magnesia, will be proper, and a free state of the bowels should be subsequently maintained by an occasional dose of some mild laxative. Assafoetida, either by the mouth or by enema, is unquestionably a remedy from which the best eftects are to be anticipated in violent cases of the disease, subsequent to depletion and the use of the warm bath. It should be administered a few hours after the paroxysm has terminated. Wichmann recommends the musk as a specific in this disease; Henke, Wendt, Goelis, and others, speak also in strong terms of its curative powers. Wendt gave it in the dose of a grain every hour. It is all-important that the child affected with spasmodic croup should be kept in a state of perfect tranquillity, warmly clad, and in an apartment where the atmosphere is pure and of moderate and equa- SPASM OF THE GLOTTIS. 347 ble temperature. During the paroxysms he should be supported in an erect posture, and all covering or ligatures should be immediately re- moved from about the neck. His food should be light and of easy di- gestion—his drinks should not be given cold—tepid lemonade or barley water slightly acidulated, will perhaps be the best. 8.—Spasm of the Glottis. (LARYNGISMUS STRIDULUS.--THYMIC ASTHMA.--KOPP*8 ASTHMA.) This disease, which consists in a sudden spasmodic closure of the glottis, giving rise to a severe paroxysm of dyspnoea, and a peculiar crowing sound in inspiration, as if from strangulation, but without fever, and often without any material derangement of the general health, is of much more frequent occurrence than is generally sup- posed. It has often been mistaken for and treated as croup, and in its milder form it has received the vague term of "inward fits." The disease generally comes on suddenly. The child, apparently in perfect health, is suddenly seized, either during or upon awaking from sleep, or in taking drink or food, or upon being teased or irri- tated, with a difficulty of respiration; inspiration being often entirely suspended for a few seconds. After violentT even convulsive struggles, he finally succeeds in getting breath, with a shrill crowing sound, somewhat similar to the ringing inspiration of hooping-cough. In severe attacks, during the vehement efforts at inspiration, the whole of the respiratory muscles are thrown into violent action. The nostrils are dilated, the mouth is extended, the eyes are rolled up- wards, and the whole countenance expresses the utmost anxiety and suffering. The head is thrown backwards, and the chest outwards; the diaphragm and abdominal muscles contract violently, and even the extremities become rigid; while the feet and hands are cold. The face is commonly pale, or of a livid cadaverous hue, and the external veins, turgid with highly carbonized blood, form black streaks upon the forehead and temples, which, according to Ley, may continue long after the cessation of the paroxysms. The backs of the hands and in- steps are often swollen and hard; the thumbs are rigidly contracted, and locked across the palms of the hands, and the toes are bent down towards the soles of the feet; the wrists and ankles being rigidly and permanently bent by the action of the flexor muscles. In many cases these carpo-pedal contractions have a very singular appearance, and in the opinion of Rees, are characteristic of the disease; the fingers are extended upon themselves, but semiflexed upon the metacarpus, and this at times upon the carpus; in the same manner the toes are flexed upon the metatarsus. The attacks of laryngismus are paroxysmal, and vary in duration and intensity. At first a single paroxysm may occur, and after a short time, often a few minutes, cease spontaneously, and the breathing, at first somewhat hurried, soon become perfectly free and regular, and the child present no apparent indications of disease. Days, and even weeks may pass without the occurrence of a second paroxysm; but in other cases, the paroxysms recur with alarming frequency, and are protracted to fifteen or thirty minutes, or even longer; while, in many 348 DISEASES OF THE RESPIRATORY ORGANS. instances, the paroxysms recur with such rapidity that there is scarcely a complete interval; their intensity and duration increasing, generally, with their frequency. In the early periods of the disease, the paroxysms usually occur in the night, or after a tranquil sleep, from which the child awakes as it were in a fright, and the difficulty of inspiration im- mediately ensues; but when the disease is more fully established, the paroxysms take place at all times of the day or night. Other symptoms are described as of constant or occasional occur- rence; thus, Kopp has noticed a thrusting out of the tongue between the lips, which is also present to a certain extent during the intervals of the paroxysms; Hirsch, an involuntary discharge of the contents of the bladder and bowels; and, in severe cases, Caspar has observed a convulsive contraction of the muscles of the hands, and abductors of the thumbs, during the intermissions. Immediately preceding, as well as subsequently to, a paroxysm— the sound of the patient's breathing is often that which would result from an increased secretion of mucus in the respiratory tubes. The patient may expire during the first paroxysm of asphyxia; or the disease may be protracted to many days, weeks or months, and death be preceded by epileptic convulsions, deep coma, hydrocephalic symptoms, or those of acute meningitis. Laryngismus is to be distinguished from spasmodic croup by the ab- sence of all catarrhal symptoms, febrile excitement, and cough, by the respiration being unaffected during the intervals of the paroxysms, and by the contractions observed in the extremities. The crowing inspiration also, of laryngismus, is not marked by the peculiar hoarse, rough and grating sound peculiar to the inspiratory effort in croup. From hooping-cough, laryngismus may be distinguished by the ab- sence of the convulsive cough, and the retching, vomiting or free ex- pectoration of glairy matter, by which the paroxysms of pertussis are so generally terminated. Hooping-cough is also more gradual in its approach, the characteristic paroxysmal cough being in general pre- ceded by catarrhal and febrile symptoms. Dr. James Reid of London, who has written a very instructive trea- tise on Infantile Laryngismus, describes it as occurring under four different forms. In the first there is only a slight constriction of the edges of the rima glottidis, occurring suddenly, and in a transient manner. This causes, for an instant, an exertion on the part of the infant to recover its breath, and produces a feeling of oppression and alarm, indicated by a short cry, and the anxiety depicted on its countenance. There is no convulsive action of any part of the body. The attacks come on at irregular intervals, and at uncertain times, although most generally whilst the infant is asleep, or at the moment of awaking. So little importance is generally attached to this symptom by nurses, that the physician, when called upon at a later period to treat the more severe form of the disease, finds that the "catching" alluded to is often not mentioned until questions are put, which at once recall the recollection of its having been of frequent occurrence, though al- SPASM OF THE GLOTTIS. 349 ways arrested immediately upon the child being lifted from the re- cumbent to an erect position. In the second form of laryngismus, according to Dr. Reid, the area of the glottis is still more diminished by the nearer approximation of its edges, the closure, however, not being perfect except perhaps for a moment. There is in this form a much longer interruption of the respiratory function, and the symptoms of impending suffocation are more immi- nent. The countenance exhibits the characteristics of great anxiety and distress, becoming at first red, but soon changing to the purple hue of strangulation; the face, and, in some cases, the tongue also become turgid and swollen. In other instances there is an ashy pale- ness of the face. The arms are thrown out; the eyes are either wide open and staring, or, more rarely, turned up in their sockets; the nos- trils are dilated; the head is thrown back; the limbs become rigid, and the abdominal muscles contracted. There is frequently, also, a convulsive and violent action of other muscles, especially of the flex- ors, causing a peculiar contraction of the wrists and ankles, a state which has been called the carpo-pedal spasm. Occasionally, the body itself is bent suddenly backwards, as if by a violent effort, and it ap- pears to the bystanders as if nature could hold out no longer, when, at length, the attempt at respiration is partially successful, being at- tended by a shrill hooping noise, which has been termed crowing, although it more closely resembles the concluding rising note pro- duced by the clucking of a hen. This sound is not of so full and sonorous a character as that of hooping-cough, but seems more acute, and it is without the rough hoarseness of croup. It is often an indi- cation that the paroxysm has terminated, but sometimes a succession of incomplete or interrupted, shrill, sibilant catches supervenes before a full and complete inhalation takes place, as if the margin of the glottis were for a time somewhat relaxed, becoming immediately again constricted, so that the expirations bear, in some degree, a resem- blance to the short and feeble bleating of an animal. When respiration is re-established, the infant most commonly bursts into a fit of crying, and falls asleep; when, however, the attack is unusually severe, a listlessness and torpor often remain for a short pe- riod afterwards, whilst in rarer instances the child continues, during some hours, in a state of anxious distress. These paroxysms vary much in their frequency, duration, and se- verity; there is no regularity in the intervals between the attacks, but as the complaint advances, these generally become shorter, and, in some instances, do not continue beyond an hour at a time, or even half that period, the slightest noise or emotion being quite sufficient to produce a paroxysm. The breathlessness, or struggling for air, is apparently relieved, in some cases, by a violent expulsion of wind from the stomach or per anum, which is succeeded by a fit of scream- ing: occasionally, also, there are involuntary evacuations during the paroxysms. Repeated attacks may occur, without the accompanying crowing noise, especially when the disease becomes less severe in its character. 350 DISEASES OF THE RESPIRATORY ORGANS. An acute plaintive cry frequently commences or terminates the parox- ysm; the child remaining quiet and subdued for some-minutes, after which it resumes its natural cheerfulness and aspect, with the enjoy- ment of perfect health in the intervals. The duration of the paroxysm varies from a few seconds to three or four minutes; in the latter description of cases, it is more properly a succession of paroxysms; air occasionally gaining admittance into the lungs, during the slight and almost imperceptible intervals between them. Remissions and exacerbations often take place for weeks, and sometimes for months, before a complete cure can be effected; whilst in other cases, on the contrary, the complaint suddenly disappears. In the third form of laryngismus, as described by Dr. Reid, there is a combination of the foregoing, with the addition of general or cere- bral convulsions; these being produced, in all probability, occasionally by the blood supplied to the brain becoming imperfectly decarbonized, in consequence of partial asphyxia. In the fourth form of the disease, there is complete asphyxia from a sudden and convulsive closure of the glottis, causing almost imme- diate strangulation. No crowing sound is audible, inspiration being totally suspended, while the face of the child, instead of being flushed and turgid, exhibits often a cadaverous aspect, similar to that of per- sons asphyxiated by carbonic acid gas, or other noxious vapours. An infant, Dr. Reid remarks, may have passed through repeated severe at- tacks of the disease, combined with cerebral convulsions; it may be also, perhaps, improving otherwise in general health, the paroxysms at the same time beginning to be separated by longer intervals, and, yet, with all the indications of apparent amendment, it is sometimes carried off in this form of the disease, without any previous warning. It may be laughing at the time, or quietly observing the occurrences taking place around it; not the slightest indication of danger being per- ceived. The appearances upon dissection are very various. The thymus and cervical glands are often enlarged or in a state of disease. The heart is often found empty and flaccid. The lungs are generally gorged with dark-coloured blood. The vessels of the brain are also often un- duly distended, and serous effusion between the membranes, in the ven- tricles, or at the base of the brain, is of frequent occurrence; tubercles of the brain are often met with, and occasionally, hypertrophy or in- duration of its substance. The foramen ovale is often found open, and not unfrequently there exists more or less disease of the gastro-in- testinal, and in some cases, of the respiratory mucous membrane. No one of these morbid appearances is, however, constantly present in the bodies of those who have died of spasm of the glottis. Perhaps, judging from the cases on record, most of which have, however, been adduced to support particular pathological views, we ought to enumerate en- largement of the thymus body, and effusion within the cranium, as among those most commonly met with; we suspect, however, that upon a more minute inquiry it will be found that enlargement of the thymus body is a much less frequent accompaniment of the disease than has been asserted. Dr. Reid states that on several occasions he has sought SPASM OF THE GLOTTIS. 351 for indications of disease, but has been unable to detect any, even in the spinal cord. As a general rule, it may be stated, he remarks, that no unusual appearances are found to exist in the glottis itself, or in the adjacent parts; no trace of oedema, inflammatory action, or persistent constriction. Dr. Reid has never met with any enlargement of the neighbouring glands sufficient to account for a fatal termination. Spasm of the glottis is almost exclusively confined to the period of infancy and childhood; it may attack, according to Kerr, at any period from within a few days after birth, to three years, but most commonly it occurs between the fourth and tenth month: Mr. Robertson, (Lon- Med. Gaz., Jan. 1849,) has found the accession of the disease to be most frequent from about the fifth to the twelfth month. Of twenty- one cases related by him, in three only did the disease occur in infants beyond twelve, and in none were they beyond fifteen months of age. Dr. Reid, in common with the majority of those who treat of the dis- ease, states, in regard to the age of infants most liable to its attacks, that it corresponds, with few exceptions, to the period of dentition. An affection, he remarks, closely resembling spasm of the glottis, if not identically the same complaint, may be caused at any period of life by local or mechanical agency; but it must, he thinks, be considered a peculiar disease of infantile life, when it follows as the result of con- stitutional irritation. Most of the writers enumerate the lymphatic temperament as one of the predisposing causes of the disease; it is in consequence of this that we find it to attack almost all tho children of some families, while those of others are entirely exempted from it. The predisposition from organization may also account for its greater prevalence in some localities than in others. Thus it is generally ad- mitted that the disease prevails much more in cold and damp, than in temperate or warm climates. In Mr. Robertson's cases the attacks occurred between the months of October and May. As the patients belonged to that class of society the infants of which are at this sea- son of the year in a great measure confined within the limits of the nursery, he thinks it probable that it is by this seclusion from the ex- ternal air the predisposition to the occurrence of spasm of the glottis is induced, a conclusion which the fact of the disease being one rarely observed in the infants of the labouring classes, who are abroad in almost all kinds of weather, daily, throughout the year, would seem to favour. Dr. Reid considers that infants of a nervous temperament, who are easily excited, who are awakened by slight noises, and who are not satisfied unless they are kept constantly "on the move," are those most susceptible to laryngismus. As exciting causes Mr. Robert- son enumerates the irritation of teething, disturbauce of the digestive organs, and any sudden excitement. Dentition is, unquestionably, one of its most common predisposing causes; nearly all the cases upon re- cord occurred during, or immediately preceding the evolution of the first set of teeth; and we have but few instances of the disease oc- curring beyond this period. Among the exciting causes may be enu- merated sudden motions, or any agitation of the body, improper food, fright, or any violent or sudden mental excitement; impure, confined, or some particular condition of the atmosphere; exposure to a current 352 DISEASES OF THE RESPIRATORY ORGANS. of cold air, efforts to swallow, or even suddenly stooping to pick some- thing from the ground. According to Dr. Reid, and his views are fully borne out by our own experience, one of the most common causes of laryngismus is a deranged state of the stomach and bowels. He has never known more than two instances of the complaint to occur without the presence of such derangement, as indicated by constipation, a morbid condition of the stools, flatulence, &c. And it is seldom, he adds, that we observe decided signs of amelioration in the little patients, until the secretions become of a more healthy character. In fact, most of the writers upon the disease, whatever may be the difference in their views as regards its pathology, admit that a vitiated state of the alvine secretions is a prominent symptom, some describing this as aggravating the disease, whilst others view the disordered condition of the bowels as a primary cause. Another cause, which experience convinces us, if it be not alone sufficient to originate laryngismus, at least materially aids in keeping up the irritation which has been produced by other causes, is atmo- spheric influence. This is proved by the fact that, in many cases of the disease, on a change of air, the symptoms have immediately ceased, but recurred when the infant was brought back to its former residence. The rare occurrence of the complaint in rural districts as compared with its prevalence in crowded towns, is, Dr. Reid remarks, a proof that atmospheric influence is concerned, in the majority of cases, as one of the exciting causes. He adduces the returns of the mortality in 117 districts of England, to prove that the mortality of infants, during the ages of teething, is six times greater in town than that met with in an equal population of a country district. It has been supposed that a damp or low locality, even in the coun- try, is apt to give rise to laryngismus. Dr. Reid considers that under certain circumstances, it may, perhaps, have some effect, in combina- tion with other causes, but that its influence cannot be very powerful. Some, as yet undetected, local influence has, at all times, no doubt, much to do in assisting to generate the disease in certain situations. Dr. Hall mentioned at a discussion of the London Medical Society, that he had known of three fatal cases of laryngismus occurring in a family who resided upwards of four miles from a large country town ; the other infants of the same family were, on this account, removed from the place, and thus escaped the disease. Dr. Reid can find no decisive evidence that cold weather has any prejudicial influence on cases of laryngismus. In more than one case he has known a removal from town to Hampstead Heath, or to the coast, during the cold bleak winds of spring, immediately to arrest the complaint. In one instance it was found that exposure to the open air in cold weather, invariably stopped the paroxysms, and that one of them never occurred during such exposure. Peculiar odours seem occasionally to act as a sufficient cause for inducing the paroxysms of laryngismus. Cases are referred to in which the paroxysms were caused by the fumes of alcohol, the smoke of pine wood, the gas produced by the combustion of anthracite coal, SPASM OF THE GLOTTIS. 353 the atmosphere of a newly painted room. A great number of similar cases could be cited. Dr. Reid considers that the most frequent, exciting causes of laryn- gismus, are the improper description of food which is administered to the infant, and the impure and irritating atmosphere which it breathes, and that these causes are both active in the majority of cases. Under the head of improper food, may, in certain circumstances; be included the breast milk of the mother or nurse. That is, when from any cause this has become deteriorated: comparatively few cases occur in infants who are fed altogether upon the breast milk of a healthy mother or nurse. Of the numerous instances which have come under his notice at various times, the disease occurred in two infants only who were not fed by hand, either altogether or partially: one of them was a child six months old, who had a wet nurse. By a curious coin- cidence, the nurse herself, two nights previously to the child being af- fected, had a similar spasmodic affection of the glottis, caused by hys- teria, and the sound produced by it so precisely resembled that which the father of the infant, a medical practitioner, had been accustomed to hear whilst his elder children had suffered from laryngismus, that he hastened up stairs, thinking the infant was also attacked by it. Two days subsequently, the child, for the first time, did show symp- toms of the disease, although they were slight, and of short duration, compared with those of the other children. North includes laryngismus among the premonitory symptoms of convulsions, and Beatty considers it in many instances to be one of the earliest symptoms of incipient hydrocephalus, which accords with our own experience. Goelis describes all its symptoms as occurring in the advanced stage of chronic hydrocephalus. Dr. Reid believes it may be fairly inferred that laryngismus is sometimes complicated with, or followed by hydrocephalus, but that in very rare instances does the latter act as a cause of the disease. Laryngismus stridulus, as we have already remarked, consists, es- sentially, in a spasmodic closure of the glottis, impeding the ingress of air into the lungs, and sometimes so completely closing it, as to sus- pend, for a few seconds, the respiration entirely. Mr. Ley, however, denies that the difficulty of inspiration is owing to a spasmodic closure of the glottis, but maintains that it is due rather to the inability of this part to enlarge to its normal size, from a want of innervation, in consequence of pressure upon the nerves by diseased glandulse conca- tenatse. From the same cause, he conceives that the transverse fibres, behind and connecting the rings of the trachea, lose their contractile power, and allow the sputa to accumulate, giving rise to the rattling sound heard in the upper part of the trachea, particularly when the patient is asleep. Few, however, have adopted these views of Mr. Ley,—the spasmodic character of the disease being admitted by the generality of those who have studied its phenomena with care. Upon the nature of the cause by which the spasmodic affection of the glottis is produced, there, however, exists a very great diversity of opinion. By the greater part of the German medical writers, and many of those of Great Britain, it is referred to an enlarged or dis- 23 354 DISEASES OF THE RESPIRATORY ORGANS. eased condition of the thymus gland, and numerous observations have been recorded, in support of this hypothesis, by Kopp, Frank, Kirmaul, Hirsch, Ecke, Van Velson, Most, Kyll, Montgomery, Hughes, Flack- man, Rees, Mitchell, Pury, and others. This view of the pathology of the disease would appear to be very fully made out, were we to take only the quantity, without reference to the quality of the evidence upon which it rests. But, when closely investigated, this will be found de- fective in many important points. There has not been adduced a single well established fact, to show that a hypertrophied condition of the thymus gland is capable, under any circumstances, of exerting upon the nerves which pass in its vi- cinity, such a degree of pressure or irritation as would produce the phenomena of the disease under consideration. M. Trousseau, who re- fers the disease to a spasmodic condition, with want of harmony in the action of the respiratory muscles, states, that during the six years he has been at the head of the wards of his hospital, he has not in a single instance met with the thymus gland sufficiently enlarged to give rise to the slightest inconvenience. We have numerous observations upon record, which prove that the thymus gland may be greatly enlarged, and that numerous enlarged lymphatic glands may exist in the course, and in immediate contact with the laryngeal nerves, without the oc- currence of the disease, even in its mildest form. We are, in fact, so little acquainted with what constitutes the exact normal size of the thymus gland—it being found to vary materially in bulk and weight, in different subjects, during a state of apparently perfect health—that it is very difficult to determine, with certainty, when it is to be consi- dered of abnormal size. From our own observations upon the relative size of the thymus, at different ages from birth to puberty, we are strongly inclined to be- lieve that in many of the cases recorded as instances of enlarged thy- mus, the gland was either not at all affected, or was actually below the size which it frequently presents in perfectly healthy children at the same age. We are to recollect, also, as Dr. Hall correctly remarks, that its enlargement, even when it occurs, may be the effect and not the cause of the morbid phenomena. It may be the natural result of the violent convulsive efforts at inspiration, observed in this terrific malady. The thyroid gland has been known to become and remain enlarged, in like manner, after the efforts of severe and protracted labour; the eyes to become bloodshot from hooping-cough; the eyelids to be distended with blood from epilepsy, and from efforts of vomiting and of parturition. In this manner we can readily understand how enlargement of the thymus may be an effect of a spasmodic closure of the glottis, and subside with the disease, which would not be the case if it was dependent on change of structure. Numerous cases are recorded by Beatty, Rullman, Toogood, Burgess, Ryland, Marsh, Rees, and others, in which the disease was produced entirely independent of the slightest enlargement of the thymus, or of any of the cervical glands. Dr. Corrigan considers inflammation of the cervical portion of the spinal cord to be the cause of spasm of the glottis, and has published SPASM OF THE GLOTTIS. 355 an interesting case in the London Medical and Surgical Journal, (1836,) to illustrate his position. But this case, in which spinal irri- tation seems evidently to have been associated with the disease, is a solitary one, and while it may be adduced to prove that a spasmodic contraction of the glottis is occasionally dependent on spinal irritation, it does not prove it to be so in every instance, or even in the majority of cases. Dr. Ildrard has made the disease the subject of an inaugural thesis. He observed numerous cases of it in the Children's Hospital at Paris, and believes it to be the result of either spasm of the glottis, or of the diaphragm. He describes three forms of it, according as one or other, or both of these organs are affected. When the spasmodic attack is limited to the glottis, the respiration is simply arrested for a few se- conds, and is restored without the production of the special cry pro- duced by inspiration during convulsions of the diaphragm. In the se- cond form, in which the diaphragm alone enters into spasmodic action, the attack is marked by several successive and sonorous inspirations; while the symptoms of asphyxia are by no means so well marked as in the first variety. In the third form both the glottis and diaphragm are simultaneously convulsed; respiration is first suspended, and one or more sonorous inspirations are heard, which, not being followed by expiration, asphyxia is soon imminent. These sonorous inspirations resemble the crowing of hooping-cough, and are produced by the same cause. Death may occur, during the attack, from asphyxia, from cere- bral disease, or it may be the consequence of gradually increasing de- bility. In the examination of the bodies of children who have died of this disorder, Dr. Herard asserts that no characteristic alteration can be detected. As to the hypertrophy of the thymus gland, he refuses to admit that it has anything to do with the production of the disease, and shows from carefully drawn up statistics that the volume of the gland is in harmony with the states of health or the strength or weak- ness of the constitution, and not with the presence of asthma. Dr. II. attributes the large size which the thymus sometimes attains entirely to the vigorous constitution of the child. The agency of hypertrophy of the thymus gland in the production of laryngismus is denied also by Caspar, Pagenstecher, Ley, Hall, Merri- man, Fricke, Rednar, Oppenheim, Cheyne, and Clarke. Mr. Ley attri- butes the disease to a suspended or impeded state of the functions of that portion of the eighth pair of nerves which is distributed to the larynx, caused by pressure from enlarged cervical and bronchial glands; while Marsh refers it to an irritation seated at the origin of the pneumogastric nerve, and others, with Clarke, Cheyne, Beatty, Rullman, Fricke, and Oppenheim, to disease of the brain. Were pressure from enlarged thymus or cervical glands a frequent - cause of laryngismus, it is difficult, Dr. Reid remarks, to comprehend why the attacks are often separated by long intervals in some cases, while the pressure continues the same. Permanent pressure would act also as a direct mechanical cause, whereas the history of the dis- ease proves it evidently to be the effect of reflex action. Dr. Mar- 356 DISEASES OF THE RESPIRATORY ORGANS. shall Hall asserts, moreover, "that such pressure would cause perma- nent paralysis and constant closure of the glottis." The experiments of modern physiologists show that the inferior or recurrent laryngeal nerves, which alone govern the muscles of the glottis, are exclusively motor nerves, and that irritation, applied even to them, will produce convulsive closure of that aperture, whilst cut- ting or compressing them, renders the glottis and movements of the arytenoid cartilages inert or passive, but does not prevent ingress or egress of air, although they impede the former. The sudden manner in which the paroxysm is resolved, in many se- vere cases of laryngismus, upon a change of air, the cutting of a tooth, the discharge of worms, or of large unhealthy stools, or the ex- hibition of antispasmodics, is inconsistent with the supposition of its dependence upon pressure from an enlarged and indurated gland. Fredrich Betz, of Heilborn, has published an interesting paper on thyroid asthma. (Jour.f.Kinderkrankheiten,\&b?>.) He regards the impediment to respiration in cases of thyroideal hypertrophy, as exist- ing neither at the upper part of the trachea nor in the larynx, but higher up, where the enlarged gland projects into the floor of the mouth. In new-born infants, both lateral lobes of the thyroid body extend backwards, between the pharynx and the vertebral column, and according to Albers, (Canstatt's Jahresbericht, 1848,) the lobes may even become blended together, so as to form a fleshy ring around the larynx and top of the pharynx. In which case any enlargement or swelling of the extremities of the lobes causes a constriction of the parts enclosed within them. This accident is easily recognised by a swelling at the upper part of the neck, with evident enlargement of the thyroid body. Expiration and inspiration are both stridulous, and continuously so during the waking state. The mouth is filled with frothy saliva; the hands, feet, lips and face are cold and bluish—there is no fever; an occasional paroxysm of coughing occurs, and the sleep is short and broken. Every attempt to swallow fluids increases the suf- focative dyspnoea, and in consequence the child is unable to suck. In severe cases death may occur at the end of from one to two days. In milder cases the swelling usually subsides, and with it all difficulty of breathing and deglutition. Dr. Betz has never known the disease to occur beyond the first fourteen days after birth, seldom beyond the first eight days. According to Dr. Hall, the disposition to spasm of the glottis con- sists in a peculiar susceptibility of the excito-motor property of the nervous system; the immediate cause of the attacks being the action of sources of irritation or excitement of this property; the most ob- vious of which are dentition, indigestible food, morbid alvine matters, external agents, and mental emotions. Nearly the same views are ex- pressed by Mr. Ryland, and they are those advocated by Dr. Reid. In one case_ related by Mr. Ryland, however, he is inclined to believe that the main cause of the paroxysms was to be referred to bronchial inflammation, which Mr. Ley also enumerates as an occasional ex- citing cause of the disease. Our own observations incline us to adopt the views of Dr. Burgess, SPASM OF THE GLOTTIS. 357 namely, that the disease is simply a spasmodic affection of the respi- ratory muscles; its chief exciting causes, when it occurs during the earlier period of dentition, or previously to its occurrence, being an irritation of the digestive organs, a cold, confined, or impure atmo- sphere, and dentition; but that when it occurs during, or subsequent to dentition, it is very often symptomatic of cerebral disease. Nearly the same views are expressed by Mr. Rees: this gentleman refers, it is true, the disease, previous to dentition, invariably to enlargement of the thymus gland, or enlarged agglomerated glands in the vicinity of the recurrent nerves; but observes, that one remarkable point in these cases is, the dependence of the paroxysms of dyspnoea upon the state of the digestive organs; whenever these are out of order, the intensity of the attacks being increased, which it seems difficult to account for, "since," he adds, "the affection so evidently depends upon a me- chanical cause." The same difficulty, he further remarks, presents it- self in accounting for the constant and immediate good effects obtained from a change of air. The difficulty, however, arises solely from the attention of the observer having been too exclusively directed to the supposed agency of glandular enlargement in the production of the disease. We have, in repeated instances, seen the most severe attacks of laryngismus produced solely from irritation of the alimentary canal, resulting from indigestible and improper food, and other errors of diet, or from the influence of an impure, irritating, and confined atmo- sphere, the disease being promptly and effectually relieved, in its early stages, by getting rid of the exciting cause in the stomach and bowels, or by removal to a pure and wholesome atmosphere. The cases combined with cerebral disease are seldom met with until after dentition has commenced. It is remarked by Rees, that if the patient survive the appearance of the first molar teeth, the case gene- rally terminates favourably. In this form of the disease the patient usually remains, during the intervals, dull, heavy, listless and drowsy; the pupil of the eye is dilated; the head hot, and frequently held ex- tended on the spine; and unless appropriate remedies be resorted to, an attack of convulsions or inflammation of the brain is always liable to supervene; carpo-pedal spasms also frequently occur. These latter are generally attended with considerable derangement of the gastro- intestinal mucous membrane. Dr. Reid, while he admits that cerebral or general convulsions are often associated with laryngismus, and that a paroxysm of the latter may sometimes terminate in the former, denies, however, that laryn- gismus is ever dependent upon primary disease of the brain. If, he re- marks, careful observation be made respecting this point, I think it will be found, that a large number of cases are unattended with cerebral convulsions; that the usual symptoms of cerebral disease are generally absent; that in fatal cases no particular lesion of the brain is, in the majority of instances, to be met with; and that the remedies most suc- cessful in this complaint, are not those which are usually adapted for the control of cerebral affections, but on the contrary, the treatment proper for the latter has frequently been productive of injury when employed in cases of laryngismus. 358 DISEASES OF THE RESPIRATORY ORGANS. Several cases are recorded, in which spasm of the glottis was evi- dently induced by an irritation proceeding from the arrest of some foreign body in the oesophagus, which, nevertheless, could not have produced sufficient pressure upon the larynx to interfere, in the least, with the freedom of respiration, but must have excited, by some re- mote, and as yet unexplained influence, a spasmodic closure of the glot- tis ; giving rise, in many of the cases, to symptoms of such intensity, as to require an operation to preserve life. The prognosis will depend entirely upon the nature of the lesion by which the spasm of the glottis is produced. In cases in which the disease has resulted from a temporary irritation of the alimentary canal, or other slight functional disturbance, the paroxysm may be of short duration, and the attack cease spontaneously, or upon a proper change of diet or air; but when symptomatic of irritation of the brain or spinal cord, or of any permanent disease of other important organs, or when it occurs in infants in whom there is an undue excitability of the nervous centres, it is always to be considered as a serious affection, and very frequently proves fatal. Nevertheless, the prognosis must in every case be somewhat uncer- tain, for the disease occasionally proceeds in a mild manner for a time, and then suddenly assumes the most dangerous form. There are no regular intervals between the attacks, and a sudden and very severe paroxysm may unexpectedly occur at any moment, particularly during the period of dentition. The principal dangers to be apprehended are suffocation and cerebral convulsions. Thus, the prognosis will be worse when the child is constantly dull and heavy, with sluggish pupil, and indications of venous congestion about the head. Should there be any family tendency to cerebral disease, the prognosis assumes a still worse aspect. An unhealthy state of the mesenteric glands is said to augment the danger of the disease, as also the occurrence of acute bronchitis; though, in a case narrated by Dr. Reid, the crowing noise disappeared during an attack of bronchitis and returned after it was subdued. The duration of laryngismus is variable—the patient may be carried oft' by the first attack, although this is a very rare occurrence: in other instances, as in one related by Rullman, the infant may strug- gle through the disease for twenty months, and then fall a victim to its effects. The mortality in this complaint varies considerably in the state- ments of the authors who have described it. According to Dr. Gooch, the disease proves fatal in one third of those attacked. In Sir H. Marsh's cases, five recovered, and two provedfatal. In Hirsch's cases, three out of five died—one complicated with hooping-cough, and the other with general convulsions. Dr. Ley considers the disease to be "not very commonly fatal;" whilst Dr. Davies reports it to be fre- quently so, especially when complicated with convulsions; he also con- siders the danger from the disease to be greater during the period of dentition, which accords with the experience of Dr. Reid, as well as our own. The latter gentleman reports six fatal cases of laryngismus out of fifty that came under his observation. His experience leads SPASM OF THE GLOTTIS. 359 him to consider the disease more likely to prove fatal in male children than in female; but according to Pagenstecher, Hackman, and others, it attacks boys much more frequently than girls. It is astonishing, remarks Dr. Reid, in some cases, how many at- tacks of the spasms and convulsions combined may take place during the twenty-four hours, without proving fatal. He has known them to occur on every slight noise in the room, so that the gentle displace- ment of any article on the table would cause a paroxysm, and yet a favourable termination of the disease ensue. The treatment during the paroxysm consists in placing the patient in an upright position, with the head slightly inclined forwards, and exposed to a full draught of fresh, cool air, while cool water is, at the same time, sprinkled over the face. Every means should be taken to remove, as far as possible, compression from the vessels of the neck. Slapping the child slightly on the back and nates, will occasionally aid in removing spasm; frictions along the spine should also be re- sorted to. If the paroxysm does not yield to these means, the patient should be placed in a warm bath; whilst in the bath, cold water should be sprinkled on the face, which will generally cause a strong inspiration and lengthened expiration, followed by a scream that usually puts a period to the paroxysm. It may be also useful to apply ammonia or ether to the nostrils. Irritation of the pharynx, by a feather, will sometimes induce vomiting, which will, of course, solve the spasm of the glottis. Dr. Charles D. Meigs recommends the application of a piece of ice, wrapped in a cloth, to the epigastrium and lower part of the sternum. This procedure will often cause a speedy solution of the paroxysm. An enema, with the addition of assafoetida or turpentine, will be useful in violent attacks. If the dyspnoea continue unabated, and death from asphyxia is threatened, artificial respiration should be resorted to, by blowing at intervals into the child's mouth, closing at the same time the nostrils, pressing the trachea against the oesophagus, and afterwards compressing the thorax and abdomen with the hands —thus alternating an imitation of inspiration and expiration. If by this means, however, the patient is not speedily aroused, the operation of tracheotomy should be immediately performed. If, during the paroxysm, there is evident congestion of the brain, a few leeches be- hind the ears, with cold lotions to the scalp, will be found advantageous. The moment the fit is over, an examination of the gums should be made, and if these are found to be, at any part, swollen or inflamed, a free incision should be made, down to the tooth. Dr. Hall recom- mends incision of the gums, not only in cases of actual dentition, but in cases in which no immediate appearance of the teeth is expected, or even in cases in which all the teeth have already appeared. He directs this for the purpose of correcting a state of the blood-vessels and nerves of the gums, which, though physiological, still borders on a pathological character; and hence he orders the incisions to be re- peated for several successive days. The bowels of the patient should be well moved daily. But, in ac- complishing this, all irritating remedies should be avoided, and we 360 DISEASES OF THE RESPIRATORY ORGANS. must also be careful not to produce severe purging, which, by ex- hausting the patient, will augment the susceptibility to subsequent at- tacks. When the discharges from the bowels are of an unhealthy character, small doses of calomel, or of the blue mass, combined with ipecacuanha and extract of hyoscyamus,1 repeated at short intervals, and an occasional dose of the infusion of rhubarb, with tartrate of potass and manna, will in general, answer our purpose. To the last mentioned prescription, it has been recommended to add a few drops of tincture of hyoscyamus, and of the aromatic spirits of ammonia, and a little of the syrup of ginger. Dr. Hall considers a most important remedy in these cases, espe- cially when the evacuations are clay-coloured, to be the repeated use of enemata of warm water or barley water. 1 R-—Calomel, gr. vj. ad xij. Ipecac, pulv. gr. iij. Ext. hyoscyami, gr. iv.—M. f. chart. No. xij. One to be given every three hours. Or, Mass. f. pill, hydrarg. gr. xij. may be substituted for the calomel. Dr. Reid recommends the use, both internally and externally, of antispasmodics, as invaluable in the treatment of laryngismus. Assa- foetida or musk, he remarks, occasionally succeed in arresting the symptoms in some cases of simple convulsions arising from teething, v.hen leeching and purging have not alone had the desired effect. In those cases where the bowels are in a very irritable state, the exhibition of small doses of hyoscyamus, Dover's powder, the hydro- cyanic acid, ammonia, or a combination of them, will often, according to Dr. Reid, produce a most striking effect in subduing the tendency to the spasmodic paroxysms. The following prescription is one which he has been in the habit of employing with excellent results: R.— Spir. ammoniae foetidi, 3ss. ; tinct. hyocscyami, gtt. x.; syrup, aurantii, 5ss.; spir. anisi, 3j.; acid, hydrocyanici diluti, gtt. v.; aquae, gj.— M. A teaspoonful to be given, three times a day, to a child ten or twelve months old—the doses being graduated according to the age of the patient. Should the above not prove speedily efficacious, the following may be tried: R.—Pulv. Valeriani, 3ij.; ammoniae sesqui- carbonatis, gr. viij.; syrup, aurantii, gss.; aq. carui, gjss.—M. To be rubbed together. The sixth part to be taken as a dose three times a day. A stimulating embrocation, with the addition of some narcotic, ap- plied to the spine, chest, and abdomen, Dr. Reid recommends as pro- ductive of decided benefit; especially when the hands and feet are affected with spasmodic contractions. The following is his usual formula: R.—Tinct. opii, 3jss.; tincturse lyttge, 5j.; liniment, saponis, Sjss.—M. To be applied two or three time3 a day. The addition of four grains of the extract of belladonna, or 3ss. of the tincture of aconite, in obstinate cases, will increase the effect. "In the secondary part of the treatment," Dr. Reid remarks, "tonics will frequently be found to possess great influence in removing the lingering symptoms of laryngismus. The different preparations of iron and bark are those best adapted for the purpose, when purgatives SPASM OF THE GLOTTIS. 361 and antispasmodic medicines have previously prepared the way for their employment. Some judgment, however, is requisite in selecting the appropriate time for commencing their use." Among the different preparations, of iron he prefers the vinum ferri of the old London Pharmacopoeia; but the ammonio-citrate and the potassio-tartrate are, owing to their comparative slight taste, eligible forms of the same mineral, as they do not nauseate the little patient. In those cases which are actually combined with a scrofulous taint, the syrupus ferri iodidi may be advantageously employed. The importance of an attention to the diet of a patient need not be insisted on; nor need we, after what has been already said in many of the preceding sections, lay down any precise directions in regard to the proper articles to be employed. The repetition of the attack, remarks Dr. Hall, whose therapeutical directions in respect to the dis- ease under consideration are replete with good sense, has so often, within my own experience, been the result of improper and indiges- tible food, that I invariably fix upon some one article or kind of diet, of the most unquestionable character, to the exclusion of all others. The confinement of the infant to the breast-milk of a healthy nurse, during the ordinary period of suckling, cannot be too strongly insisted on. In individual cases, it will be advisable to continue this mode of nourishment even beyond the usual period. If the mother or nurse's milk is suspected to be deteriorated in quality, no time should be lost in placing it at a breast from which it will be supplied with a more healthy nutriment. The importance of a pure, fresh, dry, and cool atmosphere, in this disease, is recognised by nearly every writer who has treated of it. A very slight vitiation of the air will frequently bring on the most violent attacks, which are as quickly terminated by its removal: in one case, related by Marsh, a paroxysm was induced, whenever the child was brought into a newly-painted house. When the little pa- tient has been long free from attacks, a sudden change of the wind to the north-east frequently induces a return of them; and even when they have been long obstinately repeated, and have become, as it were, chronic, a change of air, Dr. Hall remarks, has induced as suddenly a suspension of them. We have known a recurrence of the paroxysms to be kept off, so long as the patient remained in the city, and to hap- pen whenever the child was taken into the country. In the cases treated by Mr. Robertson, he employed as one of his principal means of cure, more especially in the aggravated forms of the disease, free exposure to a cool, dry atmosphere, and with the most decided good effects. Change of air, with a well-regulated diet, is often more effectual than any other means, in preventing the renewal of the paroxysms; but where this cannot be effected, the child should be taken out daily, in mild, dry weather; and the apartment it occupies should be freely ventilated, and kept strictly clean; care being taken, in so doing, to prevent exposure to partial currents, and to guard against dampness. The clothing of the child should be adapted to the state of the wea- ther, and temperature of the season, and so made as to guard the 362 DISEASES OF THE RESPIRATORY ORGANS. breast, shoulders, and arms, against exposure to cold or draughts of air. The use of the warm bath daily, as in most of the diseases of children, is an important curative as well as prophylactic means. Mr. Robertson recommends cold sponging night and morning. In cases of excessive irritability the cautious use of this remedy may be found advantageous. There is one cause capable of exciting spasmodic closure of the glottis in infants, which, though too often overlooked, should be kept constantly in mind by the medical practitioner; namely, sudden, men- tal emotion, and especially fright, or that state of nervous excitement into which infants are often thrown, when thwarted, teased, or vexed. The infant should not be suddenly awoke out of sleep, not slapped, nor harshly scolded by an angry nurse. When the latter is out of temper, there is frequently a double source of injury—her rude treat- ment of the infant, and the unwholesomeness of her milk. The slightest alarm is still more serious in its effects; all sudden noises, all rapid movements in nursing, every attempt to frighten or surprise the infant should be carefully avoided. It should be addressed, invariably, in a soft soothing tone of voice; in a word, every source of mental emotion should be carefully avoided. This advice should be strongly enforced by the physician, for though important in reference to every infant, it becomes doubly so in reference to such as are predisposed to, or have already suffered from an attack of spasm of the glottis. It has hap- pened to us to see, in several instances, most violent paroxysms, though in none attended with a fatal result, excited solely by mental emotion and fright; hence we should be cautious not to irritate the child by unne- cessary examinations; the mere act of looking at the gums, by forcibly opening its mouth, will sometimes induce a severe attack. It has been suggested by Dr. Hall, that the morbid susceptibility of the patient's system may be subdued by keeping him for some time constantly under the gentle influence of the tincture of hyoscyamus, and the infusion of hops. The tonic influence of tepid salt water, applied to the surface by sponging, is also highly beneficial. In those cases in which there is an evident tendency to cerebral dis- ease, the proper remedies indicated by the nature and extent of the latter should be immediately resorted to. In all cases, indeed, if we direct our attention to the congested condition of the brain, which is so liable to occur during the paroxysms, we shall perceive the importance of adopting measures to counteract it. Under ordinary circumstances, the spirit lotion applied to the head, and repeated several times in the course of the day, is an efficacious means of effecting this, and perhaps a much safer remedy than depletion, which, unless there is an absolute necessity for resorting to it, should be avoided, in consequence of its tendency to increase the susceptibility of the nervous system, and con- sequently the disposition to an attack. In severe cases, Hall suggests the application of the ice cap. A variety of remedies have been recommended, with the view of con- trolling the spasmodic affection of the throat, as the aq. lauro-cerasi in small and graduated doses; and the oxide and cyanuret of zinc; as well as others for destroying the predisposition to, and cause of the dis- HOOPING-COUGH. 363 ease, as a very low diet, copious and repeated local bleedings, issues on the chest, frequent, active purgatives, mercury, antimonials, cicuta, digitalis, animal charcoal, and iodine, internally and externally. To the greater part of these we object, as altogether unadapted to the dis- ease, or positively prejudicial; while the recommendation of others is evidently based upon an erroneous pathology; and even by the strongest supporters of that pathology, they are admitted to be of doubtful efficacy. 9.— Pertussis.—Hooping-Cough. Hooping-cough is usually described as a disease peculiar to child- hood, occurring but once in the same individual, and propagated by a specific contagion. That it occurs most commonly at some period pre- vious to puberty, is unquestionably true; we have, nevertheless, re- peatedly met with it in adults, particularly when it has prevailed epi- demically; and the memory of every practitioner will furnish him with instances of its occurrence, in even elderly subjects. Heberden saw it in a female of seventy, and in a man of eighty years of age, and Eberle notices two cases occurring in individuals over fifty years of age. Instances, also, of its recurrence in the same individual are, by no means, unfrequent; we have seen several, and the same fact is noticed by various writers. As to its contagious nature, notwithstand- ing it is so considered by the generality of writers on the disease, the fact is very far from being fully established, and is positively denied by a large number of accurate observers, who have particularly di- rected their attention to the subject. Hooping-cough most commonly prevails as an epidemic, and hence a number of individuals may be attacked at the same time, or in quick succession; but to prove its con- tagiousness, it is necessary to show, that when sporadic cases occur, the disease spreads from these, or that patients affected with it, when removed to distant places, communicate it there to others, which we have never known to occur; and the same remark is made by Billard, Desruelles, Laennec, Stoll, and others. The diagnostic symptom of hooping-cough is a suffocating, convul- sive cough, returning in paroxysms, terminating in an excretion of thick, glairy mucus, which is frequently#discharged by vomiting. The cough is marked by a prolonged, stridulous, convulsive inspiration, attended with a rattling in the trachea, and succeeded by several short efforts at expiration, which follow each other in quick succession. The long, convulsive, hooping inspiration is again almost immediately re- peated, and the paroxysm continues, often for many minutes, until a discharge occurs of a portion of thick, slimy mucus, by expectora- tion or vomiting, when the respiration becomes again comparatively free. During the paroxysms of coughing, the child often exhibits all the symptoms of impending suffocation, redness and swelling of the face, injection of the conjunctiva, shedding of tears, profuse perspiration about the head and forehead, and violent spasmodic action of all the respiratory muscles. The agitation of the whole body is such, that the child is obliged to lay hold of something to support him. In violent 364 DISEASES OF THE RESPIRATORY ORGANS. cases, a discharge of blood from the nostrils, and involuntary evacua- tions from the bladder and bowels are not unfrequent. Nearly all writers, since Rosen, have divided hooping-cough into different periods. In its development and progress, the disease unques- tionably exhibits several stages, but these present, in different cases, so many important variations, in their symptoms and duration, that it is difficult, as remarked by Billard, to assign to each its proper limits or distinctive characters. By Desruelles and Lombard, it is divided into the period of invasion, the period of increase, and the period of decline; by others, into the catarrhal stage, the nervous, spasmodic, or convulsive stage, and the stage of decrement; and by Blache and Williams, into the inflammatory, the congestive and nervous, and the simple nervous stage. The disease is very generally preceded by the symptoms of catarrh or mild bronchitis. There is a dry cough, hoarseness, some sense of constriction in the chest, and a feeling of weight or dull pain of the head, redness and suffusion of the eyes, and some degree of febrile ex- citement, with exacerbations towards evening. The duration of this stage varies considerably: it may be followed by the characteristic symptoms of hooping-cough, in a few days, or be prolonged for a week or two, or even longer; the cough, however, increases from day to day, and becomes gradually more convulsive and resonant. In some cases, the catarrhal phenomena have been entirely wanting, the peculiar Bymptoms of the disease occurring, as it were, suddenly: while during the prevalence of hooping-cough, as an epidemic, many children will exhibit no other symptoms than those of the catarrhal stage. Sooner or later, however, the cough assumes its peculiar, convulsive, and suffocating character, and shrill hooping sound. It occurs in pa- roxysms, at irregular periods, during the day and night; the intervals being in general longer during the period of increase, in the day, and during the decline of the disease, at night. The cough is generally preceded by a mucous rhonchus, which is more evident as the paroxysms become more frequent. The patient is, in general, aware of the approach of a paroxysm by a sense of chilliness of the surface of the body, and a tickling in the fauces, succeeded by a sense of, constriction about the throat and chest, and a dread of suffocation, which induces him to fly to his nurse, or to lay hold of any thing within his reach, for support, during the pa- roxysms. The duration of the paroxysms is very various; in some instances, they last scarcely a minute, while in others they are prolonged for five or six minutes, or even longer. The intervals between the paroxysms vary from half an hour to three or four hours: but in very violent cases, at the height of the disease, the paroxysms are often divided by intervals of only a few minutes' duration. The paroxysm usually ter- minates by the discharge of a large quantity of viscid mucus, generally by vomiting, resulting probably from the compression of the stomach, by the forcible contraction of the abdominal muscles which occurs during the violent effort at inspiration. The disposition to vomit is apparently increased by habit; and consequently as the disease advances, the pa- HOOPING-COUGH. 365 roxysms of cough terminate more frequently and speedily by vomiting or retching. Immediately after the fit, the child appears entirely relieved, and a craving for food is often experienced; after this is satisfied, he is perfectly cheerful, and returns to his ordinary amusements. When, however, the paroxysms are frequent, of long duration, and marked by great violence, the patient recovers from his distress only by degrees, remaining exhausted for some time, with hurried or panting respiration, and complains, if old enough, of a tensive pain in the forehead, and pain or soreness of the chest. In some instances, the violence of the paroxysm is such as to produce a loss of consciousness from temporary asphyxia; or the asphyxia may be complete, and death ensue. In other cases, convulsions, or cerebral congestion and deep coma may occur. The paroxysms often recur with some degree of periodicity; but they may be induced at any time by too much, or improper food, ex- citement of the mind, or exposure to cold, or a confined and impure atmosphere. They may also be excited by seeing another attacked by one. It is probable, as remarked by Lombard, that motion, amuse- ment, and the open air, contribute to lessen the cough; while rest, the horizontal position, and the close air of sleeping apartments, increase the tendency to its return. In slight attacks, there maybe but little or no fever during the con- vulsive period of the disease, and but little functional disturbance in the intervals of the paroxysms; but, usually, the presence of the sono- rous and mucous rhonchus, particularly before and after the cough, and the mucous expectoration in which the cough generally terminates, indicate that in conjunction with the nervous affection, upon which the spasmodic, stridulous respiration, and sonorous cough depend, there still exists more or less bronchitic or catarrhal disease; in fact, as the stage declines, the expectoration generally assumes the more consistent and opaque form which characterizes the concocted sputa of a termi- nating bronchitis. ( Williams.) The bowels are variously affected in hooping-cough. Though often perfectly regular, and the discharges natural, yet, occasionally, they are costive or sluggish, and, in a few cases, diarrhoea is present, with vitiated discharges, a loaded tongue, nausea, loss of appetite, epigas- tric fulness and tenderness, and other symptoms of gastro-intestinal disease. The fact has been pointed out by Dr. Gibb, that the urine, in almost every case of hooping-cough, is saccharine; the quantity of sugar being generally very small; sometimes only a trace of its existence is per- ceptible. In several cases, however, Dr. Gibb has found it to be in considerable quantity, the specific gravity of the urine, and its gene- ral characteristics being, at the same time, similar to those of diabetes. (London Lancet, Jan., 1858.) In the cases accompanied by severe bronchial inflammation, there is generally more or less cough between the paroxysms, and considerable febrile excitement; and the convulsive, hooping, cough is generally preceded and followed by considerable uneasiness, or oppression and 366 DISEASES OF THE RESPIRATORY ORGANS. pain of the chest. The bronchial inflammation, in these cases, is apt to run into pneumonia, which is hence a frequent complication of the disease. When this occurs, we have the general symptoms of the lat- ter affection, superadded to those of hooping-cough, as well as its dis- tinctive physical signs. Lobular pneumonia, and pleuritic inflamma- tion, are common occurrences in this disease. It has been very cor- rectly remarked by Dr. Parrish, (Trans. Pennsylvania State Med. Soc, 1851,) that a condition of the respiratory organs sometimes occurs in the course of hooping-cough, more especially at its height, which might be readily mistaken for inflammation by the inexptrienced prac- titioner, but is the result of extreme nervous irritation alone. The breathing becomes hurried and laboured; the cough is suppressed, and loses, to a considerable extent, its paroxysmal type; the pulse is feeble and very rapid, with a hot, dry skin; the appetite is gone, and the whole aspect of the case is of an alarming character. On close exa- mination it will be found, however, that there is no distinct crepitant sound in the lungs; the respiration though exceedingly hurried, is not uniformly so, being more difficult at one time than another, and being especially easier whilst the patient is asleep. The child is more irri- table than is usually the case in pneumonia, cries louder and more dis- tinctly, and takes more notice of surrounding objects. Hydrocephalus is one of the most serious complications of hooping- cough, and a very frequent one. It is marked by its usual symptoms —grinding of the teeth, rolling of the head, intolerance of light, con- tracted pupil; followed by squinting, vomiting, screaming, insensibi- lity, &c. We have, in a few instances, seen a state of deep coma oc- cur in the course of hooping-cough; the brain, after death, exhibiting extensive serous effusion, without any of the symptoms of meningitis or hydrocephalus having presented themselves. Anasarca is also a frequent complication of the disease. In most of the more violent cases, there is a slight degree of oedema of the face and arms; but in some cases, serous effusion occurs throughout the cellular tissue, and in the cavities. An attack of croup will often supervene during hooping-cough, particularly in its early stage. Children of robust, plethoric habits, are most subject to this compli- cation. The duration of the second stage is very various; it may continue for a very short time, or be prolonged for three or four weeks, or even longer; the symptoms then gradually diminish in intensity; the expec- toration becomes more abundant, opaque, and thicker; the cough loses, by degrees, its convulsive character; the paroxysms are of less fre- quent occurrence, and of shorter duration; and finally, by the end of two or three months from the commencement of the disease, it disap- pears with the assemblage of other symptoms. The period when the symptoms begin gradually to decline, to their final termination, con- stitutes what has been termed the third stage of the disease. It often happens, that after a very decided abatement of the symp- toms has taken place, the cough again returns, with considerable vio- lence: this relapse, though occasionally prolonged, is generally of short duration; usually after two or three days, the regular decrease will occur and continue its course. HOOPING-COUGH. 367 The disease, in many cases, assumes a kind of chronic form, and may be protracted to a very long period, the paroxysms being well marked, but occurring at considerable intervals, and of little intensity or duration; or they may be induced, in those who have lately reco- vered from the disease, by the occurrence of the slightest catarrhal affection. A curious case is related by Percival, in which the hoop- ing-cough assumed a periodical form, a paroxysm occurring daily, at a certain hour, for several months, and returning at the same season for two years. In children of a lymphatic temperament, strongly predisposed to tubercular disease, and in those in whom the formation of tubercles in the lungs has already commenced, the occurrence of hooping-cough in a severe and protracted form, very rarely fails to develop pulmonary consumption; the progress of which is often very rapid, upon the de- cline of the acute stage of the attack. The physical signs of hooping-cough are those of mild bronchitis; variable, sonorous, sibilant, and mucous rhonchi, in the upper and mid- dle portions of the chest. During the height of the paroxysm, there is diminished sound of respiration within the chest. When complicated with pneumonia, the mucous and crepitant rhonchi, with partial absence of the respiratory murmur, and dulness on percussion, will indicate the existence and extent of the pulmonary disease. The appearances upon dissection vary with the violence of the at- tack, the period at which death has taken place, and the simple or complicated character of the case. Nearly every writer who has given the result of his autopsical examinations, mentions the existence of more or less of the indications of inflammation of the mucous membrane of the bronchi, and often of the trachea; as, injection of the blood- vessels, thickening of the membrane, and the existence upon its sur- face of a layer of thick mucus, and occasionally a muco-purulent fluid filling the ramifications of the bronchi. Ulcerations about the glottis, and in the larynx and trachea, are noticed by Astruc, Mackintosh, and Alcock. When death is caused by asphyxia, in the early period of the attack, the mucous membrane of the respiratory tubes is of a dark red or bluish appearance; the lungs are gorged with dark-coloured blood; the whole substance of the brain is a little more livid than natural, and the bronchial tubes contain a little mucus, occasionally stained with blood. A very common lesion in severe cases is dilatation of the bronchi. Inflammation of the lungs, especially lobular inflammation, or per- haps more correctly speaking pulmonary collapse, is of common occur- rence, and very frequently inflammation of the pleura, with exudation or effusion. To these lesions may be added, tumefaction and redness of the bronchial glands, and emphysema of the lungs. In a large number of cases, inflammation of the meninges of the brain, and effu- sion beneath the membranes, and into the ventricles, have been ob- served. A diseased condition of the phrenic and pneumogastric nerves, is noticed by Clarus, Holzhausen, Hufeland, Breschet, Bauer, Kilian, and Autenreith. There is some doubt, however, as to the correctness of these latter observations; it is certain, at least, that a lesion of the nerves just mentioned, is of very unfrequent occurrence. 368 DISEASES OF THE RESPIRATORY ORGANS. Hooping-cough most commonly occurs as an epidemic, but gene- rally of very limited extent, its influence being confined, usually, to a single city or district, and often to a part, only, of these. Seldom, if ever, has it extended, either at once, or gradually, over large terri- tories, as is the case with most other epidemics. If, however,^ we are to receive as correct the accounts of the epidemics of 1510, 1557, 1580, 1757, 1767, and 1769, as given by De Thou, Sennertus, Sauvages, Riverius, Diversus, Conario, Geller, and Arrand, we find that these were of wide extent, many of them prevailing throughout the greater part of Europe. The disease occurs at all seasons, and in all climates; but the spring and autumn, especially when cold and damp, and cold, variable cli- mates, are admitted, by nearly all writers, to be the most favourable to its prevalence; and it is in these seasons and climates that the hoop- ing-cough proves most fatal, from its being most usually complicated with severe bronchial, pneumonic, or laryngeo-tracheal inflammation. The general production of the disease, by the joint influence of a cold and moist atmosphere, is insisted upon by Klinge, Richter, Marcus, Desruelles, and Vondembush. It has been found frequently to pre- vail most extensively, either immediately before, during, or subsequent to the occurrence of epidemic measles. Its prevalence at the same time with epidemic catarrh, has also been repeatedly observed. Children of all ages are liable to its attacks; infants at the breast are, however, less liable to it than those who are weaned: indeed, so generally does the disease attack during the period of dentition, that many have supposed this to be its most common predisposing cause. Boys and girls are equally liable to it, though, perhaps, a greater num- ber of the former will generally be found to escape an attack, than of the latter. Children labouring under chronic cutaneous eruptions have been supposed to be rarely affected with the disease; or when attacked, to have it but lightly. The fact, however, is denied by Hoffman, Haase, and others, and it is not sustained by the general re- sult of more recent observations. In regard to the true pathology of hooping-cough, much diversity of opinion has existed, and still continues to exist. By the majority of the most authoritative writers on the disease, it is viewed as essentially a spasmodic affection of the air-passages, arising from a primary irritation of the brain, or of one or other set of the respiratory nerves. This theory variously modified, is that advocated by Hoffmann, Cullen, Hufeland, Jahn, Lobel, Autenrieth, Holzhausen, Leroy, Coiter, Guibert, Breschet, Gardien, Killian, Bauer, Albers, Clarus, Eberle, AVebster, and Copland. Dr. Webster considers the affection of the respiratory organs to be secondary, and dependent on a primary inflammatory irritation of the brain or of its membranes, or of both. Most of the advocates of the nervous theory regard the pneumogastric nerves as the seat of the affection; others, however, locate the irritation in the phrenic nerves—the principal of these are Jager, Lobenstein, Lobel and Leroy; others again, as Albers of Bre- men, Pinel, Laennec, Blache and Roe, refer the irritation to both the mucous membrane of the bronchi and the pneumogastric nerves. HOOPING-COUGH. 369 The late Dr. Sanders, of Edinburgh, considered congestion at the origin of the pneumogastric and other respiratory nerves to be the es- sential pathological condition in hooping-cough, and Dr. S. Piddock, (Lancet, 1849,) adopts this opinion, and bases his treatment of the dis- ease upon it. Others consider the disease to be an inflammatory affection of some part of the mucous membrane of the air-passages: this opinion num- bers among its advocates, Darwin, Danz, Watt, Marcus, Boisseau, Alcock, Alderson, Dewees, Dawson, Pearson, Guersent, E. Watson, Fourcade-Prunet, Boisseau, Broussais, Rostan, and Duges. Dr. Watt believed it to be, "in all cases, an inflammatory disease, whose chief seat is in the mucous membrane of the larynx, trachea, bronchi, and air-cells, possibly attended with a minute exanthematous eruption there." He considers that, when mild, "this inflammation runs its course without materially disturbing the other functions of the body, or even the functions of the very membrane in which it is seated, and that whenever hooping-cough proves dangerous or fatal, it becomes so by the degree of the inflammation in the natural seat of the disease, or by that inflammation extending or being translated to other parts." Most advocates, however, of the inflammatory origin of the disease, limit the inflammation to the trachea and bronchi. Dawson confines it, at first, to the larynx, or, strictly speaking, to the glottis—an opinion, by the way, not widely differing from that of Astruc, who of old describes the disease as an "inflammation of the superior part of the larynx and pharynx." Volz, Jos. Frank, and more recently Dr. James Duncan, have, also, considered hooping-cough as an exanthematous disease of the respiratory mucous membrane. Blache is of opinion that hooping-cough is a nervous affection, having its seat both in the mucous membrane of the bronchi, and in the pneu- mogastric nerves; that it is very often complicated with bronchitis and pneumonia, but may exist without them ; and like all other purely nervous affections having no appreciable anatomical character. In this opinion Dr. Roe, Barrier, Rilliet and Barthez, and many of the more recent writers coincide. (Churchill, Diseases of Children.) According to Dr. Duncan, (Dublin Quarterly Journal of Medical Science, Aug., 1847,) the essence of the disease consists in turgescence of the bronchial glands, coinciding with or resulting from a peculiar fever caused by a specific poison; and acting on the pneumogastric nerve in the manner Dr. Ley supposes to occur in the case of spasm of the glottis. Many view the complaint as at first inflammatory, and afterwards spasmodic, or as a specific inflammation of the respiratory mucous membrane combined with irritation of the respiratory nerves, in con- sequence of which the muscles to which the latter are distributed are thrown into spasmodic action; the nervous irritation continuing after the inflammation has ceased. This doctrine, variously modified, is a favourite one with the writers on hooping-cough. Desruelles makes the disease to consist in a primary inflammation of the bronchi, com- plicated with a consecutive cerebral irritation, which by its influence over the diaphragm and other respiratory muscles, and over those of 370 DISEASES OF THE RESPIRATORY ORGANS. the larynx and glottis, changes the simple cough of bronchitis into one of a convulsive character. This opinion is the one adopted, also, by Dr. C. Johnson in his able article on hooping-cough in the Cyclopaedia of Practical Medicine, (Philadelphia Edition, vol. 2, page 453:) other writers who admit the occasional presence of cerebral disease, consider this to be invariably secondary to the bronchial aflection: of this opinion are Boisseau, Begin, Otto, and Vondembush. By not a few, especially of the older medical writers, hooping-cough is referred to an irritation of the stomach and lungs. Rosen, who supposed the disease to be produced by either an insect or a morbid poison, partly inhaled into the lungs and partly swallowed with the patient's saliva, considered that the stomach suffered more from the irritation than the lungs. Danz believed that the irritation is seated primarily in the stomach and bowels, the affection of the respiratory organs being secondary. This opinion had been previously advanced by Stoll, and is also that advocated by Chambon in his work " Dcs Maladies des Enfants." Tourtelle likewise describes the disease as a catarrhal affection of the lungs and stomach (affection pneumogas- trique pituiteuse.) Millot entertains a somewhat similar opinion ; he supposes, however, that the irritation of the stomach is secondary, and not so intense as that of the lungs and larynx. Opinions somewhat similar are entertained by Meltzer, Holdefreund, Butler, Klinge and Starck. The peculiar phenomena of the hooping-cough have been ascribed, by a few, to a physical or chemical irritant introduced into the larynx, either from without, or from the blood where it is engendered, or from the secretions of the respiratory organs. Under this head may be ar- ranged the opinion of Linnseus, who referred it to the presence of mi- nute insects; that of Sydenham, who imputed it to a subtle and ir- ritating vapour in the blood, which affected the lungs; that of Bohme and Klinge, and also, partly, that of Rosen, who ascribes it to a pecu- liar miasm, acting chiefly on the nerves. Dr. Blaud, of the Hospital Beaucaire, (Revue Medicate, March, 1831,) considers the primary cause of hooping-cough to consist in an irritation, not inflammatory, of the mucous membrane of the bronchi, under which the glands and follicles of the membrane are caused to pour forth a specific secretion saturated with hydrochlorate of soda, the irritation caused by which, when it reaches the upper part of the trachea and larynx, throws the muscles of the glottis and of respiration into spasmodic action for its expulsion, in a manner exactly similar to any foreign body which may accidentally enter the larynx. This theory of the disease Mr. Streeter, of London, in a paper read before the Physical Society of Guy's Hospital, November, 1844, has adopted and zealously advocated, " as the one most con- sistent with the phenomena observable in the symptoms, patholoo-y, and successful treatment of the disease." Mr. Streeter regards, however, the primary affection of the bronchial membranes as inflammatory, and believes that it will be found, on care- ful observation, to be attended by more or less fever of an analogous character to that which attends the influenza. The evidences upon which this gentleman rests the truth of this HOOPING-COUGH. 371 theory, are—" the testimony of adults, who have been attacked by the disease, to the unusual and excessive saline taste of the expectoration so long as the paroxysms are severe—the resemblance of the expira- tory efforts in hooping-cough to those made by the excito-motory system for the expulsion of a foreign body from the larynx—the very adequate explanation it affords, both of the extraordinary and spas- modic muscular actions which accompany the cough, and of its occur- rence in paroxysms after intervals of uncertain duration—and, lastly, the key which it furnishes to the chaotic host of apparently opposite remedies that have obtained professional or popular reputation in its treatment. Of these remedies, we find one group adapted to lessen the original bronchial affections, and favour the expulsion of the offending mucus—as emetics, antimonials, and counter-irritants applied over the chest; another which acts by altering the quality of the se- cretion, as the alkaline carbonates, ammonia, and sulphuret of potass, so strongly recommended by Dr. Blaud; another, by exciting a new action in the bronchial membrane, and, by constringing the vessels, to put a stop to the secretion, in a manner perfectly familiar to the phy- sician in chronic bronchitis, and to the surgeon in purulent ophthalmia —as the super-acetate of lead, alum, common resin, tine, cantharid., bals. copaiba, tar vapour, and even the inhalation of nitrous vapours, &c. Others, again, as musk, both native and artificial, camphor, arsenic, conium, belladonna, opium, and hydrocyanic acid, are more especially adapted for the nervous lesions; while antiphlogistic measures meet the inflammatory lesions of the third or complicated stage. " When, he remarks, the convulsive hooping is fully established, it very commonly happens that symptoms which mark the third, or what may be appropriately termed the complicated stage, are developed, and continue to mark the varying and formidable phases of the disease which mostly attract attention in practice." These tertiary phenomena usually manifest themselves, " 1st—as special lesions of the nervoug and mus- cular systems—an exalted sensibility and morbidly susceptible state of the membrane of the larynx, the pharynx, the epiglottis, under which death from asphyxia may suddenly occur—morbid association of the action of the muscles of the glottis and respiration, in conse- quence of which the cough continues from mere habit, or is reproduced by the most trivial irritation of the air passages—reflex irritation often passing into inflammation of the nervous centres of the pneumogastric nerves, involving those of the phrenic nerves also; and finally, these reflex affections may extend to the whole of the brain, or to the me- dulla oblongata and their meninges, and prove fatal by inducing ge- neral convulsions or hydrocephalus. All these, be it observed, are pathological conditions of the nervous system, which have been so constantly put forward in high relief, by the advocates of the nervous theory, as proximate causes of the disease itself." A second class of tertiary phenomena include " the various congestive and inflammatory affections that result from the mechanical disturbance of respiration and circulation, and the extension of the primary bronchial inflamma- tion to the trachea, larynx, and pharynx, and to the tissues of the luno-s themselves. Epistaxis, haemoptysis, and fatal emphysema from exten- 372 DISEASES OF THE RESPIRATORY ORGANS. sive rupture of the air-cells, have occurred within my own experience, and have apparently resulted from the mechanical violence of the cough acting upon tissues previously weakened by disease." A third class of tertiary phenomena, " include fever and cachexia," which are " present in individual cases in every conceivable variety of combina- tion." "In the absence of cerebral or pulmonary inflammation, the fever of the third stage is always asthenic, and often assumes a re- mittent tvpe when the cachexia is of a marasmic character." According to Dr. Todd, (Med. Times, 1854,) hooping-cough is pro- bably due to the influence of a poison introduced into the system, and which produces its local manifestations on the vagus nerve. It is not an inflammatory affection of any part, but is always and entirely de- pendent on a morbid state of the blood, caused by the introduction into it of some poison from without—whatever inflammation may occur in the course of it must be regarded in the light of a complication of the disease. Drs. Gilbert and Fyfe, (Prov. Med. and Surg. Jour., 1847,) regard the disease as essentially nervous or spasmodic; the latter denies that hooping-cough and bronchitis can exist together. That the essential symptoms of hooping-cough are the result of a partial spasmodic closure of the glottis, there can be little doubt; but whether this is owing to an irritation seated primarily in the larynx and trachea, or in the brain, it is difficult to determine. The disease com- mences as a simple, and often very mild bronchitis; and it is not until after the bronchial inflammation has existed for some time, that the irritation is transmitted to the laryngeal nerves, and the convulsive cough and difficulty of respiration occur. Desruelles has attempted to show that these latter symptoms are the result of an intermittent irritation and congestion of the brain, which precedes each paroxysm, ceases with the latter, but soon returns, giving rise to a renewal of the paroxism, and hence, that the disease consists in a reciprocal irri- tation of the brain and of the respiratory apparatus; the latter, upon the one hand, acting upon the brain through the medium of the eighth pair of nerves, the phrenic nerves, and those branches which are dis- tributed to the muscles of the thorax; while, on the other hand, the brain reacts upon these muscles, the glottis and diaphragm. This much, however, is very certain, that we cannot account very readily for the phenomena of the disease, excepting by referring them to irritation of the laryngeal nerves, as well as to disease of the respiratory mucous membrane. When hooping-cough is unaccompanied with severe symptoms of bronchitis, and is uncomplicated with pneumonia, or tracheitis, or with congestion or inflammation of the brain, it is seldom attended with much danger; but in its more severe and .complicated forms, it is with difficulty managed, and very frequently fatal. The younger the pa- tient, also, as a general rule, the more danger attends it. Very fre- quently, as remarked by Guersent, when it occurs in infants at the breast, it is accompanied with cerebral congestion from its very onset, and is then particularly fatal. We have also found, that when, in young children, it is accompanied with an excessive serous diarrhoea, it is seldom recovered from: a similar remark is made by Richter. HOOPING-COUGH. 373 In many of the more extensive epidemics, the mortality from hoop- ing-cough has bgen very considerable. Thus, in Sweden, during the sixteen years, from 1749 to 1764, 43,393 deaths occurred from the disease; and of these, 5,832 took place in the year 1755 alone. (Rosen.) In Glasgow, the deaths have been pretty nearly 5J per cent, of the en- tire mortality; and in one year, (1809) they amounted to 11 \ per cent. ( Watt.) In Prussian Pomerania, the deaths were as 1 to 25J of the entire mortality. In Neumarck, 1 to 21^. In Brandenburg, 1 to 29£. In Sweden and Finland, 1 to 13£. In Strasburg, 1 to 94. In Boston, 1 to 82. In Charleston, 1 to 46-6. In Baltimore, 1 to 95*38. In New York, 1 to 64-7; and in Philadelphia, 1 to 63*1. There are two affections with which the hooping may be confounded; namely, acute bronchitis with paroxysmal cough, and tuberculization of the bronchial ganglions. The diagnosis between these affections has been very ably drawn by Rilliet and Barthez. (Maladies des En- fans, T. ii. 223.) In Hooping-Cough; in the great majority of cases, the paroxysms of cough are preceded by catarrhal symptoms. The paroxysms, more or less intense, are accompanied with a pro- longed hissing sound, and succeeded by an expectoration of a tena- cious mucus, and very generally, by vomiting. In its simple form, it is in general unattended with fever, and during the intervals there is neither acceleration nor other change in the respiration. The paroxysms continue, more or less frequently, without change of character, and then decrease; and the cough assumes a simple ca- tarrhal character, and the child, if the attack is without complications, becomes convalescent. There are no relapses. The acute bronchitis with paroxysmal cough, commences suddenly with paroxysms of cough. These are in general shorter, less intense; the hissing sound is very unfrequent, or in the few cases in which it occurs it is intermittent; there is little or no expectoration, and no vomiting. The attack is attended from its onset with intense fever, and accele- ration of respiration, which constantly augments in intensity—sibilant and mucous rhonchi, afterwards subcrepitant. The pulse is very small, the dyspnoea is extreme, and these symptoms, with pallor of the face, appear, persist, or augment, and the disease terminates almost invariably in death within a variable period, often very short. Relapses are possible. In their more chronic stages, these two diseases are attended by the same symptoms. The diagnosis between hooping-cough and tuberculization of the bronchial glands is still more difficult, than between it and the dis- ease just referred to. The characters which constitute the diagnosis are the following: Hooping-cough—frequently epidemic—contagious. Three distinct periods, of which the second alone is attended with. 374 DISEASES OF THE RESPIRATORY ORGANS. a paroxysmal cough. The paroxysms attended with a hissing sound, expectoration of viscid mucus, and vomiting. Respiration and pulse natural in the intervals, when the disease is simple. The voice natural. Progress most commonly acute. Tuberculization of the bronchial ganglions. Always sporadic; not contagious; without distinct periods. Paroxysms of cough generally very short—without any hissing sound—without viscous expectoration or vomiting. Physical symptoms of ganglionary tuberculization, but in certain cases an absence of thege signs. An access of asthma in certain cases, alternating with the parox- ysms of cough, continued fever, with evening exacerbations, night- sweats, progressive emaciation, &c. Occasionally a change in the tone of the voice. Progress chronic. To complete the diagnosis, the age of the subject should be care- fully inquired into, and the causes under the influence of which the disease has occurred. We should examine whether, by constitution or inheritance, the patient is predisposed to tuberculization—whether before the commencement of the paroxysmal cough the child had be- come pale and emaciated—whether he was subject to cough, &c. It is during the second period that spasmodic croup, certain forms of bronchitis, and bronchial phthisis may be confounded writh hooping- cough. But there are others which it is not always easy to distin- guish from it during its first and third periods. A slight attack of • bronchitis does not differ in any of its symptoms from the prodroma of hooping-cough. The nature of the disease may, however, be suspected from the character of the reigning epidemic, and the circumstances preceding the attack. When hooping-cough becomes chronic, and the paroxysms, after having diminished in intensity, occur more rarely and unattended with the hissing inspiration, or when the cough is simply catarrhal—the disease, or rather the dilatation of the bronchi by which these second- ary symptoms are induced, may be readily confounded with pulmonary or bronchial tuberculization. The diagnosis is the more difficult, as it is precisely at this period that phthisis is liable to succeed to hoop- ing-cough. The emaciation, hectic fever, pallor of the skin, the sweats, all the collection of general symptoms, in fact, are the same; auscul- tation alone can throw light upon the nature of the disease. Still, however, even here there is difficulty in establishing the diagnosis with any exactness. When dilatation of the bronchi occurs, the disease is kept up, and with symptoms so closely resembling pulmonary or bron- chial consumption that it may be mistaken for the latter. The ulte- rior progress of the disease, is often the only criterion by which its true character can be determined. If the child regains his flesh—re- covers his gayety and strength—if the paleness of the skin disap- pears, and the fever or sweats cease, it is more than probable that tu- barcles are not present. If, on the contrary, the fever persists, the HOOPING-COUGH. 375 emaciation augments, and the appetite is lost; if copious diarrhoea oc- curs, and each day the symptoms become more unfavourable, it is then but too certain that tuberculization exists and is making daily prog- ress. The treatment of hooping-cough will differ, according to the stage of the disease, the violence of the attack, its simple or complicated character, and the age and vigour of the patient. The remedies proper in the first or catarrhal stage are the same, precisely, as in simple bronchitis. It is chiefly upon the proper ma- nagement of this stage that will depend, in many cases, the safety of the patient; his diminished liability to the occurrence of severe bron- chial or pneumonic inflammation, as well as to the danger attendant upon intense cephalic congestion being induced during the paroxysms in the second stage. We believe that in all cases, very great relief will be afforded by the administration of an emetic at the very commencement of the attack, and the continuance of the remedy, subsequently, in nauseating doses. In robust children, over two years of age, tartrate of anti- mony should be preferred; but in younger patients, in whom this ar- ticle is seldom a very safe one, we would prefer the ipecacuanha. By many practitioners, the latter article is considered to be particularly adapted to the treatment of hooping-cough. They prescribe it in the first, and during the acute period of the second stage, occasionally as an emetic, and subsequently, in small doses, the fourth of a grain every three or four hours, either alone or in combination with sulphur, or with sulphur and belladonna. We have followed this practice in a very large number of cases with the happiest effects: we have usually combined the ipecacuanha with sulphur and extract of hyoscjamus. R.—Pulv. ipecac, gr. iij. ad iv. Sulph. prsecip. gss.—gj. Ext. hyoscyami, gr. iv.—xij.—M. f. chart. No. xij. One to be repeated every three or four hours. Ilorst recommends the flowers of sulphur as almost a specific in hooping-cough. He gives it throughout the disease, from its onset until its termination. Schneider, Kopp, Randham, Riecken, and others, confine its use to the more advanced periods of the attack. Jadelot is said by Rilliet and Barthez to have derived the best effects from the sulphur as a remedy in hooping-cough, and in bronchitis unat- tended with fever. It is given to children between two and four years of age, in the dose of from 6 to 8 grains, two or three times a day, and to older children in doses of from 15 to 20 grains; in both cases the dose being gradually augmented. There are few cases in which, at the onset of the disease, after an emetic and the warm bath, the exhibition of a full dose of calomel, followed, in a few hours, by some mild purgative, as castor oil, rhu- barb and magnesia, or in children over two years of age, in whom the first stage is often attended with considerable febrile excitement, by small doses of sulphate of magnesia, will not be found advantageous. The bowels being kept subsequently in a regular state, by occasional doses of some mild unirritating purgative, or by simple enemata. 376 DISEASES OF THE RESPIRATORY ORGANS. Perhaps the best purgative we can employ in hooping-cough, parti- cularly in its first or catarrhal stage, is calomel: an occasional small dose, say from two to five grains, given in the evening, and followed in the morning by a small quantity of castor oil, will generally have the effect of preserving a free, regular condition of the bowels, with- out unduly irritating them or inducing severe purgation—an occur- rence which should be always carefully avoided. Whatever opinion we may adopt of its mode of action, we are certain of the utility of calomel as a mild purgative in the first, and during the acute period of the second stage of hooping-cough. We are accustomed to com- bine with the evening dose of calomel, a third of a grain of ipecacu- anha, and the same quantity of the extract of hyoscyamus, and have seldom found it necessary to give any purgative in the morning to en- sure its operation. In every case in which, during the first stage, severe bronchial or pulmonic inflammation is present or threatened, particularly if the patient be of a plethoric or robust habit, bleeding becomes an indis- pensable remedy; and it should be resorted to, also, whenever the same indications present themselves at a later period of the disease, previous, at least, to the occurrence of extensive effusion into the bron- chi. The extent of the bleeding should always be proportioned to the violence of the symptoms, and the strength of the patient. Upon our promptitude and decision in the use of this remedy his recovery will often depend. Leeches to the chest and about the clavicles, or cups between the shoulders, will be sufficient in young children ; but in those who are older, and when the symptoms are severe, it will be better to have recourse to the lancet, followed, if necessary, by leeches. We are aware that blood-letting has been considered by some an improper remedy in hooping-cough, and by others of doubtful propriety; but independently of our own experience, we have in its favour that of nearly every authoritative writer on the disease. Mackintosh ap- plied leeches over the larynx, and speaks confidently of the success of the practice. In that condition of the respiratory organs which occasionally oc- curs from nervous irritation alone, and which is liable to be mistaken for pneumonia, bleeding in common with all antiphlogistic remedies would be highly improper. On the contrary the free use of antispas- modics and tonics, with pure fresh air are required to relieve the spas- modic action of the respiratory apparatus, and rescue the patient from his condition of suffering and danger. Whenever there is a decided tendency to an affection of the brain, whether of a congestive or irritative character, blisters to the temples, or behind the ears, cold lotions to the scalp, and warm sinapised pedi- luvia or sinapisms to the feet, should be immediately resorted to. During the whole of the first, as well as during the acute period of the second stage, the patient should be confined to his chamber, which should be kept of a proper temperature, but well ventilated. Nothing has a more deleterious tendency than sudden transitions of tempera- ture, or exposure to cold and damp; almost invariably will these ag- gravate the paroxysms of cough, and endanger inflammation of the respiratory tubes or lungs. The diet should be perfectly mild and un- HOOPING-COUGH. 377 irritating, and in violent cases should consist entirely of some simple mucilaginous fluid. The occasional use of the warm bath should not be neglected. As soon as the acute character of the disease is reduced, some counter-irritant applied to the chest or between the shoulders, will be found highly beneficial: blisters are recommended by some, and if properly managed, produce, certainly, a very excellent effect; but a few of the European as well as of the American practitioners prefer the production of a more powerful and permanent irritation, such as results from the ointment of the tartrate of antimony. Autenreith states that, in two severe epidemics, in which he employed frictions with tartar emetic ointment, he lost not a single patient.1 In order to insure the efficacy of this plan of treatment, we must not, we are told, be satisfied with merely producing pustules; the use of the ointment should be continued until small ulcerations occur in the intervals between the crusts. The treatment should be persisted in for eight or twelve days. If the eruption is very painful, the best application is fomentations with a decoction of hemlock. Luroth em- ployed the ointment in this manner, in a very fatal epidemic of hoop- ing-cough, with, we are assured, the most gratifying results. Corsin also employed the emetic tartar, as an external irritant, during an epi- demic of the disease, and, according to his statement, with decided benefit in every case. He prefers, however, its application in the form of a plaster,2 which is to be worn upon the epigastrium, or between the shoulders, as long as the patient can endure it. Dr. Dewees thinks that he observed more advantage to result from the use of the oint- ment of the tartrate of antimony, than from any other external appli- cation. He used it of the same strength as directed by Autenreith, with the addition of fifteen drops of oil of lavender, or essence of lemon, and applied it high up between the shoulders. Nearly the same re- marks are made, in relation to the remedy, by Mackintosh. We know nothing of its effects from our own experience; in the few cases in which we have employed it, we could never persist in its use, (and this is said to be essential to its efficacy,) in consequence of the severe pain, and deep ulceration produced. We have no doubt, however, that in severe cases, it may prove a very valuable derivative. We have gene- rally resorted to blisters, and frictions with turpentine, the compound camphorated liniment, or a liniment of the oil of amber and oil of rose- mary, to the spine,3 and with the best results. 1 R— Tart, ant ^jss. 2 R.—Empl. conii, 2 pts. Axung. 5J—M. Empl. picis abietinse, 1 pt. A portion of the ointment of the size of Diachylon, 1 pt. a nut, is to be rubbed on the epigas- Spread on leather, and sprinkle the sur- trium, three times a day. face with from 6 to 12 grs. of the tartar emetic. s R.—Ol. oliv. ^iv. — succini, £jij. — rosmarin. ^ij.—M. In many cases, a plaster of Burgundy pitch, worn upon the chest or between the shoulders, produces a very powerful rubefacient effect and will, consequently, prove highly beneficial. At the meeting of the medical section of the British Association, in 378 DISEASES OF THE RESPIRATORY ORGANS. 1840, it was stated by Dr. Han nay, that rubbing the chest with cold water, two or three times a day, with so much activity as to produce a rubefacient effect, has been found of very great efficacy, in cases of hooping-cough; and that this practice may be resorted to, even when the case is attended with bronchitis. We have no doubt of the effi- cacy of the friction, but should certainly prefer olive oil to the cold water, which can have no other good effect, than to prevent abrasion of the cuticle. Dr. Todd speaks of sponging the chest with cold water, once or twice a day, as a practice which exercises a bracing and tonic in- fluence on the nerves, and in this way acts beneficially in cases of hooping-coughs. We much doubt the propriety of this practice. An occasional emetic of ipecacuanha will often give great relief at this period; and we have generally found the administration of small doses of ipecacuanha, extract of hyoscyamus, and magnesia, repeated every three hours, of unquestionable efficacy. When we have succeeded in removing the inflammatory symptoms, or these have been so far abated that the paroxysms are kept up chiefly by nervous irritation, and there exists no decided tendency to cerebral disease, we may commence with the use of narcotics, anti- spasmodics, and tonics. Nearly every article upon the lists, has been recommended by different writers, as almost a specific, in certain stages of the complaint, and as strongly reprobated by others, as either in- effectual, or positively injurious. It is certainly true, that the treat- ment of hooping-cough has been, in too many instances, marked by the grossest empiricism, without any reference whatever to the true patho- logy of the disease, or to its occasional complications with encephalic, thoracic, and abdominal diseases, and that not a few of the articles de- tailed in the books as certain remedies, are calculated, often, to do more harm than good, while others are perfectly inert. In regard to narcotics, strongly objected to by some, evidence of too conclusive a character has been presented in favour of their employ- ment, to leave any reasonable doubt as to their beneficial influence after the acute stage has passed by, and the paroxysms of convulsive cough are kept up from nervous irritation alone. We are constantly in the habit of prescribing them, and would certainly find it very diffi- cult to control the cough in the spasmodic stage of many of the more violent cases, without their aid. It is true, that much may be effected in this stage by a proper regulation of the diet, bowels, and clothing, and by a change of air. We agree with Mackintosh, as to the import- ance of confining the child to bland, nutritious food, keeping his bowels gently open by mild aperients, and protecting the surface by flannel, together with the occasional use of the warm bath, followed by fric- tions, and free daily exposure to the open air, when the weather is per- fectly mild and dry; under the use of these means we shall invariably find the violence of the paroxysms to decrease, and in mild attacks, often gradually to cease. There are, nevertheless, few cases of hoop- ing-cough, in which the continuance of the disease will not be very materially shortened, and convalescence hastened and confirmed, by the judicious employment, in conjunction with the hygienic measures referred to, of narcotics, antispasmodics, and occasionally of tonics. HOOPING-COUGH. 379 There exists among writera some difference of opinion as to the nar- cotic best adapted to hooping-cough; opium has been recommended by many, either alone, or in combination with tonics and expectorants. We have employed an aqueous solution of opium, with some benefit;1 and Lombard recommends the syrup of the white poppy, in the dose of a teaspoonful, once, twice, or three times a day. In some cases, the Byrup of poppy has been found to remove only the more troublesome symptoms, without shortening the duration of the disease. It is said to have proved particularly beneficial in diminishing the number of pa- roxysms during the night, by inducing sleep, but even then, it has ap- peared to exert but little influence over those occurring during the day, this is precisely the result of our experience, in relation to the effects of the aqueous solution of opium. Morphia has been employed ender- mically, and according to Meyer, with good effect; a blister is applied over the praecordia, and when the cuticle is removed, the blistered sur- face is sprinkled every evening with half a grain of morphia, rubbed up with dry starch. 1 R.—Opii pulv. gj. Aq. bullient. -"jiv. Let it stand for three hours, then strain, and add jj. bi-carbonate of soda. Dose, for a child two years old, a teaspoonful every three hours. The narcotic from which, however, the greatest amount of benefit is to be anticipated in this disease, is unquestionably the belladonna: it has been very extensively employed, and the evidence in its favour is strong and conclusive. Several of the German practitioners speak of it as an almost unfailing remedy. Laennec admitted that it calmed the spasm of the bronchi and diminished the difficulty of breathing. Guersent, Blache, and Baron also recommend the belladonna, Trous- seau combined it with opium and valerian. Dr. Wallor of London, also, bears testimony to its efficacy, and we have in its favour the evidence of many distinguished practitioners in this country. Dr. Turnbull, of Philadelphia, (Trans. Penn. State Med. Soc, vol. v.,) says that he has found nothing so prompt and efficacious in the second stage of hooping-cough as the extract of belladonna. He has employed it suc- cessfully in fifteen cases—four of which, of a most aggravated cha- racter, were in members of his own family—five males and ten females, of which the youngest was nine months and the oldest ten years of age. His mode of administering it is, after preparing the system by an antiphlogistic treatment, until the entire removal of fever and in- flammation, as indicated by the reduced state of the pulse, and dimi- nished heat of surface; there being, at the same time, no evidence of congestion of the brain or lungs present, to place the system fully un- der the influence of the belladonna—indicated by the dilated pupil, confused vision, and reddened skin. The medicine to be then inter- mitted until its effects pass off, when it should be again resumed in slightly increased doses, so as to keep the patient under its influence for several days, or until the paroxysms are fully checked, which will usually occur towards the sixth, eighth, or fourteenth day. Dr. Turnbull directs the extract of belladonna to be triturated with water or simple syrup, and if to be kept for some time, and in warm 380 DISEASES OF THE RESPIRATORY ORGANS. weather, with the addition of a little alcohol or spts. lavend. comp. The dose for a child, three months old, is one-sixteenth of a grain every three hours—for a child one year old, one-eighth of a grain, and so in proportion for other ages. Kahleiss administered the belladonna, in combination with Dover's powder and sulphur,1 and between each dose gave a mixture containing hydrocyanic acid.2 We have given to the belladonna a very fair trial, and have in many cases been pleased with the prompt and decided relief produced by it, while, in other instances, it has appeared to exert no influence whatever. A similar remark is made by Vondembush and Lombard. We have generally employed the extract, in the dose of from one-eighth to one-sixth of a grain, two or three times a day, sometimes oftener, combined with from one-fourth to one-third of a grain of ipecacuanha. 1 R.—Rad. belladonnse pulv. gr. v. J R.—Aquse chamomil. ^ss. Pulv. ipecac, compos, gr. x. Syrupi simpl. sjij. Sulphur, prsecip. sjss. Acid, hydrocyanic mj xij. Sacchar. alb. Qij.—M. Twelve drops to be given between each f. ch. No. xx. dose of the belladonna. One to be given every three hours to a child two years old. Dr. Pieper recommends frictions upon the epigastrium with the ex- tract of belladonna, dissolved in saliva. In children of six months, he rubs in one grain of the extract thus dissolved, augmenting gradually the dose. Other narcotics have been recommended, as the camphor, the co- nium maculatum, the hyoscyamus, the stramonium, and the extract of nicotiana. Of the effects of these, with the exception of the hyoscy- amus, we have no experience. The hyoscyamus we have repeatedly employed from a very early period in the attack, always in combina- tion with ipecacuanha, and have invariably derived advantage from its use. The hydrocyanic acid has been strongly recommended, as a remedy in hooping-cough, by Muhrbeck, Kahleiss, Volk, Heller, Granville, and others: by some, it is considered to possess a "specific power" over the disease. Professor Thompson regards it as the sheet anchor of the practitioner; he commences its use, immediately after the opera- tion of an emetic and brisk purgative, and continues it, with no other alteration than a gradual increase of the dose, until the disease is sub- dued. Dr. Roe is convinced, that in warm weather, it will cure al- most any case of simple hooping-cough, in a short time; that in all seasons, it will abridge its duration, and that in almost every instance where it does not cure, it will, at least, materially relieve the severity of the cough.1 Dr. Atlee, of Lancaster, has, in a number of cases, ef- fected a cure, in from four to fourteen days, by its use ;2—he restricts it, however, to the second stage of the disease. Dr. Lombard gave from half a grain to a grain of the hydrocyanuret of potass, in the twenty-four hours, in cases in which there was much irritation, and a great variety of nervous symptoms. Employed, comparatively, on a brother, whose sister was taking the sub-carbonate of iron, this last remedy had a most undoubted advantage. HOOPING-COUGH. 381 1 R-—Acid, hydrocyanic. (Scheele's) tjjj xij. 2R.—Syrup, simpl. ^j. Liquor, antimon. tartarisat. gj. Acid, hydrocyanic. nj;j.—M. Tinct. opii camphorat. ^ijss. A teaspoonful morning and evening: and if Misturae camphorse, sjvijss.—M. no uneasiness, dizziness, or sickness, is Dose.—A tablespoonf'ul every four hours, in produced within forty-eight hours, the some warm drink; the putient to remain dose to be repeated three times a day. in a warm room, and to live upon light This prescription is for a child six pudding and broth. This prescription months old: one drop more of the acid Dr. Roe directed for a delicate boy four being added for each year of the child's years old. For a healthy-looking female age, beyond one year. He has never child five years old, he directed— repeated the dose more than four times R.—Acid, hydrocyanic. (Scheele's) m» xx. a day. Liq antimon. tartarisat— Vini ipecacuanha1, ui 3Jss. Aquae, gxiij. — M. Dose—A teaspoonful every two hours. In the few cases in which we have prescribed the hydrocyanic acid, the remedy certainly produced very favourable effects; but we never trusted to it alone, and hence it is difficult to say, whether all, or how much of the benefit derived could, with propriety, be attributed to the acid. It comes to us, however, too strongly recommended, not to demand a more extended trial, particularly in the more violent cases of the disease. Of the antispasmodics that have been recommended in the treat- ment of hooping-cough, the assafoetida, zinc, and sesquioxide of iron, appear to be those most deserving of trial. The assafoetida has in its favour very strong testimony. We have employed it extensively, and have always been pleased with its effects; we have given it, by itself, in solution, or in combination with the tincture of hyoscyamus, or the watery solution of opium. Dr. Lombard states- that he has often known frictions to the spine with the tincture of assafoetida, of great service, and we have found a plaster of assafoetida applied on the chest, promptly to relieve the cough which is liable to remain after the more acute symptoms have abated. The oxide of zinc will, in many cases, be found a useful remedy in arresting the spasmodic cough, in the second stage of the disease. Dr. Lombard has employed the remedy extensively, in the dose of from four to twelve grains a day; he found it generally to abate the violence of the paroxysms, and has seen complete cures effected by it alone. In two very young infants, whose cough was attended with symptoms resembling epilepsy, the oxide of zinc stopped both the cough and the fits. Dr. L. has never seen any bad effects result from its use; our own experience is decidedly in its favour. But the remedy which appears to claim, above all others, our attention, is the precipitated sub-carbonate of iron, (sesquioxydum ferri.) This was first recom- mended by Dr. Steymann, who directed two and a half grains every three hours, increasing one grain for each year of the child's age be- yond the first. Dr. Lombard, however, gave it to the extent of from twenty-four to thirty-six grains, in water and syrup, or some cough mixture. "I think," Dr. L. remarks, "I may assert with confidence, that the sub-carbonate of iron enjoys a remarkable property to lessen the violence of the paroxysms, to diminish their frequency, and after a certain number of days, to cure entirely the hooping-cough. It en- 382 DISEASES OF THE RESPIRATORY ORGANS. joys, besides, the advantage of strengthening the little patients, and thus gives them the force to resist a complaint, which sometimes lasts for weeks, and generally leaves them weak, low, and exhausted. In some patients I have seen it cause, during the first day or two after its use was commenced, a temporary increase of the cough, but this always subsided after two or three days, and did not prevent the good effects of the remedy." In the few cases in which we have had an opportunity of employing the remedy, its curative effects were not very strikingly evinced. A great variety of other remedies have been proposed, for the cure of hooping-cough; as the tincture of cantharides, either alone, or combined with the tincture of bark, with quassia or with cicuta, &c.; by Lettsom, Sutcliff, Chalmer, Shafer, Pearson, Beatty, Millar, and Bucholtz; the musk, by Stoll, Hufeland, Gesner, Lobel, and Dewees; sulphuret of potass, ten grains mixed with honey, morning and even- ing by Blaud; the liquor subacetatis plumbi, by Forbes; garlic, inter- nally and externally, by Hufeland and Dewees; the arsenical solution by Ferriar, Simmons, and Eberle; the lobelia inflata, by Eberle and Andrews; and various fumigations, as of benzoin, tar, galbanum, nitrous acid vapour, &c., by Dohm, Watt, and Eberle. The lobelia inflata is spoken of in terms of the highest commenda- tion. Eberle states that he prescribed it for five or six years in a very considerable number of cases, generally with some advantage, and in several instances, with the most decided success,—it not only mitigating the violence of the cough, but abbreviating, in many cases, the course of the disease. He directed the saturated tincture, in union with the syrup of squills, in doses of ten drops each, four or five times daily, to a child two years old; and has raised the dose, in some cases, to twenty drops. Dr. Golding Bird remarks (Guy's Hospital Reports, April, 1845,) that in the second stage of pertussis—after all inflammatory symp- toms have subsided, and when, with a tolerably cool skin and clean tongue, the patient is still severely distressed by the more or less co- pious secretion of viscid mucus in the bronchi, each attempt to get rid of which, produces the exhausting and characteristic cough, he knows of no remedy which will be found to give such marked and often rapid relief to the child as alum. Dr. Bird gives the alum in doses of from two to six grains, repeated every four or six hours, to children from one to ten years of age. For a child of two or three years he employed generally the following formula:— R. Aluminis, gr. xxv.; extr. conii, gr. xij.; syrup, rhceados, 5ij.; aq. anethi, Siij. M. Dose, a medium-sized spoonful, every sixth hour. Dr. B. has never met with any inconvenience from the effects of the remedy on the bowels; on the contrary, in more than one instance it produced diarrhoea. The only obvious effects resulting from its use were dimi- nished secretion, and of a less viscid mucus, with a marked diminution in the frequency and severity of the spasmodic paroxysms. In a recent edition of Underwood's Treatise, edited by Dr. Davis, of London, that gentleman remarks that, after a long trial, he is dis- posed to attach more importance to alum, as a remedy in hooping- HOOPING-COUGH. 383 cough, than to any other form of tonic or antispasmodic. He has been surprised at the speed with which, in many cases, it arrests the severe spasmodic fits of coughing; it seems equally applicable to all ages, and almost to all conditions of the patient. The fittest stage for its administration, he believes to be the moist condition of the air-pas- sages, and freedom from cerebral congestion; but an opposite condi- tion would not preclude its use, should this state not have yielded to other remedies. It generally keeps the bowels in proper order, no aperient being required during its use. The dose for an infant is two grains three times daily; and to older children four, five, and up to ten or twelve grains may be given, mixed with syrupus rhceados and water. We have prescribed the alum during the second stage of pertussis, in a large number of cases, and invariably with the most decided benefit. In the Annuaire de TMrapeutique for 1846, it is stated that M. Ber- ger, in the convulsive stage of hooping-cough, in which the indication is to combat nervous irritation, having become dissatisfied with the effects of the remedies ordinarily employed, was induced to administer the nitrate of silver, from which he has obtained results singularly bene- ficial. He prescribes it in doses of from a sixteenth to a twelfth of a grain, at first three times, and afterwards four times a day; of course the remedy should not be administered in cases where the state of the digestive organs contra-indicates its employment. M. Jules Guyot, in the Union Medicate for April, 1849, recommends a strong infusion of coffee, well sweetened, in the dose of a teaspoonful for a child of two years, and a dessert-spoonful for a child of four years, repeated four times or oftener daily, as an effectual means of arresting the paroxysms of coughing in the chronic stage of per- tussis. Dr. Simpson of Edinburgh has recently recommended the inhala- tion of chloroform as an effectual means of arresting and controlling the paroxysms of violent spasmodic cough in the more severe cases of the disease. " Soon after the discovery of the anaesthetic effects of sulphuric ether, it struck me," remarks Dr. Churchill, (Diseases of Infants and Children,) " that it would be likely to modify or suspend the spasm in hooping-cough; and having a case under my care, I directed a little (I suppose about half a drachm) should be spilled upon the nurse's hand, and held before the child's nose and mouth, at the commence- ment of a fit of coughing. I preferred this simple mode of adminis- tration, (and do so still,) because of the impossibility of thereby giving an over dose. The effect surpassed my expectation: most generally the paroxysm was shortened more than one-half—often stopped imme- diately—and the duration of the disease unquestionably considerably diminished. Since then I have tried the ether in twelve or fourteen cases, and chloroform in six. In one or two cases, no benefit accrued, in others great mitigation of the spasm, and in three or four, almost complete relief when the ether was applied at the beginning of a fit of coughing. Decidedly, also, in two-thirds of the cases, the course 384 DISEASES OF THE RESPIRATORY ORGANS. of the disease was much shortened, so that I look upon this as a valu- able addition to our remedies. In no instance was insensibility or the least inconvenience occasioned." Dr. Arnoldi of Canada has recently communicated his experience in favour of nitric acid as a powerful remedy in hooping-cough. At whatever age the disease occurs, whether in a child at the breast or in a full-grown adult, he administers nitric acid in solution, as strong as lemon juice, sweetened ad libitum. "I have given, he remarks, to a child of two years of age as much as one drachm and a half of concen- trated nitric acid, in the above manner, per diem, and I have never known the disease to resist its use beyond three weeks." In some in- stances under its employment he has seen the disease cured in eight or ten days. Dr. Gibb, (Treatise on Hooping-Cough, London, 1854,) declares that he has found the nitric acid to act almost as a specific. Dr. M*Nelley,of Fayetteville, Tenn., (Trans. Amer. Med.Asso. Vol. 6,) has also employed the remedy, and with the most decided good effects. The topical application of a strong solution of the nitrate of silver to the larynx has been recommended as an efficacious remedy in hooping-cough. Dr. E. Watson, of Glasgow, (Asso. Med. Journal, 1853,) informs us that he has employed it with the best results, when the disease was at its height, the paroxysms of coughing recurring every fifteen minutes. Under the use of the remedy the spasmodic whoop was generally arrested within eight or ten days, an obvious mi- tigation ensuing upon the first application of the nitrate of silver. The remedy was also employed by him in cases where the disease appeared to be commencing—the patients being the members of families in which it prevailed, and exhibiting the usual precursory symptoms of an at- tack; in these the development of the disease was arrested. Dr. Wat- son employed the nitrate of silver in the proportion of from fifteen to forty grains to an ounce of distilled water—applying the solution every second day, first to the fauces, and finally to the larynx. He adduces in favour of the remedy, the experience of M. Joubert, of Cherion, who has employed it in sixty-eight cases of hooping-cough, of which number a speedy cure was effected in 40; great relief and shortening of the disease in 20; while no benefit occurred in 8. The cases of the disease treated by Dr. Watson from beginning to end with the local application of the nitrate of silver, were fifty-seven; in all of which, he states, a more or less speedy cure was effected— namely, in 38 cases, in from 10 to 14 days; and in 19 cases, in from three to four weeks. " Combining these two tables." he remarks, " we have, in the first place, 125 cases of hooping-cough treated in this manner without one death. Only eight of the whole number resisted the treatment. Of the remainder, 78 were speedily cured, and 39 were greatly relieved and shortened. What better proof can be asked of the efficacy of the topical treatment of hooping-cough? Am I not warranted in believing that, were it generally adopted, much suffering would be saved, and many lives would be prolonged beyond the first, the most interesting, but perhaps, also, the most dangerous epoch of human existence?" During the employment of whatever narcotic or antispasmodic re- HOOPING-COUGH. 385 medy we may adopt, its effects should be carefully watched, and if any symptoms appear, threatening the occurrence of disease of the brain or lungs; or if the tongue becomes more and more red, the dis- charges from the bowels more and more frequent, thin and vitiated, and tenderness of the epigastrium is observed upon pressure, it should be at once omitted, and leeches or cups applied to the temples, nape of the neck, or epigastrium, according to the seat of irritation, together with warm sinapised pediluvia, and the other remedies which the cha- racter and extent of the symptoms may indicate. By watching thus the incursions of disease in those organs most liable to be affected in the course of the attack, and meeting it in its onset by an appropriate treatment, we shall save many patients, which by neglect, or by keeping the attention too much fixed upon the paroxysms of spasmodic cough, would be most certainly lost. Towards the close of the disease, the patient will often be much benefited, and his convalescence confirmed, by the administration of some mild tonic; the bark, either in substance or infusion, or the sul- phate of quinia, has been highly extolled at this particular juncture. It is probable, however, that the use of the sesquioxide of iron may render the use of other tonics unnecessary. During convalescence, the utmost attention should be paid to the clothing, diet, and exercise of the patient. Exposure to cold, indiges- tible food, or overfeeding, will be liable to produce a relapse. If the bowels are costive or sluggish, they should be kept regular by gentle laxatives; if diarrhoea attend, Dover's powder, or some light astrin- gent will be proper, and if the discharges are thin or vitiated, small doses of calomel, combined with chalk, ipecacuanha, and extract of hyoscyamus, the warm bath, and a regulated diet. In some cases, sponging the body daily with tepid salt water, has been found deci- dedly beneficial. The principal writers on the disease, agree as to the importance, towards its decline, of change of air. After severe and protracted cases especially, it is, in fact, as remarked by Gregory, often the only thing that wrill give to the patient a chance of recovery. In many cases that had baffled all attempts to stop the cough, a change of air has accomplished the cure. It has been found equally indifferent, whether the patient be removed out of or into town, provided there is a change, and even a removal to a very short distance has been suffi- cient. The change, if possible, should be to the sea-coast, or to a high, dry situation in the country; this change, however, unless it be to a warmer climate, is improper so long as the weather continues cold or changeable, but in the latter part of spring, during the con- tinuance of summer, and in this climate, until late in autumn, it will be productive of the best effects. Where a permanent removal cannot be effected, daily exercise in the open air should not be neglected, always taking care to guard against cold and dampness, by proper clothing, and all other suitable precautions. 25 386 DISEASES OF THE RESPIRATORY ORGANS. 10.—-Foreign Bodies in the Larynx and Trachea. Although it is not our intention to consider all the surgical affections of children, yet as the phenomena which result from the accidental in- troduction of foreign substances into the larynx and trachea, often simulate very closely the symptoms of some of the more violent dis- eases of the respiratory organs to which children are liable, it seems proper to notice, in this place, the signs upon which the diagnosis may be founded. When the child is known to have introduced into its mouth some small body which has accidentally fallen into the trachea, giving rise immediately to severe dyspnoea, with stridulous inspiration, convulsive cough, and the other symptoms usually resulting from the existence of any impediment to the free ingress and egress of air into and from the lungs, of course the only question to decide, is the proper measures to be taken to relieve the respiration, and remove the impediment. If the foreign body be completely within the larynx or have passed into the trachea, the propriety and probable success of the operation of tracheotomy, should be fairly and cautiously considered. That the operation, when early resorted to, has repeatedly succeeded in affording complete relief, there is sufficient evidence upon record, and hence, when it has been decided upon, no time should be lost pre- vious to its performance; for we have seen, in more than one case, so violent a bronchitis ensue at an early period after the occurrence of the accident, as to render the operation unavailing, even when the foreign body has been extracted. In some cases, however, the body having passed into one of the bronchi, cannot be extracted by any in- strument introduced through the opening in the trachea, and is not dislodged, notwithstanding the violent fits of convulsive cough to which its presence gives rise. In one of these cases which fell under our notice, the child lived three months, and exhibited before death nearly all the symptoms of consumption of the lungs. Upon dissection, a small metal button was found firmly fixed, towards the middle of the right bronchus. Both lungs were affected with lobular pneumonia, and the right with exten- sive vesicular bronchitis: on being cut into, the lung appeared to con- sist of an immense congeries of minute abscesses. In the left lung, there existed extensive interlobular and sub-pleural emphysema. The mucous membrane of the right bronchus was thickened, and covered with a thick layer of dense, almost membranous mucus; traces of which were found, also, in the lower part of the trachea, and left bronchus: at the part where the button was lodged, the membrane was softened and ulcerated to a considerable extent: no part of the luno«s presented any traces of tubercles. In another case, after six weeks, during which the patient's symptoms were precisely those of chronic bron- chitis, the foreign body, a large bead, wTas expelled, and the child gra- dually regained his health. In many cases, however, the circumstance of a foreign body having passed into the larynx or trachea may not be suspected, and then it is only by a close and careful scrutiny into all the circumstances—the FOREIGN BODIES IN THE LARYNX AND TRACHEA. 387 symptoms under which the child labours, and the signs derived from auscultation and percussion—that we are able to detect the real nature of the accident. The symptoms produced by a foreign body in the larynx or trachea, are often those of laryngismus stridulus, or spasm of the glottis; in other cases, after a few days are passed, they become more nearly those of croup; while in numerous instances, the only Bymptom present is a violent, convulsive, ringing cough, coming on at irregular intervals, but without the stridulous respiration or severe dyspnoea of either croup or hooping-cough; the child, in the intervals, being apparently free from every symptom of disease. When a child, that has presented nothing to indicate the approach of any serious disease, is suddenly attacked with violent dyspnoea and convulsive cough, and symptoms of impending suffocation—the dys- pnoea being greater during respiration than inspiration—which symp- toms, after continuing for a longer or shorter period, suddenly cease, and the child appears tolerably well, with the exception, probably, of a hoarseness of respiration:—but, after a time, the same phenomena return, with similar, or even greater violence, and thus continue to intermit and recur, irregularly, we may suspect the presence of some foreign body in the larynx or trachea. When in the former, however, the paroxysms of dyspnoea and convulsive cough, are of much greater violence, and of longer continuance, than when the body has passed into the trachea; the intermissions, also, are shorter and less perfect. When the foreign body is in the trachea, or probably in one of the bronchi, we have known many hours, and even entire days to elapse, without the recurrence of a paroxysm. The stethoscopic signs are chiefly valuable at the commencement, before inflammation of the bronchi has set in. When the foreign body is fixed in the larynx, as is likely, if it be a fish-bone or other pointed substance, the healthy respiratory murmur will be plainly distinguish- able throughout the whole extent of the thorax, which will also return a clear sound upon percussion. Some mucous rhonchus will probably be audible in the upper portion of the trachea, owing to the accumu- lation of fluid, in consequence of the irritation which has been induced. When the foreign body is moveable, as a button, plum-stone, &c. would be, its motion up and down the trachea will be occasionally heard, as well as a valve-like sound, produced by its being driven in expiration against the rima glottidis. There may also be perceived, at times, a temporary interruption to respiration in one lung, when the body hap- pens to be impacted in the corresponding bronchus; the respiratory murmur again returning, when the obstruction has been removed by violent expiration. It is said that the foreign body is most likely to pass into the right bronchus, and that hence, it is in the right lung we shall most frequently observe the obstruction of respiration.—(Maun- sell.) After some time has elapsed, however, should the foreign body not be expelled by a violent fit of coughing, bronchitis, or tracheo-bron- chitis will ensue, and our only guide will then be the history of the case, as the stethoscopic signs will not assist us in our diagnosis. The most obscure cases are those in which a small, smooth, rounded 338 DISEASES OF THE NERVOUS SYSTEM. body has passed into the trachea, and lodged in one of the bronchi. We have known a case of this kind, in which, after the first day, there was a complete intermission of the dyspnoea, spasmodic cough, and every other symptom, the child continuing for very nearly a week ap- parently free from all disease, except an occasional hoarseness of res- piration, and a short hacking cough, which recurred at short inter- vals; these symptoms gradually increased, and a violent attack of pneumonia, confined principally to the right lung, occurred, and termi- nated fatally in five days; when, upon dissection, a small glass ball, of the size of a large bead, was discovered, deep in the right bronchus, the presence of which had not been suspected during the lifetime of the patient, though, upon inquiry subsequent to the autopsy, it was as- certained that it had been given to the child to amuse him, on the day he was first attacked, and had been missed from that period. " There will, however, be but little difficulty in forming a correct diag- nosis, in a majority of cases, if their history be carefully attended to. Thus, suppose a child has been playing with a grain of corn, bean, peb- ble, or similar body, and has been suddenly seized with symptoms of suffocation, violent spasmodic cough, lividity of the face, pain in the upper part of the wind-pipe, and partial insensibility, the presumption will be strong, that the substance, whatever it may have been, has slipped into the air passages, and is the immediate and only cause of the suf- fering which the surgeon has been sent for to relieve. The presump- tion will be converted into almost positive certainty, if the child was just previously in the enjoyment of good health; if he was romping, jumping, or laughing at the moment of the accident, with the substance, perhaps, in his mouth, or while attempting to throw it into that cavity, and especially if the symptoms, after having been interrupted for a few minutes, continue to recur, with their former, or even with increased intensity, at longer or shorter intervals."—(S. P. Gross, Prac. Treat. on Foreign Bodies in Air Passages, Philada., 1854.) SECTION III. DISEASES OF THE NERVOUS SYSTEM. 1—Hypertrophy of the Brain. Enlargement of the brain, from a simple increase of organic par- ticles, without any appreciable change of structure, is a very common occurrence in infancy. Its existence has been cursorily referred to by Portal, Otto, Hufeland, Scoutettin, Dance,Laennec, Jadelot, and Bouil- laud; while its occasional presence, in patients that have died of epi- lepsy, and other chronic diseases, is noticed by a few of the earlier writers. It is chiefly, however, to the observations of Andral, Munch- meyer, Sims, Green, Lees, and Mauthner, that we are indebted for any HYPERTROPHY OF THE BRAIN. 3S9 accurate views in relation to its phenomena, diagnosis, and general pathology; upon each of which particulars there still, nevertheless, exists much uncertainty. It can scarcely be doubted, that the phenomena resulting from par- tial or general hypertrophy of the brain, are almost daily ascribed to causes which have no existence at the time, while their actual source is entirely, overlooked. Convulsions, epileptic attacks, idiocy, active inflammation of the brain, terminating in softening and apoplexy, are often induced by cerebral hypertrophy, in cases in which the latter has attracted little or no attention; while in other instances the patient is supposed to be labouring under chronic hydrocephalus, and when, as is not unfrequently the case, the hypertrophy terminates in serous effusion, the post-mortem appearances are adduced as conclusive evi- dence of the correctness of the diagnosis. It is of importance that an accurate diagnosis should be established, in order that we may be enabled to detect the existence of hyper- trophy of the brain, at as early a period as possible; for if any thing is to be done to arrest the progress of the disease, it must be before the brain has acquired any considerable augmentation in size. It is to be recollected that cerebral hypertrophy is almost invariably de- veloped slowly; that the peculiar phenomena produced by it, very generally present themselves so gradually, as to excite at first but little attention or alarm, or, if noticed, they are seldom referred to their true cause, until they have acquired an extent and character when they are no longer under the control of remedies. Hypertrophy of the brain, or at least a condition of that organ strongly predisposing it to undue, and more or less rapid augmenta- tion in bulk, is very frequently congenital. Children are often born with heads, the dimensions of which far exceed the normal standard. and greatly disproportioned in size to the residue of the body; in other instances, the head at birth presents nothing remarkable in its bulk or form, but soon after, rapidly increases in size, and often attains. within a short period, an enormous magnitude. In many of these cases, the cranium being developed in the same ratio with the brain, no morbid symptoms are produced, or but slight ones. So far as our own observations extend, however, we have, in every case, observed more or less apathy, dulness and drowsiness, to accompany undue de- velopment of the brain, and this at a very early period. At a later period, and particularly when the growth of the cranium is slower than that of the brain, the symptoms that have been most generally observed, in addition to the undue size of the head, and a peculiar projection of the parietal protuberances, are, obtuseness of intellect, characterized chiefly by apathy to external objects, a very great irritability of temper, inordinate appetite, giddiness, and habit- ual headache, with severe exacerbations. The only instance we have met with in which the intellectual faculties were increased in develop- ment and activity, is that of Dr. Elliotson; the patient, a lad of twelve years of age, "used," we are told, "always to seek the company of persons older than himself; and nothing pleased him more, than to converse on the best forms of human governments. Political eco- nomy was his delight."' The patient died of apoplexy. Another 390 DISEASES OF THE NERVOUS SYSTEM. diagnostic sign, noticed by Sims and Green, as occasionally present in cases of hypertrophy of the brain, is a sensation of firmness com- municated to the finger, on pressure being made over the fontanelles. In one case of cerebral hypertrophy, in a child between five and six years of age, the skull was enlarged to such a degree, that the head acquired a magnitude equal to that of an adult, and yet the functions of the brain were undisturbed, and the only phenomena which the child presented during life, were frequent falls, occasioned by the weight of the head—which wras carried forward wheuever the patient wished to run—and a great tendency to sleep, when he remained quiet. The patient died of acute enteritis, and the brain exhibited a great develop- ment of all its parts, with only a small quantity of reddish serum in the ventricles. It must be evident that children labouring under hypertrophy of the brain, will be particularly predisposed to cerebral disease; in such, cerebral hyperaemia is readily produced by trifling causes, and from the degree of compression to which the brain is constantly subjected, whenever the hypertrophy is of any extent, much more serious conse- quences will result from a slight increase of blood in its vessels, than when the organ is in its normal condition. Apoplectic seizures have been noticed as preceding, accompanying, or resulting from hyper- trophy of the brain. We have repeatedly observed deep comatose seizures of some duration, and complete apoplexy, with extravasa- tion of blood in the substance of the brain. Children with excessive enlargement of the head, we have found, also, to be particularly pre- disposed to convulsions, acute meningitis, and hydrocephalus, from either direct or remote irritations. When the capacity of the cranium does not increase with the in- creased development of the brain, or when the hypertrophy com- mences at a period when the ossification of the skull has been nearly completed, the phenomena produced are of a much more decided cha- racter, than when the growth of the cranium and brain go on simul- taneously, or nearly so. In these cases, the symptoms usually present are, intense, habitual headache, augmented at irregular intervals; ver- tigo, or a sense of dizziness; increased dulness of intellect, amounting, in many instances, to complete idiocy; and debility of the limbs, par- ticularly of the inferior extremities, which goes on increasing, until, finally, general paralysis results. There ordinarily occur convulsive / movements or twitchings of the muscles, at first slight, and occurring at long irregular intervals, but becoming gradually more severe and frequent, until regular convuls-ive paroxysms ensue, during one of which, death often takes place; or a state of coma may ensue, termi- nating sooner or later in death. The convulsions attendant upon hypertrophy of the brain not unfrequently assume all the characteris- tics of epilepsy. In some cases there suddenly ensues a considerable reduction, and, occasionally, entire abolition of sensibility. In other instances, the patient is suddenly attacked with acute delirium or deep coma, more or less quickly followed by death. Mania was observed by Andral in one case. There is, generally, an inordinate appetite; a torpid state of the bowels; and, occasionally, a marked slowness of the pulse. In HYPERTROPHY OF THE BRAIN. 391 the majority of cases that have fallen under our notice, the patients have been inclined to fat, and often every part of their bodies was ex- cessively loaded with it. Mauthner has remarked a frequent coinci- dence of enlargement of the thymus gland, the left side of the heart, and the liver. Death, in the majority of cases of hypertrophy of the brain, has occurred suddenly, during a convulsive attack; it has, how- ever, been repeatedly preceded by an attack of genuine apoplexy, with effusion of blood in the substance of the brain; and in some cases, by all the symptoms of acute hydrocephalus. The disease is divided by Andral into two stages; 1st. The chronic; marked by few symptoms, or simply by slight obtuseness of intellect, more or less headache, either permanent or intermittent, vertigo, apathy, drowsiness, and convulsions at intervals. All of these symp- toms may occur in the same individual, simultaneously or successively, or only one or more of them may be observed. 2d. The acute stage; the phenomena of which are, sudden attacks of violent convulsions, idiocy, epileptic paroxysms, deep coma, or symptoms of acute hydro- cephalus. The duration of life in children affected with hypertrophy of the brain, is extremely variable. Many arrive at puberty with but little suffering or inconvenience, while others die at an early age from the accidental occurrence of hyperaemia of the brain, convulsions, or cere- bral inflammation, or from symptoms resembling acute hydrocephalus. In some instances, death occurs suddenly, without being preceded by any particular symptoms of disease; and occasionally death takes place from diseases unattended throughout with any indication of cerebral affection. The prognosis, according to Dr. Lees, is not necessarily unfavoura- ble, for, as the affection is rather an error of development than an ac- tual disease, there is a natural tendency in the brain to return to the normal state. The chief danger results from the very great suscepti- bility of the hypertrophied brain to disease, especially upon the occur- rence of the affections incident to dentition, of pertussis, or of either of the febrile exanthemata. The appearance of the brain upon dissection is that of simple en- largement, with flattening of the convolutions, diminished amount of blood in its vessels, little or no serum in the ventricles, or beneath the membranes, and morbid paleness of the cortical substance. The sub- stance of the brain is in many cases increased in density, resembling boiled albumen, blanc-mange, or cream cheese. Sometimes, according to Sims, the hypertrophy is confined to one lobe, or to the corpora striata or thalami. Whether these partial hypertrophies are marked by any peculiarity of phenomena, we are unable to say. In all cases the hypertrophy is chiefly confined to the cerebrum, the cerebellum being seldom much, if at all affected. In some instances, the brain, or rather the vessels of the pia mater, are injected with blood; in others, a slight amount of reddish serum is found at the base of the brain; in others, again, a clot of blood, with rupture of the fibres of the medul- lary portion, will be detected; whilst in a few, we have more or less extensive softening of the substance of the organ; but in all these cases, death will have been generally preceded by symptoms of cere- 392 DISEASES OF THE NERVOUS SYSTEM. bral disease, in addition to those which properly belong to hypertro- phy of the brain. Professor Rokitansky states, as the result of many microscopic ex- aminations, that the augmentation in the bulk of the brain is not the result of a development of new nervous fibrils, nor of the enlargement of those already existing, but that it is due to an increase of the in- termediate granular matter. The principal affection with which hypertrophy of the brain is apt to be confounded, is chronic hydrocephalus, to which its phenomena bear a strong resemblance, and with which it has unquestionably been repeatedly confounded. This occurred in cases referred to by Hufeland, Jadelot, Laennec, and Scoutettin. In the first case re- lated by Dr. Sims, the mother of the child informed him, that they had wished to tap the head at one of the hospitals; and Dr. Hennis Green saw a child who had been condemned to death by a medical man, as having water on the brain, but which was a case of simple hypertrophy, that did not interfere with the health of the patient. It has been suggested by Dr. Lees, that the peculiar projection of the parietal protuberances on which Munchmeyer particularly insists, may prove a valuable guide in aiding us to discriminate cerebral hypertrophy from chronic hydrocephalus. The sensation of firmness communicated to the finger on pressure being made over the fon- tanelles, in cases of hypertrophy, as contrasted with the fluctuating feel, in cases of chronic hydrocephalus, has also been proposed by Dr. Green as a diagnostic sign: but this, it is evident, cannot apply, excepting in very young subjects, or in extreme cases. Dr. Mauthner-(Krankheiten des Gehirns, Vienna, 1844) lays dowii the following diagnosis between hypertrophy of the brain and chronic hydrocephalus:—In hypertrophy, it is the posterior part of the skull which is observed first to become unnaturally prominent, the projec- tion of the forehead occurring subsequently, while in chronic hydro- cephalus the projection of the forehead is one of the first results of the disease. The latter affection is usually associated with a gene- rally emaciated condition; the former with a leuco-phlegmatic habit, and with increased deposits of fat. The constitutional symptoms of the two affections likewise differ; convulsions, sopor, and restlessness attend the early stages of chronic hydrocephalus, while spasmodic affections of the respiratory muscles are among the earliest indica- tions of hypertrophy of the brain, but seldom occur until an advanced stage of hydrocephalus. Hypertrophy of the brain has been most frequently observed in children of a lymphatic temperament, or in those affected with rickets. It may be preseut at birth, or be developed at any period subsequently. up to puberty. Its most usual exciting causes have not been very clearly made out; there is no doubt, however, that it may, as re- marked by Sims, be more or les3 quickly induced by any cause capa- ble of exciting the brain itself, or that is calculated to increase the nutrition of the body generally. Frequent contusions of the head have been enumerated by Dance, as an occasional exciting cause. By Laennec, Papavoine, and Rilliet and Barthez, the causes of colica pic- tonura have been supposed to have a very great influence on the de- HYPERTROPHY OF THE BRAIN. 393 velopment of the disease. M. Laennec states, that he has never seen a case of fatal saturnine epilepsy, in which there did not exist an evi- dent cerebral hypertrophy. Extensive disease of the heart and lungs, by impeding the return of blood from the brain, or obstruct- ing its circulation, has been suggested by Sims as a probable cause of hypertrophy of the latter. But, we confess, we are at a loss to under- stand in what manner a state of venous congestion of any organ is likely to increase its nutrition ; it is much more reasonable to suppose, with Mauthner, that the hypertrophy is the result of the repeated oc- currence of cerebral hyperaemia, from any cause attracting to the ves- sels of the brain an abnormal amount of blood. It must be recollected, however, that hypertrophy of the brain does not invariably result, in cases in which hyperaemia has repeatedly occurred at short intervals, and that it is frequently met with, where no hyperaemia has been ob- served. In the cases that have fallen under our notice, we have sought in vain for any cause for the excessive development of the brain, beyond a congenital tendency to excessive nutrition of that organ. In regard to the treatment, whether preventive, or that proper during the height of the disease, with the view of reducing the ex- cessive size of the brain, we have very little to say. Our own expe- rience affords us no positive results, and we find nothing satisfactory in the published observations of others. When, in an infant, a tendency to excessive development of the brain is observed, it will be prudent carefully to avoid the slightest cause of increased excitement and determination to that organ. Every precaution should be taken to prevent, as much as possible, frequent or prolonged paroxysms of crying. The bowels should be kept freely open, and the body immersed daily in a tepid bath, followed imme- diately by brisk friction to the whole surface. Sponging the scalp frequently with cold water, appears to be a judicious means of keep- ing down any undue activity in the organic functions of the brain; while, at the same time, the head should be invariably kept uncovered within doors, and be but lightly clothed when the child is taken abroad; even a luxurious growth of hair should be kept down by frequent cutting. The appetite of these children is generally craving; it should, there- fore, be kept under a cautious restraint; and, after the child is weaned, his diet should consist solely of a moderate quantity of farinaceous food, with milk. Daily exercise in the open air, to an extent propor- tioned to the age and strength of the child, should be insisted upon. When teething commences, the evolution of the teeth should be daily and cautiously watched, and the slightest indication of undue swelling, or inflammation of the gums, should be met by free scarifications, re- peated whenever the swelling or inflammation of the gums recurs. When the child is more advanced in age, a serious question will arise as to its education. This should not be commenced too soon. To tax a brain in a state of hypertrophy, and pre-disposed, from the slightest cause, to hyperaemia and undue excitement, Avith even the smallest amount of mental labour, would certainly be a very danger- ous experiment:—hence, when the hypertrophy is advancing with 394 DISEASES OF THE NERVOUS SYSTEM. considerable rapidity, every degree of mental application should be positively prohibited; and those means employed, particularly bodily exercise, as will have a tendency to direct nutrition to the muscular system, and thus, if possible, to suspend its activity in the brain. The slightest indication of undue excitement or hyperemia of the cerebral vessels, should be a signal for the application of leeches to the head, cold lotions to the scalp, the exhibition of brisk purgatives, and the application of counter-irritants to the extremities, as warm sinapised pediluvia, or sinapisms, &c. We believe that our chief efforts are to be directed to prevent the increase of the undue cerebral development;—after it has attained a certain height, we are unaware of any means capable of reducing it, without endangering the life or health of the patient. When the growth of the cranium ceases, while that of the brain continues, the morbid phenomena resulting from the compression of the brain, which invariably results, may certainly be, to a certain ex- tent, abated, the comfort of the patient increased, and life prolonged, by a proper hygienic course of treatment—but all hopes of effecting a cure must be abandoned. 2.—Cerebral Hyperaemia and Hemorrhage. APOPLEXY.--PAKALYSIS. Apoplexy and paralysis are of much more frequent occurrence during infancy and childhood than is generally supposed. We have met with these affections at every age, from one or two days subsequent to birth, up to the period of puberty.1 M. Lasserre has very satis- factorily shown the not unfrequent occurrence of apoplexy in infants immediately after birth. A very considerable proportion of the deaths annually reported as from convulsions, disease of the brain, and acute hydrocephalus in young children, we have reason to be- lieve, are, in fact, fatal cases of apoplexy. When apoplexy occurs in infancy, the attack is generally sudden; but, in many instances, it may be preceded for some days by a de- ranged condition of the bowels; or it may occur after an attack of convulsions, or in the course of some other disease. The symptoms are, invariably, more or less complete stupor, with a tumid and livid appearance of the face, contraction and insensibility of the pupils, laborious or stertorous respiration, and occasionally convulsions or a spastic rigidity of the neck and lower extremities. On recovering from the state of stupor, the child may exhibit no lesion of motion or sensation on either side of the body, or it may be that one entire half of the body, or the upper or lower extremity of one or the other side, may be in a state of complete or partial paralysis. This, however, is but rarely observed. Legendre met with it in one only out of nine cases, and MM. Rilliet and Barthez, in one out of seventeen cases. This results from the infrequency with which effusion takes place into the substance of the brain, the apoplexy of young children being 1 During the 38 years preceding 1845, there occurred in Philadelphia, in children un- der ten years of age, 69 deaths from apoplexy; namely, in those under one year of age, 2/; between 1 and 2, 16 ; betwen 2 and 5, 14; and between 5 and 10, 12. APOPLEXY—PARALYSIS. 395 generally meningeal, and without rupture or other lesion of the ce- rebral tissue. In other cases, the cerebral hemorrhage is attended by scarcely any other symptoms than frequent, intense, or long-continued convul- sive paroxysms; thus Dr. Schleifer, in the Foundling Hospital of Prague, has detected, in cases of convulsions in young infants, a hemorrhage on the dura mater, rarely between the membranes, and never in the substance of the brain. In very young infants, if proper remedies are promptly resorted to, the brain may, in general, be very speedily relieved of its state of hyperaemia, and the patients restored to perfect health; but if the disease be allowed to continue too long, or should it recur repeatedly at short intervals, and the child survive the immediate effects of the attack, serous effusion is very liable to occur in the brain, or some organic change in its structure, resulting ultimately in death, or in an impairment or destruction of the intellectual faculties, or in a per- manent lesion of motion or sensibility of some part of the body. In children somewhat more advanced in age, apoplectic and paralytic at- tacks are generally of a much more unmanageable and destructive cha- racter, often proving immediately fatal, in consequence of extravasa- tion of blood at the base or upon the surface of the brain, and occa- sionally within its texture. The appearances upon dissection in fatal cases, are usually—tumes- cence of the vessels and sinuses of the brain, with sanguineous oozing from the medullary substance of the organ, exhibited in a number of small bloody points upon the surface of incisions made in it, and occa- sionally, serous effusion beneath the arachnoid, at the base of the skull, in the ventricles, or in the theca of the spinal cord. The hyperaemia is occasionally found to affect the vessels and substance of the spinal marrow, equally with those of the brain. Even in cases of paralysis occurring in children, whether they have been preceded or not by symptoms of apoplexy, hemorrhage of the brain from rupture of the vessels, disrupture of the texture of the organ, or even serous effusion, is met with much more rarely than in the adult. In the generality of cases, the only appreciable lesion is extensive hyperaemia of the vessels of the brain and spinal column, and of the meninges and roots of the spinal nerves. (Cazanvielh, Kennedy.) We have, however, in chil- dren over two years of age, repeatedly detected hemorrhage within the substance of the brain after attacks of apoplexy, and, in many cases, have observed persistent paralysis from the rupture of the texture of the brain, caused by cerebral hemorrhage. Effusion of blood either at the base of the brain, upon the surface of its hemispheres or into the ventricles, and along the whole course of the spinal cord, is occasionally observed in children. (Abercrombie, Serres, Legendre, Schleifer.) When the hyperaemia, and effusion of serum or blood, is principally confined to the spine, constituting what has been denominated spinal apoplexy, the phenomena differ somewhat from those generally ol> served in connexion with similar lesions of the brain. When there is simply turgeseeuce of the vessels and texture of the medulla spinalis, the symptoms that have been observed are, occasion- 396 DISEASES OF THE NERVOUS SYSTEM. ally, convulsions, drowsiness bordering on stupor, lividity of the face, drawing down of the corners of the mouth, and the fixation of the arms firmly against the sides. The symptoms from serous effusion, vary somewhat in different cases; thus, in one instance, we may have severe pain in the back, and paralysis of the inferior extremities. In another, opisthotonos, difficult deglutition, and coma. In another, vio- lent convulsions, coma, and distortion of the eyes. In another, con- vulsions, followed by coma, with a permanent clenching of the hands. When blood is effused in the spinal canal, the symptoms are, pain in the back, and general convulsions, or trismus, and convulsions, either tonic or clonic. The amount of extravasation varies considerably in different cases. In one instance Dr. Weber found the dura mater of the cord, from the atlas to the sacrum, covered, both on its anterior and posterior surfaces, with a thick layer of partially coagulated blood. Paralysis may occur in infants, independent of disease of the brain or spinal marrow, from local injury inflicted upon the nerves of the parts paralyzed. Examples of this we have in injury of the portio dura, as in face presentations, or where the head has been long pressed in the pelvis against the projecting ischiatic spines: the paralysis in these cases very generally subsides in a short time. Dr. West, of London, divides paralysis, as it occurs during infancy and childhood, into three forms, according as it is congenital, as it succeeds to symptoms of cerebral disease, or as it comes on without any previous indication of disorder of the brain. It usually presents the form of hemiplegia—the leg being more fre- quently affected than the arm. Sensation is not impaired; occasion- ally, it would seem to be even morbidly increased. The first variety is usually associated with imperfect nutrition of the affected limbs; and, as might be expected, is incurable. Cases of the second variety, for the most part, do well eventually; they are often associated with constitutional disturbance, dependent on the process of dentition. Cases of the third variety occur in debilitated children, and occasion- ally succeed to the eruptive fevers. They often run an extremely chronic course, and the patient's recovery is in many cases only par- tial; or, notwithstanding his general health may become robust, the affected limb will continue powerless—in which case, it gradually wastes away, and becomes, finally, greatly reduced in size. Cerebral hemorrhage, however, often presents itself, attended by symptoms very different from those of ordinary apoplexy, and which have been very generally ascribed to other lesions of the brain. For the investigation of the pathology of this form of disease, we are in- debted almost exclusively to the labours of recent observers, particu- larly to those of Legendre. It generally occurs in children between one and two years of age, and is seldom observed after the third year. The symptoms in the early stage are rather those of encephalic irrita- tion, than of apoplexy; and in the latter stage of protracted cases, they differ but little from those of chronic hydrocephalus. The attack sometimes commences with repeated convulsive parox- ysms; at other times, with all the phenomena of cerebral inflamma- tion; and, in numerous instances, the disease has unquestionably been mistaken for acute hydrocephalus. APOPLEXY—PARALYSIS. 397 The child may be affected with vomiting, though in the majority of cases this symptom is not observed. There is, very generally, in the commencement, severe febrile excitement, with flushed face, hot skin, and a frequent, full, and hard pulse, increased thirst, and loss of ap- petite. The pulse, at first, amounts to 100 or upwards in a minute, and soon increases to 120 or 140, and in the advanced stages of the disease, becomes so rapid as scarcely to be counted. Very early in the attack the patient is affected with slight convul- sive movements, particularly of the eyeballs, followed by some de- gree of strabismus. The bowels are, in general, regular, and the stools natural in appearance. The child is often seen to carry his hands continually, but apparently unconsciously, to some part of the head. There soon occurs a permanent contraction of the feet and hands, followed by convulsions, either tonic or clonic; during which there is an abolition of sensibility and consciousness, and an increased turgescence and coloration of the face. Sometimes the convulsions affect the whole of one side of the body, sometimes the upper limb of one side only; not unfrequently, both sides are affected, but unequally; the convulsive movements being always greater in one than in the other. After continuing for a few moments, the convulsions cease, and the patient remains in a state of drowsiness, which increases with the progress of the disease. The febrile symptoms continue through- out the attack, and augment in intensity as death approaches. The convulsive paroxysms occur, at first, after irregular intervals of some length, but become gradually more frequent, until finally, towards the close of fatal cases, they are almost continual, or rather, the patient is affected with a constant tremor, with momentary con- vulsive paroxysms, during which, the injection of the face is increased, and the pulse and respiration accelerated. In no instance has para- lysis been observed during the acute stage. When death takes place, it is generally at the end of eight or twelve days. The occurrence of thoracic inflammation would appear, according to the observation of Legendre, to be in many cases the cause of death in the acute stage. Very often the disease runs a much more protracted course. The convulsive paroxysms abate in violence, or cease entirely; the febrile symptoms diminish in intensity, and finally disappear; the cranium gradually increases in size, and often attains to a very great bulk; the sutures and anterior fontanelle remaining unossified; and the parietal projections, as well as the forehead, acquire a very considera- ble prominence. In many cases the patient is affected with strabis- mus and his countenance assumes a vacant expression. The pupils are usually dilated, the dilatation being equal in both eyes; vision, according to Berard, is occasionally destroyed. In most cases the intellect of the patient diminishes as the head augments in bulk, and may finally be destroyed. It is, generally, however, only weakened, and the patient becomes, to a certain extent, idiotic; in these cases, he sometimes utters, particularly during the night, prolonged piercing screams, during which he extends his mouth widely open. Cutaneous sensibility is not impaired, even in those instances in which a complete abolition of intelligence and movement takes place. The movements of the body are, however, seldom de- 398 DISEASES OF THE NERVOUS SYSTEM. stroyed; the patients sometimes roll their heads constantly from one side to the other upon the pillow, or when seated, rock continually from side to side the upper part of their bodies. Occasionally they strike violently their head with the clenched fist, or dash it against the sides of the cradle. Grinding the teeth is a common symptom, and one case is noticed by Legendre, in which the patient, exhibiting the physiognomy of an idiot, tore off with his teeth, portions of his garments and bed-clothes, and swallowed them. During the whole of this chronic state the patients, in general, eat and drink with avidity whatever is presented to them. There is never any indication of partial paralysis, nor any diarrhoea: the bow- els are usually constipated. In the greater number of the cases that have been observed, death was, according to Legendre, the result of some accidental disease, unconnected with the affection of the brain. The chronic stage of the disease is generally protracted from eight to thirty months, and would probably continue much longer, if no accidental cause were to occur to accelerate the death of the pa- tient. Cerebral hemorrhage is not necessarily fatal. In the acute stage the symptoms produced by it may be entirely removed, and the pa- tient restored to health without the danger of his becoming subse- quently hydrocephalic. In those cases, in which the hemorrhage is to a slight extent, the blood, very probably, may be entirely removed by absorption; but when a large amount of blood is effused, an or- ganized cyst is formed around it, and the disease acquires then a chronic form. Even when this is the case, however, as soon as the disease has arrived at its height, it has, according to Legendre, a na- tural tendency to decline, and may disappear entirely:—the serous fluid ajid clots in the brain being absorbed, and the cyst containing them gradually obliterated, the cranium will contract in size, and the fontanelles and sutures become completely ossified. The movements and sensation of the body may be fully regained in these cases, but it is probable that there will always remain a certain degree of fatuity or idiocy. The appearances upon dissection, when death takes place in the acute stage, are either a simple effusion of bloody serum, or more fre- quently, of a bloody serum containing small, thin, reddish clots of blood, the whole enclosed in a kind of sac, formed by a soft, thin mem- brane, attached to the lower surface of the arachnoid. The effusion is invariably found within the arachnoid cavity. In the sub-arachnoid cellular membrane, and in the ventricles, there generally exists a small quantity of perfectly limpid, or light citrine-coloured serum. The effusion most commonly occurs upon the surface of both the hemi- spheres. It is sometimes, however, confined to one, and it rarely occurs upon the cerebellum. (Legendre, Boudet.) The coagula are usually very thin, from two inches and a quarter to two inches and a half in extent; they are soft, and of a bright red colour when recent, but become, subsequently, brownish or greenish, and are the more firm the longer the effusion has continued. They may exist on a level with the anterior or middle fossae of the base of the brain, but more generally occur upon the upper surface of the hemispheres. They APOPLEXY—PARALYSIS. 399 are invariably enclosed within a reddish, elastic, soft, delicate mem- brane, but of some degree of firmness, and about one-twelfth of an inch in thickness: it may be detached from the under surface of the arach- noid in small shreds. This membrane always becomes more elastic and firmer the longer the effusion has existed. Most writers refer its production to a mechanical separation of the fibrinous portion of the effused blood, which, deposited on the under surface of the arachnoid, becomes gradually organized:—the first vestiges of organization, ac- cording to Baillarger, present themselves about the fifth day after the effusion has occurred. The veins of the surface of the hemispheres are occasionally gorged with blood, and the cortical substance of a very bright reddish-gray; the incised surface of the brain becoming quickly studded with nume- rous bloody points. The convolutions, according to Legendre, are not sensibly flattened, nor the brain in a state of hypertrophy; the brain has been supposed by Berard, to be in some cases, even reduced in size, which is, probably, however, a mistake. Not the slightest trace has been discovered by Legendre, in any case, of gray, semi-transpa- rent granulations on the pia mater throughout its extent, nor the least appearance of tubercle in any part of the brain. When death occurs at a later period, the coagula are found enclosed in a true organized cyst, with transparent parietes, which adheres in- timately to the lower surface of the arachnoid, by means of a very fine, delicate cellular tissue, very easily torn, and that permits the cyst to be detached entire. The cyst has no attachment to the sur- face of the brain, excepting by numerous small branches of blood- vessels which pass over it to the latter. (Baillarger, Legendre.) The contents of the cyst are coagula of blood and a bloody serum, but more generally the last only, which is then always in considerable.quan- tity. (Berard, Poumeau, Legendre.) The blood is sometimes in the form of soft, red coagula; at others, the cyst contains a brownish, tur- bid serum, in the midst of which float filaments of a soft, somewhat elastic, grayish-red substance, having a close resemblance to fibrine. The cavity of the cyst is at first single, but subsequently it becomes, by'the approximation of its sides at different points, divided into a number of small cells. (Poumeau.) There is generally, according to Legendre, one triangular cavity of an inch or two in length, ex- tending along the falciform process of the dura mater. The etiology of the form of cerebral hemorrhage just described, is but little understood; age appears to be its chief predisposing cause: it has seldom been seen in infants under one year of age, and still less frequently in those over three years. In the great majority of cases the hemorrhage is the result of a simple exhalation from the vessels, consequent upon repeated recurrences of hyperaemia of the brain. It is seldom the result of rupture of a blood-vessel. When the latter is the case, death takes place almost immediately, the blood is unmixed with serosity, and there is no trace of an organized membrane around it. In the cases that have been observed by Legendre, the greater number occurred in the winter, whereas those that have fallen under our notice, occurred in summer, and at least one third of them could be traced to the effects of insolation. 400 DISEASES OF THE NERVOUS SYSTEM. The disease has appeared to us to be in all cases a true irritation of the brain, producing hyperaemia of its meninges, which terminates in an effusion more or less considerable, of blood and serum, upon the surface of the brain, without the occurrence of meningeal or cere- bral inflammation. We agree, therefore, with the suggestion of Le- gendre, that the febrile excitement and slight convulsive movements by which the commencement of the attack is accompanied, mark the period of simple hyperaemia, while the occurrence of carpo-pedal con- tractions, but more especially of violent and repeated convulsive paroxysms, followed by more or less drowsiness, indicate the period when the sanguineous exhalation in the cavity of the arachnoid has taken place. Cerebral hemorrhage is to be distinguished from tubercular menin- gitis by the early age at which it occurs. The latter being seldom developed previous to the sixth year, or at least not until a period beyond that at which the form of cerebral hemorrhage with which it can alone be confounded, occurs. Tubercular meningitis is, also, seldom accompanied by the intense febrile reaction observed in cere- bral hemorrhage. Repeated bilious vomiting and obstinate constipa- tion are likewise common in the first, but very rare in the latter; while the convulsive attacks are neither so constant nor so frequent. The permanent carpo-pedal contraction is absent in the tubercular affec- tion, and constantly present, to a greater or less extent, in hemorrhage of the arachnoidal cavity. _ In its chronic form, hemorrhage of the arachnoid is with difficulty distinguished from chronic hydrocephalus of the ventricles of the brain, the symptoms of the two being nearly the same. The latter affection, however, is often congenital, and commences, in all cases, soon after birth, without any appreciable cause; the head augmenting in size gradually, and acquiring, often, an enormous bulk. On the other hand, the hydrocephalus, which results from cerebral hemor- rhage, is never congenital, but commences, ordinarily, about the tenth month, or at the period of dentition; the head increases in size gradually, but never acquires so great a volume as in chronic hydro- cephalus; the disease is, finally, preceded invariably by repeated con- vulsions, or symptoms of encephalic disease, which mark the period of the occurrence of the hemorrhage. It may be distinguished from hypertrophy of the brain by the aug- mentation of the size of the head, in the latter, preceding the develop- ment of morbid symptoms; whereas, it is only in the chronic stage of cerebral hemorrhage that the bulk of the head is increased. It is proper, however, to remark, that children affected with hypertrophy of the brain are strongly predisposed to cerebral hyperaemia, as well as to meningeal hemorrhage. The prognosis must be based upon the source of the sanguineous effusion, the period at which it occurs, the nature of the phenomena by which it is accompanied, and the circumstances under which the patient is placed. The-source of the hemorrhage is all-important in forming our prog- nosis; if from a ruptured vessel, it is always promptly fatal. There is great difficulty in distinguishing this form of hemorrhage from that APOPLEXY—PARALYSIS. 401 which is produced by simple exhalation, excepting by its rapid termi- nation in death. The age, however, of the patient, may afford us some aid; in young children, hemorrhage of the brain from a rup- tured vessel, being comparatively rare. When the case is recent, the prognosis is the most favourable, for under a judicious plan of treatment, it is then possible that the ab- sorption of the effused fluid may be promoted, and thus, the occur- rence of the chronic form of the disease prevented. When, however, the symptoms of the acute stage are of considerable intensity, the febrile reaction violent, and the convulsive paroxysms occur at short intervals, the hopes of a favourable termination are but slender; and, according to the observations of Legendre, should the patient be at- tacked with pulmonary inflammation, a fatal termination is almost in- evitable. In its chronic stage, meningeal hemorrhage is always a serious disease; for even under the most favourable circumstances, it may produce serious lesions of motion, and more certainly of the intel- lect. When both these functions are completely abolished, the prog- nosis is still more unfavourable: there being little hope that either will be again recovered; the probability is, that before any amend- ment can occur, death will ensue from some other affection. Under all circumstances, there is greater hope to be entertained of a final recovery when the patient is placed under favourable hygienic conditions, than under opposite circumstances. In the pub- lic hospitals of Europe, the disease, according to Baudelocque and Legendre, is almost invariably fatal. In relation to the treatment of cerebral hyperaemia and hemor- rhage, notwithstanding the results of clinical experience furnish us with but little positive information, there cannot be much difficulty in deciding upon the plan best adapted to control the disease, at least in its earlier stages. In the form of apoplexy from simple over-distention of the blood- vessels of the brain, which is that most commonly met with in young infants, leeches to the head will almost invariably be demanded. The safety of the patient requires that the overloaded state of the brain should promptly be reduced, whether it occur as the original affection, or as a consequence of some pre-existing disease; and in young children leeching appears to be one of the safest, easiest, and most effectual mean9 of effecting this. A leech or two will be borne by a new-born infant, and the happiest effects will often result from their application, in cases of hyperaemia, or undue irritation of the brain. The extent of local depletion must, however, be left to the judg- ment of the practitioner; it is to be governed, in a great measure, by the age and strength of the patient, and the urgency of the symp- toms; and while everything depends upon the depletion being suffi- cient to relieve the oppression of the brain, the utmost caution should be observed not to carry it too far, as this may produce a very serious degree of debility, and actually augment, rather than re- duce, the condition of the brain it is intended to remedy. Should the loss of blood produce pallor of the countenance, a quick pulse, 26 402 DISEASES OF THE NERVOUS SYSTEM. and a state approaching to syncope, the administration of some stimu- lant, as wine whey, should be immediately resorted to, in order to prevent the serious, and even fatal consequences, that might other- wise result. If the patient is able to swallow, we should administer, immedi- ately, a brisk purgative, of which the best will probably be calomel, followed by castor oil; the calomel being repeated, subsequently, in small doses, combined with a minute portion of ipecacuanha. When a purgative cannot be administered by the mouth, we must resort to purgative enemata: one composed of tepid water, salt and molasses with the addition of castor oil, will usually be sufficient; but where the symptoms are urgent, an addition of turpentine to the enema will be proper: or it may be composed entirely of castor oil and tur- pentine. In all cases of extensive hyperaemia of the brain, a pretty smart impression made upon the lower portion of the intestines will invariably be attended with the most decidedly good effects. Immersion of the lower half of the body in warm water, while cold lotions are applied to the scalp, when judiciously managed, will often promptly rouse the patient from his state of stupor, and it may subse- quently be repeated, if any tendency is observed to a recurrence of the hyperaemia. Stimulating embrocations to the lower extremities, and along the spine, we have employed in many cases, with very de- cided advantage. Blisters behind the ears, although of little use during the apoplectic attack, have appeared to us to be often useful in preventing its return. In all cases, the immediate safety of the patient, and the prevention of the chronic state of the disease, will depend upon our being able to remove the cerebral hyperaemia, previously to the occurrence of the hemorrhage, and, subsequently, to obtain the absorption of the effused blood and serum, before it becomes enveloped by an organ- ized membrane. Leeching, or when the patient is old enough, bleed- ing from the arm, to an extent proportioned to his age and strength, and the violence of the symptoms present, followed by active purges, warm sinapised pediluvia, and cold applications to the head, will be the remedies upon which we are chiefly to depend, during the early period of the acute stage. After the bowels are smartly opened by purgatives, benefit will be derived from the administration of small doses of calomel, tartarized antimony and nitre,1 every three hours. Blisters to the nape of the neck, or between the shoulders, will occa- sionally be found useful, after the febrile symptoms have been some- what reduced. 1 R-—Calomel, gr. vj. ad xij. Antimon. tartarisat. gr. j. Pulv. nitri, gr. xxxyj. ad xlviij.—M. f. chart. No. xij. In nearly all the acute affections of the brain in children, cold lotions to the scalp are, subsequent to direct depletion, among the most powerful remedies we can employ; simply sponging the scalp with cold water will answer as well, perhaps, as any other lotion, or we may add to the water a portion of vinegar, alcohol, or camphorated APOPLEXY—PARALYSIS. 403 spirits; it is, however, upon their abstraction of heat alone, that the good effects of these lotions depend. In regard to the extent to which the depletion is to be carried, the amount of purgation to which the patient is to be subjected, and the nature of the other antiphlogistic, counter-irritant, and derivative re- medies to be employed and the proper period and intervals for their administration, much must be left to the judgment of the practitioner; no general rules can be given, as important modifications will be de- manded by the character of individual cases, as well as by the age of the patient. But there will be but little difficulty in deciding cor- rectly in relation to the proper indications, and the remedies, by which these are to be fulfilled, if the pathology of the disease be kept constantly in mind. It is to reduce the irritation and consequent hy- peraemia "of the brain, and to prevent its termination in effusion, that our remedial measures are to be directed in the first period of the acute stage; the activity of these measures being commensurate with the intensity of the symptoms in each case. The diet of the patient should be of the mildest and least irritating character. During the height of the disease, it will be proper to pro- scribe every article of food, and confine the child entirely to some simple mucilaginous drink, given cold. Whether, in any instance, meningeal hemorrhage, or rather the ir- ritation of the brain by which it is .induced, is the effect of difficult dentition, we are unable to say; but. as the attacks most frequently occur at the period of the eruption of the teeth, it is important to pay attention, in every case, to the condition of the gums, and if they are found swollen or inflamed, to relieve them by free incisions. After the occurrence of meningeal hemorrhage, the treatment must be governed by the nature and extent of the symptoms present. If depletion has been carried to a sufficient extent in the early period of the attack, leeching or bleeding from the arm will seldom be ne- cessary; but should the acute symptoms still continue with any degree of violence, the application of a few leeches to the head, or of cups to the nape of the neck will be prudent. Under all circumstances the bowels should be kept freely open; and probably the best means for doing this will be by the use of a combination of calomel, tartar- ized antimony, and nitre, at stated intervals: this combination, at the same time that it keeps up a sufficient action upon the bowels, tends to diminish undue arterial excitement. The cold lotions to the head will, also, be proper, and the repetition of warm pediluvia, with blis- ters behind the ears, will generally be productive of good effects. The diet should still be mild and unirritating; the only food allowed in addition to the mucilaginous drinks already recommended, being plain water gruel, or milk and water. Throughout the whole of the acute stage, the patient should be kept as quiet as possible, and guarded, as much as may be, against every thing capable of irritating or exciting him. The temperature of his apartment, and the quality and quantity of his clothing, should be such as will keep his body of a comfortable warmth, and protect him against the effects of sudden transitions of temperature; but, at the same time, the air he breathes should be preserved perfectly pure 404 DISEASES OF THE NERVOUS SYSTEM. by free but cautious ventilation. We are to recollect the danger inva- riably attendant upon the occurrence of any new disease in the course of this affection, and, especially, the liability of the patients to lobular pneumonia from slight causes. When the disease has attained its chronic stage, we have to con- tend against a condition of the brain very much resembling chronic hydrocephalus, but from which, judging from the few facts in our pos- session, there is a much greater probability of the patient's recovery; there being a natural tendency to absorption of the effused fluids, and to an obliteration of the sac in which they are contained. The treatment will consist in guarding against a recurrence of ce- rebral irritation, and promoting the absorption of the abnormal fluids from the arachnoid cavity. The first is to be accomplished, chiefly by judicious hygienic measures, exposure of the patient to a pure, fresh atmosphere,—a mild unirritating diet—a proper temperature of the body; by preserving the bowels regularly open by mild purga- tives, and by the daily use of the warm or tepid bath, according as the existing temperature of the patient's surface is depressed, or other- wise. How far we may be able to promote the absorption of the ef- fused fluid, by the employment of diuretics combined with calomel, iodine internally and externally, and the judicious use of tonics, we must wait for the results of a more extended experience to determine. The prophylaxis is all-important; children peculiarly predisposed to irritation and hyperaemia of the brain, should be placed under the same hygienic treatment as directed in the section on cerebral hyper- trophy. Jt 3.—Convulsions. _ From birth up to the termination of the stage of infancy, convul- sions are of very frequent occurrence; they may take place in the course of almost every disease which attacks at this period of life, and are, in fact, the common precursors of death in all of them. They are often, however, the sole phenomena that are produced by certain irritations of the brain and spinal cord, arising originally in those or- gans, or in some other organ, especially the alimentary canal. Their frequency and the danger by which they are very generally attended, demand for them a separate consideration.1 The parts most generally subject to convulsive movements, are the eyes, the muscles of the face, those of the superior and inferior ex- tremities and those of respiration. Each part of the body may be separately or successively affected with convulsions, or the whole of the voluntary muscles may be simultaneously attacked. Most com- monly, however, the convulsive movements are confined to a single limb or to one side of the body, or, if they occur on both sides, they are always more violent on one side than on the other The convulsions are very generally attended with foaming at the mouth, often with a peculiar hissing respiration; with flushing of the 1 T\\e. n^er, °f deaths from conv«lsions, in children under ten years of ase that oc- curred in Philadelphia, during the thirty-eight years preceding ?845 was 818"> or an ?^nz^rim&t£irunder L year of age: ^~" CONVULSIONS. 405 face, the muscles of which are variously contorted; with injection of the eye3, which are often turned upwards or to one side; with a co- pious perspiration about the head, forehead, and temples, and occa- sionally with a livid appearance of the contour of the eyes and mouth. The head is usually thrown backwards by a rigid contraction of the muscles, and occasionally it is turned on one side. There is often complete trismus, or repeated grinding of the teeth. In very violent cases there is often an involuntary discharge of the urine and faeces. The pulse is generally contracted, and extremely rapid. In violent paroxysms, the tongue is often wounded by its being protruded be- tween the teeth; discharges of blood from the nose are not uncommon, and occasionally extensive ecchymoses of the adnata of the eyes. The jugular veins are generally distended during the fit, as well as the veins about the head and forehead. The violence of the paroxysms is very various; in some cases the muscles are affected with a trembling vibratory motion, rather than with convulsive contractions and extensions, while in other cases the muscles arc in the most rapid and constant state of contraction and relaxation;—the contractions of the limbs are occasionally so forcible as to render it impossible to restrain them. The duration of the paroxysms is very various. They may cease after a few minutes, or continue for hours or even days. In all cases, however, the paroxysms are marked by partial remissions of the con- vulsive movements, which either abate in violence for a short time, or cease altogether for a moment or two, and are then repeated with equal or increased violence. When the paroxysm goes off, the cessation, in slight attacks, or in those of short duration, may occur suddenly; but in the more severe attacks, and those which have lasted for any length of time, the con- vulsive movements become gradually less violent and frequent, the eyes assume a more natural expression; the countenance acquires its usual look; and the patient appears altogether unconscious of what had occurred. He merely evinces more or less lassitude, and, if able to speak, complains, perhaps, of headache. A long, refreshing sleep frequently succeeds. In many cases, however, there remains, for some time after the paroxysm has ceased, a tonic contraction or a loss of power in some of the voluntary muscles, or the child may be affected with complete paralysis of one limb or of an entire side of the body. A curious case is related by Thompson, of entire loss of speech and hearing, consequent upon a sudden attack of convulsions, in a child eighteen months old. The patient regained her vivacity and general health, but continued deaf and dumb until she reached her sixteenth year, when, after the noise of a public rejoicing, she was observed to recover her sense of hearing, and she soon after began to articulate. When attacks of convulsions are frequently repeated, they may as- sume finally the character of genuine epilepsy. Children frequently die during the convulsive paroxysm; when this takes place, it is, in the majority of cases, the result of extensive hy- peraemia of the brain, or of asphyxia caused by excessive engorgement of the vessels of the lungs. Brachet describes a state of syncope as occasionally supervening upon convulsions, simulating death; in an 406 DISEASES OF THE NERVOUS SYSTEM. instance related by Johnson, a child in this state, after being laid out for interment, was recovered by friction diligently applied to its surface near the fire. The convulsive paroxysms we have known frequently to cease upon the occurrence of a hemorrhage from the nose. Their termina- tion by a copious diarrhoea is very common. Vomiting, also, very frequently causes their cessation, by removing from the stomach the offending matter, by the irritation resulting from which they have been produced. We should keep this important fact constantly in mind, in deciding upon the treatment of the convulsive paroxysm. We have repeatedly seen the most violent attacks of convulsions, in which bleeding, sinapisms, injections, and the warm bath had been resorted to without effect, cease immediately when, by the operation of an emetic, a quantity of undigested matter has been discharged from the stomach. It is scarcely possible to determine, from any of the symptoms which occur during the convulsive paroxysm, either its probable duration or ultimate result. The most violent paroxysms frequently cease within a short period, without any immediate injury to the health of the child, or the subsequent occurrence of any disease traceable to them. In other instances, the attack, apparently slight in its commencement, either destroys the child in a few hours, or is the precursor of some serious affection of the brain, by which death is produced, or the mental and physical powers of the patient are considerably and permanently impaired. The onset of many of the most serious diseases of childhood is, indeed, marked by convulsions. In general, however, when the con- vulsive paroxysms are slight, short in duration, and are succeeded by a state of cheerfulness and general health, ultimate danger is seldom to be apprehended; but when they are marked by great violence in their onset, or gradually increase in violence; when they are long con- tinued, or recur frequently at short intervals, there is great danger of a fatal termination. When the child is dull, heavy, listless, and peevish after the cessation of the paroxysm, we have cause to apprehend a speedy repetition of the attack. Immediate danger to life, during the convulsive attack, is much less to be feared, when the paroxysms are separated by long intervals, than when they recur after short and im- perfect intermissions; there is reason, however, to apprehend in these cases, a permanent affection of the brain, from which, at some future period, serious mischief may result. Convulsions produced by remote irritations, are, in general, much more manageable and less fatal than those dependent upon direct irritation, or disease of the brain or spinal cord. The appearances presented by the bodies of those who have died during an attack of convulsions, are very various. Of course, in those cases in which the attack occurs in the course of some disease of the brain, the pathological appearances are of no value in deter- mining the immediate cause of the convulsive symptoms; it is only in those cases where the convulsions present themselves as the princi- pal phenomena, that the autopsical lesions are of any importance. It is said, that in many cases, the brain and nervous system pre- sent no traces of disease whatever. This statement we are not pre- CONVULSIONS. 407 pared to deny: we can only say, however, that in every instance in which we have examined the brain after death from convulsions, more or less disease of that organ, or of the medulla oblongata or spinalis was present. In most cases, this amounted to simple, but very extensive hyperaemia, with slight effusion of serum beneath the membranes, or within the ventricles: in other cases, partial softening of the brain was very evident; tubercles were frequently detected, either meningeal or within the substance of the brain, and in a few cases, effusion of blood upon the surface of the brain at its basis, or within the theca of the spinal marrow. Inflammation of the membranes of the brain, sharp spiculae of bony matter formed in the dura mater, abscesses in the brain or effusion of blood into its substance from external violence, are the appear- ances recorded by some of the older physicians. Effusion of serum, vascular turgescence, tumours attached to the membranes or imbedded within the substance of the brain, are noticed by more recent writers. Turgescence of the vessels, a deep red colour of the dura and pia mater, and effusion of blood beneath the cranium, are the appearances described by De Claubry; vascular turgescence, at the origin of the nerves distributed to the muscles that had been affected with convul- sive movements, has been noticed by Moulson. Effusion of serum, or of a gelatinous matter, engorgement of the blood-vessels, extravasa- tion of blood, abscesses, tumours, and inflammation of the meninges of the brain, are the lesions described by others. Effusion of blood within the spinal canal, engorgement of the vessels of the brain, and extreme venous congestion of the entire substance of the brain, with serous effusion, were met with by Horner, in one case; and the same appearances with extreme mollescence of the brain, in another. Tur- gescence of the vessels of the brain, its substance of a pink colour, with serous effusion into the ventricles, at the base of the cranium. and within the theca of the spine, are noticed by Kennedy. Schmidt, who appears to have collated, with a good deal of care, the observations of the German pathologists on the subject of convul- sions, gives, as the general result of their autopsies, extensive hyperae- mia of the brain and spinal marrow; serous effusion into the ventri- cles, upon the surface, and at the base of the brain, or within the vertebral canal; in a few cases, effusion of a gelatinous matter upon the surface of the brain, and within the spinal theca; in still fewer cases, effusion of blood upon the hemispheres of the brain, or within the spinal canal: indications of meningeal inflammation, circumscribed softening of the brain and abscesses, were observed in a very few instances. In the examination of cases of trismus infantum after death, Weber, Barrier, Ollivier, Billard, Matuszynski, Levy, and Thore, report the detection of various lesions of the brain and spinal marrow; others, with Bednar, (Krankheiten der Neugebornen,) declare, that after the most careful examination, they have been unable to discover any material changes indicative of the character and location of the dis- ease. Bednar remarks that even preparations of the detached nerves- lead to no desirable results; hence we are led to the conclusion that trismus in new-born infants is a nervous affection, consisting in neither anaemia, hypera?mia, or inflammation of any of the organs. 408 DISEASES OF THE NERVOUS SYSTEM. It must be evident, from the results of the most accurate and ex- tensive series of pathological observations, that in the great majority of instances, convulsions are intimately connected with disease of the brain or medulla spinalis. We can, however, easily conceive, that in consequence of an intense irritation, occurring either primarily in the brain, or affecting it secondarily, from disease of the alimentary canal or other organs, a severe attack of convulsions may occur, and produce almost immediately the death of the patient, without any appreciable lesion of the brain being discoverable after death. Convulsions may occur, at any period, from the moment of birth up to puberty. The first few weeks of the infant's life, the period of weaning, and that of dentition, constitute the stages of infancy, at which convulsions are most liable to occur. From accidental causes, however, they may be produced subsequently to the latter period, but the tendency to their occurrence gradually decreases, from the second period up to puberty; thus we find that the greatest number of deaths from convulsions occur within the first year—the next greatest, be- tween one and two years; the next, between two and five; and the smallest number, between five and ten; after this the falling off in the amount is so considerable, that the number is not worth noticing. The frequent occurrence of convulsions in infancy, is unquestion- ably owing to the greater susceptibility of every part of the system at this age, than subsequently; the greater activity of all the organic functions; the large size of the brain compared with the rest of the body, and the very great development and activity of its capillary system engaged in the perfection of its growth and organization. Irri- tations are quickly reflected from the other organs upon the brain, and the habitual hyperaemia of the latter during infancy, is readily increased by slight causes, and though we may not understand why irritation and hyperaemia of the brain should, more readily in infancy than in after life, stimulate the muscles to irregular and inordinate action, there can be little doubt as to the fact. Few of the cerebral affections of this age are unattended, either in their commencement or progress, with convulsions; and we have seen, that in those who die of disease, the only observable phenomena of which are convulsive paroxysms, the brain almost invariably presents indications of the existence of irrita- tion—an overloaded state of its blood-vessels, and an injection, often very considerable, of its substance—these lesions frequently extending, also, to the medulla oblongata and spinalis. There can be no doubt that, from various causes, the very great susceptibility to impressions in the nervous system of the infant, is, in many cases, still further augmented, and that, with this augmentation of susceptibility, the predisposition to convulsive attacks will likewise be increased. That this is, in fact, the case, daily experience teaches us. Thus, some children are known to be far more excited than others by sensations communicated to them through the external senses, and are thrown into a state of tremor, almost amounting to convulsions, by unusual objects, sounds, and odours, which, upon others, produce little or no effect. Such children are liable to be suddenly affrighted or alarmed, to be peevish, fretful, and discontented, and, with difli- ( CONVULSIONS. 409 culty, amused; their sleep is disturbed by dreams or frequent start- ings; their faces flush, and turn pale suddenly, from causes of the most trifling character, and their whole deportment, the mobility of their facial expression, and their shrinking, quick, timid glance, in the pre- sence of strangers or of unfamiliar objects, indicate the morbid exci- tability of their nervous system. Such children are said, also, to pre- sent an unusual development of brain, and precocity of intelligence. The fact, that children, born with large heads, or whose heads increase in size disproportionately to the rest of their bodies, are particularly liable to convulsions and other cerebral affections, the result of our own observations confirms; we have not, however, observed that such children present, in general, an earlier development of intellect than others. The fact that convulsions are a frequent result of febrile disturb- ance in early childhood, is pointed out by Mauthner, and he shows how the tendency to venous congestion, which is so characteristic of early childhood, explains this occurrence. Somewhat similar are the remarks of Dr. Morell (New York Journ. of Med.) on the same sub- ject. A hereditary predisposition to convulsions has been noticed by many respectable authorities; this is not improbable, though we have seen no positive facts in confirmation of it. It is a common occurrence, however, to find a predisposition to convulsions to exist in all the children of the same family; this is, no doubt, the result of similarity of organization, in all probability, transmitted to them by their pa- rents. It is stated by North, that the children of" parents who marry at too early or too advanced an age, are more liable to convulsions, than the offspring of those who marry in the prime of life; and it is certain, that children, born of females in whom the health of the con- stitution has been impaired by luxurious habits, late hours, deficient exercise, stimulating, and otherwise improper diet, or intemperance of any kind, are more predisposed to convulsive affections than the off- spring of mothers, who are in good health, and live regular, active, and temperate lives. This is probably one of the reasons why con- vulsions are of far more frequent occurrence in large and crowded cities than in the open country. We are to recollect, however, that the stagnant and impure air of cities acts equally prejudicially upon the infantile organism as upon that of the adult, and may develop in it, subsequent to birth, a predisposition to convulsive affections, while the fresh and pure air of the open country, by invigorating the vital powers of the infant, and diminishing nervous excitability, renders it less susceptible to the impression of the ordinary exciting causes of convulsions. In older children, a neglect of exercise, confinement within doors, too early and long-continued mental application, or the excitement produced by night parties, and crowded rooms, "will develop the un- due nervous excitability which predisposes to convulsions. Although no climate nor latitude appears to afford protection against an attack of convulsions, they are unquestionably of much more fre- quent occurrence in warm and very variable climates, and unhealthy localities generally. 410 DISEASES OF THE NERVOUS SYSTEM. Those forms of convulsive disease in children, depending upon at- mosphere or climate, such as prevail in the West Indies, and in our Southern States, or in crowded hospitals, ill-ventilated suburban dis- tricts, or the narrow streets, courts, and alleys of large cities, often ex- hibit peculiar phenomena, marking them, in a certain sense, as specific diseases; like all affections that owe their existence, in a great measure, to atmospheric causes, they assume, often, peculiar types and character- istics, and prove, generally, more fatal in their tendencies. Under this head may be classed, the epidemic convulsions, which occurred at Pa- ris, described by Claubry; the epilepsy, that occurred at Copenhagen, and destroyed, according to Lange, in thirteen years, nearly thirteen thousand children; the trismus nascentium, of the West Indies, of va- rious portions of Europe and of our Southern States; and the infantile convulsions, which, previous to the year 1792, destroyed, as stated by Clarke, every sixth child born in the Dublin Lying-in Hospital. That convulsions may occur, both as an endemic and epidemic, there can be no doubt. The exciting causes of convulsions are very numerous. In new- born infants, they occasionally result from the excessive and long- continued pressure to which the head has been subjected during a protracted and difficult labour; and more particularly, when ergot has been injudiciously administered to accelerate the birth of the child. In children born in a state of partial or complete asphyxia, respiration is often but imperfectly established, and death is very liable to result from an attack of general convulsions. Convulsions may also be produced, fti young infants, by exposure to cold, or to a vivid or powerful light, or by the effects of a confined and impure atmo- sphere. In infants who are liable to violent attacks of spasmodic colic, convulsions are of frequent occurrence. The most common causes, however, of those derangements of health in infants which either immediately or eventually lead to attacks of convulsions, are errors in diet, with respect both to its quantity and quality. From the moment of birth up to the termination of child- hood, convulsions are liable to be produced by this cause. The ani- mal, Dr. Graves remarks, which, but a short time before, was nourished by the placenta, is, immediately after birth, supported by ingesta; and hence, from this sudden change, if there be any source of irritation exist- ing in the system of the child, or in the nature of its food, an unhealthy state of the bowels rapidly ensues, and gives rise to convulsive move- ments. To these, nurses have given the name of nine-day convulsions. Again, when another change is made, and the nurse's milk is left off, children are also liable to convulsive fits, and these are the convulsions of ablactation. In fact, at any period during the first year, infants are predisposed to convulsions from various causes, that act primarily, by inducing an irritation of the digestive organs;—as when they are al- lowed improper food, in addition to the breast-milk—or when this is rendered unwholesome, by the improper food or drink of the mother or nurse; by her becoming strongly affected by passion or any mental emotion; by over-exertion or exposure to the sun, or by her health, from any cause, becoming impaired. CONVULSIONS. 411 Dr. Sims, (Amer. Jour, of Med. Sciences, 1846-8,) is of opinion that the trismus of infants is oaused by displacements of the parietal or occipital bones, by which pressure is made upon the nervous centres. The disease depending more upon mismanagement at and subsequent to birth, than on any other cause. But upon this view of the causa- tion of trismus in children, it would be impossible to explain the epi- demic occurrence of the disease in some of the large hospitals of Eu- rope, of which we have well authenticated accounts. Subsequent to weaning, improper or too much food may be ranked among the most common exciting causes of convulsions. Difficult dentition is unquestionably a frequent cause of convulsive attacks. A child has been known to suffer from the time it first begins to cut its teeth repeated paroxysms of convulsions, in consequence of which its life has been despaired of from day to day, and from week to week; yet, after the lapse of several months, has recovered com- pletely, upon the appearance of the first molar teeth. Intestinal worms are very generally accused, as a frequent cause of convulsions; but we suspect this is but rarely the case; no well marked instance of the kind has ever fallen under our notice; Lieutaud, Bra- chet, North, and others, make nearly a similar statement. The imprudent or long-continued administration of opium and its preparations, to infants and young children, is to be ranked rather as a predisposing, than exciting cause of convulsions. It is unquestion- able, that a very small dose of opium given to an infant, will often be promptly followed by a convulsive paroxysm, and that its continued use will produce a state of debility, and increased irritability, that strongly favours the occurrence of convulsions from slight causes. The sudden suppression of chronic diseases of the skin, or the drying up of the discharge from long-continued ulcerations behind the ears, has been known, in numerous instances, to give rise to an attack of convulsive disease. We have already noticed, among the causes of convulsions, an im- pure and confined atmosphere;—we have known them likewise, in repeated instances, to be produced by insolation. Convulsions in chil- dren are often induced, also, by moral causes, as intense fear, or hor- ror, or sudden surprise; violent anger, and long-continued fits of crying. Although we believe that in the majority of cases, convulsions are dependent upon irritation with hyperaemia of the brain or spinal mar- row, or upon inflammation, acute or chronic, of its membranes or sub- stance, we admit that in some instances, they may result from exces- sive evacuations, or from deficient nourishment. Thus, excessive de- pletion, by bleeding or active purgation, extensive hemorrhage, and long-continued or profuse serous diarrhoea, not unfrequently give rise to convulsive paroxysms of great violence. But even in these cases, it is probable that the convulsions are preceded by very considerable turgescence of the vessels of the brain. Although, in numerous instances, convulsions occur suddenly, in children apparently in perfect health, they are frequently preceded by certain symptoms, which have been supposed by North and others to 412 DISEASES OF THE NERVOUS SYSTEM. indicate that state of increased excitability of the nervous system, which predisposes to convulsive attacks, but which, in our opinion, are the phenomena resulting from a certain degree of irritation of the brain, most commonly connected with gastro-intestinal disease. These symptoms are, sudden starting from trifling, or no appreciable cause; uneasy sleep, disturbed by sudden cries; a state of drowsiness during the day, and restlessness at night; a fretful, peevish disposition; disinclination to play or be amused; frequent fixation of the eyes, without their being, apparently, directed to any particular object, or they are thrown upwards, and steadily fixed upon the ceiling; rapid and frequent contraction and dilatation of the pupils; when a candle is held to the eyes, during the contraction of the pupils, they will sud- denly dilate, and, again, as suddenly contract, the light being steadily continued close to the eye. The effect of the light upon both eyes is not always similar; one may remain fully dilated, while the other con- tracts ; or one may remain stationary, the other being alternately con- tracted and dilated. When the child is asleep, the limbs are frequently rigidly extended, the great toe and thumb being turned inwards. There is a rapid alternation of paleness and flushing of the cheeks; at one moment the countenance expresses great animation, at the next, the utmost languor. The breathing is irregular; long, deep, apparently difficult inspirations are alternated with quick, short, catching expira- tions. This is usually accompanied by fulness of the upper lip, and a contracted appearance of the alae nasi. The hands are frequently directed towards the nose, apparently involuntarily; the fingers are either in frequent and sudden motion, or are firmly pressed towards the palm of the hand; more frequently, the thumb is contracted upon the palm, and the fingers extended, and separated from each other. When the child is put tp the breast it will suck eagerly for a moment, and then cease suddenly, and throw its head backwards, with an ex- pression of anxiety in its countenance; or perhaps it will roll its head from side to side. Deglutition appears to be performed with difficulty when these symptoms occur. Hiccup is not unfrequent, as well as a slight convulsive movement of the muscles of the face, particularly during sleep, which gives to the countenance an appearance of smiling. It is not pretended that all of these phenomena are invariably pre- sent in the same child, or that they are necessarily the premonitors of a convulsive attack;—when, however, several of them present them- selves, there is a reasonable cause to apprehend the occurrence of convulsions, and a necessity for adopting the requisite preventive measures. The treatment of convulsions must vary according to the circum- stances of each case. During the convulsive paroxysm, it has been supposed by North, Eberle, and a few others, that little or nothing can be done towards arresting it. This, however, is an error, and if gene- rally acted upon, would prove, in many instances, a very serious one. Frequently, the only time we have to act is during a paroxysm, which, unless we are enabled to arrest it, or moderate its violence, will often terminate only with the life of the patient. That the violence of the CONVULSIONS. 413 convulsive attack may be reduced, and'that, frequently, its duration may be shortened, by a prompt and judicious treatment, we are well convinced, from the result of our own experience. When the convulsions are very violent, and occur in a robust, ple- thoric child, with evident symptoms of an over-loaded state of the vessels of the brain, our first and most important remedy is direct de- pletion. We may either open a vein in the arm, if the child is old enough, or we may apply leeches to the temples or behind the ears, in numbers adapted to the age of the patient, and the character and ex- tent of the symptoms present. In numerous instances, we have seen the best effects result, when convulsions have occurred about the period of dentition, or subsequently, from cups to the nape of the neck, or between the shoulders. In cases attended with heat of the head, an injected countenance, throbbing of the carotids, a projecting, sparkling eye during the paroxysms, and a state of deep drowsiness during the remissions, it is all-important that a speedy and prompt impression be made upon the vessels of the brain; here, provided blood cannot be drawn in sufficient quantity from the arm, it is probable, that a division of the temporal arteries, opening the jugular vein, or cups to the temples or behind the ears, should be preferred to leeches. It is impossible, in these violent cases, to lay down any general rule, as to the exact quantity of blood to be drawn; this must be left entirely to the judgment of the practi- tioner. We have seen, in some cases, the loss of a very small amount of blood produce an almost immediate resolution of the convulsive paroxysm; while, in others, this has not been effected until the bleed- ing was carried as far as the age and strength of the patient rendered prudent. Even in those cases, however, in which the symptoms of cerebral hyperaemia are less strongly marked, if the patient be strong and robust, bleeding to a moderate extent will be proper, as a precau- tionary measure; for though the nervous centres may at first suffer only from simple irritation, yet, by the continuance or frequent repeti- tion of the paroxysms, the brain is very liable to become the seat of permanent disease. Next in importance to bleeding, in the majority of cases, are active purgatives; these do good, as well by determining the undue amount of blood from the brain, as by the removal of any cause of irritation that may exist in the bowels. When the child can swallow, a full dose of calomel should therefore be early administered, and followed, in a short time, by castor oil, magnesia, and rhubarb, or an infusion of senna. When purgatives cannot be administered by the mouth, pur- gative enemata are to be resorted to. The common domestic enema of salt, warm Avater, and molasses, with the addition of sweet oil, will generally answer; or if a more active one is required, a mixture of castor oil and spirits of turpentine, will probably be the best we can employ. In all cases of convulsions dependent upon derangement of the ali- mentary canal, spirits of turpentine will be found a very useful remedy, and when the patient can swallow, given by the mouth, nothing will act more promptly as a purgative, while it would appear also to pro- 414 DISEASES OF THE NERVOUS SYSTEM. duce a decidedly beneficial impression upon the diseased gastro-intes- tinal mucous membrane. R.—Spirit, terebenth. 3J. Olei ricini, £iv. Mucil. gum acacise, giv. Aq. foenil. ^ij.—M. A teaspoonful may be given to an infant three or four months old, and double that quantity to a child a year old. In those cases in which active depletion is called for, sponging the whole of the scalp frequently with cold water, is a measure from which much benefit will result. In violent cases, pounded ice enclosed in a bladder may be applied. The cold applications to the head should be continued, until the cheeks become pale, and the scalp cool, and they should be renewed if the flushing of the cheeks and the heat of the head return. During the application of cold to the head, the rest of the body should be kept perfectly warm. Even in cases in which bleeding may not be thought advisable, sponging the head with cold water will be found to be almost invariably productive of good effects; and, during the intervals of the convulsive paroxysms, as well as in children who are strongly predisposed to their occurrence, it forms one of our best means of diminishing the irritation of the brain, and, in this manner, preventing their accession. Warm sinapised pediluvia, or immersing the lower part of the body in a warm bath, subsequent to active depletion, in those cases in which this is indicated, or, at an early period of the attack, in cases in which bleeding is not considered advisable, will always be highly beneficial. During the use of the pediluvium, or while the patient is in the bath, cold water, or even ice, may be applied to the head, with the best effects. Cold water dashed or poured upon the head will, in some of the more violent convulsive attacks, produce a more prompt and powerful effect than its simple application. Upon the same principle that we employ the pediluvia and hip bath, to determine the blood from the brain, and counteract its state of irri- tation, sinapisms may be applied to the extremities, and some rubefa- cient liniment to the spine. We prefer, with the generality of Ger- man practitioners, the application of sinapisms upon the extremities, to blisters. They will be found, in many cases, to act as powerful auxiliaries to the other remedies. In some of the more chronic cases, we have seen good effects result from blisters behind the ears, or be- tween the shoulders; and, at an earlier period, when the convulsions appeared to be unconnected with any considerable engorgement of the vessels of the brain, a large blister, applied over the epigastrium, has appeared to us to have a very powerful influence in cutting short the paroxysms. We have never applied blisters to the scalp. In every case, as early as possible after the occurrence of the con- vulsions, an examination should be made of the state of the gums, and if they are swollen or inflamed, even though there exists no indication that any of the teeth are upon the point of protruding, they should be freely scarified; and the scarification should be repeated daily, so long as the swelling or inflammation remains unabated. When the gum appears firmly distended by an approaching tooth, its free incision at CONVULSIONS. 415 this point will frequently prevent a threatened, and almost instantly relieve a present paroxysm. In attacks of convulsions evidently dependent upon irritating matters or undigested food in the stomach, or where we have strong reason for suspecting this to be the case, an emetic will always be proper, and will often quickly suspend the paroxysms. In infants and young child- ren we should always prefer as an emetic the ipecacuanha, but if the infant is robust, or in older children, the tartarized antimony may be employed. In such cases, following the emetic by a full dose of calo- mel, and after this has operated, administering some gentle narcotic, as the aqueous solution of opium, or a dose of the extract of hyoscy- amus (from half a grain to one, two or three grains according to the age of the child,) with magnesia, (four grains,) will, in general, very promptly effect a cure. When convulsions are the result of excessive evacuations, either of blood or of serum, as in the copious diarrhoeas with which infants are frequently affected, the head of the patient should be considerably ele- vated, and kept constantly wet with cold water, and small doses of some gentle stimulant, combined with a narcotic, as the carbonate of ammonia, or wine whey, with extract or tincture of hyoscyamus, should be given, carefully adapted in quantity and frequency of repetition, to the age of the child. The utmost tranquillity of mind and body should be enforced, and the chamber kept darkened. Where much debility remains after the convulsions cease, some gentle tonic, as the sulphate of quinia, the protocarbonate of iron, or the oxide of zinc, combined with small doses of hyoscyamus, will be proper, with a mild nutritive diet. Where the bowels are much affected, and the serous discharges are very copious, injections of a solution of acetate of lead, with the addition of the tincture of opium, should be resorted to, and repeated at proper intervals, until the inordinate discharges from the bowels are suspended. Dr. Simpson, of Edinburgh, in a severe and protracted case of con- vulsions occurring in an infant of only one month, succeeded in arrest- ing permanently the recurrence of the convulsions, after all the other usual remedies had failed, by placing the patient for many hours un- der the influence, by inhalation, of chloroform; allowing the infant to awaken, however, at the termination of every two or three hours for the purpose of suction and nourishment. Dr. Simpson states that he has known the inhalation of chloroform similarly useful in other cases in arresting infantile convulsions, but in none in which the patient was so young as in that just referred to. Artificial respiration was resorted to by Cape, in a case of long-con- tinued convulsions, in an infant five days old, with the most happy re- sult: other cases are on record in which the same plan of treatment proved equally successful. In every case during the intermissions of the convulsive paroxysms, as well as upon their cessation, it is important that the patient be kept perfectly quiet, and free from every species of excitement; a convul- sive attack being invariably succeeded by a degree of morbid irritabi- lity of the nervous system, which will endanger a return of the parox- ysms from the slightest cause. 416 DISEASES OF THE NERVOUS SYSTEM. After the paroxysm of convulsions has been suspended, the subse- quent treatment will depend entirely upon the character of the symp- toms which remain. If any indication of disease of the alimentary canal be present, this should be treated by its appropriate remedies, which it is not necessary to recapitulate here. If decided symptoms of a continued irritation of the brain exist, we should persist in the use of the cold applications to the head, and the warm hip bath, and we should consider the propriety of blisters to the temples, behind the ears, or to the nape of the neck; the bowels should be kept regularly open, and the healthy state of the secretions poured into them promoted by the administration of small doses of calomel, at regular intervals. Com- bining the calomel in these cases with a portion of ipecacuanha, extract of hyoscyamus, and calcined magnesia, will very generally be found to increase its efficacy. R.—Calomel, gr. vj. ad xij. Ipecac, pulv. gr. iij. Ext. hyoscyami, gr. iij.—iv. Magnes. calc. gr. xxxvj.—M. f. ch. No. xij. One to be given every two, three, or four hours, according to the age of the patient. The diet of the patient should invariably be light, unstimulating, easy of digestion, and given only in moderate quantities. Animal food, in every form, should be prohibited, so long as there remains the slightest danger of a recurrence of irritation or hyperaemia of the brain. It is unquestionably true, that many cases of convulsions occurring in young infants are dependent upon indigestion, in which milk, even that of the maternal breast, but more generally of the cow, seems par- ticularly to disagree with the patient, the curd remaining in the sto- mach undigested, and producing irritation of the alimentary canal, and secondarily of the brain. In such cases, milk must be entirely prohi- bited, and the child may be allowed in its stead, rennet whey, with stale bread or crackers, chicken or barley water, plain veal or mutton broth, or thin panada; and this diet should be continued until the di- gestive organs have regained their healthy action. It frequently happens, that for some time after the convulsive pa- roxysms have been suspended, there will remain a very great degree of nervous excitability. The child continues to be peevish, fretful, and listless; the cheeks are occasionally flushed for a moment, and then become of a deadly pallor; the pulse is small and rapid; the counte- nance is ordinarily pale and distressed, and the forehead wrinkled. The carotids often throb violently for a moment or two, and then their action becomes slow and languid; and upon close examination, slight momentary twitchings of different muscles will be detected. This con- dition of the patient calls for the employment of sedatives and light tonics. The Dover's powder in small doses, the extract of cicuta or hyoscyamus, in conjunction with alkalies or the oxide of zinc, and the infusion of calomba or gentian, or the sulphate of quinia, have been recommended. There are, unquestionably, many cases in which the use of opiates, particularly in the form of the compound powder of ipecacuanha or Dover's powder, will have a very beneficial effect in quelling the ner- CONVULSIONS. 417 vous excitability consequent upon an attack of convulsions. Their em- ployment, however, in infants and young children, must be carefully watched; small doses being given at first, and gradually increased, if their effects are found to be of a soothing character. Opiates have been extolled by some practitioners, as an effectual means of arresting the paroxysm, when given during its presence. Dr. Blundell restricts them to cases verging to the chronic form, and attended with distress and restlessness; they may probably be advantageous, also, in those cases in which the convulsions appear to be excited by intense pain of the intestinal canal; they are, however, invariably a doubtful remedy during the presence of the convulsive paroxysms. Even in that state of nervous excitability already described as sometimes remaining after the cessation of the convulsions, we should, as a general rule, prefer either the tincture or extract of hyoscyamus; which may be given in conjunction with alkalies and light tonics.1 Brachet employed the hyoscyamus in combination with the oxide of zinc, varying the dose according to the intensity of the symptoms, and the age of the child.2 Schmidt gave it in conjunction with the oil of valerian, and carbonate of soda,3 and North combined it with sulphate of quinia.4 1 R.—Infus. gentian, gj. 2 R.—Oxyd. zinci, gr. xxiv. Syrup, rhei, ^ss. Ext. hyoscyami, gr. xij.—M. Tinct. hyoscyami, rt% Ixxx. f. chart. No. xij. Bi-carb. sodae, 3J.—M. One to be given every two or three hours. A teaspoonful every three hours. 3 R.—Carbonat. sodae, sjj. Or, R.—Pulv.'calombas, gj.—^ij. Syrup, rhei aromat. ^ij. Pulv. zingiber. Qij. 01. valerian. tt)j xvj. Ext. hyoscyami, gr. xij. Ext. hyoscyami, gr. xvj.—M. Magnes. calc. Qij.—M. A teaspoonful to be given as a dose, three f. chart. No. xij. times a day. One every three hours. * R.—Aq. Cinnamom. ^jss. Sulph. quiniae, gr. viij. Acid, sulphuric, dilut. titjj viij. Syrup, zingiber, ^ss. Ext. hyoscyami, gr. xvj.—M. Dose, a teaspoonful every three hours. Beneficial as we know from experience narcotics and tonics to be during that state of prostration and nervous excitability which is so commonly met with after the subsidence of severe attacks of convul- sions in children, we would caution, in the strongest terms, against their being commenced with before every symptom of undue deter- mination to the head, of acute irritation of the brain, or of general febrile excitement, has been subdued, and every source of irritation removed from the alimentary canal. The worst consequences are to be apprehended from the too early administration of narcotics and tonics in cases of infantile convulsions. Nothing need be said in relation to the hygienic measures to be pursued, in order to restore health and vigour to the system of the patient, and to guard against a subsequent recurrence of the convul- sive attack; they are precisely the same as those directed in cases of predisposition to hypertrophy of the brain. Where a paroxysm of convulsions is threatened, in cases in which blood-letting is not indicated, compression of the carotids has been re- 27 418 DISEASES OF THE NERVOUS SYSTEM. commended. Drs. Blaud and Stroehlin both report cases in which it was perfectly successful. According to Dr. Sims in cases of trismus dependent upon displace- ment of the bones of the infant cranium, the proper treatment is to place the child in such a position that all causes of external pressure shall be removed from the depressed bone, and when this is ineffectual to elevate the latter by a proper surgical operation. A very peculiar form of infantile convulsions has recently been ob- served. It consists in repeated bobbings of the head forward, at first slight and occasional, but becoming, in process of time, so frequent and powerful, as to cause a heaving of the head forwards towards the knees, succeeded by an immediate return to the upright position some- what similar to the attacks of emprosthotonos. In one case, related by West, these bowings were repeated at intervals of a few seconds, ten, twenty, or more times each attack, which continued from two to three minutes, and recurred, twice, thrice, or oftener, in the day; the attack occurring whether the patient was sitting or lying. During the attack, the child retained his consciousness. The cases that have been since recorded by Drs. Barton and Bennett, in their general symp- toms, differ in no degree from that of Mr. West, with the exception of that of Dr. Bennett, in which the disease presented a more aggra- vated form. Sir Charles Clarke has seen four cases of the disease, and from the peculiar bowing of the head, has named it the Salaam Convulsion; Dr. Locock has seen two cases. One of Sir Charles Clarke's cases recovered perfectly, the other became paralytic and idiotic, and died at the age of seventeen. Mr. West has heard of two other cases—one of the patients lived to the age of seventeen; the other to nineteen,—both became idiotic. Mr. Newnham has published four cases, including Mr. West's. In one the child was attacked with paralysis, and her intellect became weak, but she ultimately recovered. Mr. West's case became idiotic, although the bowing ceased. In another, there was partial paralysis of the upper extremities, with intellectual deficiency. In a case related by Dr. Willshire recovery took place without the occurrence of either paralysis or permanent injury to the intellect. In two cases recorded in the Jour, fur Kinderkrankheiten, 1850, one became epileptic and semi-idiotic, the other improved under the use of iron. In two cases related by Dr. Faber (Schmidt's Jahrb. vol. 62,) one became epileptic, with defective mental development; the other appears to have recovered with partial idiocy. Dr. Churchill (See Diseases of Children, Edition of 1858,) has seen one case and heard of another; in that which came under his own care, the child he states "is idiotic, but as fine a specimen of bodily development as I ever saw." The sex and ages in the cases on record, so far as we have been able to collect them, are two females of three and seven years, and three boys, one of one and two of six years. In four other cases in which the sex is not given, the ages are respectively 1, 4, and 6 years, and 16 months. Of this strange form of convulsions, the pathology is still a subject for future investigation; and until that is ascertained, its treatment must be tentative and experimental. Previously to leaving the subject of convulsions in children, it may CONVULSIONS. 419 be proper to say a word or two upon a form of convulsive disease, de- scribed by Jadelot and Guersent, which consists, simply in a power- ful tonic contraction of the muscles of the extremities. It principally attacks young infants, and children approaching the age of puberty, and is unattended with any appreciable lesion of the nervous system. The muscles of the parts affected are rigid and tense, and are often distinctly marked, and prominent, beneath the skin. This convulsive contraction of the muscles gives a remarkable rigi- dity to the wrists and fingers; the former are slightly bent on the fore-arm, and the latter upon the carpus, and separated from one an- other, requiring force to bend or straighten them. The disease is sometimes limited to the superior extremities, but most frequently affects also the inferior; in these latter, the same phenomena are then observed, as in the former, excepting that the feet are forcibly stretched on the leg, instead of being bent. The contraction of the muscles may persist for several hours, days, or even sometimes for several years, and then cease spontaneously; after a time, however, it may reappear, and this may occur repeatedly. The muscles of the other parts of the body are ordinarily unaffected, as are also the intellectual faculties, respiration, and the digestive functions. The pulse is sometimes accelerated, but in general it is natural. The disease is most liable to occur in children of a nervous and ir- ritable temperament; and appears to be sympathetically produced by intestinal worms, difficult dentition, or some gastro-intestinal irrigation. It sometimes occurs in females towards the period when the catamenia are about to be established; it may terminate fatally, but most fre- quently, according to Jadelot, the result is favourable. The most careful autopsy has detected no appreciable alteration, either in the brain or spinal marrow, nor in any of the nervous trunks. In the ex- aminations made by Guersent, the affected muscles were generally found to be in a state of hypertrophy, their pale tissue being filled with a considerable amount of fat. Essential contractions of the muscles in children are sometimes gene- ral, and sometimes local; among these last, M. Guersent ranges torti- collis, cramps, tonic spasms of the muscles of the sides, &c. Tonic spasm of the muscles of the flanks, with shortening of the corresponding lower extremity, has been observed in children of seven or eight years of age, and according to Beclard, has been mistaken for an affection of the hip joint. Sometimes the muscular contractions are almost general, and the patient is affected with immobility and stiffness of the trunk and limbs, as though the body was composed altogether of hard and solid parts. This contraction, so long as it is produced by an affection of the spinal nerves only, does not endanger the life of the patient, but it becomes more serious when it results from disease of the encephalon and ganglionic nerves, as in traumatic tetanus. Among the causes of these essential contractions, as he terms them, M. Guersent enumerates exposure to cold while the body is in a state of perspiration, and the presence of worms. 420 DISEASES OF THE NERVOUS SYSTEM. The treatment of this form of tonic convulsion will consist, in a great measure, in the use of warm or vapour baths, and friction with oil of almonds or narcotic liniments; dry friction of the skin, the application of bags filled with warm ashes, and gentle purgatives. M. Jadelot recommends, also, cold affusions; internally, camphor or vale- rian, and friction with ether or with the tincture of digitalis. M. Guersent directs friction with a liniment containing laudanum, and if this is unsuccessful, but not otherwise, opium internally. Diaphoretics, as infusions of borage, and the acetate of ammonia, have been recom- mended, as also the sesquicarbonate of iron, in large doses. If the patient is of a plethoric and vigorous habit, and the muscular contrac- tion has occurred suddenly, we should not hesitate to resort to vene- section. Contrivances to produce extension of the contracted parts have been tried, and have succeeded in some cases, when seconded by the employment of baths, emollients, &c. The section of the con- tracted muscles, has, also, been proposed, but the success attending this measure is not such as to recommend its general employment. 4.—Acute Meningitis. The whole of the inflammatory affections of the brain are, by many writers on diseases of children, included under the general term of hydrocephalus. This, however, is incorrect; the acute forms of me- ningeal inflammation occurring in children, are not invariably produc- tive of extensive serous effusion, and their phenomena differ in many important particulars from those by which that form of cerebral dis- ease to which the term hydrocephalus is more strictly applicable, is ordinarily accompanied. In the early periods of life, acute meningi- tis, it is true, is not of very frequent occurrence, as an original disease; it is, nevertheless, a very frequent consequence of many of the affec- tions peculiar to infancy and childhood. Almost invariably, when the disease occurs as a primary affection, it commences with strongly marked symptoms of febrile excitement, preceded by a decided chill. The skin is dry, and generally increased in temperature; the pulse and respiration are accelerated, but often variable; the lips are dry and frequently cracked; and the child re- peatedly picks or rubs his nose and mouth. There is usually increased thirst and loss of appetite. The tongue is coated with a whitish or yellow mucus, and is often red at its edges and apex. There is very generally copious and repeated vomitings of a bilious matter. Occa- sionally, the attack commences with vomiting. The bowels are in some cases obstinately costive, while in others they are affected with diarrhoea, the discharges being composed of a sour, frothy mucus, of either a green, almost black, or pale colour. The urine is usually spare in quantity, and high-coloured. The face is ordinarily red and turgid. There is an anxious, suffering expression of countenance, with contracted brows, and most commonly, intolerance of light and sound, contraction of the pupils and injection of the eyes. The pain of the head, which is principally referred to the forehead and temples, though occasionally it is seated in the upper or back part ot the head, is often accompanied by a violent throbbing, and a sense ACUTE MENINGITIS. 421 of constriction around the forehead. It increases in violence at short intervals, and then excites the peculiar, sharp, wild scream, so charac- teristic of acute affections of the brain in children. During the exacer- bations of pain, there is increased flushing of the face, as well as an increase of the peculiar suffering expression of countenance. In the intervals of these exacerbations, the child often rolls his head from side to side, and saws the air with his arms, moaning or complaining of his suffering, or he falls into a state of partial stupor, and grinds violently his teeth. The countenance is generally flushed, but in some cases the flushing occurs only during the exacerbations of pain, the face in the intervals being decidedly pale. Vertigo is often present. The eyelids are generally firmly closed, and in some cases, the patient resists every attempt to open them. Slight twitchings of the muscles of the face are not unfrequent. The pulse is increased in frequency, and most generally full and hard; the respiration is accelerated, but often inter- rupted by long deep sighs. # If the disease is not arrested, the patient becomes more and more drowsy, and finally, completely comatose. In some cases, from the first day of the attack there occurs an alternation of stupor and vio- lent agitation, or of coma and acute delirium. The delirium may not, however, occur until a later period. In the progress of the case, the increased heat of the surface disappears, and frequently a degree of chilliness supervenes: diminished temperature of the extremities is often a very early symptom. The external senses lose, by degrees, their abnormal acuteness, and finally become morbidly obtuse. The pupils are at first alternately contracted and dilated, but at length be- come permanently dilated, and insensible to the brightest light. The eyes are often affected with strabismus, or the eyeballs have a rolling tremulous motion, or are permanently turned upwards and outwards. The hearing becomes more and more dull, and finally there is a total insensibility to sound. The face becomes pale and cold, and the fea- tures shrunk; the eyes assume a dull and sunken appearance, and in the progress of the disease, perfect blindness most generally ensues. Con- vulsive twitchings of the muscles of the face and extremities are now more frequent and violent. Convulsions of the limbs, alternating with a state approaching to paralysis, or convulsive movements of Certain sets of muscles, with imperfect paralysis of others, are not unfrequent; but in the progress of the case, when complete coma ensues, the whole of the voluntary muscles become completely relaxed. The pulse de- creases in frequency, and becomes weak and soft, but at the same time, extremely variable; being at one moment increased in frequency, or in strength, and at the next remarkable for its slowness and feeble- ness ; it frequently becomes greatly accelerated upon the slightest ex- ertion, and again slow, as soon as the exertion ceases. Often, imme- diately preceding dissolution, the pulse suddenly acquires a remarka- ble increase of frequency, beating often with great regularity, from 120 to 160 strokes and upwards, in a minute. The respiration also becomes quick and irregular, but at the moment of dissolution again slow, and often stertorous. 422 DISEASES OF THE NERVOUS SYSTEM. The respiration is marked by irregularity and inequality. Long deep sighs are often succeeded, after a pause of some duration, by fre- quent, short, quick respirations; or there is a regular alternation of a number of slow, and a number of quick, gasping respirations. The tongue becomes of a dark brown colour, and more loaded, dry, and parched; the lips and teeth are covered with dark-coloured sordes, and the bowels are obstinately costive; but towards the fatal termination, there usually occur involuntary discharges of the faeces, as well as of the urine. There frequently occurs more or less tympanitic tension of the abdomen. The patient continues for a long time able to swallow, and before the coma has become complete, will often take food with apparent greediness, if it be placed, by means of a spoon, upon the back part of the tongue. As the period of dissolution approaches, the surface becomes icy cold; cold clammy perspirations break out, and the face assumes a sunken, ghastly aspect. The fatal event is frequently preceded by convulsions. When the inflammation involves a considerable extent of the mem- branes over the superior surface of both hemispheres, the disease may suddenly terminate, at an early period, by the occurrence of violent, general convulsions, succeeded by deep coma and death. When the meningitis is seated at the base of the brain, the disease often continues for a longer period. The patient exhibits greater and more constant drowsiness, verging, at an early period, into complete coma, and the latter stages are marked by more frequent convulsive movements, or tonic contractions of the muscles, alternating with partial paralysis, and succeeded finally by complete muscular relaxa- tion. The regular course of the disease, commencing with symptoms of more or less excitement, succeeded, after a shorter or longer period, by those of depression, and finally of complete collapse, is not unfre- quently interrupted, either by the rapid occurrence in the same case, of violent febrile excitement, convulsions, stupor, and partial para- lysis, or by the occasional and often repeated alternation of a state of stupor with the phenomena of excitement. The occurrence of acute meningitis in the course of a febrile dis- ease is marked, according to the observations of Rilliet and Barthez, by excessive agitation, without appreciable pain of the head, and un- attended with vomiting. If diarrhoea was present, it persists; the pulse, from being regular, becomes unequal, irregular and diminished in frequency; or it remains equal, frequent, and excessively small. The inspirations, if already accelerated, become slower. The face is pale, the countenance anxious. The agitation, without diminishing in intensity, continues until death, which early ensues.—(Maladies des Enfans, t. i., 634.) The appearances presented upon dissection, in cases of death from acute meningitis, are, chiefly, injection of the arachnoid membrane and pia mater, with effusions of serum, lymph, or pus. The injection of the arachnoid is, in general, of very limited extent, and occurs at a few points only: either at the upper surface or base of the brain, ACUTE MENINGITIS. 423 and occasionally within the ventricles. In place of this injection, the membrane may present a slight degree of thickening and opacity, which gives to it an opalescent or milky appearance. When death occurs at the onset of the inflammation, it is often unusually dry. The injection of the pia mater is in the form either of distinct vascular arborescences, or of a bright, uniform redness, diffused, or in circumscribed patches, according to the less or greater intensity of the inflammation. Effusion may exist in the cellular tissue, between the pia mater and arachnoid membrane, either of clear serum, albu- minous serum, or of pus. When the serum contains much albumen, in place of gradually oozing out, when the arachnoid is punctured, it is detained in the meshes of the subarachnoid cellular membrane, which gives to it a gelatinous appearance. When the disease has continued for a longer period, more or less effusion will be observed upon the upper surface of the membrane; most commonly of a limpid, serous fluid, but occasionally flocculent and turbid, from an admixture of lymph or pus. In some cases the arachnoid upon the surface of the hemispheres, or at the base of the brain, is covered with a pseudo-membranous layer, of a greenish white colour. This is often of considerable thickness. When pus is effused, it may be either liquid or concrete. When the effusion of lymph or pus is in considerable quantity, it often separates the convolutions, and penetrates to their utmost depths. This occurs most commonly at the vertex and base of the brain, and about the junction of the optic nerves, where there exists a considerable amount of loose cellular tissue. There are very often adhesions between the pia mater and surface of the brain, preventing the former from being detached without lacerating the cortical substance, which is not unfrequently reddened, and occa- sionally softened to a greater or less extent. As we have already remarked, simple acute meningitis, whether of the periphery of the brain alone, or combined with inflammation of the base, or of the ventricles, is, under any of its usual forms, an unfrequent dis- ease of childhood. The meningeal inflammation occurring at this period being usually of the granular or tuberculous character; still more rarely, however, do we observe the inflammation confined exclusively to the lining membrane of the ventricles. Rilliet records one such case as having fallen under his notice, and which terminated in ventricular effusion, loss of intelligence, confirmed idiocy and death. Another case has been subsequently described by Dr. Willshire, (London Lancet, 1853,) which that gentleman believes he is authorized as considering one of simple acute ventricular meningitis, from the absence of the ordinary characters of the acute form of simple hemispheric meningitis, as well as of those of the tubercular form; the slight evidence present, comparatively, of lesion at the base of the brain, and the very promi- nent and distinct signs of the ventricular changes, in connexion with the peculiar symptoms of the case. Among the predisposing causes of acute meningitis the most im- portant is evidently the age of childhood. It unquestionably occurs more repeatedly anterior than subsequent to puberty. Guersent places the most common age for its occurrence between the fifth and fifteenth 424 DISEASES OF THE NERVOUS SYSTEM. years;—so far as we are enabled to form a conclusion from the data within our reach, it would appear to occur more frequently in Phila- delphia between the seventh month and seventh year. The condition of the brain at this age, and the facility with which' irritations may be excited in it from various causes, render it peculiarly liable to inflam- mation of various grades. This predisposition is increased by a ple- thoric habit, hereditary irritability of the nervous system, and by pre- cocity of intellectual development, subjecting the brain to premature excitement. The exciting causes are external injuries of the head from blows, concussions, falls, &c, violent and long-continued paroxysms of cry- ing, difficult dentition, the sudden suppression of chronic cutaneous eruptions, especially those which occur about the head and face, and the imprudent drying up of a long-continued discharge from ulcera- tions behind the ears. In the majority of cases, however, acute me- ningitis in children, occurs in the course, or towards the conclusion of other diseases, as the various forms of irritation and inflammation of the alimentary canal, pneumonia, scarlatina, rubeola, and per- tussis. Deep-seated inflammations of the ear very generally ter- minate, in children, in acute meningitis. We have repeatedly seen the disease, also, produced in children by insolation. Acute meningitis is, under all circumstances, a serious affection; especially when it occurs in the course of, or subsequent to, other dis- eases; when the patient is already exhausted, and active treatment is inadmissible to the extent which is necessary for the cure of every form of acute inflammation of the brain; in many cases, also, the course of the disease is so extremely rapid as scarcely to allow time for the employment of the appropriate remedies, even when it is de- tected in its earliest stage. Nevertheless, in robust children, whose vital powers are unimpaired by pre-existing disease, or exposure to depressing hygienic influences, a vigorous treatment, commenced early in the acute stage, will very often quickly arrest the progress of the inflammation and preserve the life of the patient. The favourable indications are, an early abatement of the peculiar symptoms of the disease; a reduction of the morbid acuteness of the external senses; the disappearance of the febrile excitement; there- turn of natural, quiet sleep; the recurrence of the normal secretions; the tongue becoming moist and clean, the skin soft and cool, the bow- els open, and the evacuations natural; the urine more copious and lighter coloured; the pulse more soft, slow and equable, and the res- piration less frequent and more regular; together with an abatement of the heat, pain, and tension of the head, and a return of the ordi- nary expression of the patient's countenance. There are few diseases that occur during childhood, in which it is more important to watch the slightest premonitory symptoms, than those which affect the brain. Their onset may, in many instances, be prevented, when their cure, after they have become fully established, is doubtful, if perchance possible. This is particularly true of acute meningitis; a careful attention to the early symptoms indicative of irritation and hyperaemia of the brain, will often enable us to guard ACUTE MENINGITIS. 425 the patient against an attack that were it to occur, would in all pro- bability prove promptly fatal. The treatment of the premonitory stage will depend, in a great measure, upon the nature of the particular exciting cause in each case. When the attack occurs at the period of dentition, the gums should be carefully examined from day to day, and if swollen or in- flamed should be freely scarified, or divided down to any tooth that may be advancing towards the surface. At the same time attention Bhould be paid to the bowels, which, if costive, should be freely opened by a brisk but mild, unirritating purgative; a full dose of calomel, followed by castor oil, magnesia, and rhubarb, or simple enemata, should be preferred; and, subsequently, small doses of calomel, com- bined with ipecacuanha and magnesia, at proper intervals; with an occasional dose of castor oil, will, in many cases, be required to in- sure their regular evacuation. The daily use of the warm bath, followed by gentle friction of the surface, will form a powerful auxiliary to the other remedies. In cases of undue nervous excitement, with determination of blood to- wards the brain, nothing is better calculated to equalize the circula- tion, and moderate the morbid irritability of the system, and at the same time to promote the regular healthy action of the stomach and bowels; its effects are in all cases beneficial, and in many it is the very best tonic and anodyne we can employ. The temperature of the bath should be regulated by that of the patient's surface; when the latter is warm and dry, a tepid bath will be proper; but if the temperature of the surface is the least reduced, or there is any ten- dency to chilliness, the bath should be decidedly warm. The patient's head should be kept cool by cutting or thinning the hair, if this be thick and long; and by sponging the scalp with cold water, daily, or oftener, according to the degree of increased heat of this part, and the greater or less indications of cerebral excitement, or hyperaemia. At the same time his diet should be carefully regu- lated as well in respect to quantity as to quality; no food but the mildest and least stimulating should be given; regard being had in the articles allowed, to the age of the patient and to the particular condition of his stomach; many articles perfectly unexceptionable in themselves, will be found to disagree with one child, but to produce not the slightest inconvenience when taken by another. The mind of the patient should be kept free from excitement of every kind; the necessity of gentle daily exercise in the open air, in pleasant weather, should be insisted on, and attention should be paid to his clothing, that it does not overheat the body on the one hand, nor expose it on the other to a sudden reduction of temperature from slight atmospherical changes. When the symptoms of nervous excitability or depression appear to be connected with an overloaded state of the stomach and bowels, from excess in eating, or from the use of improper articles of food, an emetic will be advisable, followed by a smart purgative. For infants and young children the ipecacuanha should be preferred as an emetic; the wine or syrup is very readily administered, and when given in 426 DISEASES OF THE NERVOUS SYSTEM. proper doses, is sufficiently prompt in its operation: even in older chil- dren, whenever irritation of the alimentary canal is present, or appre- hended, we would advise the ipecacuanha to be employed in preference to the tartarized antimony. After the stomach and bowels are freely evacuated, and the stools have assumed a natural appearance, the warm or tepid bath, daily, with a regulation of the diet, exercise, and clothing of the patient, will very generally restore the healthful con- dition of the nervous functions. In every case where premonitory symptoms of encephalic disease present themselves, in conjunction with the other measures, it is im- portant that the child should retire to rest early in the evening, and rise early in the morning. The imprudent practice of keeping child- ren up late at night, more especially when they are exposed, at the same time, to the excitement of lighted and crowded apartments, va- rious noises, and probably improper food, is one of the most effectual means of inducing that state of the brain and nervous system, which so generally eventuates in cerebral inflammation. When inflammation of the brain has actually occurred, the only remedies to be depended upon, are active depletion by bleeding and purgatives, cold applications to the scalp, and derivatives to the ex- tremities. Bleeding should be resorted to upon the very onset of the disease, and carried, within as short a time as possible, to an extent commen- surate with the violence of the symptoms, and the age and vigour of the patient. If the child is old enough, a vein should be opened in the arm, while the patient is in an erect or sitting posture, and the blood drawn in a full stream, until paleness of the face, or other symp- toms of approaching syncope are induced; and should the symptoms of reaction, with active determination to the brain again return, the bleeding should be repeated without delay, and carried to the same ex- tent. When we are unable, in consequence of the age of the patient, to procure blood from the veins of the arm, we may open one of the jugular veins, or apply a sufficient number of leeches to the hands or feet, and promote the flow of blood from their bites by immersion of the parts in warm water. When bleeding has, in this manner, been carried to as great an ex- tent as is thought prudent or necessary, and still a slight degree of reaction or cerebral determination remains or recurs, cups or leeches should be applied to the temples, behind the ears, or to the nape of the neck. It is upon the prompt and energetic employment of active depletion in the early stage of all the more violent and acute attacks of meningeal inflammation, particularly when occurring in robust, plethoric children, that the safety of the patient will entirely depend. The extent to which active depletion by bleeding or leeches is to be carried, and the frequency of its repetition, will depend entirely upon the circumstances of each case, and the effects produced by the re- medy. Every thing depends upon the judgment of the practitioner, the correctness of his diagnosis, and the closeness and care with which the phenomena of the disease are watched. The bleeding should al- ways be carried to a sufficient extent to prevent the occurrence of re- ACUTE MENINGITI8. 427 action, and to keep down any active determination to the brain: if suspended before this is accomplished, the remedy will be of little or no benefit; if continued beyond this point, injury will very generally be produced. Cold applications to the scalp should be early resorted to, the hair being previously cut short, or removed with a razor. Ice powdered and enclosed in a bladder, which is made to envelop the head like a cap, is a very effectual means of applying cold. The ice cap should not, however, be continued on for too long a time; it should be re- moved every fifteen or twenty minutes, and a fold of linen, wet with some evaporating lotion, as two parts of water and one of alcohol or camphorated spirits, substituted. Should, however, the heat of the head, with flushing of the face, return, the ice cap may be reapplied. In cases occurring in very young children, or in those of a feeble constitu- tion, simply sponging the head with cold water or with an evaporating lotion or keeping it covered with a fold of linen constantly wet with the latter, is preferable to the application of ice. Active purging should immediately succeed the first bleeding, in every case in which this measure is not counter-indicated by the pre- sence of gastro-enteric inflammation, and even here, calomel may be employed in small doses, occasionally repeated, with the best effects. We may, in most cases, administer in the commencement of the at- tack, a full dose of calomel and rhubarb, and accelerate its operation by purgative enemata, (the best of which, in violent cases, is a mixture of molasses, water, castor oil, and turpentine,) and subsequently by proper doses of castor oil or senna tea, with the addition of the sul- phate of magnesia. After the bowels have, by this means, been actively purged, we may continue the use of the calomel in small doses, every two or three hours, according to the urgency of the case. We are in the habit of combining the calomel with ipecacuanha, prepared chalk and digitalis. R.—Calomel, gr. vj. ad xij. Ipecac, pulv. gr. iij.—iv. Cretae ppt. 33s. Digitalis pulv. gr. iij.—iv.—M. f. chart. No. xij. The dose of the calomel, and the frequency of its administration must be regulated by the character of the symptoms. In very acute and violent cases, from half a grain to two grains, according to the age of the patient, may be given, every one, two, or three hours. If irritation of the bowels, with frequent purging, ensue under the use of the remedy, we may add to each dose of the calomel, from one-third of a grain to a grain of the extract of hyoscyamus. The employment of digitalis in the acute affections of children, is very generally ob- jected to, and very specious reasons have been offered in opposition to its use, especially in cerebral inflammation; on the other hand, we can adduce our own experience in favour of its perfect safety, when cautiously administered, and its effects are carefully watched, and of the beneficial influence it occasionally exerts over the disease. When the disease occurs in the latter period of childhood, and is marked by symptoms of great acuteness, for the ipecacuanha and digi- 428 DISEASES OF THE NERVOUS SYSTEM. talis, an eighth of a grain of tartarized antimony may be substituted. The tartarized antimony, in such cases, often proves an excellent remedy. We have seldom employed it, however, in the cases of young children or infants; in whom we have never seen much good result from it, while often its effects have been positively prejudicial. After full bleeding, and the action of a brisk purgative, external revulsants may be resorted to with great advantage. The feet of the patient may be immersed in a warm sinapised pediluvium; or they may be enveloped in a blanket wrung out of hot water, in which a portion of mustard has been infused. During the use of the warm pediluvia, cold water or ice may be applied to the head, or, in severe cases, it has been recommended that cold water be poured upon the head from the spout of a tea-pot, or even in a smaller stream. Infants, however, seldom bear this well, and even older children are liable to become greatly alarmed upon its use; we have, therefore, very generally pre- ferred the ice cap, cold sponging, or the application of a cloth wet with some evaporating lotion. The application of blisters, when well timed, is very generally ad- vantageous. They should never be employed until after the inflam- matory excitement has been reduced by active depletion; as soon, how- ever, as this has been accomplished, their effects are always salutary, and often surprisingly prompt. They should be applied to the nape of the neck, and behind the ears: we have never been in favour of their application to the scalp, or of keeping up a discharge from the blistered surface, by means of irritating ointments; we prefer, in every case, a succession of blisters. The blisters, in young children, should be kept on until redness of the skin is produced, and then followed by a light emollient poultice: as soon as the blistered surface heals, it may be covered with another blister, and in this manner the blis- ters should be continued so long as their derivative influence may be desired. In the latter stage of the disease, after collapse has taken place, the application of blisters and sinapisms to the extremities has been ad- vised, with the view of rousing the sinking energies of the system; but we apprehend that at this period of the disease little permanent benefit need be anticipated from blisters, or any other remedy; instances of recovery being extremely rare. By the majority of practitioners it has been advised, in every se- vere case of meningitis, to place the system as quickly as possible un- der the influence of mercury; and with that view, in conjunction with the internal use of calomel, as we have directed above, to employ mer- curial inunction, either by rubbing the strong mercurial ointment upon the thighs and groins, to the extent of two or three drachms daily, or by dressing with mercurial ointment, the blistered surfaces; continuing the inunction for two, three, or more days, according to the effects pro- duced. The evidence in favour of this treatment is too strong and de- cided, not to recommend it to our attention; recollecting, at the same time, that however powerful an auxiliary it may prove, it is upon active depletion, in the early period of the acute stage, alone, that our chief dependence is to be placed for the cure of acute meningeal inflamma- A' ' O tion. ACUTE MENINGITIS. 429 If the gums should become in the slightest degree affected, the use of the mercury must be at once suspended; the bowels being kept re- gularly open by mild aperients. When a decided improvement in the symptoms of the case becomes apparent, the use of the mercury, both internally and externally, should be gradually suspended; care being observed neither to discontinue it too early, nor to continue it too long. During the continuance of the acute stage, every species of food should be prohibited; the thirst of the patient may be allayed by the use of cold toast, gum, or barley water. If the child is old enough, a small portion of ice held in the mouth, will prove refreshing, and ob- viate the necessity of large quantities of drink being taken. After the acute stage has passed, a small quantity of plain gruel or panada, may be allowed. The patient should be kept perfectly quiet, and free from every species of excitement; his chamber should be darkened, and of a mo- derate temperature, due attention being paid to preserve the air fresh and pure by proper ventilation. His head should be elevated and un- covered, while the covering of the body should be light, but sufficient to protect it from the slightest sensation of chilliness; it is particularly necessary to attend to this in the progress of the disease, as the tem- perature of the surface is very apt to sink, upon slight exposure. In cases attended with delirium, or when coma ensues, the state of the -bladder should be ascertained by actual inspection, twice or thrice a day, and if distended, the urine should be drawn off by the catheter. Stillicidium will occasionally occur, which may mislead the practitioner as to the state of the bladder, unless its condition be examined by the hand. During convalescence the diet of the patient should be cautiously regulated; for a long time he should be confined to farinaceous pre- parations, plainly cooked, and taken in great moderation, their effects upon the digestive organs being carefully watched. Excitement of every kind, as well as too long continued application of the mind, should be avoided; only the gentlest exercise should be undertaken at first, and the utmost precaution observed to prevent fatigue. The state of the bowels should be regulated by gentle aperients, if costive- ness be present; or if diarrhoea occur, by some gentle astringent. For a long period after recovery, the danger of a relapse from slight causes, should be kept constantly in mind, and the patient, in consequence, should be placed under a judicious hygienic course of treatment, until his health is firmly established. It occasionally happens, that after active depletion has been carried as far as the circumstances of the case will warrant, and the acute symptoms are entirely removed, the patient sinks into a state of deep coma, with a small, rapid, and feeble pulse, paleness of the counte- nance, and reduced temperature of the whole surface. In such cases, the practitioner must, by a cautious investigation of every circumstance, decide whether these symptoms are the result of an inflammatory con- dition of the brain, or arise from mere exhaustion. If from the latter, the cautious administration of opiates, and even diffusible stimulants, 430 DISEASES OF THE NERVOUS SYSTEM. with a nourishing diet should be commenced, and if the patient im- proves, a more free but judicious employment of these means will, in a short time, restore his health. Opiates are not, however, so gene- rally useful in the comatose condition, as in the state of delirium from exhaustion, and even here they should not be pushed to too great an extent; if they do not, when given in moderate doses, quickly produce a state of calmness and refreshing sleep, they should be discontinued. Strong beef or mutton broth, wine whey, or wine itself, in small and frequent doses, in general, prove more efficient remedies in these cases. Blisters to the nape of the neck, and sinapisms to the extremities, will often act as valuable auxiliaries. The practitioner must recollect, however, that whilst it is important to rouse the patient from the state of exhaustion upon which his coma or delirium depends, over-stimula- tion must be guarded against, lest in the irritable state of the brain, we suddenly excite an undue action of its vessels, which may rapidly terminate in extensive serous effusion. Meningitis encephalica. Dr. Brockman has recently described, un- der this name, a peculiar form of acute cerebral disease incidental to childhood, in which the membranes of the medulla oblongata and pons varolii are chiefly affected. Dr. Brockman has met with fourteen cases of this affection. It was at first observed by him as a sequel of scarlatina, but subsequently he has seen it to occur most frequently as an idiopathic affection. It is sometimes associated with general disease of the brain; at others, it is uncomplicated. Notwithstanding in its earlier stages it is unattended by any serious symptoms, it is an affection fully as dan- gerous as cerebral meningitis. The first stage, or that of simple hy- peraemia, generally continues for one or two days. The child is dull and heavy, and the occiput is often hot; the bowels, however, are re- gular; there is no vomiting; no intolerance of light, nor any disturb- ance of sleep. The general dulness of the patient, and vague com- plaints of some uneasy sensation in the head, increase as the inflam- matory stage sets in; the heat of the occiput is augmented; the head becomes retracted, as in the ordinary cases of acute meningitis; and convulsive twitchings of the limbs occur, similar to the effects of slight electric shocks, which recur every few minutes while the patient is awake, but cease during sleep. The general febrile symptoms con- tinue during the third stage; the pulse, however, diminishes in fre- quency and fulness, but does not become either irregular or intermit- tent. The general disquietude of the child subsides by degrees into a comatose condition, in which the head becomes still more retracted, but unattended with strabismus, or any morbid condition of the pupil: the peculiar air of stupidity that characterizes hydrocephalic patients is wanting. Two pathognomonic symptoms, however, indicate the oc- currence of the stage of effusion. One of these is deafness; the other is difficult articulation, and difficulty in moving the tongue—both of which latter occur at the same time, probably from paralysis of the motor nerves of the tongue. The deafness and affection of the tongue usually occur suddenly; sometimes they are first observed upon the child awaking from a quiet sleep. They are, according to Dr. EPIDEMIC MENINGITIS. 431 Brockman, the earliest and most certain indications of the occurrence of effusion. This stage continues sometimes for three, and sometimes for fourteen days. Its termination is in fatal paralysis, the occurrence of which is often preceded by various singular nervous phenomena—as sudden pauses in the respiration, or equally sudden syncope. In some cases, however, the paralysis does not follow, but the anomalous symp- toms subside, and the patients gradually recover; until, indeed, the paralytic stage is fully established, the recovery of the patient is still possible. In the uncomplicated cases of the disease, upon examination after death, the cerebrum in general presents an extremely pallid and anae- mic condition, in striking contrast with the cerebellum; the vessels of which are turgid with blood, while its substance, also, is often in a state of marked hyperaemia. The hyperaemia increases in intensity towards the central portions of the encephalon; and the membranes covering the pons varolii and medulla oblongata are found in a most decided state of inflammation: the portion of inflamed membrane is perfectly isolated, and not more, usually, than a square inch in extent —the membrane of the cerebellum being entirely free from any indi- cations of inflammation. There is ordinarily an effusion of a serous fluid into the subarachnoidal tissue; sometimes to the extent of several ounces; occasionally a gelatinous matter is effused, and, in some cases, the effusion is of a purulent character. This form of disease is most frequently observed in children from three to ten years of age, and who had previously enjoyed good health. The treatment recommended by Dr. Brockman, in its first two stages, is depletion, by leeches to the posterior part of the head, cold applica- tions to the scalp, and the free administration of calomel, which latter may be continued during the stage of effusion. Here, however, it be- comes necessary to support the strength of the patient: for this pur- pose ammonia is directed by Dr. Brockman, but he remarks that, in some cases, the administration of wine may be required. According to his experience powerful counter-irritants, as a large blister, or the actual cautery, prove, also, sometimes beneficial. 5.—Epidemic Meningitis'. Acute meningitis, or, to speak more correctly, cerebrospinal menin- gitis, has, within the last ten or twelve years, occurred in different parts of the world as an epidemic of a very formidable character. In the several portions of France Avhere the disease has prevailed, it was, in a great measure, confined to the younger portion of the soldiery, par- ticularly the new recruits; while in Gibraltar, as well as in those parts of Ireland and of the United States, in which the epidemic has oc- curred, it has principally attacked children from five to fifteen years of age. This circumstance, and the fact that when the disease occurs sporadically it is very generally in individuals under the age of puber- ty, would seem to demand some notice of it in a work devoted to the consideration of the diseases of children. The symptoms by which the disease commences are usually of a very formidable character, and its accession is often sudden and quite un- 432 DISEASES OF THE NERVOUS SYSTEM. expected; in a large number of cases the patient is in his ordinary health and spirits up to the very moment of the seizure, and experi- encing no premonitory symptoms to Avarn him of his danger. In four of the cases at the South Dublin Union, the boys had eaten a hearty dinner, and retired to bed in apparent health, Avhen the disease, all at once, declared itself. Very generally, however, the attack is preceded by pain of the head—generally continuous, but occasionally remittent or intermittent. It is commonly seated in the forehead, temples, over one or both eyes. or in the occiput; or, occupying the whole head, it is most acute at the occipital and frontal regions. In some instances, there is also pain in the back of the neck, and along the course of the spine, soreness in the muscles and joints, facial neuralgia, and, very rarely, giddiness, with or without dimness of vision. In few cases is the attack preceded by any impairment of strength, or sense of general malaise. The appe- tite is seldom much affected, though occasionally it is entirely lost, or greatly diminished. Occasionally, the attack commences with a feeling of chilliness, suc- ceeded by a slight increase of the heat of the surface, and pain, ex- tending from between the shoulders to the occiput, with stiffness, to a greater or less extent, of the posterior cervical muscles. In other cases, the patient may be attacked by chilliness, pallor of countenance, cold- ness of the extremities, low moaning, or muttering delirium, quickly succeeded by restlessness, flushing of the face, a frequent pulse, a wild expression of the eyes, and a hot and dry skin. In other cases, again, the disease may be ushered in by a sense of lassitude and uneasiness, considerable prostration, and a dull heavy pain of the head, with more or less vertigo, especially when an attempt is made to assume the erect position; the eyes are languid and half closed, the speech laborious and indistinct. Occasionally the patient is suddenly attacked with deep coma, or with more or less stupor, attended by a sense of extreme debility, giddiness, dimness of sight, or double vision. Or, finally, the attack may commence with severe pain of the abdomen, immediately succeeded by nausea, and perhaps vomiting. In violent attacks of this character, the extremities become, at the same time, cold and of a bluish colour, and the pulse is reduced to a mere thread. After a few hours, reaction, more or less complete, generally ensues. Whatever may be the character of the initiatory symptoms, they are replaced, sooner or later, by a state of violent agitation, or by a state of stupor more or less decided, with a slow, occasionally full, pulse, and dilated and immovable pupils. When in this condition, touching any portion of the patient's body will sometimes cause him to emit a short plaintive cry; at others, the patient utters, from time to time, acute cries, and carries his hand frequently to his head. When spoken to, he will, in general, exhibit a degree of consciousness by a motion of the head, by an attempt to articulate, or by opening his eyes for a moment. Pain, more or less intense, of the head, and along the spine, is pre- sent in the early stage of nearly all cases. Pressure applied to the cervical portion of the spine will often produce pain of the head, dart- EPIDEMIC MENINGITIS. 433 ing to the forehead, eyes, and temples, as well as pain at the top of the sternum; while pressure on the dorsal vertebrae will cause pain at the middle of the sternum; or about the umbilicus, according as it is made higher or lower. The pain is frequently severe, and continues for some time after the pressure is removed. Delirium is very commonly present from an early period of the at- tack. It is often attended with contraction of the pupils; occasionally with dilatation of one pupil and contraction of the other; sometimes with ptosis of the eyelids, and ecchymosis under the eyes. The deli- rium ordinarily lasts only a short period, but quickly returns. In most cases, the mind of the patient is desponding and apprehensive. In the majority of cases there is more or less intolerance of light and sound; in some, to such an extent, that the slightest ray of light, or the least unusual sound, is apt to excite convulsive movements. Im- perfect vision has been occasionally noticed in the first period of the attack—the patient seeing objects double, or only one half of them, or they appear to him as if enveloped in a mist. The conjunctivae are often injected, and the eyes of a glittering and watery aspect. In- sensibility of the eyes to light, and complete blindness of one or both eyes, are noticed as having been present in many cases. Violent in- flammation of one or other eye is described as being of frequent oc- currence in some epidemics. In some cases there is partial or complete deafness; in others a con- stant ringing in the ears is complained of from an early period of the attack. An exalted sensibility of the entire surface of the body is very ge- nerally present. The patient winces upon the slightest touch, even of the bed-clothing, and refuses to change his position, from the pain con- sequent upon every attempt at motion. This exalted sensibility of the cutaneous surface is often manifested only towards the close of fatal cases. Diminution of tactile sensibility and confirmed stupor, when they occur, are always indications of imminent danger. In very violent cases, petechiae occur upon the extremities and over the eyelids, within a few hours after the attack. An exanthematous eruption, also, occasionally makes its appearance. The respiration is sometimes irregular and laboured—a difficulty would appear to be experienced in some cases in expanding the lungs —>vith respiration chiefly through the nostrils. Stertorous respiration is not a frequent symptom. There is often continued irritability of the stomach, with insatiable thirst, and tenderness of the epigastrium upon pressure. These symp- toms are entirely independent of disease of the abdominal viscera. In two cases in Avhich they persisted in a very marked degree to the close, Dr. Mayne, upon examining the abdomen after death, found the sto- mach, intestines, and other organs, without any appreciable lesion. Constipation and suspended secretions are common symptoms of the disease. The tongue is usually more or less coated with a pale ash, Avhite, or yellowish fur. In the more grave and malignant forms of the disease, it has been observed to be broad and flabby—sometimes so enlarged as to impede articulation, and indented around its edges by 28 434 DISEASES OF THE NERVOUS SYSTEM. pressing upon the teeth. An increased flow of saliva is commonly present. The pulse, during the period of excitement, is usually full and fre- quent—from 120 to 140 in a minute—often, however, it is very slow— sinking, sometimes, to 48 or 50 in the minute. The pulse has been ob- served to vary in the number of its beats at different periods of the day. The most striking characteristic of cerebro-spinal meningitis is that presented by the condition of the muscular system. The muscles of the neck, in particular, become rigidly contracted, drawing back the head upon the vertebral column, and firmly fixing it in that position, so that the patient is unable to move it forwards; neither can this be done by the attendants with the employment of any justifiable degree of force. The countenance, at the same time, assumes very much the tetanic expression. In some cases, the contraction is confined to the sterno-mastoid muscle of one or both sides; in others, again, it is the extensors that are principally affected, the head being retained perma- nently in its natural erect position. Rigidity is very commonly ob- served, also, in the muscles of the extremities. The patient loses the power of moving his limbs and of assuming the erect posture. In some instances there is a quivering motion of the muscles of the face, with tremors of the hands, and embarrassment of the movements of the ex- tremities, or spasmodic twitchings in the flexors of the limbs, with a disposition to a constant movement of the legs from side to side, alter- nately. In some epidemics, rigidity of all the spinal muscles was a common symptom—occasionally, the whole spine, from the occiput to the sacrum, being bent forcibly backwards, like a well-strung bow, so as to prevent the patient from lying flat upon his back. Contraction of the recti muscles of the abdomen is often present. In many cases there is a difficulty of prehension, it being with great difficulty that the patient can take and drink water from any vessel Avithout assistance. In some cases involuntary twitchings of the mus- cles are produced whenever the patient attempts to move or seize any thing, as if he Avere under the influence of strychnia. In others, vio- lent convulsions are induced the moment the inferior extremities are raised up, or merely touched. There is great irregularity as to the period when the tetanic symptoms occur. They may set in as early as the first day of the attack, or not until after the lapse of several days. Cerebro-spinal meningitis, although it is generally marked by pain in the head more or less intense, ischialgia, heat of the scalp, conges- tion of the conjunctivae, some degree of intolerance of light and noise, exalted sensibility of the cutaneous surface generally, tendency to coma, and a tetanic affection of the muscles of the neck, and perhaps extre- mities, may, nevertheless, in many instances present no symptoms of so decided a character as to lead us to suspect the existence of serious disease of the brain and spinal marrow, until the laboured pulse, the dilated pupil, the profound coma, or the severe spasmodic or convul- sive attacks indicate but too plainly the near approach of death. In other cases, again, and those by no means of rare occurrence, symptoms of a most formidable character may present themselves at the very outset of the disease. Thus, the patient may be attacked at once with EPIDEMIC MENINGITIS. 435 violent paroxysms of general convulsions, requiring manual restraint to protect him from injury; or, he may suddenly, without any striking premonitory symptoms, sink into a state of coma almost apoplectic in its character, or, into a half-unconscious condition, with constant moan- ing or plaintive cries, and grinding of the teeth. Intermissions of a periodic character are not uncommon in the course of the disease. So complete are these, in some cases, as to lead to the hope of a speedy recovery of the patient, the fallacy of which is shown by the return of the symptoms, in perhaps an aggravated degree, on the following day. When death is not early induced by the violence of the attack, the patient sinks, more or less rapidly, into a state of profound coma, his pulse becomes slow and labouring, his powers of speech and deglutition entirely fail, his tongue becomes dry, and, together with his lips, en- crusted with dark sordes; his stools are passed involuntarily, while his bladder becomes distended with urine, or allows it constantly to dribble away: death finally closes the scene, often preceded by paralysis of one side of the body, or of one or other extremity. In his account of the epidemic of cerebro-spinal meningitis that occurred in the State of New York during the year 1857, Dr. Squire describes five modes in which the disease may terminate. In the first place it may be "nipped in the bud;" in which case the patient speedily recovers, without experiencing the first chill; 2dly, death may take place during the cold stage, previously to reaction; 3dly, the patient may die during the hot stage, which often lasts seve- ral days; 4thly, he may survive the stage of febrile reaction, and die eventually from the effects of effusion; and, 5thly, he may outlive the entire course of the disease, and regain, finally, either perfect or par- tial health of mind and body. (Trans. Med. Soc. State of Neiv York, 1858.) The duration of the disease is very variable. Death may occur within a few hours from the commencement of the attack. The gene- rality of cases terminate about the fourth day, some, however, are pro- tracted to over fourteen, twenty, or even fifty days. Convalescence is usually slow and lingering. Even after an apparently perfect re- covery, secondary diseases are apt to occur, and sooner or later de- stroy the patient. Dr. Squire presents the details of forty-three fatal cases, observed by him in New York State, during the year 1857. Of these forty-three cases, in 12 death took place within from 2 to 12 hours from the onset of the disease; in one, within 16 hours; in 5, within 24 hours; in 18, within from 1 to 5 days; in 3, within from 5 to 10 days; in 2 the disease continued for 8 weeks before death occurred; in 1, 4 months, and in another, 10 months. (Trans. Med. Soc. State of New York, 1858.) The diagnosis in cerebro-spinal meningitis is somewhat obscure. There is no symptom or series of symptoms which can be considered as strictly pathognomonic. The disease is in general characterized by acute and fixed pain of the head, rachialgia, aversion from light, injection of the conjunctivae, increased sensibility of the surface, acute cries, low, muttering delirium or coma, pain, and stiffness of the 436 DISEASES OF THE NERVOUS SYSTEM. posterior-cervical muscles, with permanent retraction of the head, often rigidity of the large extensors of the spine, spasmodic tremors or twitchings of the muscles, particularly of the face, and tetanic convul- sions of the limbs. When a disease, marked by several or all of the above symptoms, occurs, especially as an epidemic, we may pretty con- fidently pronounce it to be cerebro-spinal meningitis. The prognosis is for the most part unfavourable—sporadic cases, it is true, frequently do well under an appropriate treatment, but in its epidemic form, it has been found to terminate fatally in the great ma- jority of cases. When the attack commences with great prostration, coma, and general symptoms of collapse, death often ensues very speedily without the occurrence of reaction. Few cases recover after severe tetanic symptoms make their appearance. Irregularity of res- piration, difficulty of swallowing, great enlargement of the tongue, ex- tensive petechiae, violent general convulsions, and deep persistent coma, are all unfavourable symptoms. As already remarked, it is chiefly from the occurrence of cerebro- spinal meningitis as an epidemic, that the disease has of late years at- tracted the attention of physicians. These epidemic visitations are occasionally confined within very narrow limits, while, at other times, as was the case in France, between the years 1837 and 1842, they spread successively over extensive regions. Their occurrence would appear to be altogether independent of any morbific agency referrible to pe- culiarities of climate, season, or locality. Age, and to a certain extent sex, would appear to rank as predisposing causes of the disease, what- ever may be the nature of the epidemic agent by which it is produced. Its subjects, wherever it has occurred, have been young persons, gene- rally of the male sex. In Ireland, boys under twelve years of age, were those almost exclusively attacked. In Gibraltar, in the great majority of cases, it occurred in males betAveen two and fifteen years of age. In Tennessee, its principal victims were children between the ages of six and fifteen years. In Missouri, between ten and fifteen years. In San Augustine, Texas, the patients were generally under fifteen years: in but two or three instances did the disease attack those over eighteen years of age, and not in a single instance a female. Of the 43 cases given by Dr. Squire, in his account of the New York epi- demic, 31 were in males and 12 in females. Twenty-seven of the patients Avere under 14 years of age; 9 between 14 and 25, and 7 over 25 years. In Alabama, however, the majority of those attacked—over 50 per cent. —were beyond twrenty years of age. Fifty-four per cent, were males. In Texas there was not an instance of the disease occurring among the negroes, who were probably more exposed to morbific agencies than the whites. In France, the disease occurred, for the most part, among the young conscripts who had lately joined their regiments. We have not the slightest evidence that the disease is communicable by contagion or infection, but on the contrary, much that would appear very satisfac- torily to establish its non-contagious character. The lesions detected after death from epidemic meningitis are chiefly confined to the cerebro-spinal meninges. The pia mater is deeply injected with blood, and the large vessels and sinuses are re- EPIDEMIC MENINGITIS. 437 markably turgid. The free surface of the arachnoid is generally dry and clammy, and in several places the membrane is slightly opaque. Lymph and other inflammatory effusion is seldom met with within the cavity of the arachnoid, but, between the latter membrane and the pia mater there is, in many cases, more or less serosity, either lactescent or turbid, yellowish/and often semi-gelatinous. In others, there is met with, disseminated along the course of the vessels, drops, varying in size, of a yellowish colour and purulent appearance. More generally, patches or bands of a consistent substance, of a yellowish or greenish colour, resembling concrete pus, exist beneath the arach- noid, on the upper and lateral portions of the hemispheres, but espe- cially at the base of the brain, in the space corresponding to the circle of Willis; many of the cerebral nerves being, at their origin, im- bedded in it. The effusion is spread over the anfractuosities, which it rarely penetrates. In the spinal cavity, this puriform matter extends, in bands, along the anterior or posterior face of the medulla, and, in some instances, entirely envelops it, and extends often, to the loAvest extremity of the cauda equina; investing each of the spinal nerves at its source. In some cases, true purulent collections are present. As in the cranium, so also in the vertebral canal, these morbid deposits are confined to the subarachnoid space. The substance of the brain and spinal marrow are usually free from any decided lesion. In a few cases, however, the brain and spinal marrow have been found implicated. In some, the ventricles of the brain contained inflamma- tory effusions, and the choroid plexus appeared unusually vascular; in others, more or less of the substance of the brain and spinal mar- row was found in a state of softening; in others, again, sero-purulent effusion was detected at the base of the brain, and in the theca verte- bralis; but, in every instance, the serous membrane was the part es- sentially diseased. In a great majority of the fatal cases, in which great disorder of the cerebral functions was manifested, after death, the substance of the brain was found to be either not at all or only slightly affected. Dr. Ames, however, in all the cases examined by him, found, on cutting into the substance of the brain, besides the red points commonly present in cases of congestion and inflammation, an infinite number of red vessels, containing sometimes fluid, and at others coagulated blood. These were seen, likewise, upon removing the membranes, ramifying over the base of the brain, and the floors and Avails of the ventricles, as well as on sections of those parts. The gray and white matter had a pink colour, dependent on the presence of vessels that were separately visible. Of these alterations, the cere- bellum partook, to a greater or less extent, in every case. Still there is reason to conclude that when the brain or spinal marrow is found affected it is only secondarily—the disease having been propagated to the substance of the cerebro-spinal axis from its meningeal investments. In all cases in which pus Avas detected on the spinal medulla, it ex- isted, also, in the brain; occasionally, however, it was confined entire- ly to the latter. M. Tourdes hence infers, that the inflammation commences invariably in the encephalon, and extends from thence to the spinal marrow. 438 DISEASES OF THE NERVOUS SYSTEM. The rapidity with Avhich suppuration may occur in cases of epide- mic meningitis is somewhat surprising; M. Leonard, of Toulon, reports an instance in which the disease ran its course to suppuration in fif- teen hours, and cases are recorded by M. Broussais (Hist, des Meningi- tes Cerebro-Spinales) in which suppuration occurred in thirty-six and forty-eight hours. Slight redness of different portions of the gastro-intestinal mucous membrane is occasionally met with, in the form of patches, arboriza- tions, or dots. In some instances, a diseased condition of the fol- licles, in others reddening, thickening or softening, to a greater or less extent, of portions of the mucous membrane of the stomach and ileum are present. Dr. Ames, Avho describes this latter lesion, mentions also four autopsies in which were found enlargement, and in one case ulceration, of the agminated and solitary glands of the lower portion of the ileum, with enlargement, reddening, and in one case, softening of the mesenteric glands. These lesions of the digestive organs have seldom been observed excepting in patients who survived the first few days of the attack, and, consequently, can be viewed only as the result of an accidental or secondary affection. In regard to the condition of the blood in epidemic meningitis, M. Faure-Villars found in the post-mortem examinations made at Ver- sailles, in 1839, the left cavities of the heart almost entirely empty, while those of the right side were filled with large fibrinous coagula, of a yellow colour, and some consistence. The same thing was ob- served by the physicians in other parts of France, especially in cases in which the blood drawn during the lifetime of the patient was buffy, and contained but little serosity. In four analyses of the blood, pro- cured in two cases at the first venesection, in one at the second and in another at the third, M. Tourdes states, that the principal alteration detected was an increase of the globules and of the fibrine, but espe- cially of the former. Dr. Ames found the blood drawn from the arm, and by cups, to form large, loose coagula, in which all the red glo- bules were rarely included. The serum separated slowly, and in small quantity. The colour was generally bright—in a few cases approach- ing to that of arterial blood. Of thirty cases, it was buffed only in four. It presented an excess of fibrine. With respect to the treatment of cerebro-spinal meningitis but little can be said of a very positive or satisfactory character. The rapid march of the disease in the larger number of cases, allows but a short interval for the application of appropriate remedies. At the height of the epidemic, especially in cases where the attack commences with symptoms of extreme violence, or in which a state of extreme collapse is present from the very onset, the most judicious and best directed treatment will very generally fail to arrest a fatal termination. In the commencement of the attack, when symptoms of prostration and of deep stupor are absent, as well as during the early period of the stage of excitement, there can be no doubt of the propriety and efficacy of direct depletion. The amount of blood to be drawn is to be measured by the age and condition of the patient and the effect pro- EPIDEMIC MENINGITIS. 439 duced. If a weak pulse rise, or a strong one retain its character during the flow of blood, this may be allowed to continue; but if the pulse be- comes Aveak, a moisture breaks out upon the surface, and the face be- comes pallid, indicating approaching syncope, the flow of blood should be instantly arrested, even though Ave may find it necessary, from the rising of the pulse, and the renewed flushing of the face, to re-open the vein a few hours afterwards. The extent of our bleeding should never be proportionate to the degree of restlessness and delirium with which the patient may be affected: these states of violent nervous erethism quickly exhaust the powers of life, and when present, a too copious venesection Avould be liable to induce a sudden and speedily fatal collapse. Subsequent to general bleeding, cups should be applied to the back of the neck, and along the spine, and leeches to the temples and neck, and behind the ears, and repeated at short intervals, so long as any indication for direct depletion remains. After the first bleeding an active mercurial purgative should be ad- ministered, and cold applied to the shaved scalp, by means of a bladder half filled with powdered ice, or cloths wet with iced Avater, or iced Avater and vinegar. At the same time the feet and legs should be immersed in hot Avater, followed by sinapisms to the feet and ankles. In conjunction Avith direct depletion by the lancet, active purgation cannot fail to prove an important remedy, by producing a determina- tion from the diseased organs. There will scarcely be met with a case in Avhich the presence of gastro-enteric inflammation Avill contra-indi- cate its employment. Tartar emetic in divided doses, combined with some one of the saline diaphoretics, will no doubt prove beneficial in the early period of the stage of excitement. In the epidemic Avhich occurred at Vicksburgh, Miss., Dr. Hicks gave it, in combination with camphor, in the following prescription, and, as he states, with the best effects:—R. Antimon. tart. gr. ij., Pulv. camphor. $\j., Mucilag. g. acaciae, 3vj. Mix. Dose, a tablespoonful every two hours. After direct depletion has been carried as far as, under the circum- stances of the case, is judged advisable, especially if the patient falls into a state of coma, with feeble pulse and deficient reaction, sinapisms or blisters along the Avhole course of the spine will often be found of ad- vantage. Blisters to the upper portion of the spine very generally had the effect, Dr. Ames informs us, of removing or greatly relieving the cephalalgia, even Avhen bleeding had failed to do so. The relief afforded by them in the malignant forms of the disease is, Ave are informed, very decided. Blisters to the scalp have been advised; we much doubt, however, the propriety of their application to this part. When the attack commences with symptoms of collapse, or when a state of collapse ensues after a short and imperfect reaction, the most poAvorful excitants—mustard, ammonia, or turpentine—aided by heat and friction, should, without delay, be applied externally, along the spine and to the extremities, and perseveringly continued, at short in- tervals, until the torpid sensibility is aroused. It is probable that, in such cases, the actual cautery, as employed by M. Rollet, will be found 440 DISEASES OF THE NERVOUS SYSTEM. of advantage. This gentleman passes the iron, at a white heat, six, eight, or more times, upon as many different points, along each side of the spinal processes. He states that, in the worst cases, the first ap- plication of the actual cautery does not elicit from the patient any in- dication of sensibility; it is only at the third, fourth, or even fifth ap- plication that a slight muscular movement proves that pain is expe- rienced. Some patients utter cries during the last applications, but immediately relapse again into a comatose condition. Should Ave succeed in establishing permanent reaction, the patient must be carefully Avatched, and if the reaction transcend the proper grade, resort should be immediately had to general and local blood- letting, to an extent proportioned to the violence of the symptoms, and the age and strength of the patient; at the same time, cold applica- tions should be made to the head, and the other means of keeping down excessive reaction employed. The early and free exhibition of mercury, both by the skin and mouth, with the vieAV of producing promptly its specific action, is favourably spoken of by several of the American w*riters on the disease. Dr. Ames, of Alabama, considers it a more efficient remedy than blood- letting, as Avell in the promptness as in the permanence of its beneficial effects. The French physicians condemn mercurial frictions; more, however, we suspect, from theoretical vieAvs, than from any actual experience of their bad effects. It is proper to remark that, in many cases, mercury, even when its specific effects have been induced early in the attack, has failed to exert any perceptible influence in retarding the fatal march of the disease. The same is true, however, in reference to every other remedy that has been resorted to. Subsequent to the employment of venesection and the other anti- phlogistic remedies, the administration of opium has been recommended by several of the French physicians. Forget commenced its use be- tween the fifth and seventh days of the disease, in the form of a syrup containing half a grain of opium as a dose for an adult. This he found to relieve the pain of the head, and to calm the delirium and muscular spasms. M. Chaufard states that the early employment of the most energetic antiphlogistic means failed in his hands to cure the disease, but he found it to be promptly arrested by opium given in large doses: in many cases it was advantageously combined with quinine. It is stated that before this plan was adopted, only one case was cured out of thirty, but subsequently the disease was even less fatal than in its sporadic form. M. Tourdes admits the inefficacy of the usual an- tiphlogistic remedies, but cannot agree Avith all M. Chaufard has as- serted in favour of the curative effects of opium. Dr. Ames, of Ala- bama, does not consider opium as generally a safe remedy in the more violent inflammatory cases, or as beneficial in the congestive malignant cases. In other forms of the disease, he speaks of it as a safe and very valuable remedy. We are informed by Dr. Roberts, that at St. Augustine, Texas, opium and morphia were tried in a few cases, but without any good result; they appeared rather to increase the stupor, without relieving the pain and restlessness. The Avater of the cherry laurel and of valerian, combined with mucilage, were employed by some EPIDEMIC MENINGITIS. 441 of the French practitioners with a view to their sedative operation, subsequent to antiphlogistics and revulsives. The distilled water of bitter almonds is preferred by M. Mialhe, as furnishing more definite proportions of hydrocyanic acid. By certain of the French army physicians quinine is recommended as a most efficacious remedy in cerebro-spinal meningitis; by the ma- jority of them, however, it is denounced as positively injurious. Dr. Ames employed it frequently in the graver forms of the disease, and sometimes with partial success. He found it occasionally to arrest the paroxysms Avhen the disease was attended by fever of a regular remit- tent character. In other forms of the disease, if not absolutely in- jurious, its effects were not such as to encourage a continuance in its use. Dr. Thomas, in his account of the disease as it prevailed in central and Avestern New York, during the spring and summer of 1857, remarks that, in Elmira and Watertown, quinine Avas given with de- cided benefit. Speaking of the same epidemic, Dr. Kendall says, that there often occurred a lull in the severity of the symptoms of the dis- ease, tAventy-four to forty-eight hours from the commencement of the attack, Avhen the administration of quinine in full doses was sometimes productive of a sudorific and anodyne effect, and proved then a valu- able remedy; and that still later in the disease, in smaller doses, it Avas also of some value as a tonic. It exerted little or no influence, hoAvever, over the course of the disease. (Trans. Med. Soc. of the State of New York, 1858.) Dr. Ames speaks highly of the effects of potass in this disease. It was given to children in doses of from three to five grains, every two hours. He states that no case proved fatal, so far as he could learn, in which the potass was freely and continuously employed. Under the use of the remedy, in many cases unattended with true febrile symptoms, the cephalalgia Avas speedily and permanently relieved, and in others, its use was followed by a prompt reduction of arterial excitement, de- lirium, and the intense pain of the head. Ethereal inspiration, it is said, was practised, with the best effects, by M. Basseron, physician-in-chief of the Military Hospital of Musta- pha, in Algeria. During the period of excitement, cooling drinks should be alloAved, and a strictly antiphlogistic diet enjoined. Absolute rest and quiet, with the seclusion of light, as far as these are consistent Avith due ven- tilation, are all-important. In the comatose cases, and during the stage of collapse, care should be taken to prevent an accumulation of urine in the bladder. Convalescence from epidemic cerebro-spinal meningitis is usually protracted, and relapses are liable to occur from slight errors in diet and regimen, hence the greatest Avatchfulness is to be observed until the general health and strength of the patient are fully re-established. Dr. Hicks found the annexed prescription to act as a most admirable tonic, after the violence of the disease had been subdued, for relieving the inertia of the nervous system that remained in every instance in Avhich recovery took place: R. Iod. ferri, 9j.; iod. potass. t>\].', iodini, gr. viij.; syr. sarsaparil. .siv. Mix. To be given in teaspoonful doses, every four hours, in an equal quantity of pure water. 442 DISEASES OF THE NERVOUS SYSTEM. 6.—Subacute Meningitis. TUBERCULAR MENINGITIS—ACUTE HYDROCEPHALUS—DROPSY OF THE BRAIN. Subacute meningitis, particularly with tubercular deposition, is pro- bably the most frequent form of cerebral inflammation occurring during childhood. It is that to which the term hydrocephalus is now most generally applied by medical Avriters. By many, however, all the forms of meningeal inflammation, without distinction, have been de- scribed as hydrocephalus. Thus, the more intense form of acute me- ningitis terminating speedily in effusion, constitutes the rapid hydro- cephalus of Cheyne; the ataxic of Guersent; the tumultuous or hy- peracute of Monro and Gb'lis; and the inflammatory of Brachet and Hopfengartner; while the subacute form of meningitis has been de- scribed by Cheyne as the sloiv or gradual hydrocephalus; by Hall as the strumous; and by Brachet and Hopfengartner as the nervous. But, notAvithstanding all these subdivisions, the pathology of that form of meningitis to which the term hydrocephalus is usually applied, was not, until recently, accurately made out. The error has been in re- garding serous effusion within the cranium as an essential character of the disease, upon which its distinguishing phenomena are mainly de- pendent, when, in fact, it is a mere consequence, and often is either entirely absent, or takes place to so slight an extent, as to be capable of producing, of itself, little or no effect. Laennec was among the first Avho pointed out the frequent presence of tuberculous formations upon the pia mater and arachnoid membrane, and more rarely within the medullary substance of the brain, in cases of meningeal inflammation: these Avere viewed, however, by most sub- sequent Avriters, as an occasional complication of the disease, and, by Guersent, Dance, and a few others, as a distinct variety of meningitis. It Avas not until more accurate researches had established the fact, that the very general and intimate connexion betAveen tuberculous deposits upon the membranes and in the substance of the brain, and the most frequent form of subacute meningitis in children, commonly described as hydrocephalus, Avas recognised. Subacute meningitis occurs chiefly in delicate, scrofulous children, especially in those distinguished by great irritability of the brain and nervous system, with large heads and precocity of intellectual develop- ment. Among its earliest symptoms, is a marked change in the disposition and deportment of the child. He becomes listless, and inactive, peevish, fretful, and restless, with a vacant, abstracted air and look; is indif- ferent to the objects Avhich before most attracted his attention, and is with difficulty soothed and diverted. He is unusually wakeful, or if he falls into a doze, this is broken by repeated starts and cries. The external senses become morbidly acute ; the child starts and cries at the slightest noise; is averse to being touched or handled, and impa- tiently Avithdraws his eyes, when they are accidentally directed to- Ayards the light; even in the ordinary light of the chamber, the eye- lids are often but half unclosed, and the brows drawn doAvn, giving to the countenance a kind of habitual frown. The pupils are most TUBERCULAR MENINGITIS. 443 generally contracted, and occasionally there is an injected state of the conjunctiva. Strabismus, or a rolling of the eyes upwards and out- Avards, is sometimes observed. When the child is old enough to give an account of his sensations, he complains of frequent, often continued, headache, while the younger infant will carry its hand repeatedly to the head, or roll the latter from side to side upon the pillow or nurse's lap. Frequent twitchings of the muscles are not uncommon. There is in some cases a rigid ex- tension of the upper or lower extremities, or more frequently a clench- ing of the hand, Avith the thumb bent firmly upon the palm, or a draAving of the head back, with rigidity of the muscles of the neck. In other cases, the patient exhibits a state of apathy and inertness. He is constantly dull and listless, and frequently moans, gapes, or sighs, and Avhen aroused is fretful and morose. His sleep is disturbed and broken. The countenance is habitually pale and sunken, though often marked with transient flushes. If the child is able to walk, his gait is feeble and staggering, and, according to Golis, he is frequently observed in advancing, to raise the foot, as if stepping over some ob- ject. Headache is occasionally present; more generally, however, the patient complains of a sense of weight over the forehead, or of gid- diness. In some cases, with these symptoms, there is a morbid acute- ness of the external senses, or, on the contrary, there may exist more or less obtuseness of sensation. In most cases, there is some degree of febrile excitement, especially towards evening. The skin is dry, but not much increased in tempe- rature; the pulse and respiration are accelerated, but often variable; the lips are dry and often cracked; and the child frequently picks or rubs the nose and mouth. There is usually increased thirst and loss of appetite, though occasionally the appetite is voracious or capri- cious. The tongue presents upon its surface a coating of whitish or yellow mucus, and is often red at its edges and apex; the breath has a sickly offensive odour. The bowels are in some cases obstinately costive, and in others are affected with diarrhoea, the discharges being composed of a sour, frothy mucus, of either a green, almost black, or of a pale colour. There is frequently more or less tension of the ab- domen, with tenderness of the epigastrium upon pressure. The attack is most generally preceded for some length of time, va- rying in different cases, by most or all of the premonitory symptoms just detailed. The disease very generally commences with an increase of the rest- lessness and irritability of temper. Although the face is usually pale, there is often an occasional flush of one or both cheeks. There is more or less increased heat of the scalp, with transient, acute shoot- ing pains of the head, and often acute transient pains of the abdomen. The surface of the body is usually dry, and somewhat above the na- tural temperature; the pulse is frequent, quick, and tense, but seldom full. The tongue may be either perfectly clean and slightly red- dened, or covered with a thin layer of whitish mucus, with increased redness about its point and edges. When, however, the disease of the brain is attended with gastro-intestinal irritation or inflammation, 444 DISEASES OF THE NERVOUS SYSTEM. the tongue generally becomes, at an early period, loaded with a dark brown incrustation of some thickness, which, towards the close of the disease, becomes black, dry, and rough. The appetite is occasionally unimpaired; at other times it is voracious; but, most generally, it is destroyed. The bowels are usually costive or torpid; but when gas- tro-intestinal disease is present, they are ordinarily relaxed, and the discharges are unnatural in colour and consistence. The pain of the head is, in general, seated in the forehead, shooting backwards towards the temples and vertex. It most commonly in- creases in intensity with the progress of the disease: it is seldom, how- ever, continuous, but occasionally remits, and then exacerbates;—the exacerbations causing the patient to utter a peculiar sharp, quick cry, Avhich has been considered in some degree diagnostic. The infant also manifests his sufferings by carrying his hands frequently to the forehead, and sometimes by keeping them constantly applied to the temples. The stomach is very generally irritable, the patient being affected Avith repeated retching or vomiting, particularly on rising from the recumbent position. This symptom is seldom absent. In some cases the pain in the head and vomiting alternate; the former ceasing, as soon as the latter occurs, and recurring with its discontinuance. In general, the abdomen is collapsed or flattened, and often tender upon pressure. The patient's sleep is short, imperfect, broken and dis- turbed; he tosses his hands about; rolls his head constantly from side to side; frequently grinds his teeth, or moans, or whines, as if from suffering. The respiration is quick and irregular, and repeatedly in- terrupted by deep, prolonged sighs, which occur more frequently as the disease verges towards the period of effusion. Delirium is occasionally observed towards the latter period of the stage of inflammation; it is generally, however, calm, very seldom violent or furious, and so slight, that when the patient's attention is roused, he is able, ordinarily, to give correct answers to the questions put to him. After an indefinite duration, shorter or longer in diffe- rent cases, the delirium becomes more frequent, and of longer conti- nuance; the countenance assumes a peculiar expression of stupor and surprise, very difficult to describe, but very characteristic. There is very considerable torpor or inertness of the intellectual faculties, with an apparent difficulty of directing them to any object; so that the patient's attention can scarcely be arrested, or he be induced to utter more than monosyllables, in reply to the questions put to him. The eyes are morbidly sensible to light, the conjunctiva is injected, and the pupils either strongly contracted, or alternately, or irregularly contracted and dilated. During sleep the eyeballs are generally turned upwards and inwards, so as completely to hide the cornea under the inner edge of the upper eyelid. Strabismus is a common symptom, particularly towards the period when deep coma and para- lysis are about to ensue. The patient soon manifests a constant disposition to drowsiness; he becomes inattentive to surrounding objects; and, when roused from his stupor, soon relapses into it again. The pulse decreases in fre- TUBERCULAR MENINGITIS. 445 qucncy, until it attains its natural standard, or falls below it; it is, however, readily accelerated by any slight exertion, as by raising the patient to a sitting position, or from the bed; the increased rapidity ceasing almost immediately upon his resuming the horizontal posture; the pulse is also irregular, and of unequal force. The sensibility of the system is diminished; the eyes are dull, heavy, and vacant; the countenance pale and sunken, and in a few cases oedematous. The nose is dry, and the lips pale, dry, and cracked; and the countenance acquires a peculiar vacant, stupid look, which has been considered by Golis as pathognomonic. M. Trousseau mentions as a diagnostic sign of tubercular menin- gitis, the appearance of a remarkable red line remaining upon the skin of the forehead or of the abdomen, after drawing the finger across it. In a female patient in the Massachusetts General Hospital, Avho died of the disease, the presence of this sign was pointed out by Dr. Slade of Boston. Dr. Parks of Boston also observed it very dis- tinctly on the eighth day of the disease. (Amer. Med. and Surg. Journ. 1853-55.) Dr. Baines of London, has also observed this tache meningitique, as Trousseau has named it. Though most commonly seen in patients suffering from hydrocephalus, it is present also in other cases, as in acute cerebral congestion, acute pneumonia of children, and in the head symptoms dependent upon the irritation of teething or of worms. AVhat is of some practical value is the fact of its absence in cases of gastric and remittent fever in children, where the most urgent and promi- nent symptoms are referrible to the head. (London died. Times, 1856.) Constant drowsiness is the most common and distinctive symptom of the advanced stage of the disease; as it increases, the patient lies in a soporose state, with half-closed eyelids; rousing, hoAvever, occa- sionally, and uttering an imperfect exclamation or a wild piercing cry. The drowsiness is finally succeeded by a state of complete coma. Preceding this, very generally, paralysis of one of the extremities, or of one side of the body occurs. Commonly, a tremulous motion of one arm is observed, Avith the fingers firmly bent inwards, and the hand upon the wrist; the power of motion in the arm and leg of the same side is gradually lessened, and very soon complete paraplegia ensues. Not unfrequently the arm of the opposite side is kept in a state of constant oscillatory motion, or is continually saAving the air. The pupil of one or of both eyes is usually now permanently dilated and insensible to light, and strabismus, with paralysis of the muscles of the eyelids, is almost invariably present. According to Dr. Hennis Green, a temporary but firm contraction of the eyelid often occurs at this period, which for a time prevents us from exposing the eyeball. -, It is very common, towards the period when the inflammatory stage of the disease terminates by effusion in the brain, for a sudden amend- ment in all the more prominent symptoms to occur; the patient, in fact, often appears to be quickly verging towards convalescence; the deceitful calm is, however, of short duration; sooner or later, a pa- roxysm of convulsions supervenes, or the patient again sinks into a state of fatal coma, followed, more or less quickly, by death. Con- 446 DISEASES OF THE NERVOUS SYSTEM. vulsive movements are very generally observed at this period, if they have not occurred previously. The pulse, which in the early stages of the attack, was quick, fre- quent and tense, when stupor comes on, becomes slow, full, and irre- gular, or even intermittent; and Avhen paralysis, and especially con- vulsions supervene, it becomes again very much increased in frequency, and not uncommonly small and corded. In the latter stage of the disease, the patient is often affected with a total loss of sight and hearing; the sense of touch, however, very generally continues unimpaired up to the last moment. The patient Avill occasionally lay hold of the nipple, and suck greedily, even when in a state of constant stupor, and deprived entirely of the sense of vision. At length the extremities become cold, the respiration un- equal and stertorous, the pulse weaker and weaker, and death takes place, often preceded by convulsions. The disease does not invariably attack in the same gradual manner, nor is it always preceded by the train of symptoms we have described. In many cases, the child, after a few days of languor and peevish- ness, is seized with symptoms of a decided febrile reaction, attended with pain of the head, flushing of the countenance, and tenderness of the abdomen; the febrile symptoms being marked by frequent, irre- gular intermissions. During the exacerbations, the patient is gene- rally affected with considerable stupor, marked by an occasional start- ing up, and screaming, as though he were in a state of the utmost ap- parent alarm and agitation; vomiting is frequent, and often excited by a mere change of position; the bowels are generally obstinately costive, and the expression of the countenance that of terror and suffering, or of dejection and intellectual torpor. In some cases, without any previous manifestations of febrile excite- ment, the disease is ushered in by an attack of convulsions. In gene- ral, however, in such cases, there is more or less evidence of impaired health existing previously to the occurrence of the convulsions; as a peevish and fretful, or impatient temper; deficient or variable appe- tite; irregular bowels; tumid abdomen; foul breath; restless and dis- turbed sleep, with grinding of the teeth and frequent starting. There is, in fact, a very great diversity in the mode of commence- ment, as well as in the progress of the sub-acute form of meningitis. The order of the symptoms may be changed; some may be absent, or only slightly marked, and others prominent and long continued. In some cases, the only symptoms indicative of the occurrence of the dis- ease have been coma, with deep sighing, coldness of the extremities, pallor of the countenance, and partial paralysis; while in others the disease, according to Quin, Rush, Monro, and Eberle, has commenced, and run its course, with scarcely any other important symptom than drowsiness, a slight febrile excitement, with little or no pain of the head, but a frequent desire to urinate, the urine being voided in very small quantities, and with difficulty. Equal irregularity marks the disease in regard to its entire duration, and that of its several stages. The first or premonitory stage may exist for a few days, or many weeks; the period of excitement, from TUBERCULAR MENINGITIS. 447 a few hours to one or two days, or even longer; that of oppression, from four or five days, to tAvo Aveeks; and the paralytic stage, from an hour or two, to ten or twelve days. The disease in general, however, runs a protracted course. Rilliet and Barthez have never knoAvn death to occur before the seventh day—most commonly it occurred from the eleventh to the twentieth day; in some cases the patients lived sixty to sixty-seven days. Of 117 cases collected by Dr. Green, 31 died before the seventh day; 49 before the fourteenth; 31 before the twentieth, and 6 after the twentieth. Of 30 cases noted by Dr. West, of London, the average duration was twenty days and a half. In one, death took place in five days; in ten, before the fourteenth day; in eleven, during the third week, and in three, during the fourth week. The appearances detected after death, in the brains of those who have fallen victims to sub-acute meningitis, are indications, to a greater or less extent, of inflammation of the membranes, principally at the basis of the brain, and within the ventricles. The arachnoid membrane is often dry, thickened, and opaque; the vessels of the subarachnoid cellular tissue considerably injected, and its meshes filled with serum of a whitish colour, or mixed with lymph, and occasionally with pus. The pia mater is often greatly injected, and, in some cases, more adherent to the surface of the brain than natural. Its external surface is almost invariably found studded with tubercles, varying in size from that of a pin's head to that of a pea;— they are generally hard, semi-transparent, and of a gray or yellowish colour. Sometimes they present themselves in patches of an inch or more in extent, but, in general, are scattered irregularly over the mem- brane, as Avell as over the surface of the brain, between the convolu- tions, and at its base. According to the observations of Rilliet and Barthez, they are more frequent, however, upon the hemispheres than at the base. When they occur in patches they are usually surrounded by traces of inflamma- tion, either acute or chronic. The miliary tubercles, either isolated or collected together, so as to form an irregular mammelonated mass, enclosing portions of the pia mater, more or less changed, occur, comparatively more frequently, ac- cording to Rilliet and Barthez, on the convexity of the hemispheres, than at the base, and upon the left hemisphere than upon the right. They rarely occupy the depressions of Sylvius. As they become de- veloped, they are surrounded with a netAvork of vessels, and subse- quently with a cyst formed at the expense of the pia mater. Tubercles are met with, also, imbedded in the gray matter of the brain, where they are often surrounded by a halo of redness, generally connected with an enlarged vessel, ramifying from the pia mater. (Bennett.) More rarely they are detected in the medullary portion of the brain, where they are often overlooked in consequence of their pale, semi-transparent, yellow tint. The lining membrane of the ventricles is occasionally injected, opaque, or covered with a pseudo-membranous exudation, or with nu- merous white flocculi, Avhich become very apparent when the mem- 448 DISEASES OF THE NERVOUS SYSTEM. brane is immersed in water. It is often easily separated from the cerebral substance. The convolutions of the brain are sometimes flat- tened, apparently from pressure against the skull. A case is related by Golis, in which, upon opening the skull, the whole brain expanded, so that it could not again be replaced within the cranium. The gray substance of the convolutions, when the subarachnoid tissue is strongly injected, is usually of a pale rose, or bright red colour, from morbid injection. When the brain is cut into, very frequently the surface of the incision is studded with numerous bloody points. Some- times, however, the brain is paler and less vascular than natural;—it occasionally presents an appearance as though its substance was infil- trated with serum. The plexus choroides is very often injected, thick- ened, or covered with tubercles; sometimes it is pale and discoloured, and beset with small hydatiform cysts; this latter appearance has also been found in the cellular texture of the pituitary gland. Traces of inflammation in the membranes or substance of the brain, or, in other Avords, increased vascularity, or thickening of the mem- branes, and pseudo-membranous, or purulent effusion, are by no means invariably detected in cases of chronic meningitis. In some cases, the substance of the brain has been found of a firmer consistence than natural, and, to a certain extent, hypertrophied. (Laennec, Jadelot, Bricheteau, Golis, Schmidt.) We have seen many such instances, but invariably accompanied with decided indications of meningeal inflam- mation. One of the most common lesions detected, is serous effusion, either in the arachnoid or subarachnoid cavities, or in the ventricles, or in all these parts at the same time. It may be to only a small extent, or in such quantity as to separate the convolutions from each other, and greatly to distend the ventricles. The greatest amount is generally met with in the lateral ventricles; and here it may occur to such an extent as to enlarge the posterior cornua, elevate the fornix, rupture the sep- tum lucidum, and thus establish a free communication between all the ventricles. The cellular tissue of the choroid plexus may also be dis- tended with serum. The serum varies in quantity from one ounce to several; but seldom, it is said, exceeds six. Many cases are attended with a much less amount of serous effusion, and, in some, there has been scarcely a trace discovered. When the serous effusion in the brain is considerable, it is often found, also, in the spinal canal. The effused serum may be clear, colourless, thin, and transparent; or bluish, red- dish, greenish, or of a citrine hue; or it may be opaque, whey-like, turbid, or puriform. It occasionally contains albuminous flocculi. In many cases it is uncoagulable, but in others coagulable. The substance of the brain is, most generally, softer in consistence than natural, particularly the medullary matter in the immediate neigh- bourhood of the ventricles, including the septum lucidum, and fornix. This softening is of various degrees, from a slight deviation from the normal consistence, to a perfectly fluid condition of the brain, the Avhite substance resembling cream. Very generally, the abdominal viscera exhibit more or less extensive evidences of disease. The liver is often inflamed, with tubercles upon TUBERCULAR MENINGITIS. 449 its surface or in its substance, or is otherwise diseased. Inflammation, particularly follicular, of the mucous coat of the alimentary canal; contraction of the caliber of the intestines, and invaginations have been repeatedly met with, and, occasionally, softening of the inner coat of the stomach. Tubercles are very commonly present in the serous membranes of the thorax and abdomen, and in the lungs. A strong predisposition to the occurrence of chronic meningitis, par- ticularly the tubercular form, which, in children, is by far the most frequent, is manifestly hereditary or constitutional, in perhaps the ma- jority of instances. The peculiar liability to the disease in some fami- lies, is often strikingly exemplified; in many, all the children dying of it, as they successively arrive at a certain age. It would be more correct, perhaps, to say, that peculiarities of here- ditary, organization predispose to the disease; more especially the lym- phatic temperament or scrofulous diathesis, characterized by a large head, delicate, irritable, and often beautiful frame of body, prominence of the external lymphatic glands, with acuteness of intellect, and live- liness, or rather fitfulness of disposition. The most common exciting causes are irritations reflected from other organs upon the brain. In perhaps the majority of instances, the disease i3 preceded, for a longer or shorter time, by gastro-intesti- nal irritation; this constitutes the symptomatic form of hydrocephalus of Cheyne and other Avriters. Subacute meningitis may, however, be induced by blows or falls upon the head, violent mental emotion, or too early and close application of the mind to intellectual pursuits; violent, long-continued, and frequently repeated paroxysms of crying; the sudden suppression of spontaneous or habitual evacuations; the sudden drying up of ulcerations behind the ears, or of various chronic eruptions, as those Avhich occur about the head during dentition. The irritation attendant upon difficult dentition is a very frequent exciting cause. The disease is often produced by the deep-seated chronic inflammations of the ear, so common in scrofulous children. It may occur, also, in the course of, or during convalescence from various other diseases. We have already noticed its frequent con- nexion with gastro-intestinal affections; it is likewise often developed during or subsequent to, scarlatina, measles, bronchitis, pneumonia, croup, hooping-cough, &c. The hydrocephalic form of chronic menin- gitis is said to have occurred occasionally as an epidemic. The age most liable to the occurrence of sub-acute meningitis is com- monly stated to be between two and seven. According to Rilliet and Barthez, the disease is most frequent between the age of six and ten years; its order of frequency being first, between three and five, then between eleven and fifteen, and lastly, betAveen one and two years. Sex appears to exert but little influence in regard to the predisposition to the disease; it has been asserted, however, that during the first ten years it is most common in boys, but after that, in girls. In Philadel- phia, during the ten years preceding 1845, 1906 deaths took place from hydrocephalus; of these, P92, or more than one-half, occurred in children between one and five years of age; 748 in infants under one 29 450 DISEASES OF THE NERVOUS SYSTEM. year; 166 betAveen five and fifteen; 1020 were males, and 886 females. Under ten years, 998 were in males, and 838 in females. The prognosis in cases of subacute arachnitis, particularly when combined Avith the development of tubercles in the brain—as is most commonly the case in children—and after the disease is fully developed, must be always extremely unfavourable. It is by directing our efforts towards the prevention of the disease, by the prompt and judicious management of its preliminary and early stages, that we shaH be the most likely to secure the safety of our patient. After it is fully formed, there is but little chance of arresting its fatal course by any plan of treatment. It is nevertheless true, that cases of recovery have occurred under the most unfavourable circumstances; and it is said, even in the latter stages. Dr. Hahn (Meningite Tuberculeuse, 1853,) believes it to be in a very great number of cases susceptible of cure, which is the opinion also of Dr. Lie'gard, Avho repudiates the idea of the disease being of a tubercular character.—(Rev. Medico-Chirurg. 1855.) The treatment of the preliminary stage is to be governed by the na- ture of the symptoms present in each case. Our great object should be to procure a regular and healthy condition of the various functions, and to restore a due degree of tone to the several organs; guarding, at the same time, the brain from excitement, and counteracting any undue determination of blood to it, by removing, as far as lies in our power, every cause that may have a tendency to produce this effect. It is unnecessary to repeat here the remarks made in reference to this subject, when treating of the preliminary stage of acute meningitis. The treatment of subacute meningitis, in its early stage, must be governed by the age and vigour of the patient, and the nature and ex- tent of the symptoms present. Blood-letting is very generally recommended, at the onset of the disease, and during the period of excitement; and there can be no doubt that, in robust children, and when the pulse is tense, quick, and active, and the symptoms of cerebral excitement and of hyperaemia are strongly marked, it constitutes one of our most efficient remedies, and will often, when promptly and judiciously practised, succeed in arrest- ing the progress of the inflammation. It is to be recollected that, in the cases to which it is adapted, the earlier the remedy is resorted to, and the more quickly it is carried to the extent judged advisable, the greater is the chance of its proving beneficial. When, therefore, the indications for the employment of blood-letting are strongly marked, and the age of the child will admit of it, a vein should be opened in the arm, and a sufficient amount of blood drawn off at once, to make a decided impression upon the prominent symptoms of the case, or until commencing paleness of the countenance of the patient warns us to desist. In infants, the application of leeches to the hands or feet, and encouraging the Aoav of blood, by immersing these parts in warm water, will very generally produce similar results to those derived from venesection in older patients. With respect to the quantity of blood to be taken away, and the propriety of repeating the bleeding, no general rule can be laid down. TUBERCULAR MENINGITIS. 451 It has been said that, in infants of a year old, the abstraction of three ounces is sufficient; and that the bleeding, to a similar extent, may be repeated in tAvelve hours, if necessary. In judging of the extent of direct depletion, the physician, however, must be governed entirely by the character of the symptoms, and the effects of the remedy: it should be sufficient to reduce the tension and quickness of the pulse, or to produce a decided diminution of the heat and pain or sense of con- striction in the head, unless symptoms of approaching syncope previ- ously occur. If, after the first bleeding, the symptoms of cerebral ex- citement again recur with equal, or nearly equal violence, it should be repeated, without delay, to the same extent. In most cases, however, in place of a repetition of the general bleeding, the application of leeches or cups about the head should be preferred. There is reason for be- lieving that these tAvo modes of blood-letting, when successively em- ployed, make a greater impression on the disease than either of them is capable of effecting when singly had recourse to. By some, cupping is preferred to leeches, and we think, from our own experience, that much more prompt and decidedly good effects result from the applica- tion of cups than from leeching; they may be applied to the temples, behind the ears, and to the occiput and nape of the neck. In those cases in which the symptoms of the first stage are of a less violent character, or the patient is possessed of little vigour of consti- tution, or has been debilitated by previous disease, bleeding, though it may still be advisable, must be practised with much greater caution, and carried to a much less extent: here, leeching or cupping, propor- tioned to the extent and violence of the symptoms, should be preferred to general blood-letting. The repetition of the local depletion must be governed by circumstances; if the pulse again rise, or the heat and pain of the head recur, it may be necessary to have recourse to a se- cond application of the cups or leeches, and probably to the same ex- tent as in the first instance. The utmost caution and judgment will, however, be required in the employment of blood-letting, in the cases referred to. Within certain limits it is unquestionably calculated to produce the very best effects; but Avhen carried too far or too frequently repeated, it may, on the other hand, be productive of much injury. There may even occur cases, where the symptoms of exhaustion, and the general condition of the patient, will render blood-letting, to any extent, improper. In cases accompanied with much tenderness of the epigastrium, cups or leeches to this part will always be proper, and, in many instances, will prove strikingly beneficial. Next to blood-letting, active purgatives are, perhaps, the remedy from which the most good Avill be derived in the early stage of the dis- ease. Their importance, in all cases, but especially in those in which active depletion is indicated, is admitted by nearly every practitioner. Independently of removing from the bowels any irritation that may re- sult from accumulation of faeces or vitiated secretions, they tend to counteract the afflux of blood to the brain, and to reduce excitement. In cerebral affections generally they are considered by Abercrombie as a remedy scarcely inferior to blood-letting. 452 DISEASES OF THE NERVOUS SYSTEM. The repeated use of active purges has been recommended by Cheyne and others in every case in which the bowels are torpid, or the eva- cuations unnatural in appearance; but we are to recollect, that the unnatural condition of the alvine discharges is not always dependent upon functional disorder of the alimentary canal and liver, but is, in many cases, connected with a diseased condition of the mucous mem- brane of the stomach and bowels, which repeated active purgation cannot fail to aggravate. While, therefore, in ordinary cases, attended with constipation or torpor of the bowels, we should be inclined to advocate active purging, we are convinced, that, in cases in which decided symptoms of acute or subacute inflammation of the alimen- tary canal are present, the mildest purgatives alone should be em- ployed, and only to a sufficient extent to remove from the intestines any faeces, or other irritating matters, they may contain. Calomel is, under all circumstances, the best purgative we can em- ploy: from three to six grains, according to the age of the patient, should be early administered, and followed, in a short time, by a dose of castor oil, or sulphate of magnesia. Subsequently, the calomel should be given in small doses, and the freedom of the bowels main- tained by the occasional use of castor oil, or mild laxative enemata. When the calomel alone does not prove sufficiently active as a pur- gative, it may be combined with jalap, which, when toasted, is said by Golis not to be so liable to cause griping pains; with extract of colo- cynth and gamboge; with scammony, or with rhubarb. Elaterium has been recommended by Elliotson, in the more violent forms of the dis- ease, and the croton oil by Abercrombie. The first, hoAvever, is very unmanageable, often producing severe watery purging attended with sickness and vomiting, and the second, though strongly recommended by the smallness of its dose, and the ease Avith which it may be admi- nistered to children, we have found to be very uncertain in its opera- tion—in some instances producing little or no effect, and in others, acting with the utmost violence. In cases in which the stomach is very irritable, it has been recom- mended by Cheyne, to give one or two drachms of magnesia, saturated with lemon juice, every tAvo or three hours; and when calomel produces considerable intestinal irritation, it has been proposed by A. T. Thom- son, to substitute the hydrarg. cum creta, with poAvdered colchicum. We have seldom, however, found calomel administered, at first, in a full dose, and repeated in smaller doses, daily or oftener, with the occa- sional interposition of castor oil, a solution of the sulphate of magnesia, or purgative enemata, to fail in producing the desired effect. Small doses of calomel, combined with magnesia, and the third or fourth of a grain of ipecacuanha, Avill rarely be rejected by the stomach, or pro- duce irritation of the alimentary canal. In many cases of the disease, particularly in those attended with vitiated discharges from the bowels, we have repeatedly found the spirits of turpentine by the mouth, or in the form of enema, a very valuable purgative, and even in cases attend- ed with obstinate torpor of the bowels, combined with castor oil, it has appeared to us to agree better with the stomach, and to aid more effec- tually the action of calomel than most other articles. TUBERCULAR MENINGITIS. 453 Independently of its action upon the bowels as a purgative, the al- terative effects of calomel, if early obtained, are often in the highest degree beneficial. Under precisely the same circumstances as demand the employ- ment of direct depletion, cold applications to the head will be found particularly advantageous. Cloths wet with cold water, the ice cap, or evaporating lotions, may be employed in the same manner as di- rected in acute meningitis, and continued until the increased heat of the head is permanently reduced. Even in cases which do not admit of blood-letting or active purgation, frequently sponging the head with cold Avater alone, or with the addition of a small portion of alcohol or camphorated spirits, will be found advantageous. Pouring Avater in a small stream upon the head, has been recommended as particularly efficacious, in the early stage of the more violent cases, or even after coma or convulsions have occurred. The tartrate of antimony, in combination with calomel, has been recommended in the treatment of the subacute form of meningeal in- flammation by many of the writers on the disease. James's powder is, however, the preparation of antimony most generally employed. The addition of the antimony is, in many cases, a very valuable one; it is chiefly adapted, however, to the early stages. Large doses of the tartrate of antimony have been employed by a few physicians, and their effects are reported to have been decidedly advantageous. But in cases attended with gastro-enteric disease, they cannot fail to do more or less harm, and should be resorted to with the greatest caution. Subsequent to bleeding, in the more severe cases, Avarm sinapised pediluvia constitute an efficient means of derivation from the brain, and may be advantageously employed in conjunction with cold appli- cations to the head. The frequency of their repetition must be de- termined by the circumstances of each case. After the stage of excitement has passed by, blisters will often prove highly advantageous. They should be applied behind the ears, or to the nape of the neck; and we believe, that in all cases, a succession of blisters is preferable to keeping up an irritation of the blistered sur- face by the savine, or any other ointment. When there exists a con- siderable degree of tenderness of the abdomen, after the application of leeches, a blister over the part will often prove advantageous. As de- rivatives, the ointment of tartarized antimony, moxas, and various sti- mulating embrocations have been recommended, and may be resorted to, in many cases, with the best effects. Digitalis has been employed, as well during the stage of excitement with a view to its sedative effects, as after effusion has taken place, to promote the absorption of the fluid by its diuretic properties. It is given in the form of tincture, in the dose of eight or ten drops, every six hours, increasing it gradually, by two or three drops at a time, until its effects are fully produced; or, in powder combined with calomel and opium. The tincture we have seldom employed, having found it very uncertain in its effects, but from the employment of the digitalis in the form of powder, combined Avith calomel and ipecacu- anha, (one-fousth of a grain of each, every three or four hours,) we 454 DISEASES OF THE NERVOUS SYSTEM. are convinced that, during the early stages of the disease, we have frequently derived very considerable advantage. Mercury, early resorted to, and pushed to an extent sufficient to pro- duce its specific effects, is unquestionably one of the remedies from the effects of which the greatest advantage is to be anticipated. The evidence adduced in its favour by Percival, Dobson, Rush, Currie, Cheyne, Chapman, Mills, Schmidt, and Golis, is of the most unequivo- cal character. From half a grain to one or two grains of calomel should be given every two, three, or four hours, according to circumstances, and con- tinued daily, until swelling or tenderness of the gums, or foetor of the breath, or a decided improvement in the symptoms of the disease occur, when the calomel should be discontinued for a day or two, and afterwards, if necessary, repeated in smaller doses, and at longer inter- vals, until the disease is completely subdued. The good effects of mercury, in subacute meningitis, would appear to be altogether inde- pendent of salivation, which should, as far as possible, be guarded against. The effects of the calomel are often increased by the addi- tion of small portions of ipecacuanha, or James's poAvder. With the view of placing the system more quickly under the influence of the mercury, as well as in those cases in which the use of the calomel in- ternally produces constant nausea and vomiting, or frequent griping, with repeated greenish, slimy discharges from the bowels, one or two scruples or more of the strongest mercurial ointment, may be rubbed upon the neck, arms, and legs of the patient, as well as upon the blis- tered surfaces, night and morning, until the effects of the remedy are obtained. It has been recommended by Cheyne, Mills, and others, to combine the calomel with opium. The good effects of this combination are said to depend upon its power of equalizing the circulation, increasing the secretions, and exciting the healthy action of the cutaneous vessels. The watery extract is the preparation of opium which should be pre- ferred in the disease before us, inasmuch as it procures rest by dimi- nishing pain and irritation, without exhibiting, to any great extent, the narcotic or nauseating properties of the drug in its ordinary forms. The Dover's powder has likeAvise been strongly advocated as a re- medy, in subacute meningitis, by Brooke, Percival, Cheyne, and Crampton. There can be no doubt that, in many cases after bleeding and active purgation have been carried to a sufficient extent, a judi- cious employment of opium, especially in combination with calomel and ipecacuanha, will be beneficial, by diminishing any irritation of the boAvels, and abating undue nervous excitability; but, in the early stages of the more violent cases, opiates, even in the minutest doses, will invariably do harm by increasing the congestion of the brain. In cases in which opium is found to produce disagreeable effects, some of the earlier German writers strongly recommend the substitution of mode- rate doses of hyoscyamus in powder or extract; and from a pretty extensive use of the article, we are persuaded that, in the disease under consideration, as well as in most of the affections of childhood, where we desire to allay pain and irritation, or undue nervous excita- bility, it will often prove a very valuable remedy. TUBERCULAR MENINGITIS. 455 After effusion has taken place, the use of various diuretics and of iodine has been recommended, with a view of promoting the ab- sorption of the fluid from the cavities of the brain; of their success, under these circumstances, we cannot speak from experience. They may, however, prove, in some cases, valuable auxiliaries to the other remedies employed, and hence, are worth a trial. We have already spoken of the use of digitalis; the squill, in combination with calomel, has also been strongly recommended by Percival, Bricheteau, and Schmidt. By Kleber and Bischkofft the vinum scillae, in combination with the tincture, has been used externally, in the form of friction to the scalp. By others, the turpentine in enemata, or formed into a liniment, and rubbed into the scalp, has been considered as the most poAverful diuretic in hydrocephalic cases. It unquestionably, in many instances, will produce a very good effect; we have used it internally in enemata; and in the form of liniment to the epigastrium, and along the spine, and, we think, always with advantage. The iodine, either in the form of the proto-ioduret of mercury externally, or of the iodide of potassium, combined with diuretics, is said to have proved successful in many cases. Christie of Scotland, and Woniger of Hamburgh, report each a case of acute hydrocephalus, in Avhich the cure was effected after the disease had reached the paralytic stage, by the administration of iodine. By the first a solution of grs. xvj. of iodide of potassium, and four grains of iodine in one ounce of water, was employed, given in the dose of a teaspoonful every four hours; at the same time a weak ointment of the biniodide of mercury was rubbed upon the scalp. Woniger employed a solution of one drachm of iodide of potassium, dissolved in half an ounce of Avater, in the dose of forty, and subse- quently, fifty drops every tAvo hours. In Dr. Christie's case the first indication of improvement occurred in thirty-six hours after the use of the iodine was commenced with,—but in Dr. Woniger's case, not until after the end of seventy-two hours. In both the recovery was complete and permanent. The iodide of potassium, in large and fre- quently repeated doses, is said by Roser to have proved successful in cases where paralysis had already occurred, and death appeared im- pending. He gave thirty drops every hour, of a solution of one drachm of the iodide of potassium in half an ounce of distilled Avater. We have employed the iodine in the manner recommended by Dr. Christie, and in several cases its beneficial effects were strikingly dis- played; in others, however, no apparent advantage Avas derived from its use. The colchicum, the sweet spirits of nitre, the compound spirits of juniper, and various other diuretics, have been recommended, but the evidence in their favour is not sufficient to recommend them strongly to our notice. The simple vapour-bath, or the vapour-bath impregnated with vine- gar, has been noticed, the former by A. Hunter, the latter by Itard, as a remedy of very considerable power, even in the last stage' of the disease: we believe that it will frequently be found of decided ad- vantage, after the stage of excitement has passed. Various symptoms occurring in the course of the disease, will occa- 456 DISEASES OF THE NERVOUS SYSTEM. sionally require particular remedies. When considerable tenderness of the abdomen occurs, we have already noticed the propriety of ap- plying to this part leeches followed by blisters. In milder cases, warm emollient cataplasms will supersede the necessity of blisters. Vomit- ing is often a distressing symptom; it will, in many cases, be effectu- ally relieved by minute doses of calomel combined with magnesia and ipecacuanha,1 and the application to the epigastrium of a sina- pism, or of frictions with spirits of turpentine. Ten, fifteen or twenty drops of the spirits of turpentine internally, or half a drachm of tur- pentine mixed up with thin starch, and administered as an enema, we have repeatedly found to allay very promptly the irritability of the stomach, in this disease. 1 R-—Calomel, gr. iij. Magnes. calc. gr. xxiv. Ipecac, pulv. gr. ij.—M. f. chart. No. xij. Oue to be given every one, two, or three hours. Convulsions may be relieved by cups to the nape of the neck, fric- tion along the spine, warm pediluvia, cold affusion upon the head, and turpentine enemata. From the very onset of the disease, the patient should be confined to his chamber, which should be kept darkened, well ventilated, and of a moderate temperature, and every possible means should be adopted to screen him from noise of every kind, and from all other causes of excitement. He should lie upon a hair mattress, with his head somewhat ele- vated, and be covered with no more clothing than is sufficient to keep him of a comfortable temperature. All sudden, or, indeed, all un- necessary movements of the patient should be avoided; and the ut- most kindness should be invariably observed by the attendants in their deportment towards him. His diet and drink, in severe cases, and during the stage of excite- ment, should be restricted pretty much to simple mucilaginous fluids, given cool. At a later period, after the stage of excitement has fully passed, plain water gruel or panada may be alloAved; and in the last stage, when collapse has occurred, the diet should be nourishing, but mild and easy of digestion, as beef tea, plain chicken or mutton broth, animal jellies, &c.; at the same time, we may attempt to support the strength of the patient, by the cautious use of ammonia, Avine whey, valerian or camphor, combined with infusion of gentian, calombo, or quassia. During convalescence, the utmost care should be observed to pre- vent a relapse. The bowels should be kept regularly open by gentle laxatives; the diet should be of the mildest and least irritating articles, but at the same time sufficiently nourishing; the patient's clothing should be cautiously adapted to the temperature of the season, and in quantity and material, calculated to prevent the influence of sudden changes in the weather; every source of fatigue or excitement should be avoided; but, at the same time, daily gentle exercise, in a dry, pure air, will be attended with the best effects. Sponging the CHRONIC HYDROCEPHALUS. 457 body daily with warm salt water, the temperature being gradually reduced as the activity and tone of the patient's system is gradually increased, will act as a safe and very powerful tonic. The patient's hair should be kept short, and only a light covering worn upon the head. In cases in which there is a strong predisposition to a renewal of disease in the brain, it has been recommended, and the recommenda- tion is certainly a judicious one, to insert an issue in the neck, or to keep up a constant irritation, for a considerable period, at this part, by the use of the ointment of tartarized antimony. Several writers have described a morbid affection incident to the period of infancy, resembling, in nearly all its symptoms, the latter stages of subacute arachnitis, but resulting invariably from exhaustion, and Avhich Hall has proposed to designate by the term hydrencephaloid. We believe, however, as has been already pointed out by Bennett, that this affection differs only from that described above, in its occurring in children labouring under considerable exhaustion and debility. This variety of the disease unquestionably demands, however, a very important modification of treatment. All debilitating remedies are positively injurious. The strength of the patient should be sup- ported by the breast-milk of a healthy nurse, or if weaned, by beef tea, plain mutton or chicken broth, and similar articles of nourish- ment. Where, the exhaustion is very great, wine Avhey, the carbonate of ammonia, or even wine itself may be required:—these should be exhibited, hoAvevcr, in moderate portions, and their effects closely and carefully watched. In young children, the exhaustion is very frequently the result of extensive serous diarrhoea; this, if it continue, should be checked as quickly as possible, and we believe the remedy, upon which, in these cases, the most dependence is to be placed, is the acetate of lead given in solution, in the dose of a grain, every two or three hours, by the mouth and to the extent of three or four grains, as an enema. In many cases, however, the chalk mixture, with the addition of catechu, or the decoction of the dewberry root, will succeed. After the diar- rhoea has ceased, the bowels may be regulated by small doses of calo- mel, prepared chalk, ipecacuanha, and extract of hyoscyamus. The warm bath will be found, in most cases, a very valuable remedy, and should be repeated daily. The patient should be kept in a re- cumbent posture, and where he may enjoy the advantages of a free circulation of air, and the temperature of his extremities should be maintained by dry friction and flannel. If the patient sink into a comatose condition, blisters or sinapisms should be applied to the nape of the neck, and to the lower extremities, and frictions made with some stimulating liniment along the spine. 7.—Chronic Hydrocephalus. (DROPSY OF THE BRAIN.) This form of disease is very generally congenital, or is developed soon after birth. It consists in an accumulation of a serous fluid often to an enormous extent, generally within the ventricles of the brain, but occasionally upon its surface. 458 DISEASES OF THE NERVOUS SYSTEM. When the disease occurs subsequently to birth, it is generally de- veloped slowly and insensibly, being seldom preceded by any very marked symptoms; the first thing that attracts attention being an en- largement of the whole head, Avhich sometimes acquires an immense size—the sutures become separated, and the fontanelles enlarged, presenting, as it were, tense, semi-transparent tumours, in which a distinct fluctuation is perceptible upon pressure. The head gradually enlarges, as the effusion increases within the cranium, until, in many instances, its size becomes so great that the patient is no longer able to support it erect, and it droops continually upon the shoulder, or forward upon the chest, when he is in the up- right position: the face, at the same time, retaining its natural size, the physiognomy of the patient acquires a very peculiar expression. As the disease advances, the senses become blunted, the intellect im- paired, and the muscular poAver so much enfeebled, as to prevent the patient from moving about, or using the least exertion. Convulsive movements, paralysis, and cOma, occasionally occur; but generally the patient sinks into a state of deep stupor, which terminates, sooner or later, in death. In some instances, in place of a general enlargement of the head, a large tumour gradually forms at the situation of the posterior fon- tanels, or somewhat loAver, pressure upon which produces coma or convulsions. Patients affected with chronic hydrocephalus may live for many years, without any very decided impairment of the intellectual facul- ties. Occasionally, the sense of sight, hearing, and taste, are de- stroyed permanently, or only for a time; in other cases, one sense only is affected; in others, two or more, the rest remaining entire. Emaciation is a common symptom, as is also some degree of giddiness in the erect posture. Strabismus is frequently, and opacities of the cornea, are occasionally, seen in those affected with the disease. Death often takes place from the intervention of other affections; very fre- quently from ulceration of the bowels, sometimes from phthisis pulmo- nalis, and occasionally, from inflammation of the tissues of the lungs. Upon examination after death, the brain presents the appearance of an extended bag, Avith thin parietes, filled with a serous fluid. It was supposed that, in these cases, the substance of the brain had become absorbed, in consequence of the pressure of the fluid within, but upon a more accurate examination, it is found that no portion of the brain is destroyed, its convolutions being merely deployed. In other cases, however, the brain has been found in a perfectly rudimentary state. (Gall, Spurzheim, Cruveilhier, Breschet, Billard.) The lining mem- brane of the ventricles is occasionally vascular, and frequently very much thickened, and easily separated from the medullary matter to which it is attached. According to Dr. Weber, the pia mater, and also the arachnoid mem- brane, are so far changed, that they clothe the cerebral ventricles as a firm, thick, opaque membrane; and he considers that it is from disease originally seated in these membranes that the excessive effusion of serum results by which are produced all the other abnormal appearances present in the brain and cranium. CHRONIC HYDROCEPHALUS. 459 M. Blache in a communication read before the French Academy of Medicine, describes the pathological alterations that occur in chronic hydrocephalus, and arrives at the following general conclusions; (L' Union Medicale, 1855.) 1. The serum accumulates in the cerebral ventricles, but not in the cerebellar, or fourth ventricle. It does not communicate with the cephalo-rachidean fluid. 2. Contrary to the opinion of some authors, the white and gray substances are recognisable in the nervous laminae, into which the pres- sure of the effused fluid transforms the ventricular walls. When the distention is less considerable, the circumvolutions are also discover- able, and in all cases, thickenings, which are their vestiges. 3. The corpus callosum, fornix, and septum lucidum, are almost en- tirely destroyed, and converted into fibrous laminae. 4. The tuberculum annulare, the cerebellum, and the origin of the cranial nerves, preserve their integrity, with the exception of the optic and olfactory, in which more or less alteration is always met with. 5. The ventricular membrane is so much thickened that it may be dissected off throughout its entire extent, by which the fact of its continuity with the choroid plexus, and its prolongation across the aqueduct of Sylvius and the foramen of Monro, has been established. 6. In the interval betAveen the two laminae, which, by facing each other, form the septum lucidum, it is easy to demonstrate the existence of the fifth ventricle, and its communication with the third. 7. The pituitary body is canaliculated. 8. The anterior orifice of the aqueduct of Sylvius was found obli- terated in the two cases where it was examined: the cerebral cavities Avere thus completely closed. 9. Regarding the nature of the malady—the absence of all soften- ing of the cerebral substance, and the very slight plasticity of the fluid effused, discountenance the idea of chronic hydrocephalus being the result of inflammation. In the opinion of M. Blache it is simple hydropsy. Chronic hydrocephalus is not a very frequent disease in Philadel- phia. In a practice of thirty-six years we have seen but two con- genital cases, and only one that Avas developed subsequent to birth. In the treatment of chronic hydrocephalus, our chief object must be, to palliate the symptoms as they occur, by the occasional applica- tion of leeches, and the use of repeated blisters, the tartar emetic ointment or issues. The bowels should be kept regularly open, by gentle aperients, and the diet of the patient carefully regulated. Mercury has been strongly recommended, and is deserving of a fair trial. The radical cure of the disease has been attempted, by properly regulated and continued pressure applied to the head; and cases of success from this plan of treatment, have been published by Blane, Barnard, Engleman, and others. But the plan in favour of the feasi- bility, safety, and success of Avhich, the greatest amount of evidence has been adduced, is that of draAving off the effused fluid by punc- 460 DISEASES OF THE NERVOUS SYSTEM. turing the brain and preventing its re-accumulation by pressure ap- plied round the head. The operation consists in passing a small and delicately constructed trocar into one of the lateral ventricles, and drawing off as much fluid as the powers of the constitution will admit of. The most eligi- ble spot at which the trocar can be introduced is in the course of the coronal suture, about midway between the crista galli process of the ethmoid bone, and the anterior fontanelle, so that the danger of wound- ing the corpus striatum is avoided on the one hand, and the longitudi- nal sinus on the other. The instrument usually penetrates about two inches, and in most cases the serum discharged is colourless, but occa- sionally it is tinged Avith blood. Sometimes on withdrawing the trocar, the Avater will not flow until a probe has been passed along the canula, to remove portions of brain which block it up. After taking aAvay all the fluid that can be removed consistently with safety, the head Avhich should always be steadily compressed by an assistant during the ope- ration may be strapped with adhesive plaster, so as to retain its dimi- nished size, and avert the fearful consequences of suddenly removing long continued pressure from the brain. Cases of a successful result of puncturing the brain in chronic hydrocephalus are reported by Schoepf, Merei, Lagre, (Revue Medico-Chirurg. torn, vi.) Whitney, Ketsell, (Amer. Jour. Med. Sciences, 1843, 1850,) and Edward, (Edin. Month. Journal, 1846.) There is reason to believe, however, from a care- ful analysis of the cases on record in which the operation has been per- formed, that its successful results have been greatly overrated. In no instance, has it been clearly shown that a well marked congenital case has been permanently benefited; the cases in which the operation has been most successful, according to Conquest, are those in which the effusion has manifestly resulted from an inflammatory condition of the brain, and in which cerebral excitement follows the operation. It is proper to remark, however, that even in these, the operation has been found unsuccessful in the larger number of instances; and that it has been pronounced by high authority, (Golis, Heister, Hecher, Portenschlag, Fergusson,) as one, in all cases both cruel and useless. 8.—Chorea. Chorea is a very common disease of childhood, occurring more fre- quently between the eighth and fourteenth years, than at any other period of life. It consists in involuntary convulsive movements of the voluntary muscles, particularly of the face and extremities, and occa- sionally of those of the neck and trunk. In some cases, nearly the whole of the voluntary muscles are more or less affected with convul- sive or irregular movements; while in others, these are confined to one side, to the face or neck, or to a single extremity. The distinguishing characteristic of the disease is an incomplete subservience of the muscles of voluntary motion to the will, by which their actions are rendered irregular and uncertain. Thus, the patient intending to approach a cup of water to his lips, will involuntarily cast it from him, or throw its contents over his shoulder; or, in attempting to advance his foot forward, in the act of walking, carries it in every CHOREA. 461 possible direction excepting the right one. The movements of the face, arms, and hands, often resemble the gesticulations of buffoonery. The name of the disease, (Chorea Sancti Viti—the Dance of Saint Vitus,) is derived from the circumstance of the patients affected with it formerly repairing annually to the chapel of St. Vitus, near the city of Ulrn, in Swabia, where they danced day and night, as a means of effecting their cure. Chorea affects children of both sexes, but more frequently girls, par- ticularly those of a Aveakly constitution, or Avhose health and vigour have been impaired by confinement, impure air, improper or deficient nutriment, or preceding disease. Previous to its occurrence, the patient is, in general, affected with the ordinary symptoms of derangement of the digestive organs,—a depraved, variable, or defective appetite, tumid abdomen, constipated boAvels, and a loss of his previous vivacity and playfulness. The attack in general commences Avith slight, irregular, involuntary movements of different muscles, particularly those of the face, which are often mistaken for voluntary grimaces; these, after a shorter or longer period, are succeeded by the more constant and general move- ments by which the disease is characterized. Any one set, or all of the muscles of voluntary motion, may be affected in different cases. Usually the first indications of the disease are an unsteadiness in the patient's gait, which is marked, often, by a peculiar jumping or start- ing; or one leg is dragged along, in place of being lifted in the usual manner; while the arms are moved about, as if the patient were per- forming various intentional gesticulations. He is often unable to per- form the common and necessary movements with the affected arm, the involuntary action of the muscles entirely counteracting those directed by the will. These convulsive movements are more or less violent, and are often constant while the patient is aAvake;—during sleep, in most cases, they cease entirely. Although, occasionally dif- ferent muscles become successively affected, yet in the generality of cases, it is in those first attacked, that the convulsive movements re- main throughout the disease. In consequence of the affection of the muscles of the tongue and throat, in some instances, articulation and deglutition are impeded or performed with difficulty. Tavo cases of chorea are referred to by Romberg (Diseases of the Nervous System, vol. ii. p. 55,) and they Avere the only ones he had ever met with, in which the muscles of the external and internal respiratory apparatus were involved. In one of these cases, a child eight years of age, the choreic movements of the right half of the body Avere associated Avith dyspnoea, whistling inspira- tion, and palpitation. In the second case, a boy of eight years, only the muscles of the extremities, the face, and the eyes, Avere at first at- tacked; subsequently, the choreic movements ceased in these parts, and the muscles of respiration became affected. In extreme cases, the eyes lose their lustre and intelligence, the face becomes pale, and the expression of the countenance is that of vacancy, indifference, and languor. The mouth is often distorted, so as to give to the face the appearance of a habitual silly grin. The patient acquires, in fact, the 462 DISEASES OF THE NERVOUS SYSTEM. features of idiocy. In a few cases, indeed, when the disease has continued for a length of time, partial or even complete fatuity has been known to ensue. Fatuity, however, is by no means a very com- mon sequel of chorea, even in its most violent and chronic forms. Many instances are on record, and similar ones have fallen under our OAvn notice, in which the disease has continued, with but slight inter- missions, from childhood to an advanced age, without the integrity of the intellect being much, if at all, impaired. In some cases, the patients are affected with a species of melancholy, or with the pecu- liar nervous temperament that commonly accompanies hysteria. Throughout the attack the bowels are generally costive, and the appetite defective, capricious or ravenous. Febrile reaction is not necessarily an attendant upon chorea, and when it does occur, is ge- nerally the result of gastro-intestinal irritation or some accidental affection. When the disease is very violent and protracted there in general occur great emaciation, a flaccid state of the muscles, great depression of strength, paleness and discoloration of the skin, and the other indications of impaired energy of the digestive and nutritive functions. Pain, remarks Dr. Churchill, is seldom complained of by patients affected Avith chorea, and but little general distress. Out of twenty cases related by M. Dufosse', eight suffered from slight headache, six from palpitations, and two from a pain, increased by pressure upon the spinous processes. M. Richard states that most of the girls he has seen affected with the disease presented a lateral curvature of the spine, and he seems inclined to attribute the chorea to an overstretch- ing of the nerves. The heart is, according to Dr. Todd, (Lumlean Lectures, for 1849,) very frequently morbidly affected in chorea; and this morbid affec- tion shows itself, not in any disturbance of the rhythm of the heart, which, so far as his observation extends, never is affected, but in a derangement of its sounds. A bellows sound is frequently found, and is either aortic, systolic, when it is almost always an accompaniment of the anaemic state of the patient, or, much more frequently, mitral, systolic, or regurgitant. This condition of the cardiac sounds in chorea Avas described by Dr. Todd in the Croonean Lectures on the pathology of rheumatism in 1843. But to Dr. Addison, of Guy's Hospital, is due the merit of having first made known the morbid condition of the sounds of the heart in this disease. Epilepsy and hemiplegia are not uncommon results of chorea; and in many of the cases that have fallen under our notice the patients have died from tubercular meningitis—the lungs and serous tissues of the thorax and abdomen exhibiting, also, tubercular depositions. According to Dr. Todd, the choreic convulsion is frequently suc- ceeded by a paralytic state of the limbs previously convulsed; the convulsive movements cease, and the limbs remain paralyzed; the paralysis is seldom complete, although considerable. When the choreic convulsion has affected one side, the paralysis will likewise affect the same side; it will be hemaeplegic, and will resemble very closely he- maeplegia from diseased brain, for which it is very apt to be mistaken CHOREA. 463 by those not aware of the fact. We have occasionally met with this paralytic state as a consequence of violent attacks of chorea, but have not found it so common a sequel of the disease as stated by Dr. Todd. Chorea has been defined by some writers to be an irregular motion of the muscles, when excited into action by the will; the disease con- sisting in a loss of the power of volition over their mode of action— that is, of directing and combining their action, for the accomplish- ment of any particular movement. The disease has, consequently, been supposed to result from some lesion of the cerebellum. This de- finition Avould, however, exclude a number of cases, in which the con- vulsive movements of the muscles certainly occur independently of the Avill, and unassociated Avith consciousness, differing from convul- sions only in the orderly nature of the motions. Such are cases of malleation, in which the convulsive paroxysm consists, principally, in a constant striking the knees with one or both hands, as with a ham- mer;—or of rotation of the whole or a part of the body, as in the case described by Watt, in an early volume of the Medico-Chirurgical Transactions. In this case the patient, a girl ten years of age, Avas seized Avith an irresistible propensity to turn round on her feet like n top, then to lie down, and roll rapidly backwards and forwards: in a more advanced stage of her disease, while lying upon her back, to bend herself up like a bow, by draAving her head and heels together, and then suddenly to separate them, so as to cause the buttocks to fall with considerable force upon the bed; and to repeat this continually, for hours: at a still later period she Avas seized with a propensity to stand upon her head, with her feet perpendicularly upwards: as soon as her feet gained the perpendicular all muscular action ceased, and her body fell as if dead, her knees first striking the bed, and her but- tocks striking her heels; this w*as no sooner done than she instantly mounted up as before, and continued these evolutions, sometimes for fifteen hours consecutively, at the rate of twelve to fifteen times in the minute. Rufz mentions a case in which the child threw itself out of bed, and crawled about the room like a Avorm. To this same class belong also the salaam convulsions, noticed in a previous section. But it would be impossible to describe all the various forms under which the disease occasionally presents itself; in many of which, no description can convey an adequate idea of the odd appearance, and strange gesticulations of the patients; so that we need not be the least surprised, that in times of ignorance and super- stition it was ascribed to supernatural causes, and the agency of demons. It is more than probable, as remarked by Carpenter, that many cases of stammering are to be regarded as a species of chorea of the muscles of the voice. Allied to the movements of chorea, remarks Dr. Todd, are the fidgets of children, and perhaps, also, those of grown persons. In some child- ren, these fidgety movements are so excessive, that the child becomes almost a nuisance in a room. All the muscles are affected; the child incessantly makes grimaces of the most various kinds; every minute he assumes a new attitude; if any thing comes in his way, he must 464 DISEASES OF THE NERVOUS SYSTEM. handle or touch it; and these irregularities are always the* greater Avhen there is derangement of the general health. Children thus af- fected might readily be thrown into the convulsions of chorea by a strong mental emotion. It is very possible, remarks Dr. Churchill, (on the Diseases of Infants and Children,) that while some cases of stammering may in fact be a vocal species of chorea, the same is true also of those cases of incessant Avinking or twitching of the nose or mouth, which we meet with occasionally, and which are so difficult to cure, although they often get well. I have, he.adds, at this moment under my care a little boy, very nervous, but healthy, who ordinarily Avinks about twice as often as other children, but if it be noticed, or if he be unusually earnest about any thing, the eyelids are in incessant motion, and closed with unusual force. Chorea, as it ordinarily presents itself in children, will be readily recognised by the symptoms we have detailed. In 429 cases referred to by Dufosse* and Rufz, 130 occurred in boys, and 299 in girls. If I may trust to my own experience, says Dr. Watson, [Lectures on Practice of Physic,'] it is much more common in children having dark hair and eyes, than in those of a light complexion; and I think I have seen the same remark in some book,,but I forget where. But, according to Mr. W. H. Bell—(Diet, des Etudes Medicates) Dufosse" (ibid.) and Rufz (Archives Generates de Med., iv. 239)—the subjects of chorea have chiefly light hair. It usually occurs, as already remarked, between the eighth and four- teenth years, but is by no means confined to this period. The con- vulsive actions may be continuous, intermittent, or remittent; they are excited and increased by observation, contradiction, ridicule, or any other cause of irritation, and especially by any attempt forcibly to re- strain them. According to Andral it may be excited by imitation,— the fact is, hoAvever, denied by Rufz and Blache. Chorea is, of itself, seldom fatal; it frequently terminates sponta- neously about the period of puberty in boys, or upon the establishment of the catamenia in girls. When recent, and occurring in children possessed of some degree of constitutional vigour, it may often be en- tirely removed by an appropriate treatment; though not unfrequently the patient preserves during life a tendency to involuntary twitching of the muscles of the eye, eyelids, face, and even of the limbs. The mean duration of chorea is stated by M. Rufz to be thirty-one days. M. Dufosse, however, extends it to fifty-seven days, while, ac- cording to Rilliet and Barthez, it ranges from six weeks to two months. Relapses are very frequent. Dr. Copland observed it to occur three times in one patient, M. Rufz, six times, and Rilliet and Barthez no- tice its recurrence once, tAvice, and thrice, in nineteen cases. According to Rilliet and Barthez, when a patient labouring under chorea is attacked with measles, scarlatina, variola, or other of the acute febrile diseases of childhood, the chorea will be generally dimi- nished in intensity or entirely removed. They state that out of nine- teen cases, nine were attacked by other diseases, and eight were evi- dently influenced by them: sometimes the chorea diminished from the CHOREA. 465 commencement; while in others it increased at first, but afterwards disappeared. M. Rufz, on the other hand, denies that the concurrent disease exercises any influence upon either the duration or intensity of chorea. Pathological anatomy throws but little light upon the true nature of chorea, so far, at least, as regards the nature and seat of the lesions of the nervous centres upon which the phenomena of the disease imme- diately depend. In a large number of cases, after the most minute examination, no morbid changes are detected that can be regarded as necessarily connected with the disease (Duges, Oliver, Hawkins, Rufz, Gerhard, Hache, Vielde, Rostan, Lawrence, Rilliet and Barthez;) while those which have been recorded by various writers, are evidently accidental lesions, or to be regarded rather as effects than causes of the complaint; such as inflammation of various parts of the brain (Clut- terbuck, Serres;) turgescence of its vessels, with effusions of serum (Coxe, Patterson, R'oser, Willan, Copland;) hypertrophy and injection of the brain and spinal cord (Monad, Hutin;) turgescence of the ves- sels o'f the brain and spinal cord, with several bony plates upon the pia mater, half-way up the spine (Bright;) a concretion in the medul- lary substance of the left hemisphere of the brain (Brown;) a tumour pressing on the corpora quadrigemina, inflammation of these parts, with sanguineous effusion (Serres;) ecchymosis of the membranes, and a pulpy condition of the spinal cord (Keir;) and, in a single case, an abscess within the cerebellum (Sehrbde.) In the absence of positive facts, speculations upon the nature of any disease are of little value. Reasoning from the nature of the pheno- mena by Avhich the disease is characterized, chorea has been referred by Dr. M. Hall to lesions of the spinal system of nerves; but this, it has been remarked by Carpenter, can scarcely be regarded as a correct conclusion. Although there is often considerable irregularity in the ordinary reflex actions, yet the disease mainly consists in an absence or deficiency of the controlling power of the will over the actions of the muscles of animal life, and in many cases, in a spontaneity of ac- tion in the performance of certain movements. According to the most probable view of the functions of the cerebellum, it would seem that this organ is the chief seat of the disease; the morbid phenomena, however, in the majority of cases, not resulting from any direct lesion of the cerebellum, but from remote irritations, in which it participates sympathetically. Dr. Elam, in a very interesting paper in the Provincial Med. and Surg. Journal, February, 1849, maintains that the movements of the muscles in chorea are of an automatic character. He relates the case of a child nine years of age, who had been three weeks suffering from the disease, as shoAving the peculiar distinction between the voluntary and automatic motions. Whilst eating, the right arm of the child acted regularly in carrying the spoon to the mouth, whilst the left arm and both legs were violently convulsed, yet not a drop of food was spilled. The patient, instead of acting instinctively, as it may be termed, when directed to do any thing with the right arm, or asked 30 466 DISEASES OF THE NERVOUS SYSTEM. to give her hand, she did it always in the jerking irregular manner so characteristic of the disease. The effect of music upon the ancient form of St. Vitus's dance would seem to Dr. Elam to indicate, that whilst volition has but little in- fluence of itself in controlling the irregular actions of the muscles, yet by external agencies, acting through the senses, an instinctive modifi- cation of these actions may take place, and if persevered in, the habit may be broken altogether. Another peculiarity of these motions, he remarks, is that, in defiance of their apparent irregularity, there is a sort of rhythm or order—a series of actions recurring with greater or less constancy. This is most manifest in the milder forms. In some cases it is confined to a periodical twitching of one or more muscles of the face or eyeballs. In one case, both eyeballs were turned so far upwards and laterally, as almost to hide the iris. This and a corre- sponding twitch of the orbicularis, were the constant and only symp- toms, and recurred with tolerable regularity every forty seconds. We have met with many such cases. As, hoAvever, the affection becomes more violent, the regularity of the motions becomes less evident, one class of spasms interfering with and modifying the others: in one very violent and fatal case, the recurring character of the convulsive move- ments was evident almost to the last. According to Dr. Elam, for the production of these automatic mo- tions, if they are acknowledged to be of this character, there must be a stimulus acting upon the extremities of the excito-motor nerves, and the impulse reflected from the motor centres upon the muscular sys- tem. In health, stimuli of a certain character are constantly applied to the extremities of these nerves. To produce disease, either the stimulus must be increased in intensity, or the extremities of the nerves must be in a more irritable condition, and it is to the latter cause that the production of chorea must be almost invariably attributed. In nearly every case the cause must be looked for in some local or general excitability (perhaps from irregular distribution of blood,) in the ex- tremities of the excito-motor nerves, compelling them to respond in a more vigorous, and consequently irregular manner, to the ordinary physical agents. It seems probable, too, that this excitability is al- most exclusively manifested in the alimentary canal, .the uterus, or the skin. Dr. Elam notices the great similarity between chorea and tic dolou- reux, both as to their causes and the plan of treatment most successful in both. One attacks the motor, and the other the sentient nerves; both are chiefly dependent on derangement of the intestinal or uterine func- tions,—both are generally diseases of debility—both are relieved by tonics, and both are almost incapable of relief by narcotics. Dr. Copland has shown, by post mortem examination, the frequent complication of chorea with rheumatism, rheumatic pericarditis, and disease of the membranes of the spine, and his observations have since been confirmed by Drs. Pritchard and Roser. Todd, in the Lumlean Lectures for 1849, has pointed out its relationship to rheu- matism, and the liability to the occurrence in those affected by it of CHOREA. 467 rheumatic endocarditis. M. See (Memoires de VAcadem. de 3Ied.,\o\. xv.) notices its frequent connexion with inflammation of the pericar- dium, and with external and internal rheumatism. The same fact is pointed out by Nairne, (Lond. Jour, of Med. 1851,) Begbie, (Ed. Month. Jour. 1852,) Kirkes, (Med. Gazette, 1850,) Trousseau and others. M. Trousseau is accustomed to point out to his class the correla- tion so often observed between disease of the heart and chorea; so that examination of this organ, and inquiry into the history of the case as regards rheumatism, should never be neglected; inasmuch as such correlation supports the views of those who regard the disease as rheumatic or rheumatoid. The most common predisposing causes of the disease would appear to be the period of childhood; bad nursing; impure and confined air; unnutritious or improper articles of diet, and deficient exercise; and a disordered condition of the digestive organs. The usual exciting causes are irritations seated in the stomach or intestines; retained faeces, worms, &c.; fright, violent fits of anger, injuries of the head, difficult dentition, rheumatism, and improper excitement, as well as certain affections of the genital organs. It has been stated that, in some cases, a predisposition to the disease may be transmitted from parent to child; and this corresponds with the result of our own ex- perience. Like all other convulsive diseases, chorea may unques- tionably be excited by imitation, notwithstanding the fact has been denied by recent observers. The disease has not appeared to us to be much influenced by the sea- son of the year or the condition of the atmosphere. Duges,;Rufz, Span- genburg and Blache state that it occurs most frequently in summer. According to the statements of Rochoux, Chervin, and Danste, it is a rare affection in the southern hemisphere. It is not a very frequent disease in Philadelphia. "According to some authors, for example, Mezerai, Cullen, and Hecker, chorea has occurred epidemically. Albers, cited by Frank, mentions a school in which it appeared as an epidemic, and Rilliet and Barthez, a village in the Tyrol, in which it occurred recently. Dr. Copland has given an interesting lecture on nervous disorders, resembling chorea; as, the effect of the bite of the tarantula, the leaping ague of Scotland, and an affection which spread rapidly among a sect of religious enthusiasts in Tennessee and Kentucky, de- scribed by Dr. Robertson, &c, &c, which strikingly resemble chorea, and the extensive prevalence of which may have originated the idea of an epidemic." (Churchill—Diseases of Infants and Children.)^ In the treatment of chorea, the first and most important indication is the removal or avoidance, as far as possible, of the exciting causes. The means for effecting this will, of course, depend upon the circum- stances of each case. The remedies that have the greatest amount of evidence in their favour for the removal of the disease, are bleeding, active purging, counter-irritants, antispasmodics, and tonics. Bleeding from the arm, or from the foot, or by leeches from the head and upper part of the spine, has received the sanction of several 468 DISEASES OF THE NERVOUS SYSTEM. eminent practitioners, and cases have been published in evidence of its efficacy. There will be found, we apprehend, but few cases, however, in which bleeding will be indicated. That the disease may occur under circumstances and accompanied by symptoms in which the detraction of blood will be demanded, we admit; thus, when it attacks children of a plethoric habit, and is attended by the indica- tions of cerebral inflammation or hyperaemia, a judicious and timely resort to general or local bleeding will, no doubt, be productive of immediate benefit, and prepare the system for the action of other re- medies. Such cases, however, are of rare occurrence. Purgatives are a remedy of much less doubtful propriety. As a valuable adjuvant to the other means employed, there are few cases in which they will not be indicated, while in those connected with a torpid and loaded condition of the bowels, they will invariably pro- duce a decided alleviation, and in many, an entire removal of the symptoms. From the time of Sydenham, there are few writers on the disease, by whom their employment is not strongly insisted on, while, by a few, they are considered as almost the only remedy. In the early period of the attack, and in slight cases, any of the pur- gatives which have the effect of promptly unloading the bowels with- out producing much irritation or occasioning watery stools, will be proper. In the more advanced periods of the disease, however, and in the more severe cases, the bowels are very apt to be affected with a very considerable degree of torpor, and for their evacuation will demand the more active purgatives, given in successive doses, in such a manner as to produce a full and continued operation. Not only, however, is it necessary, in these cases, effectually to unload the bowels; but,by a judicious use of purgatives, to maintain their regular action; not a day should be allowed to pass, without one or two full evacua- tions being obtained. In the early stages and ordinary forms of the disease, calomel com- bined with rhubarb or jalap, and followed by castor oil, or infusion of senna, with the addition of any of the neutral salts, will answer; but where these are not found sufficiently active, the croton oil, or combi- nations of aloes, scammony, colocynth, gamboge and blue mass may be employed. A very certain and effectual purgative, in cases of chorea, is the spirits of turpentine, either alone or combined with cas- tor oil. We have employed it pretty extensively, preceding its use by a full dose of calomel, and in very few instances without decided ad- vantage. R.—01. ricini, Or, R.—01. ricini, Spir. terebenth. ail gas.—M. Spir. terebenth. ii"i gss. It may be given in doses of a tea or dessert- Tinct. sennse, 3HJ. spoonful, according to the age of the pa- Syrup, zingib. ^ij.—M. tient, and repeated three times a day or Given in the same manner. oftener. In conjunction with actiA'e purging, the use of tartarized antimony has been suggested by Breschet, in as large doses as the stomach will bear without exciting vomiting, which is carefully to be avoided. By others, emetics, repeated every other day, for a longer or shorter period, according to the violence and obstinacy of the case, have been CHOREA. 469 ' strongly recommended. We have no experience as to the efficacy of either plan of treatment, but can easily conceive that cases may occur, where the disease i3 either produced or aggravated by an overloaded state of the stomach, or the presence of some irritating matter in that organ, in which great benefit may result from emetics. They can scarcely be considered, however, as a remedy generally applicable to chorea. Counter-irritants have been extensively employed in the treatment of the disease, and doubtless, in many cases, their effects will be found decidedly beneficial. Blisters along the spine are recommended by Stiebel, Chisholm, and a feAV others; but friction with the tartar emetic ointment appears to be better adapted to produce a counter-irritant effect in cases of chorea. It is more prompt in its effects and more easily managed than blisters, and is, perhaps, even more efficacious. Pustulation with the croton oil along the spine, has, also been recom- mended, as a valuable remedy in chronic cases. In the treatment of chorea nearly every article upon the list of tonics has been prescribed, and for the superior efficacy of each article the highest authorities may be cited. Bark, and.the salts of quinia, may be taken, however, as the representation of the vegetable tonics, while in regard to the mineral articles, the sesquioxide and sulphate of iron, sul- phate of copper, oxide and sulphate of zinc, nitrate of silver, and ar- senite of potassa, have, in different hands, been all found eminently suc- cessful. The testimonies in favour of the sesquioxide or proto-carbonato of iron in large doses, and of the sulphate of zinc, are perhaps the strongest. The cyanuret of iron, in the dose of three grains, three times a day, in the form of a pill, has also been strongly recommended by Zollickoffer. M. Faivre D'Esnans states in the Journal de Medicine et Chirurgie Pratiques, that he has obtained the happiest results from the cyanuret of iron in chorea and epilepsy, and he gives several cases' where the cure was obtained in between four and eight days. He em- ploys the following formula: cyanuret of iron, grs. xv.; extract of va- lerian, grs. xlv. Make into twenty-four pills: one pill to be given three times a day, at six hours' interval, each pill to be followed by a wineglassful of infusion of valerian. The cyanuret of zinc, in the dose of one-third of a grain, twice a day, gradually increased to fourteen grains in the tAventy-four hours, has recently been highly spoken of by the physicians of Berlin and elsewhere. There is a very great diffi- culty in pointing out the particular cases to Avhich the one or other of these remedies is best adapted. Perhaps the safest rule is to make trial of one, and if it does not succeed, after it has been continued for a reasonable time, to suspend its use, and substitute another. To de- rive any good from the employment of either of them, will, in general, require a perseverance in its use for some length of time. We have known the best effects result from the use of the ammo- niated tartrate of iron, in five to eight grain doses, repeated three or four times a day or oftener, according to the age of the patient and the extent of the choreic symptoms. With the exception of the arsenite of potassa, to be noticed here- after, the sesquioxide of iron, the oxide of zinc, the valerianate of 470 DISEASES OF THE NERVOUS SYSTEM. zinc, and nitrate of silver, in combination with some one of the vege- table tonics, and occasionally with a narcotic, are the articles which, in our hands, have succeeded the most promptly and generally in the removal of the disease. We have, nevertheless, found many cases to occur, in which the use of one, and then of another, has appeared to be unproductive of the slightest effect, when, on substituting a third, the morbid phenomena have been very quickly and permanently con- trolled. It is stated by Dr. Babington, that the sulphate of zinc has seldom failed in his hands in curing the disease. He found it necessary to administer much larger doses, however, than are usually given; good effects being seldom perceptible until twelve or fifteen grains are taken three times a day. By gradually increasing the quantity, a single grain at a time, even much larger doses may, generally, be given, without exciting sickness, and with the best effect. Sulphate of zinc, however, will not be borne by some stomachs, in the smallest dose; and even the other mineral tonics can with difficulty be pre- scribed in the cases of children in doses sufficiently large, or be con- tinued sufficiently long to derive from them in this disease a decided remedial effect. In such cases, the liquor potassae arsenitis, in doses of three drops, gradually augmented to twelve, fifteen, or twenty, two or three times a day, according to the age and strength of the patient and other concomitant circumstances, may be prescribed. It is certainly one of the most powerful remedies we possess, in cases of chorea; and when cautiously employed, desisting from its use the moment that any sickness, or griping pains, or intumescence of the face or extremities occur, we have found it to be a perfectly safe and manageable article. The testimonies in favour of its efficacy are numerous and positive. Very decided testimony has been presented by Young, of Pennsyl- vania, Lindsly, of Washington, Hilddreth, of Ohio, Kirkbride and Professor Wood, of Philadelphia, and Beadle, of New York, in favour of the efficacy of the cimicifuga, in cases of chore*. It may be given in the dose of half a teaspoonful of the powdered root three times a day; or from one to two drachms of the saturated tincture, or a wine- glassful of the decoction. We have prescribed it in a number of cases, and have been much pleased with its effects. The nux vomica, either in the form of extract or tincture, given in as large doses as can be safely borne, has in our hands proved a valuable tonic in this disease. Iodine has likewise been employed, and it is said with advantage. Nearly all the narcotics have been recommended by different writers, and, for the relief of certain symptoms their use would appear to be occasionally beneficial. Opium Avas employed by Sydenham, after bleeding and purging, as an anodyne at bed-time, and Cullen declares, from a good deal of ex- perience, that opiates are very generally successful in the cure of cho- rea. Opium, in the hands of other physicians, has, however, entirely failed in producing any decided relief: Ave cannot say that we have ever known it to produce any good effect in cases occurring in chil- dren. Camphor has been found by Wilson, Richter, and Poissonnier, CHOREA. 471 to be beneficial in some cases, in combination with tonics and the cold bath. We have occasionally employed it, in combination with the protocarbonate of iron, and extract of gentian, with unquestionable ad- vantage. The belladonna, stramonium, and hyoscyamus, are all highly extolled, especially by the German writers. The latter we have em- ployed very extensively, as well in combination with purgatives, as with the metallic salts; it is certainly, in most cases, a very valuable adjuvant. Graves employed it, in one case, with the best effect. The strychnia has been employed by Romberg, the veratria by Ebers, and the hydrocyanic acid by Stuart; of their value we know nothing from our own experience. Trousseau has recently treated thirteen cases of chorea with strych- nia, ten of them with complete success. He employs the sulphate of strychnia dissolved in syrup, one grain to giijss.; of this tAvo and a half drachms are given daily in three doses; and the quantity is every day increased 3j^, until itching of the scalp and slight muscular stiff- ness are observed. The cure is generally completed in one month. The tincture of the nux vomica we have repeatedly employed, in the dose of six drops three times a day, and, we are persuaded, with de- cided advantage. In favour of the effects of assafoetida, in large doses, we have very strong testimony. In conjunction with the foregoing remedies, the cold bath, especially in the form of douche, will be found an important auxiliary. Cases are recorded by Crampton, Stiebel, Dupuytren, and Rufz, in which it Avas evidently productive of very great advantage. Stiebel directs the douche to be applied to the spine. When too severe a shock is pro- duced by the cold douche, the tepid or warm douche, or simple tepid bathing, may be substituted. We have seen the best effects produced by daily sponging the entire surface with salt water, at first warm, and gradually reduced in temperature, until it can be used perfectly cold; the whole surface of the body being submitted, immediately after the sponging, to brisk friction with flannel or a flesh-brush. Sulphurous baths, made by dissolving about four ounces of the sul- phuret of potassa in about twelve bucketfulls of water, and repeated daily, have been employed with very decided success. A number of cases are cited by Dehaen, Underwood, Fothergill, Gordon, Baumes, Addison, and Bird, in which the entire and perma- nent cure of chorea is referred to electricity. Its success, in numerous instances, appears now to be very well established. In the hands of Dr. Bird, it is said to have cured twenty-nine out of thirty-six, and to have produced relief in five of the remaining cases: in one no benefit Avas experienced, and one patient left, alarmed by the remedy. In the majority of instances, nothing else Avas prescribed, excepting oc- casional mild cathartics; which, in conjunction with other remedies, had been used previously without advantage. The electricity was ap- plied in the form of sparks, taken in the course of the spinal column, every other day, for about five minutes each time, or until an eruption appeared, which is often caused by electricity when applied in this manner. From the transmission of electric shocks along the affected 472 DISEASES OF THE NERVOUS SYSTEM. limbs no good whatever resulted, but on the contrary, the involuntary movements were, in every instance, increased, often to an alarming extent; and if the shocks were employed after the patient was conva- lescent, they invariably aggravated every symptom, and frequently rendered the disease as severe as when the patient was first placed under treatment. In the paralysis which occasionally succeeds to chorea, the proper treatment will be a course of tonics, particularly the preparations of iron, shower-baths, and the regular exercise of the affected limbs. During the whole course of the disease, the diet should be light and easy of digestion; in cases attended with hyperaemia, or evidences of cerebral excitement, it should, of course, be very moderate in quantity, and consist chiefly of simple farinaceous articles; but in those cases in which tonics are indicated, it should be nourishing, and more libe- rally supplied. Daily exercise in the open air, whenever it can be taken, is all-important to the success of the cure. A properly regu- lated course of gymnastic exercises, it is reasonable to suppose, may aid the success of whatever remedies are employed, independently of its invigorating influence, by engaging the attention of the patient, and teaching, as it were, the muscles to obey the direction of the will, and to combine properly their actions. M. Blache, (Gazette Med. de Paris, 1855,) in a memoir presented to the Academy of Sciences, proposes to trust the cure to gymnastic exercises alone, without conjoining with it any of the usual remedies for the disease; believing it to be a plan of treatment superior in efficacy to all others that have been pro- posed. His conclusions are founded upon the result of 108 cases—84 girls and 24 boys, treated by gymnastics alone, or by these in combi- nation with sulphurous baths, regulated diet, etc. In 102 of these cases the cure was complete in 39 days on an average, and in the six remaining, recovery took place in 122 days: these latter he considers unsuccessful cases. A country residence is to be preferred to one in a large city; and it would be still better if, with the advantages of country air, the patient could command those of sea-bathing. The utmost caution must be observed, as well during the disease as for some considerable time subsequent to recovery, to guard the patient against the occurrence of any of its exciting causes, whether of a men- tal or physical character. If the attack occur during the period of dentition, a close attention should be paid to the condition of the gums, and irritation from this source counteracted by repeated scarification. It is hardly necessary to say, that any disease with which the attack of chorea may be complicated is to be treated by its appro- priate remedies, and that the general remedial management of the case must be modified accordingly. ERUPTIVE FEVERS. 473 SECTION IV. DISEASES OF THE SKIN. CHAPTER I. ERUPTIVE FEVERS—EXANTHEMATA. The eruptive or exanthematous fevers are characterized by a febrile excitement, succeeded or accompanied by a specific eruption upon the skin; Avhich, in the majority of instances, appears, in each disease, constantly at a stated period, and runs a regular and definite course. The most prominent of these diseases, measles, scarlet fever, chicken-pox, and small-pox, are manifestly capable of being propa- gated by contagion; and the individual in whom any one of them has occurred, is, as a general rule, ever afterwards sheltered from its re- currence, though he still remains equally liable to be attacked by all the other affections of the class. The only exception to this rule we knoAv of, is the well established fact, that the vaccine disease consti- tutes a preventive to the occurrence of small-pox; though if the iden- tity of the two latter affections shall be established, as there is every reason to believe it will be, if it has not been already, even this will, in fact, form no exception. The symptoms of the eruptive fevers are usually well defined, and to the practical physician their diagnosis is seldom attended with any difficulty. It is said, it is true, that cases of eruptive fever occasionally occur in which one or more of the most important symptoms are absent, and it is very certain that during the epidemic prevalence of some of the acute exanthemata, of scarlatina, in particular, that instances are ob- served of a febrile affection unattended by the specific eruption upon the skin, resulting probably from the morbific action upon the system of the same aerial poison productive of the prevailing exanthem, but to an extent insufficient for the full development of the latter. In other instances, the symptoms appertaining to different eruptive fevers are found to be combined. Thus we often meet with cases in which certain of the phenomena of measles and of scarlet fever are blended together in the same patient. There are many reasons indeed, for be- lieving that a very close relationship exists between these two diseases, Avhich may probably account for the frequent commingling of their phenomena. It, however, has been very clearly shown, that an indi- vidual who is exposed at the same time, or in quick succession to the contagion of any two of the eruptive fevers may contract a disease in 474 DISEASES OF THE SKIN. which the features of both are intimately blended. Mr. Marson, (Medico-chirurg. Trans., 1847) has adduced several examples of the simultaneous occurrence not only of measles and scarlatina, but, also, of small-pox and measles, of measles and the vaccine disease, and of varicella and the vaccinia, and a large number of cases of a similar kind are recorded in the various medical journals. Dr. George Engelman (Trans. American Med. Assoc. 1855) remarks, that careful observation in the course of a number of epidemics of scarlet fever and measles has convinced him that an epidemic of scarlet fever can, and often does, change gradually into one of measles, and that the transition form is the disease known to the German physi- cians as roseola, rubeola, rothlein, and here sometimes popularly dis- tinguished as French measles. Of the existence of such a disease Dr. Engelman is well convinced, and equally so that it is neither a hybrid caused by the commingling of scarlatina and measles, nor a variety of one or the other of these, but a transition form of disease from the one into the other. The violence and fatality of the different exanthemata are in direct proportion to the extent and confluence of the eruption. There is a prejudice current among physicians and in the community, that the reverse is the case in respect to measles and scarlatina; but, as Trous- seau has remarked, this is a serious and dangerous mistake, the con- fluence of the eruption being as fatal in the diseases just named as in small-pox. 1.—-Measles. RUBEOLA—MOBBILLI. Measles, strictly speaking, is a catarrhal fever, attended with a spe- cific eruption upon the skin. It is, for the most part, a disease con- fined to childhood; though adults, who have passed through that pe- riod without being attacked, are by no means exempted from it; a case is related (Trans. Pennsylvania State Med. Soc. 1851,) of its oc- currence in a female nearly seventy years of age. The disease is ushered in by the usual febrile symptoms; languor, shivering, succeeded by increased heat of the skin, thirst, loss of ap- petite, &c. To these are quickly added all the usual phenomena of an ordinary catarrh:—tenderness, injection, and watering of the eyes, with a slight turgescence of the eyelids; the discharge of a serous fluid from the nostrils; frequent sneezing; some degree of hoarse- ness, with a sense of roughness or slight soreness of the fauces; a harsh, dry cough, and some difficulty of respiration. The head is affected Avith pain, or a sense of stupor or drowsiness; the bowels are generally costive, and the stomach not unfrequently rejects its con- tents. About the fourth day, an eruption makes its appearance upon the skin; first about the forehead and chin, and then over the rest of the face. On the succeeding morning it is visible, also, on the neck and breast, and by the evening it has spread over the trunk, and finally over the extremities. The eruption on the face is most vivid, gene- rally about the fifth day, and on the sixth begins to fade. By the MEASLES. 475 seventh day the eruption on the body, which is at its height on the sixth, begins to subside; while that on the backs of the hands, which was the latest in appearing, is likewise the latest in subsiding, seldom beginning to fade before the eighth day. By the ninth day, all that usually remains of the eruption, on any part of the body, is a slight discoloration of the surface, that commonly disappears before the end of the tenth day. A desquamation, in the form of very minute scales, takes place in most cases upon the decline of the eruption, and is usually attended with a troublesome itching of the skin. The desquamation is espe- cially visible on the face and upper portion of the chest. Desquama- tion is by no means, however, a constant phenomenon. Its frequent absence has been observed by Sydenham, J. Frank, Trousseau, Bou- chut, and others. The eruption is not confined to the skin, but extends also to the mu- cous membrane; the fauces and mouth being covered, at the height of the disease, Avith reddish, slightly elevated spots; which are often strikingly visible upon the surface of the tongue. With the appearance of the eruption, most commonly, there is an increase of the cough and pain of the head, and often of the fever, while the difficulty of respiration, the injection and suffusion of the eyes, and the other accessory symptoms, remain without abatement until the eruption has finished its course. During the height of the disease there is usually a quick, frequent, full pulse, great heat and dryness of the surface, loss of appetite, in- tense thirst, and a swollen, red appearance of the face. The eyelids are red at their edges, the conjunctiva is injected, the eyes humid and brilliant, the nostrils dry and slightly reddened. Breathing through the nose is attended with difficulty. The respiration is but little ac- celerated. The cough is hoarse and sonorous, or dry and frequent. By auscultation, sonorous or humid rhonchi may be detected. There is sometimes slight soreness or pain of the throat, some degree of diar- rhoea, and the nights are agitated or wakeful. In severe cases the evening exacerbations of fever are often attended with delirium. As the eruption declines the febrile symptoms abate, the skin often becomes moist, the cough generally loses its hoarseness, while the hoarseness of the voice continues, or is now for the first time apparent. The rhonchi may still be heard, or they may augment and become more humid. The appetite now gradually returns, the thirst dimi- nishes, the bowels become regular. The skin continues still to be marked by patches of a faded red or coppery hue, which do not dis- appear upon pressure. Upon the declension of the eruption, in many cases, a diarrhoea oc- curs—if it had not existed at an earlier period—which often appears to afford relief to the remaining symptoms. The above description applies to the more marked cases of measles uncomplicated with any other affection. Not unfrequently, from undue exposure or other accidental causes, at a more or less early period of the disease, laryngitis, pneumonia, or bronchitis, often of a very intense grade, occurs. In these cases there is an augmentation of the cough, 476 DISEASES OF THE SKIN. a continuation of the fever subsequent to the declension of the erup- tion, with, at the same time, a development of the phenomena proper to the accessory disease. Occasionally a more or less copious diarrhoea comes on immediately preceding the disappearance of the eruption, with pain or tenderness of the abdomen, indicating the occurrence of disease of the alimen- tary canal. In some cases the eruption is preceded by coma, or by partial or general convulsions, and the other indications of encephalic disease. In some instances, when the eruption disappears, the fever abates, the child sits up, and has some return of appetite, but in place of con- valescence becoming confirmed, the cough continues, the face becomes pale, the patient Aveak, and gradually emaciated, the bowels are regu- lar or affected with diarrhoea, and there occurs towards evening, a slight febrile exacerbation. These symptoms mark the origin of some chronic affection of the thorax or abdomen, which, after running a longer or shorter course, terminates in death. In children of a scrofulous diathesis, there is apt to occur chronic in- flammation of the deep-seated structure of the ear, and of the eyes and edges of the eyelids, with painful swellings of the lymphatic glands, occasionally terminating in suppuration, and followed by tedious and extensive ulceration. Meningitis, either acute or subacute, may super- vene in cases of measles; and the disease is liable to be succeeded by gangrenous stomatitis, and in girls, by a peculiar ulceration of the pudendum. In some cases the eruption occurs at a very early period, as upon the second day; whilst in others, the catarrhal symptoms continue for two weeks or longer, previous to the appearance of the rash. Occa- sionally, the eruption makes its appearance first upon the body, and subsequently extends to the face; while, in a few instances, it has been entirely confined to the face and trunk throughout the attack. Cases are referred to by Frank, Willan, and Conolly, in which the eruption has declined, and then suddenly reappeared, together with the febrile and catarrhal symptoms. By Vogel, Stanbach, Metgyer, Rayer, and a few other writers, a va- riety of measles is described, in which there is an absence of fever, catarrh, ophthalmia, &c, and which leaves behind it a susceptibility to the future occurrence of the genuine or febrile variety. This is the false measles of most of the German writers, the rubeola sine catarrho of Willan, and the rubeola sinefebre of others. An interval of many months, even two years, may elapse between the occurrence of thi3 and the subsequent febrile rubeola; but the latter, according to Bate- man, more frequently occurs about three or four days after the non- febrile eruption. Many of the cases described as false or non-febrile measles, were, we suspect, cases of roseola. According to the observations of Dehaen, Morton, Sydenham, Rich- ter, Consbruck, Gregory, Guersent, and Vogel, a rubeolous fever may occur unattended by any cutaneous eruption; in other Avords, during the prevalence of epidemic measles, some patients are affected with ca- tarrhal fever, without measles. If the observations of Richter are to MEASLES. 477 be depended upon, such patients are usually exempted from an attack of measles during the subsequent continuance of the epidemic, but Ave have no evidence that they are less liable than the unprotected to the occurrence of the disease subsequently. As the diagnosis in measles depends pretty much upon the character of the eruption upon the skin, a close attention to its form and general appearance is of some importance. The eruption usually shows itself first in the form of distinct, red, and nearly circular spots, resembling, in their general appearance, very nearly, the areola of ordinary flea- bites, though probably not quite so large. As these spots increase in number, they coalesce, forming small, irregular patches, approaching the nearest in shape to semicircles or crescents; these patches are in- termixed with the single circular spots, and separated by interstices in which the skin retains its natural hue. The redness disappears on pressure, and returns immediately afterwards. On the face especially, the eruption is slightly raised above the surface of the cuticle so as to give a feeling of roughness or inequality of surface to the finger when passed over the skin. The whole face is often sensibly swelled at the height of the eruption; and occasionally, in violent cases, the tume- faction of the eyelids is so great as to close the eyes for a day or two. In many cases, miliary vesicles appear upon the neck, breast, and arms, during the height of the eruption; while papulae occasionally occur on the wrists, hands, and fingers. Before the eruption disappears its redness becomes fainter, and more dusky, and it is diminished in extent, leaving, upon pressure, a yellow spot. It is not uncommon for each patch of exanthem to be replaced by a yellowish spot or stain on the skin, which may continue for fifteen or twenty days. These stains have been referred to by Guersent, Blache, Rayer, Bouchut, and Trousseau. The latter remarks, that they occupy the spots where the redness of measles possessed the greatest intensity. But slightly apparent when the child is calm, they acquire a more decided tint when the skin becomes coloured during a state of crying and agitation. They appear to occupy the dermis itself, as they do not disappear on pressure. It is queried whether they are a species of ecchymosis. They appear to be allied to a relatively serious form of measles. M. Bouchut regards these maculae as arising from a change in the cutaneous pigment produced by a local and circumscribed inflammation of the dermis. (Bouchut, on Diseases of Children.) Heim notices a peculiar odour as attendant upon the measles during its first six days. He compares it to the smell of the feathers of the goose recently plucked. Heyfelder states that he perceived it, par- ticularly when a number of patients were collected in a small apart- ment, and when the eruption was intense. He describes it as more decided in the morning than in the evening. Meissner, Wildberg, Rilliet and Barthez never perceived it, and we may say the same for ourselves. The autopsical appearances will vary, of course, according to the period when death has taken place, and the nature of the concomitant disease by which the fatal event has been produced. 478 DISEASES OF THE SKIN. Measles in its simple form, uncomplicated with any severe pul- monary, gastro-intestinal, or cerebral affection, is seldom, of itself, the cause of death. Although the symptoms attendant upon the disease indicate more or less bronchial affection, the exact nature and extent of this it is impossible to determine with any degree of certainty. The mucous membrane of the trachea, oesophagus, and the surfaces of the abdominal viscera generally, have been said to present, when the case has terminated fatally during the eruptive stage, the same species of exanthem as the skin. In some cases, effusion of lymph mixed with blood or pus, has been found in the cavity of the thorax; in others, inflammation of the sub- stance of the lungs, with extensive effusion in their texture; in others, extensive bronchial or pneumonic inflammation; and in others again, condensation of the pulmonary tissue, as in cases of lobular pneumonia. The morbid appearances present in the cases examined by our- selves were: the various lesions observable in severe cases of bron- chitis, and of lobar and lobular pneumonia; oedema of the lungs, ex- tensive engorgement of their blood-vessels, with effusion of bloody serum in the air-cells and minute bronchial ramifications; tuberculiza- tion of the lungs, and of the serous membranes generally; gastro- enteric inflammation; follicular inflammation, and occasionally ulcera- tion of the ileum and colon; enlargement of the mesenteric glands, and meningeal inflammation, particularly at the basis of the brain, with tubercular deposition, and effusion within the ventricles and arachnoid cavity. There was no case in which some degree of bron- chial or pulmonary disease did not exist; in a very large number there also existed indications of more or less disease of the gastro-intestinal mucous membrane. The indications of cerebral disease were the least frequent. The most usual forms under which measles presents itself are the simple catarrhal, which we have described—the congestive, and the gastro-intestinal. The congestive form is marked by imperfect reaction, and occasion- ally its entire absence; a general depression of the energies of the system; pallor of the face; a sunken and anxious expression of the countenance; torpidity of the bowels; a slow, weak, oppressed pulse; slow and oppressed respiration, and coldness of the extremities. The eruption may not appear, or it occurs slowly on some portions only of the surface. If reaction does not take place spontaneously, or is not induced by an appropriate treatment, stupor or deep coma, and occasionally, convulsions, ensue. In some cases, symptoms of conges- tion ensue after the eruption has made its appearance; in these cases, the latter either becomes of a pallid or livid hue, or entirely disap- pears. In those instances in which an autopsic examination has been made, extensive engorgement of the pulmonary vessels, and, generally, of the vessels of the brain also were detected. This form is said to occur most commonly in infants, and children of a feeble and relaxed habit. We have not, however, found it to be confined to any particular age or constitution. In some epidemics it occurs much more frequently than in others; we have met with it more MEASLES. 479 often, however, in confined and unhealthy neighbourhoods, than in those of an opposite description. When measles is complicated with gastro-intestinal disease, it is ordinarily accompanied by a less decided febrile reaction, a small and feeble though generally frequent pulse, and considerable pain of the forehead. A sense of tension and fulness is usually experienced at the epigastrium, which is more or less tender upon pressure. Vomit- ing and profuse diarrhoea often precede or follow the appearance of the eruption, which is pale, and often indistinct. The skin is dry and harsh, but seldom much increased in temperature. The tongue is dry and brown, and often the patient complains of frequent sharp pains in the abdomen. There is considerable thirst, and occasionally great restlessness, dyspnoea, and an anxious expression of countenance; particularly on assuming an erect posture. The cough is short, dry, and almost incessant. In some cases, particularly in young and irri- table children, great difficulty of respiration, and a sense of oppres- sion in the chest, will suddenly ensue. The patient may sink under the ordinary symptoms of fatal gastro- intestinal disease, or of pulmonary inflammation; or symptoms of cerebral inflammation may ensue, quickly terminating in coma, con- vulsions, and death. In its simple, uncomplicated form, measles is ordinarily a disease attended with very little danger; and so mild in its symptoms as to run its course and terminate favourably, Avithout the necessity of any very active interference on the part of the practitioner. Although in every case it is requisite to employ a precautionary treatment, to guard against the occurrence of violent or unfavourable symptoms, yet, as a general rule, active remedies will neither be necessary nor proper. When, however, the disease becomes complicated with severe affections of the respiratory organs, alimentary canal or brain, it is invariably attended with considerable danger, and will often prove fatal even under the most prompt, judicious, and energetic course of treatment; while its occurrence, under all circumstances, in children of a feeble and debilitated constitution, or who, from any cause, are strongly predisposed to disease of the lungs or brain, is to be viewed in an unfavourable light, as in such, it is very apt to prove the exciting cause of some of the most unmanageable and fatal maladies to which the infant constitution is liable. Dr. Churchill states, (Diseases of Children,) that in foundling hos- pitals or poor-houses, where many children are crowded together, and the atmosphere becomes vitiated, we occasionally find ulceration of the rectum, or, in girls, of the labia pudendi, which may either be simple or gangrenous. Sir Wm. Watson mentioned that in the putrid form of measles which prevailed in the London foundling hospital, the girls who died had most commonly mortification of the pudendum, and that one died from mortification of the rectum. Dr. Lees relates two cases of ulceration of the rectum, and one in which both rectum and pudendum were affected. As a general rule, an individual who has suffered an attack of measles is not subsequently liable to reinfection; instances, however, 480 DISEASES OF THE SKIN. have occurred of a second attack, several of which have fallen under our own notice. Measles usually occurs as an epidemic, often of very considerable extent. Of the particular state or condition of the atmosphere upon which the production of the disease depends, we know nothing. Epi- demics of measles are said by Sydenham to commence, generally, in the month of January, and to cease soon after the summer solstice. According to our observations, they are very apt to occur at the same seasons, and under nearly the same sensible conditions of the atmo- sphere, as epidemic catarrh. Sporadic cases of the disease may occur in almost every month of the year:—they have occurred in the midst of summer. Whether measles is capable of being propagated by contagion, is still a disputed question: although the affirmative is generally assumed, there are many who maintain the negative. The disease, it is said, occurs always as an epidemic, and on its first appearance a number of individuals are invariably simultaneously affected; while it cannot be traced from house to house, or from street to street, as in small pox and scarlatina. There is some evidence, however, that measles may be communicated by inoculation. Dr. Hume, for this purpose, dreAV blood from a cutaneous vein where the eruption was most confluent, and applied a dossil of lint impregnated with this, to a wound made in the arm of the individual to Avhom the infection was intended to be communicated. Of the general certainty and value of the operation, it is impossible to form any positive conclusion from the few instances in which it has been practised. By a recent notice in one of the Austrian medical journals, it ap- pears, however, that Dr. Katona, of Borsoder, in Hungary, has tested, in a large number of cases, the efficacy of inoculation for measles. In a very fatal and wide-spread epidemic, which prevailed during the winter of 1841, he inoculated 1122 persons with a drop of fluid from a vesicle, (?) or with a drop of the tears of a patient affected with the disease; the fluid being inserted in the same manner as the virus in vaccination. The operation succeeded in about 93 per cent, of the cases in which it was performed—producing a mild attack of measles. A red areola at first formed around the puncture by which the fluid was inserted, but soon disappeared. On the seventh day, fever com- menced, Avith the usual prodromi of measles; on the ninth or tenth day, the eruption made its appearance; on the fourteenth, desquamation commenced, with a decrease of the febrile symptoms, and by the seventeenth day the patients were very generally perfectly well. In no one of the inoculated cases did the disease terminate fatally. Dr. M'Girr, of Chicago, Illinois, reports the result of inoculation for measles in fourteen cases. The operation was performed by in- serting blood, drawn from a vivid exanthematous patch, into the arm. In the inoculated patients the disease was less severe and dangerous than in those in the same institution—the Catholic Orphan Asylum— who contracted the disease in the ordinary way, during the period the effects of inoculation were tested by him. Although no age is absolutely exempt from an attack of measles, MEASLES. 481 the most common period of its occurrence is from that of weaning to the age of puberty; after which latter period, the older the patient the more troublesome and dangerous it is said the disease generally proves. A late writer (?Fontgomery) dissents from thi3 doctrine, and states, that from his own observations he should pronounce a directly opposite opinion; Avhich corresponds precisely with «ur own experience. The only disease with which there is any risk of confounding measles is scarlatina; from which, however, it may be very readily distinguished by the following circumstances: The distinctly-marked catarrhal symp- toms by which the eruption in measles is preceded and accompanied, and their absence in scarlatina; the appearance of the eruption in measles being seldom very evident until the fourth day; whereas that of scarlatina usually appears on the second day of the fever. In measles, the colour of the eruption is dark scarlet, or of a raspberry hue; Avhile in scarlatina, it is of a vivid red, resembling the hue of the lobster after boiling: the eruption in the latter is also much more full and extended than in the former, forming large, irregular patches, which often coalesce, so as to cause a uniform redness over a consider- able extent of surface. In the treatment of an ordinary case of measles, the attention of the practitioner should be chiefly directed to the fever and catarrhal symp- toms, which, Avhen they are mild, the eruption at the same time follow- ing a regular course, will demand little else than a cautious attention to preserve the body of the patient of an equable temperature, and to prevent exposure to cold or damp; to place him upon a spare, simple, and unirritating diet, and to keep his bowels regular, by the occasional use of mild purgatives; while we endeavour to mitigate his cough by plain demulcent drinks, rendered more palatable by the addition of a small portion of some vegetable acid, as lemon juice, or the like. The patient should be kept at rest, and in a large, well ventilated apartment, of a suitable temperature, and free from currents of cold air. His drink should be taken rather of tepid warmth than cold. When the cough is troublesome, the inhalation of the steam of warm water Avill, in many cases, if the patient is sufficiently old to conduct the inhalation properly, prove an excellent palliative. In some cases, a pediluvium at bed-time, followed by a dose of Dover's powder, will cause the patient to sleep, and mitigate the more troublesome catarrhal symptoms. We are persuaded that in all cases, an emetic of ipecacuanha or tartarized antimony, administered in the early period of the attack, and followed by a full dose of calomel combined with magnesia—the operation of the calomel being promoted by a dose of castor oil given a few hours subsequently—will be found beneficial, by rendering the course of the disease milder, and the occurrence of severe bronchial or pulmonary inflammation less frequent. It is a practice we have fol- lowed for many years, and invariably with the best effects. When the febrile excitement is considerable, with a good deal of dry- ness and heat of the skin, the employment of antimonials, or the milder diaphoretics, will be demanded.1 When the catarrhal symptoms are 31 482 DISEASES OF THE SKIN. very severe, the same remedies will be necessary as in severe cases of ordinary catarrh. 1 R.—Mucilag. g. acacise, giij. Or R.—Liquor, acetat. ammonia?, 5VJ. Syrup, limonis, =j. Spir. seth. nitr. Spir. seth. nitr. 3HJ. Vini antimonii, iiii ^iij. Tart, antimon. gr. j.—M. Syrup, limonis, gij— M. Dose, a teaspoonful every three hours. Dose, the same as the above. Or, R.—Ammoniae hydrochlor. Pulv. ext. glycyrrh. ail 3HJ. Tart, antimon. gr. j. Aquae, Jjviij. Dose, a teaspoonful every three hours, for a child under two years of age, and a dessert-spoonful every two or three hours, for one over two years of age. In regard to the employment of blood-letting in severe cases of mea- sles, there appears to be very little difference of opinion; most practi- tioners concurring in its recommendation. Some difference of senti- ment has, however, existed as to the most appropriate period for its employment; some directing it only during the height of the eruption; others postponing it until the eruption has subsided; while others again consider it equally proper at any period of the disease, when symp- toms are present which call for its use. The proper rule, however, is easily laid down. Whenever great shortness or difficulty of respira- tion ; a full, hard, and quick pulse; great heat and dryness of the sur- face ; a frequent dry, harassing cough, with severe pain in the chest or head; and, more particularly, if the physical signs of extensive bron- chial or pulmonary inflammation are present—the abstraction of blood to an extent sufficient to relieve these symptoms, will be proper at any stage of the disease, but more particularly if the above symptoms su- pervene at the period when the eruption disappears. Of course, in di- recting the extent and repetition of the bleeding, due attention must be paid to the age and vigour of the patient. Under the circumstances just recited, not only general bleeding, but cups to the chest, antimonials, and blisters—in fact, all the remedies demanded in ordinary cases of severe bronchial and pneumonic inflam- mation will be necessary, and upon their prompt and judicious employ- ment will the safety of the patient in a great measure depend. Exposure to cold air, or even the use of the cold affusion, which has been found so beneficial in scarlatina and other of the exanthemata, has likewise been recommended in measles. In the latter disease, however, it is a remedy of, to say the least, very doubtful propriety. It certainly would appear to us to be calculated to augment the catar- rhal and pulmonary affections, which, in the great majority of cases, are unquestionably the most serious features of the disease. Dr. Walz, (Schmidt's Jahrbueh,) states that he has employed inunc- tion of the skin with fat in three hundred and forty-three cases of mea- sles, fifty-seven of which were severe—and all Avere speedily cured. In thirty of the cases, he remarks, the patients were tuberculous, and in these the progress of phthisis was arrested. In the congestive form of measles, the remedies best adapted to pro- mote reaction, and to relieve the oppressed state of the internal or- gans, are, 1st, Emetics, the action of which has been found among the MEASLES. 483 very best means of favouring the eruption upon the surface, and un- loading the engorged vessels of the lungs. 2d. The warm bath. Im- mersion in the bath should succeed the operation of the emetic, and be followed by brisk friction over the whole surface with the hand, or a soft flannel. 3d. Blisters or sinapisms to the extremities, and to dif- ferent parts of the surface, particularly in the neighbourhood of the organs which appear to be the most oppressed. There are few of the more violent cases of congestive measles, in which these remedies will not be found of decided advantage. In their application in young chil- dren, and in debilitated subjects, caution should be observed not to al- low them, particularly the blisters, to remain on too long, but to re- move them in one or two hours, the sinapisms in a much shorter period, and to substitute large emollient cataplasms. 4th. Diaphoretics. The choice of the diaphoretic will depend, in a great measure, on the ur- gency of the symptoms. In most cases, the Dover's poAvder, a combi- nation of camphor, ipecacuanha, and extract of hyoscyamus,1 or of the acetate of ammonia, aqua camphorata, wine of ipecacuanha, and tinc- ture of hyoscyamus,2 will be proper; the patient, at the same time, drinking freely of some tepid fluid. 5th. Bleeding. In a large num- ber of the congestive cases of measles, a cautious abstraction of blood, either from the arm, or by cups from about the head and chest, par- ticularly after the operation of an emetic, and the warm bath, will often produce very decided relief. The effects of the bleeding, however, should be carefully watched; and the quantity of blood abstracted, or the necessity for the immediate cessation of the bleeding should be go- verned by the degree of relief obtained and the effects upon the pulse. If the symptoms of oppression are evidently diminished, and the pulse becomes fuller and more free under the bleeding, it may be continued, within moderate limits; but if the oppression is augmented, the ex- haustion of the patient increased, or the pulse sinks, these are signals for the immediate suspension of the operation, and the administration of some gentle stimulant, of which the best is, perhaps, the carbonate of ammonia, in combination with camphor. 1 R.—Fulv. camphor, gr. iv.—vj. 2 R.—Acetat. ammoniae liquor. 3iij. Magnes. calc. J^ijss. Aquas camphorae, §ij. Pulv. ipecac, gr. iij. Yin ipecac. 3'j. Ext. hyoscyami, gr. vj.—viij.—M. f. Tinct. hyoscyami, ^iij. ch. No. xij. Syrup, zingiber. §j.—M. One for a dose, to be repeated every one, two A teaspoonful for a dose; to be repeated or three hours, according to circumstances. every one, two, or three hours, accord- ing to circumstances. When, in the course of the disease, the eruption suddenly recedes, or becomes of a pale or livid hue, and symptoms of severe oppression of either of the internal viscera occur, nearly the same remedies will be demanded. Bleeding will, in such cases, when cautiously employed, generally be found beneficial; and if a state of deep coma ensue, cups to the head, sinapised pediluvia, followed by sinapisms or blisters to the extremities, should not be neglected. In regard to the administration of stimulants, to bring out, as it is termed, the eruption, some degree of caution is invariably to be ob- served. That there may occur cases in which, from a deficiency of vital 484 DISEASES OF THE SKIN. energy, the specific action upon the surface of the body does not take place, or suddenly ceases, and symptoms of a very violent character ensue, Ave are not inclined to deny, though such cases have never fallen under our notice. Under such circumstances, the warm bath^ and a judicious use of external and internal stimulants, would unquestionably be demanded, to remove the extreme danger there exists of the patient speedily sinking. But before venturing upon the use of stimulants, the practitioner should be very certain that the non-appearance, or re- trocession of the eruption, and the symptoms of oppression, do not de- pend rather upon extensive central congestion than upon mere debility; recollecting that in cases of congestive measles, the incautious admi- nistration of active stimulants internally is, in nearly every instance, positively mischievous. It occasionally happens that about the seventh or eighth day of the eruption, the latter suddenly assumes upon different parts of the body a livid appearance, with an intermixture of yelloAV. This constitutes the rubeola nigra of some writers. Such an occurrence has caused often much alarm, it being vieAved as the indication of imminent dan- ger; we are assured, however, that such symptoms very speedily give way, under the use of the mineral acids. The gastro-intestinal symptoms with which measles is occasion- ally complicated, require to be treated on general principles. The Avarm bath, leeches to the epigastrium or to the surface of the abdo- men followed by emollient cataplasms, with small doses of calomel, ipecacuanha, and extract of hyoscyamus, in combination, and a pro- perly regulated diet, are the chief remedies demanded. When a pro- fuse serous diarrhoea occurs, this should be promptly arrested by the administration of the acetate of lead, by the mouth or in enema. We should recollect, hoAvever, that a moderate diarrhoea is, generally speaking, rather beneficial than injurious, particularly Avhen it occurs towards the termination of the eruption; we are, therefore, unless it be attended by prominent symptoms of gastro-intestinal disease, to refrain from interfering with it, especially in robust and plethoric subjects. During convalescence, the utmost care should be taken to guard the patient from the influence of cold and damp. Even during the Avarm season, he should not be allowed to go out of doors, excepting in the middle of the day, and in dry weather. His diet should be light, nourishing, and unirritating; every species of stimulating drink should be avoided. The use of the warm or tepid bath daily, will always be advantageous. It is said that when any cutaneous disease occurs after measles, the internal organs are seldom liable to become affected; and that even when some internal disorder has already existed, it has disappeared on the occurrence of a spontaneous eruption upon the skin. We should, therefore, be cautious in interfering with vesicles, pustules, boils, and the like, when they occur subsequent to an attack of mea- sles. Various diseases may remain or occur upon the decline of the erup- tion, Avhich require great attention, as they are often exceedingly SCARLET FEVER. 485 troublesome, and attended Avith even greater danger than the original malady. They are usually bronchial or pulmonic inflammation, and, occasionally, inflammation, either acute or subacute, of the intestinal canal. In a large number of instances, these may be entirely prevent- ed, or rendered more manageable when they do occur, by a proper treatment of the measles from its commencement. When they present themselves, they must be treated in accordance with their character, extent, and violence, and the condition of the patient's strength. 2.—Scarlet Fever.—Scarlatina. Scarlatina, in its mildest and most simple form, is a febrile exan- them, characterized by a diffused efflorescence, of a bright scarlet colour, which appears upon the surface of the body, usually on the second day after the occurrence of the fever, and terminates in a des- quamation of the cuticle, at the end of about five days. Most com- monly, however, it is accompanied with a severe affection of the throat, or of some one or other of the internal organs, by Avhich its symptoms and progress are very considerably modified, and the dis- ease, which, in its regular and uncomplicated form, scarcely demands the interference of the physician, becomes then one of the most unma- nageable and destructive to which children are liable. In consequence of the various modifications under which it presents itself in the same, or in different epidemics, scarlatina has been divided by practical writers into several varieties. Those most commonly re- cognised are: the scarlatina simplex; the scarlatina anginosa; and the scarlatina maligna. The last of these denominations is particularly objectionable. The terra malignant is, to say the least of it, indefinite; while from its former, and even now very common application, it is extremely apt to lead to erroneous views, in regard to the nature and proper treatment of the affections it is employed to designate. To the above varieties, some writers add a fourth, in which, from expo- sure to the contagion of scarlatina, the throat alone becomes affected, without any eruption occurring upon the skin. This, however, cannot, with strict propriety, be considered as scarlet fever. The malignant form of scarlatina has, with an approach to greater clearness and precision, been divided by Armstrong into three varie- ties : the highly inflammatory, the highly congestive, and the irregular congestive. We propose to consider the disease under two divisions only:—1st. The inflammatory, including the simple and anginose varieties of Willan, and the highly inflammatory of Armstrong. 2d. The con- gestive. To distinguish the different modifications of inflammatory scarlatina and the consequent variations of treatment that is demanded, we shall describe it as it occurs:—1st. Under the form of simple excitement; 2d. Attended with inflammation of the fauces; and 3d. "With inflam- mation of one or more of the internal organs. The disease seldom manifests itself until from about the third to the fifth day subsequent to exposure. In its mildest form it is usually ushered in without much rigour, or 486 DISEASES OF THE SKIN. disturbance of the stomach; but there is ahvays present more or less pain, or uneasy sensation in the head, restlessness, and lassitude, with paleness of the face, and a weak pulse. These symptoms may con- tinue from one to three days, when they are succeeded by a general febrile reaction. It is usually on the second day after the occurrence of the febrile excitement, that the efflorescence upon the skin begins to show itself, first about the face and neck, in innumerable red points, which, Avithin the space of twenty-four hours, are to be seen over the whole surface of the body. As the points multiply, they coalesce into small irre- gular patches; and, by the third day, the eruption presents a diffuse and continuous efflorescence over the limbs, and around the fingers, giving to the skin a colour somewhat similar to that of the shell of a boiled lobster. Upon the body, the efflorescence is seldom continuous, but is distri- buted in diffused irregular patches; the scarlet hue being most vivid about the flexures of the joints, and around the loins. The efflores- cence is often accompanied with a perceptible roughness of the skin, which is most evident upon the extremities, and front of the body, giving a sensation as if the surface was covered with granules. This is caused by an enlargement of the cutaneous papillae. Where the redness of the skin is most intense, and particularly when the patient has been subjected to a heating regimen, small miliary ve- sicles occasionally appear upon different parts, more generally upon the trunk. About the fourth or fifth day of the efflorescence, an erup- tion of semi-globular vesicles, filled with a thin pearl-coloured serum, is occasionally observed about the forehead, neck, chest, shoulders, and extremities. They vary in size, and succeed one another without de- terminate order. The efflorescence is not confined to the surface, but extends over the mucous membrane of the mouth and fauces, and even of the nos- trils, and is occasionally visible upon the adnata of the eyes. The papillae of the tongue, also, are considerably elongated, and project their scarlet points through the white coat with which the surface of the tongue is covered. On the fourth day, the eruption is usually at its height; and on the fifth, begins to decline by interstices, leaving the small patches as at first; on the sixth it is very indistinct, and is generally entirely gone before the termination of the seventh day; a desquamation of the en- tire cuticle taking place, which often occupies many days before it is completed. Early in the stage of excitement, there is most generally experienced some degree of soreness, or a sense of fulness in the throat, and the voice is not quite so clear and sonorous as ordinary. The skin, from the excessive injection of its blood-vessels, becomes morbidly sensible, dry, and hot. Its temperature seldom, however, exceeds 103 degrees of Fahrenheit. The lips are of a vivid red; the face is flushed and somewhat tumid, and the tongue is covered upon its centre with a white mucus, but is red around the edges. The pulse is, in general, increased in strength and quickness, but seldom rises SCARLET FEVER. 487 above 100 or 110 in the minute. The thirst is seldom very urgent; the appetite is lost, and the boAvels are costive; and when evacuations are obtained, they are frequently of a much darker hue than natural. The febrile symptoms slightly remit towards morning, but gradually increase during the course of the day, and attain their greatest inten- sity in the evening, when some degree of delirium is often present. The stage of excitement seldom continues longer than from four to five days, when it gradually subsides; the pulse becoming slower and softer, and the skin cooler and more relaxed. The foregoing description is that of the most usual form of simple scarlet fever; which seldom continues longer than fourteen days, and is occasionally of shorter duration. Its termination is very generally favourable; the first stage being attended with but a slight degree of visceral congestion, the second being marked with general, but short and moderate excitement, which is succeeded by no serious collapse. In its course, however, either suddenly or by degrees, symptoms of a more decidedly inflammatory character may become developed, and the throat being now more deeply affected, the case assumes the angi- nose form of scarlatina. Scarlatina anginosa commences nearly in the same manner as the simple form. It is generally ushered in, however, by a greater degree of chilliness, headache, and restlessness. There is a sense of greater oppression at the praecordium, with prostration of the voluntary powers, nausea, retching or vomiting. The eruption upon the skin generally appears Avithin the first three days, and about the same period the fauces become red and swollen, and the patient complains of a stiff- ness in the neck and jaAVS, and a fulness and soreness of the throat, particularly in speaking or swallowing. The pulse is quicker than in the preceding form; there is also greater thirst, and more uneasiness of the head; the tongue is drier and redder at its edges, and the heat of the surface is more elevated, ranging from 106° to 108° or 112°. The discharges from the bowels are darker, and of a more bilious ap- pearance. The evening exacerbations are more intense, and more often attended with delirium, during which the patient, if alone, or in the dark, talks much to himself. The efflorescence does not pervade so generally the surface of the body, in the anginose as in the simple form; but usually occurs in scattered patches on the chest and arms. In some cases, it is confined to the back of the hands and wrists, and sometimes entirely disappears on the second day, and partially reappears at uncertain periods. When the eruption is slight, or speedily disappears, it is often not suc- ceeded by desquamation. In other instances, however, desquamation continues often to the end of the third week, or even longer; large portions of the cuticle occasionally separating, particularly from the hands and feet. When the febrile symptoms begin to abate within the first four or five days, the tonsils and fauces are seldom covered with membranous exudations; there is merely an increased secretion of tenacious mucus, some of which often adheres to the fauces; and the constant efforts made by the patient to expel this, increase his sufferings. But, when 488 DISEASES OF THE SKIN. there is a longer continuance or higher grade of febrile excitement, small patches of a grayish hue are observed upon the tonsils and fauces, which are often mistaken for sloughs; but by gargling the throat of the patient, the exudation may frequently be removed, when the mu- cous membrane beneath will be found entire. The exudation is re- newed from time to time, and frequently extends into the lateral parts of the pharynx and oesophagus, but seldom into the larynx or trachea. As the fever declines, which is frequently about the eighth day, the patches of exudation separate, and leave the fauces somewhat redder than natural, but free from ulceration. It occasionally happens, however, that instead of so favourable a termination, symptoms of a much more alarming character arise in the progress of the disease; the patches in the throat acquire a darker colour, and the secretions from the fauces and nostrils become highly offensive, causing considerable foetor of the breath; painful indurations of the glands of the neck ensue, and the patient is troubled with griping pains of the abdomen, with tenesmus, or diarrhoea. In some cases, a state of collapse quickly ensues, and terminates promptly in death. One of the most common and remarkable accompaniments of scar- latina anginosa, remark Rilliet and Barthez, is an inflammatory intu- mescence of the submaxillary glands, which in general presents itself the day subsequent to that upon which the swelling occurs in the pha- rynx. There then takes place a swelling, painful to the touch, and sometimes tense and red. The inflammation is at first confined to the glands, but in many cases soon extends to the surrounding cellular tissue, often producing an enormous tumefaction, reaching around the front of the throat from ear to ear, and preventing the jaw from being opened Avider than just to permit the tip of the patient's tongue to be protruded. Ordinarily, the swelling is produced by an cedematous con- dition of the cellular tissue of the throat, and quickly disappears as the inflammation of the glands diminishes. Occasionally, however, a suppuration takes place, commencing either in the glands or in the cellular membrane, and an abscess occurs, which is always a very un- favourable result. The inflammation sometimes attacks the skin, when suppuration takes place still more readily. In other cases, during the stage of excitement, symptoms of cerebral disease manifest themselves, and the patient dies comatose, about the end of the second week. Not unfrequently, also, there occur slight pain, tenderness, and tumefaction at some part of the abdomen, with increased frequency of the pulse and respiration. The pain and ten- derness of the abdomen quickly increase in intensity, and are at length attended with vomiting, eructation, general restlessness, and a tympa- nitic condition of the abdomen. At the end of six, seven, or eight days, the pain and tenderness diminish or disappear; the pulse groAvs more rapid and feeble; the respiration more anxious, and the vomiting more urgent. Cold, clammy sweats, and universal collapse now speedily ensue, and are the imme- diate precursors of death. In many cases, there is a much greater tendency to inflammations of the serous membranes of the brain or of the thoracic or abdominal regions, than of the substance of the organs. SCARLET FEVER. 489 Not unfrequently, the anginose form of scarlatina is attended with a very intense degree of febrile excitement; the inflammation of the throat runs very quickly into a gangrenous condition; and there is often severe cerebral excitement, with a redness of the eyes, intolerance of light, and a throbbing pain of the head, with tinnitus aurium, watch- fulness, confusion of mind, and delirium. To these symptoms there may succeed a state of stupor, occasionally interrupted by loud screams, or by fits of violence or of fretfulness. In other cases of scarlatina, symptoms of severe abdominal inflam- mation ensue; considerable pain, increased upon pressure, with ten- sion, fulness, and heat of the abdomen; short, quick, anxious respira- tion; very quick, contracted pulse; considerable irritability of the stomach, and either a costive state of the bowels or diarrhoea. In other cases, again, neither the head nor abdomen seems so de- cidedly affected; but the greatest uneasiness is referred to the respi- ratory organs—the trachea, bronchi, pleura, or lungs. Whatever may be the organ or organs affected, the stage of excitement is of short du- ration, and is succeeded by a greater or less degree of collapse; in which the heat of the surface is diminished, the energies of the system sink; the pulse becomes weaker and more quick; the skin relaxed; the tongue fouler; the respiration more laborious; and finally, the pa- tient is attacked with convulsions, violent vomiting, or symptoms of suffocation, according to the organ principally affected, which quickly terminate in death. The anginose form of scarlatina, and that accompanied with acute or subacute inflammation of the central organs, differ only in the seat, and the greater or less violence of the attendant affections. One of the most frequent of the sequelae of scarlatina is an cedema- tous affection of the eyelids, faoe, and lower extremities; frequently, complete anasarca ensues after the disappearance of the eruption. Effusion within the serous cavities is, also, not unfrequent. In cases of general anasarca, a sudden effusion sometimes takes place into the cavity of the chest, or into the ventricles of the brain, by which the patient is destroyed in a few hours. The dropsical effusion is usually produced by an imprudent exposure to cold. In many cases, however, it is attended with albuminous urine, and no doubt with a diseased condition of the kidneys. In more than one half the cases Avhich fell under the notice of Rilliet and Barthez, the patients were affected with anasarca, more than two-thirds of which presented after death a characteristic lesion of the kidneys. To un- derstand correctly the double influence of the action of cold and of al- buminous nephritis in the production of the dropsies consequent upon scarlatina, the authors just quoted point to the following well-estab- lished facts: 1st. Albuminous nephritis may exist as a sequela of scar- latina, Avithout producing dropsy. 2d. The dropsy may exist without albuminuria and without albuminous nephritis. 3d. In the great majority of cases, the action of cold in the production of the dropsy is manifest, and in many cases, an exposure to this cause is immediately folloAved by anasarca. 4th. In many patients who have been exposed to cold, there will occur an albuminous nephritis, of which the action 490 DISEASES OF THE SKIN. of cold and humidity has been shown to be one of the causes. 5th. The action of cold in the production of the dropsy cannot always be proved. It hence results that we cannot deny the influence of cold and of nephritic disease, which often concur in the production of the dropsy. The influence of the first is probably more general than that of nephritis; it is in many cases the cause both of the dropsy and of the nephritic disease. Consequently, it is particularly against exposure to a cold and damp atmosphere during the latter stages of scarlatina, and during the period of convalescence, that we should especially guard. Of the occasional occurrence of albuminous urine consequent upon nephritic disease in the dropsy succeeding to scarlatina, there can be no doubt. Some writers have gone so far as to assert that an albumi- nous condition of the urine is almost invariably to be detected in the course of the fever. Professor Bennet, of London, believes that the coagulability of the urine observed in scarlatina, as well as various de- posits which appear in it on critical days, are to be considered as an evidence of the excretion of the morbid products which have circulated in the blood. Hence it is common, not only in scarlatina, but in all inflammatory affections, as well as fevers. Dr. Newbigging (London Monthly Journal, Sept. 1849,) states that in an early stage of the disease, even at the time when the eruption was just declining, having instituted an examination of the urine, he ascertained that, in every case, the albuminous haze was distinctly present, and remarkably so during the progress of the desquamation. That this appearance occurred without alteration, either in the spe- cific gravity, except to a very small extent, or in the quantity of the secretion, and that it continued from a period varying from four or five to ten days, gradually becoming less defined, and finally disap- pearing altogether. This occurred in cases in Avhich the urine main- tained its normal standard as to quantity, where the patients Avere well, and certainly unaffected by any dropsical symptoms. It is worthy of remark, that the quantity of urine voided at the period of desquamation is even greater than in health, although it may contain albumen; and this Dr. Newbigging considers to be an interest- ing fact, as in dropsy occurring, it may be, subsequently, in the same case, the amount of the urine is greatly diminished, sometimes altoge- ther suppressed, so that any diminution of this secretion, without ap- parent increase of albumen, may be almost certainly considered as the forerunner of anasarca. These observations correspond with those of Martin Solon, who as- certained the presence of albumen in twenty-two out of twenty-three cases, but are irreconcilable with those of some other authors: thus, Philippe states that, although the succeeding dropsy was very common in the mild epidemic which he witnessed, yet in sixty cases of the dis- ease, in which he tested the urine for albumen by both heat and nitric acid, no trace of that principle was discovered. Dr. Scott Alison, on the other hand, remarks, that he has observed dropsy to ensue more frequently after a severe attack of scarlatina than when the symptoms were of a more moderate character. That the urine in some cases, ac- cording to his analysis, was of a specific gravity of 1.005, while in SCARLET FEVER. 491 others it was as high as 1.030; and he is of opinion that the kidney becomes organically affected at an early period of the disease. Dr. Behrend (Coustatt's Jahrbuch., 1850,) describes two forms of dropsy as occurring after scarlatina. The first depending upon an inflamed state of the kidney, and the other being a consequence of anaemia. The first form may occur sooner or later after the eruption, as oedema, ascites, hydrocardium, hydrothorax and hydrocephalus. The more considerable the oedema, the less the effusion into the se- rous membranes, and vice versa; ascites, however, being an exception to this rule. .„, In the great majority of cases, the dropsical symptoms that suc- ceed to scarlatina are by no means unmanageable, but very gene- rally yield to a simple plan of treatment. Not unfrequently, spasmodic asthma, chorea, epilepsy, and neural- gic pains of the extremities are met with, as sequelae to the inflamma- tory forms of scarlatina. In other cases, chronic cutaneous eruptions, rheumatic pains of the joints, abscess and enlargement of the tonsils, enlargement and suppuration of the parotids and other glands of the neck, chronic ophthalmia, otitis, with deep-seated abscess of and fetid discharges from the ears; inflammation of the testicles; chronic bron- chitis; tubercular phthisis; or inflammation of the mucous membrane of the intestines, have also been observed as consequences of severe cases of scarlatina. A complete loss of the hair, which never grows well again, is likeAvise a frequent consequence of the disease. The autopsical appearances, in fatal cases of scarlatina, are very dissimilar in different cases. Rilliet and Barthez have attempted to show that one of the most common results of scarlatina is a change in the condition of the blood. In the observations made by them, the blood, whether contained in the heart or blood-vessels, was sometimes liquid and very fluid, dark-coloured, and in other cases, serous and clear. It seldom presented in any situation abundant or firm coagula. Those Avhich occurred, Avere soft and easily broken, or gelatinous and pale. Sometimes the blood Avas effused to a considerable extent into the tissues, as Ave see in cases of variola. Sometimes, on the contrary, but rarely, certain organs were pale and contained little blood. According to Tweedie, in those instances in which the contagion appears to have been of so intense a character as to destroy life within a short period, and without the occurrence of reaction, or with only partial and imperfect reaction, there are often no apparent lesions discoverable. In other instances, the mucous membrane of the mouth, fauces, pharynx, trachea, and bronchi, is found to be strongly injected, and of a deep red colour. There is often more or less intumescence of the tonsils and fauces, which are frequently covered, to a greater or less extent, with membraniform exudations. Occasionally, the mu- cous membrane of the fauces is of a dark livid hue, and covered with dark-coloured, ragged patches of exudation. Indications of violent inflammation of the mucous membrane of the larynx, trachea, and bronchi, and of lobar or lobular pneumonia, are very frequent. In many cases, the mucous membrane of the intestines presents va- rious grades of inflammation: follicular inflammation of the ileum, 492 DISEASES OF THE SKIN. and occasionally of the colon, we have met with, in cases in which but slight indications of inflammation of the throat, or of the respiratory tubes, Avere observed. When symptoms of cerebral disease are^ pre- sent previous to death, injection of the membranes and substance of the brain, thickening and opacity of the arachnoid membrane, with effusion of transparent or lactescent serum, are the lesions generally met writh. In cases succeeded by dropsical effusion, the kidneys occa- sionally present the same change of structure, as occurs in the morbus Brightii. Purulent deposits have also been observed in the cavity of the joints, without inflammation of the synovial membrane. Not unfrequently, indications of pericarditis are met Avith. Dr. Alison has called the attention of the profession to the not uncommon occurrence of this complication in cases of scarlatina. Scarlatina most commonly occurs as an epidemic, often of wide ex- tent, and it is very generally believed that it is capable of being pro- pagated by a specific contagion, emanating from the bodies of those labouring under the disease. Upon this point, however, there is some difference of opinion among physicians. It is certain that in many epidemics we find the disease to prevail extensively in a particular locality, while in those immediately adjoining, and between which and the one where the disease prevails, there is the most unrestricted in- tercourse, scarcely a single case will occur. Often, upon its decline or cessation in the locality where it first appeared, it will make its ap- pearance in one or other of those adjoining, and thus passing from locality to locality, successively travel, as it were, over a large city; a fact that would seem to militate against the idea of its eminently contagious character. Dr. Charles D. Meigs remarks, that one might well venture to resist the general assertion of the contagion of scar- latina, seeing that it so very often breaks forth fearfully in places where no suspicion of human intervention can be indulged, and that it often enters populous households, affecting only one or two, and sparing three, or six, or eight other members of the family, even Avhere not the slightest precaution against its propagation is taken by way of quarantine, disinfectant, or other means. Dr. M. F. Colby, of Canada East, states that in 1832 the disease prevailed within a circuit of fifty miles around him, "ever occurring in isolated families." On the other hand, however, we are presented with the experiments of Sir B. Harwood, who, it is asserted, succeeded in producing the disease by inoculation with the fluid from the vesicles which were in- termingled with the eruption of scarlatina, although he was disap- pointed in producing a milder disease. Dr. Copland met with a case in which the disease was supposed to be induced by the contact of a small quantity of the discharge from the throat of a patient affected with the malignant anginose scarlatina. M. Miguel de l'Amboise is also said to have succeeded in producing the disease by inoculating with the blood of a patient labouring under it. If no error shall be discovered in regard to these several statements, we then are willing to admit, Avith Dr. Churchill, (Diseases of Infants and Children,) that whatever doubt may have existed in regard to the contagious character of scarlatina, must be entirely removed. SCARLET FEVER. 493 There is, it is asserted, abundant evidence that a febrile affection, attended with scarlet eruption, and possessing all the other characters of scarlatina, occasionally results from exposure to cold. That the disease may result from atmospherical causes, totally independent of contagion, we know from repeated observations of our own:—Ave sus- pect, however, that the cases referred to by Dr. Gregory were severe cases of roseola, or the rotheln of the German writers, which, when of some intensity, strongly resembles scarlatina. In scarlatina, the period of the greatest activity of the contagion is said by Cazenave to be the period of desquamation. The disease, most generally, affects individuals but once during life. Second attacks have certainly been observed, but are of very rare occurrence, and are merely to be viewed as exceptions to the general rule. The subjects of scarlatina are, for the most part, children; adults are by no means exempt from the disease, though much less sus- ceptible to it than the former. In a few epidemics, however, it has been chiefly confined to subjects beyond the age of puberty. In adults, the disease is said not to occur at so early a period after exposure to its contagion, as in children. It seldom attacks infants previous to Aveaning; and there is scarcely an instance upon record of its attack- ing persons advanced in life. Females are said to be more susceptible to it than males; this does not, however, correspond with the results of our own experience. It is a curious circumstance, that there are certain individuals who appear to be entirely unsusceptible to the dis- ease, never becoming affected, though fully and repeatedly exposed to its causes. Scarlatina prevails at all seasons, but a warm, humid state of the atmosphere, and Ioav, marshy districts, would appear to promote its dissemination, and increase its violence. Great irregularity at times, marks the progress of the disease, when epidemic. After raging ex- tensively with great violence, it will occasionally suddenly abate or nearly disappear, and then recur with symptoms of greater malignancy than before. The causes of scarlatina appear sometimes to linger for several years in a certain district, affecting, from time to time, only a few individuals. In simple and uncomplicated cases of the inflammatory form of scarlatina, no very active remedies will be demanded. It is the duty of the physician, however, to watch closely the disease throughout its entire course; for even, in apparently the mildest form, symptoms of a severe and dangerous character are very liable to become sud- denly or slowly developed, and which it is all-important to attack at once by appropriate remedies. We cannot be too much upon our guard against unexpected and unfavourable changes; even in the mildest case, as Armstrong very justly remarks, the diligentia medici should never be lost sight of. It is important, also, that the treatment of every case of scarlatina be commenced, if possible, at the very onset of the attack. By the simplest remedies, administered at this period, Ave will often haA'e it in our power to effect a very important modification in the subsequent features of the case; and frequently to 494 DISEASES OF THE SKIN. render mild and extremely manageable an attack, which, if neglected, might have proved one of extreme violence and danger. In every case of inflammatory scarlatina, we should never hesitate, upon the occurrence of violent symptoms, to reduce them at once by a cautious resort to direct depletion, recollecting always, that Avhen demanded, the earlier it is resorted to, the more efficient it will prove, and the less doubtful is its propriety; and, that while morbid action in its early stages is frequently with ease subdued, after the lapse of a few days, or even hours, when it has become more firmly seated in important organs, it is with difficulty, and too often ineffectually, com- bated. This is particularly true in reference to the more violent and complicated forms of scarlatina. The stage of excitement is often ex- cessive, and of short duration; extensive disorganization of some im- portant organ is rapidly effected, and an irretrievable exhaustion of the vital power is thus early induced. It is thi3 speedy occurrence of collapse that has induced practitioners to forbid bleeding and every evacuant, in the treatment of scarlatina, and to administer, from its very onset, cordials and tonics, in order to prevent the occurrence of debility, or subsequently to recover the patient from it. It unfortunately happens, that the physician is seldom called in until the stage of excitement is fully developed. Whenever, hoAvever, he has it in his power, the treatment of scarlatina should be commenced during the forming stage, by the administration of an emetic of ipeca- cuanha or tartarized antimony, followed by the warm bath, and a brisk cathartic—calomel succeeded by castor oil;—the patient immediately upon his coming out of the bath, being lightly covered in bed, and given to drink plentifully of some bland and tepid diluent. The early exhibition of an emetic, in all cases of scarlatina, has the recommendation of nearly every one who has written on the disease. Our own experience is decidedly in favour of the practice. Dr. Rush combined the emetic with a cathartic, by adding to five grains of calo- mel one grain of tartarized antimony, or five of ipecacuanha, and in many cases this will be found an excellent plan. Should any symptoms occur indicating a state of engorgement of either of the internal organs, immersing the patient in a warm bath strongly impregnated with salt, and immediately afterwards applying a few leeches in the immediate vicinity of the affected organ, or ab- stracting a few ounces of blood from the arm, and subsequently ad- ministering a brisk cathartic, will not only often produce immediate re- lief, but in nearly every case, will moderate the subsequent reaction, and save from disease important organs. We have repeatedly experienced the good effects of this practice. The abstraction of blood, at this early period of the disease, is proper, only, however, Avhen unequivocal indications of an overloaded condition of some internal organ exists; and even then, should be practised cautiously, and to a very moderate extent. The treatment proper, after the occurrence of febrile reaction, will in a great measure depend upon the extent of the excitement, and the simple or complicated character of each case. In the simple form of the disease, with a moderate degree of febrile excitement, and but SCARLET FEVER. 495 slight affection of the throat or of any of the internal organs, little else will be required than an active purgative, some gentle diaphoretic, the free exposure of the patient to a cool, dry atmosphere, cool drinks, and a spare, light, unirritating diet, composed entirely of farinaceous articles. The purgative should be so administered, as to procure full and free discharges from the bowels throughout the stage of excitement. Calo- mel is unquestionably the best article we can employ; it should be prescribed in a full dose, in combination with jalap or rhubarb, and followed by divided doses of a solution of the sulphate of magnesia, or of the infusion of senna with the addition of any of the saline ca- thartics. We are in the habit of directing from three to six grains of calomel, and the same quantity of calcined magnesia, every other night, and during the day, a teaspoonful, every three hours, of a saline mixture with the addition of a small portion of tartarized antimony.1 Under this treatment, the milder forms of the disease will, very gene- rally, be conducted to a favourable termination. 1 R.—Aquae, giv. Sulph. magnes. gvi. Tart. ant. gr. j. Spir. aeth. nitr. £iv. Syrup, liraon. ^ss.—M. In the milder cases of the anginose form, active purgation during the stage of excitement Avill generally be found equally efficacious in subduing the pungent heat of the surface, the violent pain of the head, the turgescence and flushing of the countenance, and the full, quick pulse, Avhich mark the disease, and in preventing any extensive pseudo- membranous exudation in the throat. Calomel should invariably be preferred; it not only effectually unloads the bowels and diminishes the morbid excitement, but exerts an influence over the whole capillary system, by Avhich the circulation through it is equalized, and morbid action prevented or subdued. The calomel may be administered in the same manner as in the simple form of the disease. When considerable inflammation and tumefaction of the throat occur, Ave have found very decided benefit to result from a combination of the hydrochloride of ammonia and tartarized antimony, given in repeated doses.2 The hydrochloride of ammonia is a favourite prescription of some of the German physicians, in these cases. 2 R.—Aquae, t*f iv. Sulph. magnes. gv. Hydrochlor. ammoniae, gij. Tart. ant. gr. j. Syrup, limon. 553.—M. Dose, a teaspoonful every three hours. Whenever the febrile excitement is very intense, and the inflamma- tion and tumefaction of the fauces considerable, there should be no hesitation in directing the abstraction of blood, to an extent commen- surate Avith the age and vigour of the patient, and the violence of the symptoms. To trust such cases to the effects of purgatives, antimo- nials, and cold applications to the skin, will, if it do not endanger the life of the patient, prolong, at least, the duration of the disease, and 496 DISEASES OF THE SKIN. allow the development of various affections of the internal organs, dif- ficult to manage, and the effects of which are ahvays of long duration, and may continue for the remainder of the patient's life. The bleeding, in these cases, should be either from the arm, or by leeches applied upon the sides and over the anterior part of the throat. After the loss of a proper amount of blood, the purgative plan will often succeed in very readily subduing the remaining symptoms, and insuring a prompt and favourable convalescence. We are to recollect, however, that blood-letting, purging, and all other depleting remedies, are to be confined strictly to the early period of the stage of excitement; though the occasional use of calomel in small doses, combined with ipecacuanha and extract of hyoscyamus or camphor, will be required to preserve a regular condition of the bowels, even after the state of collapse has set in. In all the more violent cases of scarlatina, especially in those in which the brain or the thoracic or abdominal organs arc threatened with inflammation, or in which some internal inflammation has already commenced, blood-letting, carried to a proper extent, is essential to the safety of the patient. Properly timed, and judiciously practised, it is the only remedy calculated to reduce the violence of these cases, and arrest their fatal tendency. In the early period of the stage of excitement, or upon the first appearance of the slightest symptoms in- dicative of visceral inflammation, the abstraction of a very moderate quantity of blood, will, in general, be sufficient; but if the latter has acquired any degree of intensity, particularly if the patient is of a plethoric and robust habit, and the febrile reaction is violent, the bleeding should be more copious, and followed by leeches or cups to the vicinity of the affected organ. The earlier that direct depletion is resorted to the better; and the more promptly it is carried to the extent required for reducing the violence of the reaction, or of controlling internal inflammation, the more certain will be its beneficial results, and the greater our hopes of arresting the destructive march of the disease. If possible, the necessity for a repetition of the bleeding, whether from the arm or by the application of cups or leeches, should be avoided by a sufficient depletion in the first instance. In tepid and cold affusion, or sponging, AATe haA'e a remedy, Avhich, in most cases of inflammatory scarlatina, is equally efficacious with blood- letting, and one much more generally applicable in the treatment of the disease. In many instances, as remarked by Bateraan, it is almost the only febrifuge, diaphoretic, and anodyne, that will not disappoint the expectations of the practitioner. When resorted to under appro- priate circumstances, and at a proper period, it will be found very speedily to diminish the frequency of the pulse, to abate the thirst, render the tongue moist, the skin soft and cool, and the eyes bright, and to be speedily followed by a calm, refreshing sleep. It may be employed in all cases, during the early period of the stage of excitement, Avhen the heat of the entire surface is steadily above the natural stand- ard, and at the same time dry, and when there is no sense of chilliness present. It should be freely used at short intervals, day and night, SCARLET FEVER. 497 until the heat of the surface is permanently subdued; as a general rule, it will require to be repeated from four to six times, during at least the first twenty-four hours of the stage of excitement, to be productive of any permanent advantage. While in every case in which we are permitted to employ it, we be- lieve that in the application of cold to the surface, affusion is the mode from which the most benefit is to be derived; yet when in consequence of the fears of the patient, the prejudices of his friends, or any other circumstance, we are prevented from resorting to it, we must content ourselves with free and repeated sponging of the entire surface with cold water, or cold water and vinegar. It is only in the commencement of the stage of excitement, however, that we are to expect from cold affusion or sponging any decided advantage:—after the third day, it will in general be prudent to substitute the tepid for cold affusion, which may be repeated daily, until towards the termination of the excite- ment. Many practitioners prefer tepid affusion or sponging from the commencement, in cases in which the throat is much affected: we are convinced, however, when the heat of the surface is very considerable, regularly diffused, and unattended with moisture, the application of cold water is preferable in the commencement; it is certainly much more efficacious than tepid water. By some, the warm bath is recommended in the treatment of scarla- tina. It will, unquestionably, be found in many instances a very va- luable remedial agent. It may be employed in all cases to which the tepid affusion is adapted; and in those accompanied by symptoms of abdominal disease, it should invariably be preferred to either cold or tepid affusion. Covering, in these cases, the abdomen with a warm emollient poultice, when the patient is taken out of the bath, is calcu- lated to increase the efficacy of the latter. In the advanced stage of even the more violent cases of inflamma- tory scarlatina, neither the cold nor tepid affusions will be proper. At this period, the first especially would prove decidedly injurious. When the patient is much exhausted, it will be prudent to avoid the fatigue incident to the employment of even the warm bath. If judged neces- sary, partial ablutions with tepid vinegar and water may, however, be practised, at the same time that cool, fresh air is freely admitted into the patient's chamber. In cases of scarlatina attended with visceral inflammation, cold af- fusion has been recommended in the commencement of the stage of ex- citement. We are not prepared to assent to the propriety of this re- commendation. There may occur cases, we admit, in which tepid af- fusion will be found useful, as a means of reducing the morbid heat of the skin, and in this manner moderating the violence of reaction; but, as a general rule, we believe that the tepid or warm bath is an agent much better adapted to this form of the disease. When the brain is much affected, cold affusions upon the head, or sponging the scalp with cold Avater, will generally be productive of good effects, and may be employed in conjunction with the Avarm or tepid bath. When there is a considerable degree of inflammation and swelling of the tonsils and fauces, by which the act of swallowing is rendered dif- 32 498 DISEASES OF THE SKIN. ficult, the application of a blister to the throat, it is said, has been oc- casionally found decidedly beneficial. We confess, however, that we have not found this practice one from which, in such cases, much ad- vantage has in general resulted:—this is the experience, likewise, of Sims, Withering, Armstrong, and other writers on the disease. In most cases, the early and judicious application of leeches to the throat will render the use of blisters unnecessary. Dr. Stewart, of Berks county, Penn., (Transactions of the State Me- dical Society, vol. ii. p. 100,) recommends in all cases of scarlatina, the application of a sinapism to the throat. "Regarding," he remarks,* "scarlet fever as one of a family of diseases for which there is no as- certained specific, all he has aimed at has been to take care of*1 the throat, and attend to other local symptoms as they presented them- selves, and to keep the system in proper order. With this view, in or- dinary cases, he has, for the last four years, prescribed nothing beyond castor oil, to keep the bowels open, and, once or twice a day, during the continuance of the disease, a sinapism to the throat,—and he can truthfully say, that within that period he has not had a single case which ended in sore throat. Even in cases in which this was threat- ened, the mustard prevented its occurrence." When the affection of the throat is attended with considerable diffi- culty of swalloAving and of respiration, the inhalation of the vapour of warm water and vinegar will, generally, procure relief. An emetic we have often found, under these circumstances, productive of good results. We are, also, accustomed to have the.throat washed with a pretty strong solution of the acetate of lead, and always with the best effects. When the fauces and throat are extensively covered with patches of pseudo-membranous exudation, for the local treatment pro- per in such cases, we refer to our section on pseudo-membranous in- flammation of the throat. In the simple anginose form of scarlatina, when the pulse is soft and feeble, Dr. Watson recommends the citrate of ammonia, with an excess of the carbonate, so that four or five grains may remain, in each dose, unsaturated by the lemon juice. The use of the carbonate of ammonia in scarlet fever was first advocated by Strahl, and it is now employed as a most important remedy by M. Baudelocque, at the Hospital for Infants, in Paris, as well in the mild as in the more ma- lignant forms of the disease, and also in cases in which the eruption has receded. He states that he has derived great advantage from its employment in regular scarlatina, with cerebral disorder and depres- sion of the vital power; in scarlatina with the production of false membranes on the different mucous surfaces; in hemorrhagic scarla- tina, and in the consecutive dropsy, whether this be confined to the cellular tissue, or extends to the serous cavities. He administers it in the form of mixture, simple or aromatized, and in gradually aug- mented doses. Dr. M. F. Colby, of Canada East, in a communication on the nature and treatment of scarlatina, published in the Boston Med. & Surg. Journ., June 15,1853, speaks in strong terms of belladonna as a remedy in this disease. He employs the German solution of the extract— SCARLET FEVER. 499 three grains to the ounce, and continues its use during the whole pro- gress of the case. "I am confident," he remarks, "that no physician who has not given the belladonna a thorough trial, is aware of its good effects. It lessens the violence of the disease, keeps out the eruption, and effectually equalizes the circulation in the capillary vessels." In cases of scarlatina complicated with visceral inflammation, blis- ters over the affected organ will often have a favourable influence upon the local affection. In the advanced stage of the disease, however, they should seldom be employed, in consequence of the general irri- tation they sometimes produce, and from the danger of their causing gangrene of the part upon which they are applied. In the year 1849, Dr. Schneemann, physician at the Court of the King of Hanover, recommended the inunction of the entire surface, with the exception of the face and scalp, as an effectual means of pre- venting the injurious effects of the exanthem on the functions of the skin; the inunction so modifying the eruption that scarcely any des- quamation takes place; and the skin, thus continuing in a state of comparative integrity, so beneficial an influence is produced on the several organs implicated in the disease, particularly the throat, that their normal condition is, in every case, and in every part, speedily restored. Dr. Schneemann directs the patient to be rubbed, every morning and evening, over the whole body, except the face and hairy scalp, with a portion of bacon, in such a manner that the skin may be regu- larly but not too quickly saturated with fat. This simple plan of treating scarlatina has attracted no little atten- tion. Some of those who have given it a more or less extensive trial, speak of it favourably, while others believe it to be productive of little or no benefit. Dr. Lindsly, who resorted to it during a very severe epidemic of scarlatina, concludes, that it "will probably be found the^ most im- portant improvement that has been made for many years in the ma- nagement of scarlet fever." Dr. Ebert employed inunction during an epidemic of scarlatina in Berlin, and the result, according to his account, was tolerably en- couraging: of twenty-eight severe cases six terminated fatally; of these six, five had' not been subjected to inunction; the remaining one was an infant who died suddenly after one inunction. According to Dr. Ebert, the inunction of the surface appeared to hasten rather than to prevent the appearance of the exanthem. In those cases which were assiduously anointed, no desquamation occurred, neither were any of the sequelae, as anasarca, abscesses, &c, observed. The anointing was also thought to prevent infection. Dr. Walz (Schmidt's Jahrbuch.,)has employed inunction in seventy- four cases of scarlatina, all of which recovered. In sixty-nine cases there was no desquamation; in four there was secondary dropsy, which was readily cured in one case by diaphoretics, and in three by sulphur. Dr. Paul F. Eve, of Augusta, Geo., has resorted to inunction in scarlatina, and reports favourably of its effects, as does also Dr. Cain, of Charleston, S. C. 500 DISEASES OF THE SKIN. In the reports on epidemics, made to the American Medical As- sociation, as well as the Pennsylvania State Medical Society, at their session of 1852, the inunction of the surface with clean lard in cases of scarlatina, is occasionally spoken of in very favourable terms. As yet we have not in our possession a sufficient amount of evidence, in regard to the general results of the practice, to enable us to form any correct opinion in respect to it. We have had no opportunity of testing its effects in our own practice, but from the decided bene- fit we have invariably derived, in cases of erysipelas, from covering the inflamed surface with a thick coating of fresh lard, we should in- fer that the same practice might be beneficial, also, in scarlatina. Throughout the attack, the patient should be confined to a large well-ventilated apartment, the utmost attention being paid to insure the strictest cleanliness of the chamber, as well as of the bed-clothing, and of the garments worn by the patient. His diet should be adapted to the degree and stage of the disease, but should be invariably spare, light, and easy of digestion—being composed entirely of farinaceous articles, boiled in water. His drink should be given cool, and slightly mucilaginous; the addition of a small portion of lemon juice will ren- der them more palatable, and at the same time, as many suppose, somewhat remedial. In the anginose form of the disease, the dilute mineral acids have been considered advantageous. The free use of diluted sulphuric acid, is said by Steiglitz and Wolff, to produce an excellent effect; while, by Montsey, and a few other practitioners, the hydrochloric acid, largely diluted with water, is recommended both as a drink and as a medicine. We have found, in many cases of scarlatina attended with disease of the throat, much advantage from the use of hydrochloric acid in- ternally. Our common prescription is a drachm of the acid to five ounces of water, well sweetened with sugar: of this we direct a tea- spoonful to be given every two or three hours. Dr. J. P. Hiester, and Dr. Beaver, of Berks county, Pa., both speak favourably of the effects of diluted hydrochloric acid in scarlet fever, Avhen freely ad- ministered. (Trans. State Med. Soc, vol. ii. pp. 96, 98.) Dr. I. B. Brown, of London (on the treat, of Scarlatina by Acidum aceticum dilutum, 1846,) has recommended the diluted acetic acid of the London Pharmacopoeia as an excellent remedy in scarlatina, and Dr. Schneck of Lebanon, Pennsylvania, bears testimony to its effi- cacy. The latter diluted 3j. of the officinal acid Avith giv. of water, and gave a table-spoonful every few hours, sweetening it at the time of its administration. In the fourth volume of the Medical Gazette of London, there is a communication from Messrs. Tayton and Williams, in praise of chlo- rine as a remedy in scarlatina. The chlorine is procured by dis- solving two drachms of the chlorate of potass in two ounces of hydro- chloric acid, diluted with tAvo ounces of distilled water. The solu- tion is to be immediately put into a stoppered bottle, and kept in a dark place. Two drachms of the solution are to be mixed with a pint of distilled water, and one or two tablespoonfuls of this, accord- ing to the age of the patient, may be given for a dose frequently. SCARLET FEVER. 501 The plain soda water of the shops affords, in many cases, a very grateful and refreshing drink. The bowels of the patient should be kept regularly open, by any mild laxative. The daily use of the tepid or warm bath will always be found advantageous. After the disappearance of the eruption, it will be necessary to allow a more nutritious diet; but at the same time, we should be cautious to proscribe all indigestible and stimulating articles of food, and to pre- vent too much of even the lightest and most appropriate from being taken. Daily exercise in the open air, in mild, dry weather, will be proper, as soon as the patient is sufficiently strong to attempt it. In some cases, it will be necessary to aid in the restoration of the patient's strength, by the administration of some gentle tonic; the cold infusion of cinchona, the sulphate of quinia or an infusion of wild cherry tree bark, may, in such cases, be employed with advantage. The more stimulating tonics and wine should be avoided. For some considerable time subsequent to his recovery, the patient should be carefully guarded against exposure to cold or damp, which is very apt, even after recovery from attacks of the mildest and most simple character, to produce dropsical effusion, and other disagreeable consequences. To promote the growth of the hair, which is liable to fall out after an attack of scarlatina of any severity, the head, during convalescence, should be shaved two or three times, and frequently washed with warm water, followed by smart friction with a brush or coarse towel __care being taken, in cold and changeable weather, to preserve the head moderately Avarm by a light cap. It is the congestive form of scarlatina which constitutes the malig- nant scarlatina of most writers. The suddenness of the attack, in the more violent cases, the extreme faintness, and the pale and sunken countenance of the patient; the dark livid or dusky appearance of the eruption; the absence of any decided reaction; the dark gangrenous appearance of the throat; the rapid occurrence of a general depres- sion of the vital powers, with the dissolved state of the blood, the pe- techiae, vibices, &c, have all concurred to deceive physicians in regard to the real character of the disease, and lead them to view it as one bearing the unequivocal stamp of putridity, and requiring for its cure the most active stimulants, antiseptics, and tonics. Sounder notions of general pathology have led, however, to more correct views in re- gard to the nature of this form of scarlatina, and its appropriate treat- ment. . , The congestive form of scarlatina has, with great propriety, been divided by Armstrong into the regular and irregular; the first being unattended with any marked reaction, while in the latter, a partial and irregular reaction is manifested. The more violent cases of the first variety run their course with extreme rapidity, and are always at- tended with the utmost danger. Often has the patient been known, when the disease prevails epidemically, to sink, almost immediately, upon exposure to its infection, into a state of complete insensibility, terminating shortly in death. The irregular form of congestive scar- 502 DISEASES OF THE SKIN. latina, though confessedly a very formidable malady, is, however, by no means so dangerous as the former, nor so rapid in its progress; and as it forms a kind of intermediate link between the inflammatory and purely congestive varieties, it will be first considered. It attacks pretty much in the same manner as the inflammatory; with a sense of chilliness, headache, sickness and lassitude, &c.; which symptoms, after continuing for a much longer period than in the former, are succeeded by a partial reaction—the heat being prin- cipally confined to the trunk and upper portions of the extremities, while the wrists, hands, ankles, and feet are often cool, or at least remain of the natural temperature. Throughout the day, the patient complains at one time of a sense of heat, and at another of chilliness; the latter being often complained of when the surface of the body feels hot to the touch of another person. During the period of imper- fect excitement, the eruption upon the skin becomes more florid, and again fades as the reaction subsides. The fauces become more or less red and swollen, and in a few days, grayish specks appear upon their mucous membrane, and assume a dark gangrenous appearance often as early as the end of the first week, but more commonly, not until the second week. The efflorescence upon the skin is less diffuse, and of a duller hue, than in the inflammatory form; it is also more liable to disappear, leaving the face of a sickly pallid colour; the lips and edges of the tongue, also, are less intensely red. Early in the attack, the patient often evinces an appearance of dejection or alarm, which is strongly expressed in his countenance; occasionally, he sinks early into a state of dulness or stupor—of confusion or indifference;—the eyes having a dull, vacant look, with dilatation of the pupils. In some instances, the mind remains for a time perfectly clear; though there is invariably a sense of uneasiness in the head, and often of oppression and anxiety at the region of the heart. Delirium is not common in the early stage, but very generally ensues at a later period, and is usually a conspicu- ous symptom in the advanced stage of the disease. The bowels are irregular, and the discharges always unnatural in colour and odour, in- dicating either a deficient or morbid secretion of bile. At the commencement of the attack, the pulse is slow and oppressed, but with the effort at reaction, it becomes quick and variable, though it rarely acquires much firmness or fulness. When uninterrupted in its progress, this variety of scarlatina often runs on to the end of the second week, and sometimes for a much longer period. When it terminates favourably, the patient recovers very slowly. Unless properly treated in its early stage, symptoms in- dicative of some serious affection of one or more of the internal organs most generally ensue, which, if not promptly arrested, augment in violence, and coma, low muttering delirium, extreme difficulty of res- piration, or violent vomiting and purging occur, and speedily terminate in death. Towards the close of the disease, indications of a dissolved state of the blood often ensue; such as dark-coloured petechiae, oozing of dark-coloured blood from the mouth, nostrils, bowels, &c. In this variety of scarlatina, there is, throughout, an imperfect effort SCARLET FEVER. 503 at reaction; the stage of excitement, however, being never fully de- veloped. In the purely congestive variety, next to be described, there is, as it were, but one continued stage of oppression, which gradually augments, until life is extinguished. The patient is, for the most part, attacked suddenly with paleness of the face, faintness and nausea; he complains chiefly of a sense of heaviness, pain and dizziness of the head; great oppression, and con- siderable uneasiness at the praecordia. Occasionally he sinks at once into a state of depression, with the utmost confusion and torpor of the intellect, and makes but little complaint. In other cases, he may con- tinue about, for one or two days, in a languid, listless condition, and then take to his bed, as though worn out by great fatigue. When the disease is fully formed, the respiration becomes quick and anxious, or slow and laborious. The paleness of the countenance is often mixed with a degree of lividness: the eyes are dull, ^hough oc- casionally they have a glassy appearance, and acquire a vacant or drunken expression in the course of the disease. Delirium soon en- sues ; or there is an indifference to surrounding objects, succeeded by a state of stupor, in which the patient expires. From the commence- ment of the attack, the pulse is ordinarily low, impeded, and irregular, and generally continues unchanged to the close of the disease. The tongue is, at first, commonly paler than natural, whitish in the centre, and thickly covered with a ropy mucus; towards the close of the dis- ease it often assumes a rough and darkish aspect. The breath is usually more or less offensive. The bowels are commonly distended with flatus; they are costive or irregular, in the first stage, but are fre- quently affected with diarrhoea; in the last, the discharges being either of a darker or lighter colour than natural. There is often great irri- tability of the stomach; occasionally, however, it retains whatever is taken into it. As the disease advances, deglutition becomes more and more difficult. • The efflorescence, from its first appearance, is of a purplish, cop- pery, or livid hue, Avhich becomes deeper as the disease proceeds; oc- casionally, it quickly recedes, without again returning. In some very rapid and fatal cases, the throat is but little affected:—when, however, the disease continues beyond the fourth day, and the vital powers begin rapidly to sink, the fauces are generally covered with dark- coloured specks. The heat of the surface is usually rather below, than above the natural standard; and even when the central portions of the body are Avarm, or perhaps hot, the extremities are, for the most part, cold. In this form the disease frequently runs its fatal course in two, three, or four days from the occurrence of the symptoms of general depres- sion. Its final stage is almost invariably attended with petechiae, oozing of dark-coloured blood from the mouth or nostrils, and dis- charges of the same kind from the bowels or bladder. A few hours previous to dissolution, there is often a transient glow over the body, a dark flushing of the face, great difficulty of respiration, accelerated pulse, and partial or general perspiration; the excitement, however, quickly subsides, the extremities become cold, the face of a cadaverous 504 DISEASES OF THE SKIN. hue, and where the skin is pale, it has often the smooth waxen ap- pearance of a corpse. Under such circumstances, life seldom lingers long- The prominent symptoms of both the varieties of scarlatina just described, are evidently dependent upon a lesion of the nervous sys- tem giving rise to extensive engorgement of the central organs, and of the large venous trunks; the abortive efforts at reaction, in the one case, producing a degree of irregular and transient excitement, while in the other the organic functions of the brain and nervous system appear to be completely paralyzed, the patient sinking from a gradual extinction of the powers of life, in consequence of the organs being unable to react under the load by which they are oppressed. In the irregular congestive variety, the congestion is seldom to such an extent as to occasion any immediate danger; still the more important organs are predisposed to serious lesions, from the irregu- lar determinations of blood which are liable to take place during the stage of imperfect reaction. The brain, the lungs, and abdominal or- gans are those which most commonly suffer, and present, after death, either an injected state of their vessels, or the indications of subacute inflammation. In the regular congestive variety, the brain, the lungs, and the liver, as well as the heart, and the large vessels in its vicinity, are found to be extensively engorged with dark-coloured grumous blood, without any vestiges of inflammatory action. In congestive scarlatina, it is only in the early period of the case that we can expect any decided benefit to result from medical treat- ment. Called, therefore, to a child that has been recently attacked, we should direct him to be at once immersed in a warm bath, and his body, at the same time, to be briskly rubbed with the hand or a flannel cloth. On coming out of the bath, he should be carefully wrapped in a blanket, and have sinapisms applied to the extremities, and over the epigastrium. In violent cases, if a warm bath cannot be immediately prepared, no time should be lost in waiting for it; but friction of the surface with a warm flannel cloth, impregnated with any warm, stimu- lating liquor, as vinegar, common spirits, Cologne water, bay rum, &c, should be instantly employed; while bottles or bladders filled with warm water, are applied to the lower extremities. A full dose of calomel should be administered without delay, and followed, in a few hours, by a proper dose of infusion of senna with the addition of sul- phate of magnesia, or of the compound powder of jalap; and if these be tardy in their operation, some active purgative enema should be re- sorted to. During the first day or two, it is important to repeat the bath, at least twice in the twenty-four hours; and in severe cases, its action may be augmented by the addition of salt, or a small quantity of pow- dered mustard;—subsequently, the Avarm bath should be used daily, until symptoms of recovery ensue. Calomel would appear, in most cases, to be the purgative best adapt- ed to this form of scarlatina:—it unloads the liver of its undue amount of blood; excites the mucous membrane of the intestines to a more healthy secretion; and seems to produce throughout, a more equable SCARLET FEVER. 505 and healthy action of the capillary system. The calomel should be administered at first in full doses, and followed by such cathartics as will insure its full action upon the bowels. As soon, however, as the pulse becomes more free and full, the skin of a moderate and equable warmth, and the discharges from the bowels of a more healthy appearance, the calomel may be omitted, and castor oil, magnesia and rhubarb, or any other mild laxative substituted; calcined magnesia, saturated with lemon juice, is said by Armstrong to be, under the circumstances referred to, a very excellent purgative: the turpentine, combined with castor oil, is the one we have generally employed, and it has appeared to us to be beneficial, independently of its action upon the bowels. It is important to recollect, that until convalescence is fully esta- blished, a free and regular condition of the bowels should be maintained, without, however, endangering the occurrence of excessive purgation; a neglect of this precaution, may cause a recurrence of all the more serious symptoms. Every case of congestive scarlatina should be closely watched, and if symptoms ensue indicath'e of considerable oppression of the brain, lungs, or other important organ, the cautious abstraction of a small quantity of blood, by leeches or cups, from the neighbourhood of the affected" part, will, in general, produce great relief, and often insure a permanent, moderate, and general reaction. Much judgment will be demanded in the employment of blood-letting in these cases; its effects upon the pulse should be carefully watched, and if the slightest ap- pearance of sinking occurs, it should be immediately suspended. The best time for bleeding is immediately upon the patient coming out of the bath, or it may be performed whilst he remains in the bath:— the amount taken away should, under all circumstances, be moderate, even though a repetition of the bleeding be thought advisable. During the flow of blood, the skin should be well rubbed with a coarse cloth or flesh-brush dipped in warm vinegar, in which a quan- tity of salt has been dissolved. The finger should be constantly upon the pulse, and if this become more full, free, and regular, the bleeding may be continued; but if, on the contrary, the pulse becomes Aveaker, or seems disposed to sink, the orifice should be immediately closed; though, subsequently, it may be again proper to try the effects of bleed- ing, Avith similar precautions. It is all-important, however, that the bleeding be not carried too far, even when the pulse rises under the flow of blood, otherwise a dangerous state of collapse may be induced: above all, the slightest approach to syncope should be avoided. It must be recollected, also, that blood-letting is proper only in the early period of the attack, unless violent reaction, as is sometimes the case, should occur, when the treatment should be precisely the same as in any other acute form of disease. In numerous cases, bleeding, more especially by cups, in the imme- diate vicinity of the affected organ, constitutes, unquestionably, a most important remedy in congestive scarlet fever, upon the cautious and judicious employment of which the safety of the patient will often mainly depend; and hence, while it should be unhesitatingly resorted 506 DISEASES OF THE SKIN. to whenever the brain or lungs exhibit symptoms of serious oppression, we must, at the same time, recollect that it is not a remedy equally applicable to every case, and that in none can it be employed with the same freedom as in diseases of a purely inflammatory character. The great object of the practitioner should be, to relieve, as quickly as possible, the brain from its undue load of blood; by so doing, he will increase the nervous energies of the other organs, and enable them the better to relieve themselves of the oppression under which they labour. Sinapisms upon the extremities, and friction to the surface generally, being at the same time resorted to. In violent attacks, after the warm bath, friction of the surface, and the cautious abstraction of blood, the administration of a large stimu- lating enema will often produce prompt relief, by unloading the lower portion of the intestinal canal, and diminishing the irritability of the stomach. The ordinary domestic enema, with the addition of turpen- tine, may be employed. In conjunction with the remedies already recited, some gentle dia- phoretic will often be found beneficial; the liquor acetatis ammoniae, or a combination of camphor, ipecacuanha, and hydrochloride of am- monia,1 may be employed. In some instances a weak infusion of ser- pentaria, or small and repeated doses of the carbonate of ammonia, will be found to produce a gentle and universal diaphoresis, which contri- butes materially to the relief of the overloaded organs, and, in this manner, to occasion a gentle and permanent reaction. 1 R.—Pulv. camphor, gr. iv.—vj. " ipecacuanhae, gr. iij. Hydrochlor. ammoniae, ^ijss.—M. f. ch. No. xij. One to be given every three hours. In scarlatina maligna, Dr. Peart recommends the carbonate of am- monia, in doses of five or six grains every second or third hour, as somewhat of a specific. The patient may be allowed to partake of any warm, diluent drink, as thin gruel, panada, chicken Avater, or the like; when given imme- diately upon his removal from the bath, it tends to promote reaction. The same kind of drink may be continued at regular intervals through- out the disease. When, however, the skin remains cool, and reaction is with difficulty established, it will be proper to allow the patient small and repeated portions of Avarm wine whey, or warm wine and water; but the moment that reaction ensues, every species of diffusible stimuli should be immediately discontinued, and warm diluent drinks substituted. When a state of collapse begins to manifest itself, it will be neces- sary, in most cases, to administer moderate portions of some diffusible stimulant, as warm wine whey, or a little Madeira wine diluted with milk, or brandy with milk. It is probable, also, that the infusion of serpentaria, and small doses of the carbonate of ammonia, will, in such cases, prove beneficial. While, under the circumstances referred to, direct stimulants will often be demanded to support the patient's strength, it must, nevertheless, be recollected that a too early resort to their use, or their administration in too large quantities, or at too short SCARLET FEVER. 507 intervals, is to be cautiously avoided. Close attention and much judg- ment will be demanded properly to time their use, and graduate the proper extent to which they should be carried. When, by an energetic and well-directed treatment, a general, free, and moderate reaction has been brought about, the stage of collapse will be slight, and of short duration, and require no difference in its management from that following the inflammatory form of scarlatina. The utmost care should be taken to guard against exposure to cold or damp, to avoid every species of stimulating food or drink, and to pre- serve the bowels in a free, regular condition. By a neglect of these precautions, dropsical effusion—of more frequent occurrence after the congestive than after the other varieties of the disease—will very ge- nerally be produced, or the occurrence of a subacute inflammation, par- ticularly of the brain or alimentary canal, of long continuance, and difficult to manage, will be endangered. We have had a full opportunity, in the course of several severe epi- demics, to test the value of the practice above recommended, and have no hesitation in saying, that, when judiciously carried into executfon, it is calculated to disarm the disease of its malignancy, and to prevent the necessity, in the advanced period of the attack, of a resort to "powerful cordials, tonics, and antiseptics," to remove " the putnd symptoms which then show themselves." The " bold and indiscrimi- nate use of the lancet" we should certainly strongly object to; but of the beneficial effects of a cautious employment of blood-letting, in the manner and under the circumstances directed, we speak from actual observation; it is unquestionably, in a large number of cases, the only "restorative and tonic" upon which any confidence can be placed. The discredit into which blood-letting has fallen, in the treatment of all the forms of scarlet fever, has, we suspect, arisen altogether from the want of due attention to the circumstances under Avhich it is alone proper. It is a remedy of great efficacy, for good or for evil. If used at random, and without a careful discrimination of the circumstances of each case, the reprobation that has been thrown upon it by Currie, will most assuredly be justified; it may then prove, in many instances, " a fatal practice." If, on the other hand, it is employed at the proper time, and in sufficient quantity, it will prove, as Dewar has very cor- rectly remarked, a means of cure, safe and successful, far beyond any other with which we are acquainted. Before quitting the subject of scarlatina, it will be proper to say a few words in relation to some of its most common sequelae. One of the most frequent is anasarca, either local or general. Effusion may also take place in the brain and the serous cavities generally, and this, occasionally, after the mildest cases; usually, however, it occurs only after an attack of the more violent forms of the disease. The effusion is, in a large number of instances, the result of exposure to cold and damp, or of an injudicious administration of stimulants and restoratives, during the period of convalescence. It may, however, occasionally occur, according to Reil, as a strictly complemental affection. It is seldom attended with much danger, and is readily removed by an ap- propriate treatment. 508 DISEASES OF THE SKIN. In many cases, the effusion is accompanied with a quick, frequent, tense, and sometimes full pulse; a hot and dry skin, costive bowels, and scanty, high-coloured, and albuminous urine: under these circum- stances, blood-letting will, in general, be demanded, and its good effects are attested by numerous writers. Combinations of calomel, nitrate of potassa, and digitalis,1 will be found often to remove the effused fluid with great rapidity. Calomel, alone, in large doses, five to ten grains daily, is strongly recommended in these cases, by Richter and Kreisig. As a drink, a weak solution of the bitartrate of potassa will be among the best we can give. In some cases, benefit will be derived from the following mixture.2 ^.—Calomel, gr. xij. 2R.—Aquae, gvj. Nitrat. potassae, 3J. Sulph. magnesiae, 31V. Pulv. digitalis, gr. iv.—M. f. ch. Spir. aeth. nitr. giv. No. xij. Nitrat. potassae, 3'j. One to be given for a dose, every two, Tart, antimonii, gr. j.—M. three, or four hours. Dose, a teaspoonful every three hours. TJhe daily use of the tepid bath, followed by friction of the surface, will always be advantageous. Perfect quietude should be enjoined, in a dry, freely ventilated apartment, and every precaution should be taken against exposure to cold or damp. The mildest farinaceous diet should be the only one allowed. When the effusion is connected Avith a relaxed and debilitated con- dition of the system, bleeding will be improper. If the bowels are confined, they should be freely evacuated by calomel, followed by some gentle aperient. As diuretics, the squill, spirits of turpentine, and tincture of cantharides, have been highly recommended. The sulphate of quinia, the proto-carbonate and tincture of the sesquichloride of iron, will often be found decidedly advantageous. Mauthner, (Journ. f. Kinderkrankheiten, 1841,) objects to the use of diuretics in cases attended with bloody and albuminous urine. He depends entirely upon a well regulated diet for the cure of the dropsy. By the employment of an exclusive milk diet, he has seen the action of the kidneys so regulated, that a copious secretion of urine free from albumen was established, and a speedy removal of the dropsy ensued. When this fails, he administers urea or the nitrate of urea, in doses of a third of a grain, combined with a little powdered sugar, which has generally produced the desired effect. Scarlatina, particularly the anginose variety, is often succeeded by a deep-seated pain in one or both ears, with deafness, followed, in a short time, by a discharge of either pus or a fetid serous fluid. This in general arises from the inflammation of the throat extending along the Eustachian tube to the internal ear. When violent, long continued, or neglected, this inflammation sometimes terminates in an entire de- struction of the organ of hearing. In the early period of this variety of otitis, leeches should be applied behind the external ear, followed by repeated blisters, and the bowels should be kept in a regular, healthy condition, by small doses of calomel, prepared chalk, extract of hyoscyamus, and ipecacuanha, at bed-time, and mild aperients during the day. SCARLET FEVER. 509 R.—Cretae ppt. gr. xxxvj. Calomel, gr. xij. Pulv. ipecac, gr. iv. Ext. hyoscyami, gr. vj.—M. f. ch. No. xij. When a discharge from the ear has occurred, the meatus should be frequently syringed with tepid barley water, or other bland mucilagi- nous fluid; or when the discharge is dark-coloured and offensive, the ear may be injected twice a day with a weak solution of the chloride of soda, or a decoction of black oak bark. The patient should be confined to a light, nourishing diet, and have regular exercise daily, in the open air, Avhenever the weather is mild and clear. Repeated blisters behind the affected ear we have found, in many cases, to ar- rest the discharge, and occasionally, under their use, the function of the ear has become fully restored. From the severe and fatal character of scarlatina, particularly when it occurs as an extensive epidemic, various plans of prevention have been proposed. The one which has attracted most attention is that suggested upwards of forty years ago, by the celebrated founder of homoeopathy. When given in small and repeated doses, it was long known that belladonna would cause a heat and dryness in the throat, and an efflorescence upon the skin, having a very close resemblance to that of scarlatina. Hahnemann hence maintained, in accordance with one of the fundamental principles of his system, that when adminis- tered so as to give rise to these symptoms, it would prove a certain preventive against the occurrence of the latter; and in proof that such is actually the case, a considerable amount of testimony has been pre- sented from various sources. In a paper published by Bayle, in 1830, it is stated that of 2027 individuals to whom the belladonna was administered, 1948 were pre- served from scarlet fever, and 79 were attacked. Dusterberg reports, that all who were placed under the influence of the belladonna for the space of two weeks, were preserved from the scarlet fever. In order to ascertain the real value of the article, he purposely omitted to ad- minister it to one child in each family, and this one alone, according to his report, was seized with the disease. He adds, however, that occasionally a child who had only been taking the remedy during three or four days, Avas attacked, but the fever was in such cases always mild, and often only manifested its presence by the occurrence of desquamation. Zeuch, physician to the Military Hospital for Chil- dren, in Tyrol, after 84 of the children were attacked Avith scarlet fever, was induced to try the prophylactic powers of belladonna on the remaining 61 children: with a single exception, all of these were preserved from the fever, although it prevailed all around them. Schenk, Berndt, Kohler, Meglin, De Lens, Massius, Bayle, Godelle of Soissons, and many other respectable practitioners, speak in equally high terms of the preservative properties of the belladonna. Re- cently, however, Dr. Stievenart, of Valenciennes, has published the results of a very extensive trial of the belladonna, as a prophylactic during the prevalence of epidemic scarlatina: which results, if they are correctly stated, and all sources of error have been carefully guarded against in the performance of the experiments upon which 510 DISEASES OF THE SKIN. they are founded, go very far to prove that the belladonna does ac- tually possess the property of shielding the constitution from an attack of scarlet fever. An epidemic of the disease ravaged, during the winter of 1840-1, in several villages in the neighbourhood of Valen- ciennes, Avhen Dr. Stievenart was induced to try the prophylactic pro- perties of belladonna. The fatality of the epidemic was such that 30 had already died out of 96 attacked; consequently any means of pre- vention was a subject of vast importance. In a small village, out of 250 individuals, 200 took the belladonna, and were all preserved from the attack of scarlet fever. Of the fifty others, 14 were seized with the fever, and four of them died. At the village of Curgies, Dr. Stieve- nart administered the belladonna to the children at the public school, and allowed them to continue at their lessons, and have free commu- nication with the other children of the village. All to whom the bella- donna was administered escaped the scarlet fever, while a few who re- fused to take it were seized with the disease. He gave it either in solution or in powder. Two grains of the recent alcoholic extract of belladonna were dissolved in an ounce of any aromatic infusion; of this two drops were given to a child of one year old, daily, for nine or ten days; an additional drop being added for every additional year of age. The largest daily dose Avas, however, limited to twelve drops. Of the powdered root half a grain, mixed with a small quantity of sugar, was divided into ten doses. One of which was given, morning and evening, to children of from one to two years old; two to those from three to five; three to those from six to nine; four to those from ten to fifteen, and five to adults. These small doses never produced the toxicological effects of belladonna; in fact, they scarcely exhibited any marked action. In five or six cases, it is true, a rash similar to that of measles was observed; and, in a few others, headache, with dilata- tion of the pupils, dryness of the fauces, and a slight soreness of the throat, but having no resemblance to that of scarlatina anginosa. Dr. Stievenart, generally, continued the use of belladonna for from nine to ten days; in some cases, it was given for fifteen days. He recom- mends its use to be resumed if the epidemic, after abating, should re- turn. In an epidemic of scarlatina which occurred in South Carolina, Dr. Irwin made a very extensive trial of the prophylactic properties of belladonna. Of two hundred and fifty children who were placed under the influence of the drug, less than half a dozen had the disease, and that very mildly. In the families, the members of which were not placed under the influence of the belladonna, the disease occurred with scarcely an exception. Dr. M'Kee, in the extension of the same epi- demic, made use of the belladonna, and derived from it the same pro- tective influence. Dr. Rufus Hammond, of Indiana, also bears testi- mony in favour of the prophylactic powers of belladonna, based upon ample opportunities for observation. Thus, we have, unquestionably, strong evidence, and from sources deserving of great consideration, that the influence, whatever that may be, which belladonna exerts upon the organism, when given in small doses, for a certain length of time, is sufficient to protect it from the mor- bific action of the poison of scarlatina. Viewed en masse the evidence SCARLET FEVER. 511 on this point would seem, indeed, to be irresistible. When, however, we subject it to a careful analysis, and weigh cautiously the observa- tions upon which it is based, it will not be found of that conclusive character which at first sight it would appear to be. Every thing con- nected with scarlatina—the manner in which it spreads, the character it assumes as to mildness or severity in different epidemics, or in dif- ferent cases during the same epidemic, the susceptibility of the several individuals exposed to its infection, to become attacked, are always subject to such wide variations and unexpected anomalies, that unless it could be shown that in all, or at least in the great majority of in- stances, those who had been placed fully under the influence of the belladonna, at all times and in every visitation of the disease, escape an attack, we cannot with any certainty affirm, that in a single one of those who during the prevalence of scarlatina in their vicinity remain unaffected by it, or if attacked, have the disease in its mildest form, OAve their immunity or the mildness of the attack in their case to the belladonna they may have taken. In addition, we have the most positive and direct evidence that the belladonna, even Avhen the most carefully and faithfully administered as a prophylactic, will not posi- tively and generally prevent, in all epidemics, an attack of scarla- tina. The experiment has been made by placing a certain number of children under the influence of belladonna, and allowing an equal num- ber to whom no belladonna had been given, to remain as fully exposed as the first to the infection of scarlatina, and there was found to be no striking difference in the numbers who were attacked in the two classes. According to Dr. Andrew Wood, of Edinburgh, recent observations, especially those made by Mr. B. Bell, in Watson's Hospital, of that city, and by himself in Heriot's Hospital, would seem to prove that belladonna neither prevented scarlatina nor mitigated its symptoms. Dr. G. W. Balfour, is not only thoroughly convinced from his observa- tions, of its utter inadequacy to prevent the disease, but he believes its use to be absolutely improper, as Avhen given in even the ordinary small doses, it is sure to give rise to disordered digestion, foul tongue, etc., not the most likely condition of body to ward off any epidemic.— (Monthly Journal of Medical Science, 1853.) We have, in repeated instances, tested the prophylactic power of belladonna, but although redness and dryness of the throat, and a dif- fuse scarlet efflorescence were produced in the majority of the cases, we never found it, in any, to exert the slightest influence in miti- gating the character, or preventing the occurrence of scarlatina. The experiments were made during the prevalence of the disease, and in numerous instances the subjects of them were attacked. In one case, the efflorescence Avas kept up, by the use of the belladonna, for forty- eight hours; in a week afterwards, this individual took the disease in its most violent form, and died on the fourth day. It has been asserted, that scarlatina, like many other analogous dis- eases, may be inoculated so as to determine a local inflammation which has little reaction on the economy, but is preservative in the same manner as the vaccine virus against small-pox. M. Miguel employed the matter procured by pricking several papulae with lancets, which 512 DISEASES OF THE SKIN. was inserted in incisions made in the arm of the child intended to be infected. In three cases, he states that he was enabled in this manner to produce a local disease, which followed the march of the scarlatinous inflammation. Although not invariably successful, yet it will be prudent, in all cases to endeavour to prevent the spread of the disease by the seclu- sion of the sick, by free ventilation, by frequent changes of linen, and by the strictest cleanliness. 3.—Roseola.—Scarlet Rash. Roseola consists in a rose-coloured or scarlet efflorescence, without wheals or papulae, not contagious, and in many cases accompanied by a sensation of tingling or itching. The efflorescence may be confined to the face, neck, and upper extremities, or it may occasionally ex- tend over the greater part of the body. In some cases, the redness is diffused over a large surface; in others, it assumes the form of rings and spots, while in others, again, irregular lines of a darker colour have their interstices filled up by a lighter shade of red. We have often found the efflorescence to be much more decided around the larger joints, than upon other parts of the surface. The disease is frequently ushered in by a slight degree of febrile ex- citement, which abates as the efflorescence makes its appearance, and disappears with it. The pharynx often presents a similar efflores- cence to that upon the skin, and the patient feels a sense of dryness and roughness in swallowing. The efflorescence upon the surface gra- dually declines after the second day, and in general, disappears by the fifth. It seldom continues longer than a week, and is not followed by desquamation of the cuticle. It occasionally reappears and declines again and again, without any perceptible cause, or in consequence of any undue excitement, or upon the use of heating food or drinks. The efflorescence often occurs, in succession, on different parts of the body, and, if generally diffused, in the form of small patches, with intervals of sound skin between them, is sometimes with difficulty distinguished from measles, the difficulty being increased in many cases by the pre- sence of catarrhal symptoms. The sudden recession of the efflorescence is frequently attended by some derangement of the stomach, headache, and more or less of lan- guor and lassitude, which immediately cease, upon its reappearance. In a number of instances, we have found the eruption attended by A*ery decided catarrhal symptoms, and to be preceded and followed by pains of the limbs, and sometimes by slight redness and tumefaction of the joints. Roseola is peculiar to no age or sex; it is, however, much more frequent, during infancy and childhood than subsequently. In infants, the peculiar irritability of the skin, and of the constitution, predis- poses to its occurrence from the most trifling causes. It is most com- monly observed during the period of dentition, or in connexion with the ordinary intestinal and febrile affections of infancy; but it may originate from any slight irritation of the stomach or of the alimen- tary canal generally. It is more common during the summer and autumnal seasons, than at any other period of the year. SCARLET RASH. 513 Roseola has been divided, by Willan and others, into several varieties, founded upon the age or season at which it most generally prevails, and upon some slight difference in the appearance of the erup- tion. This division is more apt, however, to perplex and mislead, than to serve any useful purpose. The affection is one of little or no importance; requiring, in many cases, no treatment, and in none any further interference than to re- lieve the bowels of any cause of irritation which may exist, by some gentle laxative, to moderate the tingling or itching sensation of the surface by the use of the tepid or warm bath, and to place the patient upon a mild, unirritating diet. When the disease becomes chronic, or returns several seasons in succession, and continues for many months, attention to the condition of the alimentary canal will be demanded, with sea bathing, and the use of mineral acids. We have deemed it necessary to notice the disease, in this place, from the fact of its having been repeatedly mistaken for a mild attack of measles or scarlatina, and in this manner has given rise to some of the reported cases of a second attack of the latter diseases. So closely do some of the forms of roseola resemble measles, that it has been questioned by Sydenham, Rayer, and others, whether it is not, in fact, a modification or variety of that disease, without catarrh; and Orlov, Seiler, Heim, and Stromeyer, have thought it necessary to devote dis- tinct treatises, to determine the diagnosis betAveen it, scarlatina, and measles. But no difficulty can be experienced by an attentive ob- server, in readily distinguishing roseola from the other febrile exanthe- mata, by the difference in the appearance of the eruption—the patches of which are more regularly circular in shape, and more circumscribed than those of either measles or scarlatina, Avhile they are larger than those of the former, and smaller than those of the latter—and by the general symptoms, which are very distinct. The slight evanescent febrile excitement of roseola, can scarcely be confounded, even by the most careless observer, with the severe catarrhal fever of measles, or the intense febrile reaction of scarlatina. Dr. Engelman thus enumerates the principal characteristics of scar- latina, rubeola or roseola, and morbilli or measles. (Trans. American Med. Assoc-1855.) Scarlatina.—Eruption uniform over the whole body; or in large, irregular blotches, not elevated above the surface; or with many miliaria like papulae. Mucous membranes of the organs of degluti- tion affected, those of the organs of respiration, primarily unaffected. Desquamation of cuticle generally in large laminae or patches. Con- secutive diseases principally parotitis and anasarca. Rubeola or scarlet rash, which Dr. Engelman believes to be a tran- sition form of disease from scarlatina to measles. Eruption in spots, generally large, of an irregular, angular shape, of a high colour, ele- vated above the surface; redness disappearing under pressure of the finger, and generally reappearing first in the circumference. Mucous membrane of the organs of deglutition, respiration, and vision affected— angina, cough, and coryza present. Desquamation furfuraceous, slight, and often none at all. Consecutive diseases probably the same as 33 514 DISEASES OF THE SKIN. those of scarlatina or measles, according as the character of the exan- them approaches the one or the other. Morbilli or Measles.—Eruption in spots, generally smaller than in roseola—circular, or somewhat angular, of a paler rose colour, ele- vated above the surface only in the centre, the redness appearing there first after the pressure of the finger. Mucous membranes of res- piration and vision affected; those of deglutition not. Desquamation furfuraceous, generally slight, or entirely absent. Consecutive dis- eases always affections of the chest—pleuritis with exudations^ pneu- monia, or asthma. 4.—Variola.—Small-pox. This "loathsome malady," though no longer the same scourge of infancy, as it was previous to the discovery of vaccination, is still of sufficient frequency to demand our close attention. Notwithstanding the means for its entire extirpation is within the reach of every community, yet, from an almost criminal supineness upon the part of our legislative bodies, and ignorance and prejudice on the part of a large portion of the community, it is still allowed to prevail, destroying throughout the world many thousands annually, and stamping with deformity the countenances of those who are fortunate enough to pass through it without loss of life. Hence, the physician is obliged to make him- self fully acquainted with its pathological character, and proper mode of treatment, for he knows not at what moment he may be called upon to watch its progress, and lend his aid to mitigate the sufferings it entails, and, if possible, prevent its destroying those to whom he has not been permitted to afford a certain protection against its attack. Variola is an eruptive fever, marked by the occurrence .of pus- tules over the entire surface of the body, which appear at a definite period, run a regular course, and upon separating in the form of dry crusts, frequently leave a deep and indelible cicatrix. It is propagated by contagion, but often prevails as an epidemic—the first cases being traceable to no focus of infection. As a general rule, to which the exceptions are comparatively rare, it affects an individual but once during life. Like other febrile affections, variola commences with chills, or rigors, succeeded by a febrile reaction, of more or less intensity, Avhich may continue for two or three days before the eruption upon the skin appears. The attack is very generally preceded by pains, more or less intense, in the back and limbs; often, for many days, by some degree of lan- guor or lassitude; the patient feels depressed; his nights are often restless, and his digestion somewhat impaired. This constitutes what has been termed the stage of incubation, the duration of which has been variously stated, as from one to two weeks; to fix its limits is, in most cases, however, impossible. It has been said that the moment of infection is often marked by some disagreeable sensation—giddiness, sickness, or an inward feeling of alarm. We cannot say that we have observed any thing of the kind. Frequently the infection remains for a long period latent in SMALL-POX. 515 the system: thus we have known an individual to continue in apparent health, in the midst of an epidemic of small-pox, by which nearly every unprotected person in the same dwelling and neighbourhood with him- self were infected, and after the epidemic had entirely ceased, and no cases had occurred for weeks, to be suddenly attacked with the dis- ease in its most virulent form. Often the period of incubation is marked by no particular symp- toms, either of a general or local character; the first indication of in- fection b'eing a severe long-continued chill, or several slight attacks of rigour, occurring at short and irregular intervals, and speedily followed by a febrile reaction, often of considerable intensity, during Avhich the pulse is quickened, and the skin becomes hot and dry, or disposed to perspiration. The patient often complains of pain, or a sense of sore- ness in the limbs, and generally, of severe pain, or a feeling of weak- ness in the back. There is commonly pain in some part of the head, particularly in the temples and forehead. The child frequently ex- hibits a degree of drowsiness, and usually awakes with a start, or in a state of alarm. There is commonly considerable prostration of strength, and, in many cases, an anxious, suffering expression of coun- tenance. • In some instances, the attack is marked, in its early stages, by great irritability of stomach, frequent vomiting, oppression at the prae- cordia, and a pungent pain at the epigastrium, increased upon pres- sure. Not unfrequently, there occurs considerable difficulty of respi- ration, with cough, wheezing, and other indications of bronchial or pneumonic disease. Occasionally, the reaction is slight and imper- fect; or the disease commences with a state almost approaching to complete 'collapse; the surface of the body being pale, cold, and re- laxed; the pulse feeble, and the countenance anxious and contracted. The eruption is frequently preceded by a severe epileptic paroxysm. Many of the foregoing symptoms may abate in violence, or entirely disappear, upon the occurrence of the eruption, while others continue with greater or less intensity. The eruption upon the skin usually oecurs at the end of forty-eight hours from the occurrence of the chill, the pain in the back, or gastric distress. In delicate subjects, and in those who have been debilitated by loss of blood, long-continued vomiting, or severe purging, or from exposure to cold, the appearance of the eruption is not^ unfrequently delayed;—its occurrence previous to the third day being extremely rare. It first appears upon the face in the form of small red papulae, elevated above the surface of the skin. Subsequently, similar papulae occur on the neck and wrists, and then upon the trunk and thighs, and, finally, upon the feet. By the end of the first or second day the eruption usually extends over the entire surface of the body; but, occasionally, not before the end of three or four days. It is seldom that it occurs to the same extent over every portion of the surface;—it being gene- rally most considerable about the folds of the joints, and such parts of the body as are kept permanently warm. It has been known, in a few instances, to commence upon some part 516 DISEASES OF THE SKIN. of the body, or upon the inferior extremities, and occasionally one or two papulae may appear about the face, and assume the vesicular form, previously to the occurrence of the general eruption. The papulae become rapidly more and more distinct, and by the end of the first day, they are of a decided red colour, and sensibly ele- vated; by the third day, a small vesicle forms upon each papula, filled with a thin transparent fluid, and surrounded with an inflamed circular margin. The vesicle soon becomes depressed in the centre, and so con- tinues until about the sixth day. As the vesicle becomes more com- pletely distended, and of a more globular form, the indentation dis- appears; the vesicle now assumes a yellowish-Avhite, or pearly appear- ance, and instead of being filled, as at first, with a transparent fluid, it is now distended with a yellowish puriform matter, of the consistence of cream. When the pustules are numerous, the parts upon which they are situated become swollen, and the surrounding skin assumes a deep red colour, from the extension to it of the inflammation. The swelling is usually to the greatest extent in the face, hands, and feet. About the seventh day, some of the pustules on the face burst, and upon the eighth or ninth, they begin to dry, and become converted into scabs; the pustules successively assuming a yellow, then a brown, and, when perfectly dry, a very dark brown, or almost black colour. The scab adheres for a few days, and then falls off, leaving, in gene- ral, especially upon the face, a deep pit, or depressed cicatrix. The skin usually remains, after the scab falls off, of a dark brown mottled appearance, and it is often many weeks, or even months, before it re- gains its natural hue. From the appearance of the papulae, to their complete maturation, there generally intervenes a period of seven days. But as the papulae do not appear simultaneously upon every part of the surface, their ma- turation takes place successively;—thus, upon the face, they assume the pustular form, burst, and are converted into scabs, first; then upon the trunk and the upper extremities; and, finally, upon the loAver ex- tremities. As many as four or five days may intervene, betAveen the complete maturation of those upon the face, and those upon the feet. During the stage of maturation, the surface of the body emits a sickly, disgusting odour, which is peculiar to the disease. At the period when the eruption appears, the throat generally be- comes more or less affected, and most commonly redder than natural; in seA'ere cases, it is often considerably inflamed, and frequently co- vered with aphthous ulcerations. The latter, however, generally pre- cede the eruption on the surface, and often disappear earlier. When the inflammation of the throat is extensive, the entire mucous mem- brane of the respiratory tubes is very liable to be likewise affected. During the eruptive fever, the tongue is generally covered with a thin layer of white mucus; when the eruption is completed, this is par- tially removed, and, at its tip, a few eruptions usually appear. It is commonly moist, excepting when the patient is confined to a close and impure atmosphere, when it may become dry and dark-coloured. With the complete maturation of the eruption, the febrile symptoms SMALL-POX. 517 in general subside or entirely disappear:—frequently, howe\*er, some degree of febrile excitement continues, until scabs are formed over the greater part of the surface. When the eruption is at its height, there is always more or less tenderness of the skin; which is so considerable in some cases, as to occasion great distress to the patient. Frequently, there is considerable itching of the surface, which causes the patient, unless restrained, to scratch and rupture the vesicles, by which, gene- rally, his suffering, as well as the danger of deformity, from deep, large, and irregular cieatrices, is increased. When the eruption is finished, there is, very commonly, some degree of salivation, in con- sequence of the affection of the mucous membrane of the mouth and fauces. The bowels are usually constipated throughout the disease. Some- times, however, they are affected with more or less diarrhoea, which occasionally results from some degree of inflammation of the ileum and colon. The extent of the eruption is very various; in some cases only a few papulae appear, scattered over different parts of the body, which run their course, and are converted into pustules, that dry and fall off, with- out any further affection of the skin. In other cases, although the eruption occupies the greater portion of the surface, each pustule re- mains distinct and separate from the others;—while in other cases, again, they are very numerous, and so close together, as to run one into the other. The first two constitute the distinct small-pox of me- dical writers, and the last the confluent. The violence of the disease is generally in proportion to the extent of the eruption upon the skin. Thus in the confluent form, all the precursory symptoms are more severe; the eruptive fever is more in- tense; the difficulty of respiration, and the pain and uneasiness at the epigastrium, greater; convulsions and delirium are likewise more com- mon than in the distinct form. There is also more danger, from the intense inflammation by which it is attended, of extensive sloughing or ulceration of the skin; while, in general, the affection of the throat and respiratory mucons membrane, is more extensive and more liable to give rise to troublesome and dangerous complications. There is still another form of small-pox—the congestive ; in which the reaction is incomplete or absent. The patient labours under symp- toms of severe oppression, and great difficulty of respiration; his sur- face is cold, his pulse feeble; the eruption is slow in appearing, sel- dom very extensive, and when vesicles form, these are flat, flaccid, and never properly mature. We have remarked, that the severity of the febrile symptoms during the stage of maturation, is always in proportion to the number of pus- tules. Their severity is also in some degree influenced by the condi- tion of the patient, and certain external circumstances. Thus, in per- sons of a healthy, but not plethoric constitution, of a tranquil disposi- tion and temperate habits, occupying large, cool, and well-ventilated apartments, and subjected to a proper diet and regimen, the eruption, although extensive, may maturate with the occurrence of only a mo- derate degree of febrile excitement; while under opposite circumstances, 518 DISEASES OF THE SKIN. even a less amount of eruption may be attended by severe fever, and other unfavourable symptoms. Considerable attention has been paid, by several modern observers, to the structure, or anatomical characters of the variolous vesicle. The inflamed spot with which the eruption commences is seated in the cutis vera. It commences at a central point, spreads by radiation on the surface, and penetrates to a greater or less depth in different cases. A substance of a pulpy consistence, forming a kind of pseudo-membranous layer, is secreted immediately beneath the epidermis, which it slightly elevates. The vesicle is cellulated, or divided into numerous cavities, having for its floor the papillated structure of the cutis, elevated and marked with fissures and chinks, and, at the height of suppuration, swelled and moist like a sponge. At the central point, the chorion and epidermis adhere, causing the central depression on the surface of the vesicle. The lymph by which the cells are first distended, and subse- quently the purulent matter, is furnished by vessels which shoot from the central point. The lymph distends, at first, the sides of the vesi- cle, which it raises above the level of the surrounding skin; at length, with the more full distention of the vesicle, the central filamentous at- tachment is destroyed, and the central depression is no longer observed. The pustule now acuminates and finally bursts, discharging a purulent matter, of a yellowish colour, and of the consistence of cream. The inflammation of the cutis vera is surrounded by a damask red areola, more or less vivid according to circumstances, and extending to some distance beyond the margin of the vesicle. Between the ninth and eleventh days there takes place, in all the more violent forms of variola, an accession of febrile excitement; the heat of the skin becomes increased, the pulse quicker, and the patient more thirsty and restless. This is the secondary fever of medical Avriters. In many cases, this secondary fever is comparatively light and manageable; but in cases of confluent small-pox, it is generally marked by symptoms of very great violence, resulting from a renewed inflam- matory affection of the skin, or the occurrence of inflammation of one or other of the internal organs. Thus the breast, back or extremities, may become covered with an efflorescence very similar to that of scar- latina;—the tongue being at the same time morbidly red, and the throat red, swollen and painful. In other cases, an erythematous eruption, sometimes passing into confirmed erysipelas, with extensive vesications, occurs upon the head, trunk, or extremities. In other in- stances, boils, abscesses, and carbuncles, form in the neck, axillae, groins, elbows, and thighs; or a gangrenous inflammation attacks a large extent of the skin, especially of the legs and feet, and in a few days, lays bare the subjacent bones and muscles; or it may attack the scrotum and prepuce, and produce a rapid destruction of those parts. Diffuse cellular inflammation may occur in the scalp, or deep-seated abscesses in various parts of the body; or the larger joints may become filled with purulent matter. The surface, and particularly the cellular membrane under the lower eyelids, may be occupied with an ecthyma- tous eruption, giving rise to ulcers that pour out a thin ichor, and heal with difficulty. SMALL-POX. 519 Ophthalmia is a very common accompaniment of the secondary fever, and is almost always coincident with abscesses, or extensive destruc- tion of the surface in some distant part. It is of a very intense cha- racter, setting in, generally, about the tenth day, and rapidly involving in more or less complete destruction some one, or all of the tissues of the eyeball. Sometimes it causes a sloughing of the cornea, followed by prolapsus of the iris; at others, thickening and opacity of the cor- nea; occasionally, the whole globe of the eye is violently inflamed, and converted into one immense protruding abscess. The inflamma- tion is most generally confined to one eye. It is not produced, as many suppose, by pustules upon the cornea or conjunctiva; these may be traced just within the inner edge of the eyelids, but never beyond it. The brain not unfrequently suffers. Children are observed to grind their teeth, and squint; by degrees, symptoms of cerebral inflammation are developed, and the patients die, either from convulsions, or in a state of coma. The same affection of the nervous system that fol- Ioavs the destruction of large portions of the skin by burns or scalds, often occurs. The symptoms are severe—repeated rigours, followed by general tremors; low delirium; a quick, thready, and tremulous pulse; a dry, broAvn tongue; collapse of the features; cold extremi- ties; subsultus tendinum, and death. The thoracic viscera become in many cases the seat of disease. Most frequently, inflammation of the pleura, as well costal as pulmonary, occurs. Its course is, usually, very rapid, terminating in death on the third or fourth day, or even earlier. The symptoms are, for the most part, very severe and unequivocal; in some cases they are, hoAvever, less violent; presenting, at first, the characters of pleurodynia or tho- racic rheumatism; and frequently the disease is chronic and latent, and to be detected only by its physical signs. The substance of the lungs is occasionally affected with inflammation, and sometimes symptoms of croup occur. The abdominal viscera are often affected; either the peritoneum, particularly that portion investing the liver, is inflamed; or, more ge- nerally, the mucous membrane of the ileum and colon become the seat of inflammation, attended with tenderness of the abdomen, diarrhoea, and red and aphthous tongue. During the period of convalescence, either strumous ophthalmia, or enlargement of the glands of the neck, terminating in suppuration or continuing in an indolent state for a long period, may occur in the predisposed, Avhile in other cases, severe, deep-seated otitis, or all the symptoms of incipient or confirmed phthisis ensue. The confluent form of small-pox may present itself accompanied with symptoms indicative of an adynamic condition of the system, or of more or less extensive engorgement of one or other of the internal viscera. This constitutes the malignant, petechial, typhoid, or conges- tive variola of various authors. The temperature of the surface seldom rises above the natural stand- ard ; the pulse is sIoav, feeble, and oppressed; the strength of the pa- tient is greatly depressed; the respiration is weak and panting; the tongue becomes quickly dry and brown, the teeth covered with sordes; 520 DISEASES OF THE SKIN. the countenance contracted and depressed, and of a leaden or tawny hue. At an early period, petechia, or subcutaneous ecchymoses, of large extent, or dark-coloured hemorrhages from the nose, mouth, sto- mach, or bowels, occur. The eye is often the seat, also, of extensive ecchymoses. The gums bleed upon the slightest touch, and often pro- fusely. In some cases death takes place previously to the appearance of the eruption; in others, the eruption is pale, or copper-coloured, or dusky, with a leaden hue of the lips, and a dark appearance of the face. When vesicles form, they are often filled with a dirty, turbid, red fluid, or dark-coloured blood, and there are often petechiae scat- tered between them. This variety has been termed the black pock (variola nigra.) In many cases, no maturation of the vesicles takes place. Symptoms of extensive bronchial disease often present themselves from the very commencement of the attack: there is then a feeble, inefficient cough; difficult and oppressed respiration; a leaden or dusky hue of the lips and cheeks; great drowsiness; a suffering, anxious expression of countenance; a feeble, compressible pulse; cool- ness of the surface, and great prostration of strength; and the patient often dies in a state approaching to asphyxia. Delirium, or a degree of stupor, bordering upon coma, very fre- quently occurs; though in many cases of petechial small-pox, the mind remains perfectly clear throughout. During the prevalence of epidemic small-pox, numerous cases of a febrile affection are frequently observed, marked by tenderness of the epigastrium; pain in the back and limbs; some degree of soreness of the throat; salivation; profuse perspiration, from which no relief re- sults; and, not unfrequently, petechiae. This has been denominated variolous fever without eruption. This fever generally begins and ends at the same time with the variolous epidemic. We have repeat- edly met with such cases, as well in the unprotected, as in those who have been vaccinated, or who had previously had the small-pox. That the disease results from the same infection as the small-pox, we have no doubt:—how far it affords subsequent immunity from the latter, Ave have had no opportunity of judging. A number of other varieties of small-pox, founded upon some slight modification in the form or distribution of the eruption, are described by medical writers; but as they are distinguished by no striking patho- logical characters, Ave have thought it unnecessary to present a de- scription of them. The appearances after death, in fatal cases, vary considerably, ac- cording to the period at which death has occurred, and the particular organs that have become affected in the course of the disease. The lesions peculiar to small-pox are observed chiefly in the skin and mu- cous membrane of the mouth, fauces, and respiratory tubes. In many instances, these are the only lesions that exist, excepting, perhaps, an overloaded state of the great venous trunks, and of the parietes and parenchyma of the internal organs, resulting probably, from the im- pediment which the disease presents to the free performance of the functions of the skin and lungs. SMALL-POX. 521 Very generally, excepting, perhaps, upon the palms of the hands and soles of the feet, at the base of each pock there exists a small depres- sion or orifice, resulting from the rupture of the excretory duct of one of the cutaneous glands. Where the cutis is not occupied with pocks, it is often loaded with a white puriform matter. At an early period of the disease, the inferior layers of the epidermis are in a softened state; at a later period the connexion between the epidermis and cutis is en- tirely destroyed. The cutaneous glands are invariably enlarged, and increased in vascularity, and their excretory ducts are often distended with the secretion of the glands. The epithelium of the tongue and mouth is much softened. The subjacent mucous membrane frequently exhibits erosions, varying in depth. The mucous follicles of the tongue and tonsils are greatly distended; their orifices being sufficiently wide to admit readily the introduction of a large probe. When death takes place previously to the twelfth day, the mucous membrane of the larynx and trachea is deeply injected with blood, and covered with a copious viscid secretion of a purulent or puriform fluid of a gray or brownish colour. When this is removed, the mem- brane is found to be thickened, pulpy, and, in severe cases, black or sloughy. The surface of the epithelium exhibits, at an early stage of the disease, a number of dull, rounded spots, of the size of a lentil, pro- duced by the exudation of a fluid beneath it. In the progress of the disease, this effusion becomes more copious, and raises the epithelium, which may then be stripped off, exposing the inflamed, sometimes ulcerated mucous membrane. The ulcerations vary in number and depth, extending sometimes to the submucous cellular tissue. The marks of disease in the trachea are not always uniformly diffused over its Avhole surface, though the epithelium may be easily separated, even in the unaffected parts. Disorganization of the bronchial mucous membrane, may be traced into the third series of branches. The oeso- phagus has been found, in some instances, studded with minute eleva- tions, Avhich have been described as pocks. By many writers, the mucous membrane of the intestinal canal is described as presenting numerous small circular ulcerations: by some these have been sup- posed to be true variolous pustules; others, however, with greater accuracy, regard them as enlarged or ulcerated follicles. Variolous vesicles have been seen upon the mucous membrane of the rectum, in cases of prolapsus; and upon the granulations of the dura mater, in a case of fractured skull. The several organs are more or less congested with blood, which, particularly in the cavities of the heart and in the large blood-vessels, is very fluid, and often of the colour of the dregs of wine. If coagula exist, these are small, black, soft, and diffluent. They are rarely pale and fibrinous, excepting when there co-exists an acute inflammation of an important organ, of some intensity. Indications of pulmonary inflammation are occasionally met with, or of pleuritis, generally confined to one side, and accompanied with sero-purulent exudation. The brain and its membranes often exhibit an overloaded state of their blood-vessels. In many cases there is found an effusion of turbid serum between the membranes of the brain, and in the theca of the medulla spinalis. 522 DISEASES OF THE SKIN. It has been stated by Dr. G. Gregory, that morbid appearances are very rarely detected in the mucous membrane of the alimentary canal; our own observations would lead us, however, to a very different con- clusion. In the majority of the cases we have examined after death, diffused or follicular inflammation, ulceration, or softening of the mucous membrane of the stomach and duodenum, but more frequently of the lower portion of the ileum, and upper portion of the colon, Avas observed. In the post-mortem examinations made at the Small-pox Hospital, during the variolous epidemic which prevailed at Philadel- phia, in the years 1823-24, in nearly every case, more or less disease of the stomach and upper portion of the small intestines was observed. Drs. Bell and Mitchell, in their report of the epidemic referred to, re- marked that, " we cannot refuse our assent to the belief, that the mu- cous surface on which the preparatory process of digestion takes place, is mainly affected" in small-pox. In relation to the causes of small-pox, we possess little positive know- ledge. That the disease may prevail epidemically, spreading rapidly over large communities, and even over extensive districts of country, is a fact well established; and that the disease is capable of being pro- pagated by contagion or infection, is equally certain. But whether, in any instance, it is possible for the small-pox to originate spontaneously, or to be produced by certain electric, or other conditions of the atmo- sphere, independent of a specific contagion emanating from the bodies of the sick, is a question that has excited very considerable dispute, and the settlement of which is attended with no little difficulty. And yet, the sudden occurrence of the disease in a vicinity where no cases had been observed for many years; its appearing stimultaneously in distant parts of the same city, without the possibility of tracing it, in either, to an original source of infection, as was the case in the epi- demic of 1823; the rapidity with which it spreads; its greater viru- lence when it prevails as an extensive epidemic, than under ordinary circumstances, as well as its sudden cessation, incline us to believe that small-pox may originate now, as it must have in the first instance, solely from atmospherical causes. During the entire course of the disease, there emanates from the body of a small-pox patient a contagion, which, by combining with the air of the chamber in which he is confined, renders it capable of infecting those Avho respire it. The contagion is capable, also, of attaching itself to the bed and its coverings, and to the clothes of the patient, provided these be closely wrapped up and excluded from the atmosphere; and probably, also, to the walls of the apartment, when free ventilation and a process of purification have not been resorted to; and in this manner may communicate the disease at a distance from the source of contagion, and after a considerable lapse of time. But free exposure to the air, and the ordinary means of purification, will very quickly destroy the infecting property. The contagion of small-pox may likewise be communicated by the matter of the pus- tules; or even by the scabs, applied to the skin, or to the mucous membrane of the nose, or still more certainly, when applied to a wound or abrasion of the cuticle. The dry scab retains the contagious prin- ciple for a long period; experience has also shown, that for a consider- SMALL-POX. 523 able time after the death of the patient, the matter of the pustules con- tinues energetic; thus the air may be infected by the body of a patient affected with confluent small-pox for at least ten or twelve days after death. Small-pox may prevail at all seasons of the year, and it attacks alike individuals of both sexes, and of every age. According to our own observations, it is much more liable, however, to occur during the colder months, than during the other portions of the year. In Philadelphia, at least, the influence of the summer months in diminish- ing the frequency of the disease, is very apparent. Some pains have been taken in order to determine to what distance the contagious effluvium may extend, beyond the individual from whose body it emanates; and it has been concluded, that in all cases its sphere of action is limited to the circumference of a few feet. We are inclined to believe that the distance differs under particular cir- cumstances. Thus in close, foul, and unventilated apartments, ever}' portion of the air appears to become charged with the contagion; so, also, in confined and narrow courts, lanes, and alleys, in which the air becomes stagnant and impure, the contagious miasm extends to a much greater distance than in situations differently circumstanced. Hence, in all epidemics, it is among the poorer classes, and in the least salu- brious districts, that the disease prevails the most extensively and in its severest forms, and to Avhich, under ordinary circumstances, it is almost exclusively confined. NotAvithstanding no period of life is exempt from the attacks of small-pox, it is very evident that the great majority of its subjects are children. Some individuals appear much more susceptible to the con- tagion of the disease than others; but from what that susceptibility arises, it is impossible to say. In Philadelphia, it has been remarked that the blacks are peculiarly obnoxious to the disease, and that in them it is more fatal than in the whites; our own observations have confirmed the truth of this statement. In very severe epidemics, this difference of susceptibility is not, however, observed so generally as in an ordinary occurrence of the disease. Under all circumstances, it has appeared to us that a neglect of personal cleanliness, habits of intemperance, and fear, or a timid, desponding state of mind, strongly predispose to an attack. The foetus in utero has in numerous instances been known to be- come infected by the variolous poison, through the system of the mother. In one instance, related by Mr. Flinders, the disorder was eight or ten days later in the latter than in the former. In the Ame- rican Journal of Medical Sciences, a case is recorded of a child which was born completely covered with discrete variola in the pustular stage, apparently about the eighth day of the disease. The mother had been vaccinated when a child; had never before had small-pox, and suffered during her pregnancy from a very mild attack of the dis- ease. The foetus may even contract the disease, through the medium of the mother, although she, having had it previously, may be unaf- fected by the contagion. Dr. Mead relates the case of a woman, who Avhen near her reckoning, attended her husband in this distemper. 524 DISEASES OF THE SKIN. She was delivered at full time, of a dead child, which was covered with the pustules of small-pox. Dr. Jenner gives an account of an infant, Avhich when five days old became indisposed, and on the seventh ex- hibited an eruption of small-pox. In this case the contagion must have been communicated to the foetus in utero. The mother, a few days before her confinement, met, in the street, a person covered with small-pox pustules, the smell and sight of whose body had sensibly affected her. Sir Wm. Watson describes an instance in which the scars left by the pustules were visible on the infant at its birth. The child was aftenvards inoculated without taking the disease. Its mo- ther, who had formerly had it, nursed, when far advanced in her preg- nancy, a servant ill of the disease. Dr. Pearson met with a case in which a female was inoculated by him in her sixth month of utero- gestation, and had the disease severely. Her child was twice inocu- lated with small-pox matter, but without effect. (Watson's Lectures.) The extent of the eruption upon the skin, and the intensity of the accompanying symptoms, are in no degree influenced by the character of the disease in the individual from whom the infection was received; thus, the contagion from a confluent case will often produce a mild at- tack, whilst infection from the latter may give rise to the confluent and most malignant form of the disease. The quantity of eruption is mainly determined by the state of the surface at the period of its development. Whatever has a tendency to augment the cuticular circulation, whether too much clothing, ex- ternal heat, irritating substances directly applied to the surface, or stimulating food, drinks, or remedies, taken into the stomach, increases the extent of the eruption; while whatever has a tendency to reduce the determination of blood to the surface, as cold, a plain and abste- mious diet, aqueous drinks, bleeding or purgation during the stage of incubation, diminishes the quantity of eruption. A plethoric state of the body increases the intensity of the disease, and according to Gre- gory, is mainly instrumental in occasioning cellular complication. Whatever has a tendency to impair the health and vigour of the system, and vitiate the blood, imparts to the small-pox an adynamic and malignant character; and this is one of the chief causes of the prevalence of the worst forms of the disease among the poor, ill-clothed, ill-lodged, badly-fed, dissolute and intemperate classes of society. There is observed in many persons, and even in some of the mem- bers of the same family, an undefinable constitutional tendency to suffer more severely than others from, and a greater liability to sink under, even slight attacks of this, as well as of most other affections, while there are others, whose constitutions seem to react favourably under the severest forms of the disease, and to resist successfully their fatal tendency. It is a curious circumstance that, while in one epidemic nearly all the cases are distinct and mild, in another they are almost all confluent and malignant; the modifying cause being evidently connected with some unappreciable morbid condition of the atmosphere. In South America, according to Humboldt, these epidemic varieties have been strikingly evinced; at one time, small-pox occurring as a mild and SMALL-POX. 525 comparatively harmless affection; whilst at another, nearly all attacked fall victims to it. A strong predisposition to disease of particular organs, as the brain, lungs, boAvels, &c, or to scrofulous or tubercular affections, will give rise to serious complications in those attacked with small-pox, altering in some degree its character, and increasing its fatality. The influence of vaccination, as a protective against small-pox, will be considered hereafter. Small-pox is unquestionably one of the most destructive diseases to which man is liable. Prior to the introduction of vaccination, the average mortality is usually stated to have been one in four of those attacked, or tAventy-five per cent. At the London Small-pox Hospital, according to Dr. Gregory, the average of twenty-five years gave thirty- two per cent. In Germany it is stated by Heim to be twenty per cent. In Philadelphia, the average relative mortality, from 1786 to 1802, inclusive, was one in fourteen, nearly, or about 7.28 per cent. From the years 1807 to 1811, inclusive, variolous inoculation being still permitted, and extensively practised, the deaths from small-pox were to the entire mortality of the city and suburbs, as one to twenty- five, or four per cent. In 1811, variolous inoculation was prohibited by an act of the legislature, and during the succeeding four years, no death from small-pox occurred. From 1816 to 1841, the deaths from small-pox amounted to 1864; giving a relative mortality of one to sixty-six, or about 1.66 per cent. In England, prior to 1800, that is, before the period Avhen vaccination influenced the results, the deaths by small-pox were to the total deaths, both in town and country, as 16 to 100. From the report of the Registrar-General of England, it appears that, in 1837, there were only five diseases more fatal in Eng- land than small-pox; and that the deaths throughout England and Wales by that disorder, amount noAv, annually, to about 12,000. The greatest mortality in the unprotected, takes place in children betAveen two and five years of age. It is computed by Haygarth, that at Chester, (England,) during the latter part of the last century, one-half of the deaths in children below ten years of age, was due to small-pox. In Philadelphia, during the 40 years preceding 1845, 3022 deaths from small-pox occurred in persons of all ages; of these, 1810, or more than one-half, occurred in children under 10 years of age, namely: under 1 year, 555; between 1 and 2, 335; between 2 and 5, 624; between 5 and 10, 296. Death may take place at any period of the disease—even prior to the appearance of the eruption; or the disease may run its course, and death may then occur from some one of its ordinary sequelae. Most commonly, hoAvever, a fatal termination is to be anticipated between the eighth and twelfth days from its invasion. In a table of 16-8 fatal cases given by Dr. Gregory, it appears that in 32, death took place between the third and seventh days; in 83, between the eighth and twelfth days; in 39, between the eighth and twentieth days; and in 16, between the twenty-second and thirty-eighth days. The danger from small-pox varies materially in different cases. In its distinct form it is ordinarily a disease of very little danger; and 526 DISEASES OF THE SKIN. under a simple treatment, very generally terminates favourably. Con- fluent small-pox, on the other hand, is always attended with danger, particularly when the confluence occurs about the head and face: in such cases, death often takes place suddenly and unexpectedly. In every attack the danger is in proportion to the amount of eruption, and the accompanying affection of the throat and respiratory organs. As a general rule, liable, however, to some exceptions, when small- pox occurs as an epidemic of wide extent, it is more violent and fatal, and less under the control of remedies, than when but a few isolated cases make their appearance. In patients occupying large, comfort- able apartments, or airy, healthy neighbourhoods, the disease is at- tended with much less danger than in those placed under opposite cir- cumstances. In the cellars of London, Dr. Armstrong remarks, small- pox is almost invariably confluent and violent; while in garrets, espe- cially in open streets where there is a free ventilation of air, it is often distinct, and generally more mild. A similar remark may be made in reference to Philadelphia. In individuals of a broken-down constitution, or in whom, previously to the attack, the powers of life have been impaired by intemperate and licentious lives, or by exposure, bad food, and uncleanly habits, small-pox is very apt to assume an adynamic, hemorrhagic, or conges- tive character, and very generally terminates fatally. In persons of a plethoric habit, it very generally assumes an aggravated form, and is often fatal. A predisposition to scrofulous or tubercular affections, is very apt to render the sequelae of the disease particularly severe and unmanageable. When many patients are crowded together in a small space, even with the advantages of free ventilation, it always increases its malignancy, or endangers the occurrence of some fatal malady during its latter stages. The age of the patient has likewise a considerable influence in in- creasing or diminishing the danger of an attack of small-pox:—as we have already seen, it is much more fatal in children under ten years of age, than in the middle periods of life; the same is true, also, of persons advanced in years. The most favourable age, it is said by one of the most authoritative writers on the disease, (G. Gregory,) for taking small-pox, is from the seventh to the fourteenth year, when the powers of life are in full vigour, without the risk of plethora. This does not, however, conform with our own experience; we have met, almost invariably, with the mildest cases, and the smallest number of deaths, even in the more violent forms of the disease, between the ages of ten and twenty. In a table of 2465 cases, copied from the official records of the Health Office, at Philadelphia, the ages at which the deaths took place are as follows:— Jnder one year 425 Between forty and fifty 124 Between one and two 262 " fifty and sixty 41 " two and five 452 " sixty and seventy 14 " five and ten 235 " seventy and hundred and ten 10 " ten and twenty 170 u ___ " twenty and thirty 460 Total 2465 " thirty and forty 272 The unfavourable symptoms are confluence, a flat, flaccid condition SMALL-POX. 527 of the distinct vesicles, with a dark-coloured areola; imperfect, defi- cient, or excessive reaction; extensive disease of the throat and mouth, and early hoarseness of voice; a suffocating cough, and difficult, pant- ing, laborious respiration; a dark appearance of the vesicles, from their being filled with a bloody fluid; petechiae, vibices, and a hemor- rhagic tendency generally; prominent symptoms of adynamia; great nervous excitement, with a tendency to cerebral disease; fear and de- spondency on the part of the patient; great restlessness, particularly at night, and symptoms of extensive gastro-enteric disease. The fa- vourable or unfavourable termination of the case will, of course, be greatly influenced by the period of the attack at which a judicious plan of treatment is commenced; and by the physician having it in his power to remove, at once, the patient from the influence of a foul and confined atmosphere and other injurious agencies. The immediate causes of death are, a state of great depression or collapse occurring at the onset of the disease, the powers of life sink- ing at once, without an effort, or but an ineffectual one, to react:— after the seventh day, violent and extensive disease of the respiratory mucous membrane; during the period of secondary fever, the occur- rence of cerebral effusion, pleurisy, pneumonia, laryngeo-tracheitis, gastro-enteritis, or extensive gangrene of the skin; at a still later period, death may occur from erysipelas, tubercular phthisis, effusion into the chest or brain; or it may arise from excessive exhaustion. Many, however, of these latter results, are to be attributed to mis- management of the earlier stages, or to imprudences committed by the patient or his friends. Although, as a general rule, an attack of small-pox protects the system from the influence of the disease throughout the remainder of life, yet, though the instances are comparatively rare, cases have oc- curred in which a second attack has taken place. We have ourselves met with several such cases, and still more frequently with those in which patients who had at a former period, passed through the small- pox, suffered during an epidemic of the latter, a pretty severe attack of variolous fever, without eruption. It is stated by Gilbert Blane, that all the well-authenticated cases of secondary small-pox have been of persons Avho, in the first instance, had it severely. In three-fourths of the cases which had fallen under our notice, the individuals were deeply pitted, and otherwise deformed by the first attack; in the re- maining cases, there existed indubitable proofs of the previous attack, but not the same evidence of its severity. In one-third nearly of these secondary attacks, the disease was confluent, and terminated fa- tally. In no instance have we met with the recurrence of the disease, excepting in those in whom the attack, in the first instance, was spon- taneous, and not from inoculation. It is no unfrequent occurrence for a local effect to result from the application of variolous matter to the bodies of those who have already undergone small-pox. We have repeatedly seen well-formed A*ariolous pustules upon the breasts or arms of nurses who had previously had the disease, whilst taking care of infants affected with it; in two in- stances there was marked febrile excitement. 528 DISEASES OF THE SKIN. The treatment of small-pox naturally divides itself into that proper during the several periods of incubation, eruption, maturation, desicca- tion, and convalescence. As we are seldom able to determine the exact period of infection, we should act upon the supposition that every unprotected individual, who has been exposed to the contagion of small-pox, is already infected, and Avithout alarming his fears, immediately subject him to a proper hygienic course of treatment; placing him on a moderate, plain, and unirritating diet, with aqueous drinks, keeping his bowels regular, freely exposing him to a cool, fresh atmosphere, Avhile his body is properly protected by clothing suited to the season of the year; guard- ing him from the night air, and from every species of undue excite- ment; and, whenever it is possible, removing him from a confined and unhealthy dwelling or district, to one of an opposite character. The diet must of course be modified according to the state of health and constitution of each individual. The robust and plethoric should be confined to farinaceous articles and milk, in moderate quantities; while the feeble and delicate should be allowed a more nourishing, but equally unstimulating diet. In purgatives and emetics as prophylac- tics, we have no great faith:—if the bowels are costive, a brisk but mild purgative will be proper; or if the stomach be overloaded with undigested food, an emetic will be demanded;—but neither is to be employed solely with reference to the possibility of an attack of small- pox. The tepid or warm bath—the one or the other being used ac- cording as the temperature of the surface is sustained or depressed— will, in most cases, be advisable; it has a powerful influence in equal- izing the circulation, and overcoming any tendency which may exist to local hyperaemia. During the eruptive fever, we must be guided in our remedies by the degree of reaction, and the presence or absence of indications of visceral disease. In the ordinary cases of distinct small-pOx, the symptoms are gene- rally mild, and demand but little interference on the part of the phy- sician beyond the administration of some mild purgative to open the bowels freely, and the direction of a mild, bland diet, and cooling drinks; the body of the patient, at the same time, being kept cool, by a free ventilation of the apartment he occupies, without, however, ex- posing him to the influence of a direct current of air; and by causing him to lie upon a hair mattress, but lightly covered with bed-clothes. Sponging the surface of his body with tepid water, will generally be attended with good effect. The saline effervescing draught will be proper, if there be considerable heat and dryness of the skin. When intense pain in the head is complained of, leeches applied to the tem- ples will afford great relief, and should not be neglected; in cases, also, attended with considerable pain and tenderness of the abdomen, leeches to this part will be demanded. When, hoAvever, the febrile action is intense, with great heat of the surface, a tense, or full, labouring pulse, severe pain of the head, back, or epigastrium, great irritability of stomach, oppressed breathing, or other symptoms of local inflammation or hyperaemia, a much more SMALL-POX. 529 energetic practice is demanded. Blood-letting, general and local, is here our mo>t important remedy, and upon its prompt employment, to an extent commensurate with the violence of the symptoms, will mainly, if not entirely, depend the safety of the patient. Upon no subject connected with the treatment of disease, has there existed a greater discrepancy of opinion than in relation to the pro- priety of bleeding in small-pox. By some it has been entirely con- demned in every ^ase, as a measure calculated to retard or prevent the eruption, to interfere with its regular progress, and to impede its maturation. It has, however, under the circumstances referred to, received the sanction of many of the most distinguished practitioners, from the time of Sydenham to the present day. It is only, however, for the reduction of excessive excitement, or for the removal of local inflammation or hyperaemia, that the loss of blood is demanded in any case of small-pox. The extent to which blood-letting should be carried must be decided by the violence of the symptoms which indicate its employment, and the effects of the remedy. In cases of congestive variola, in particular, the abstraction of blood should be performed with great caution, and with the finger upon the pulse: if the latter sinks, the operation should be at once suspended; if it becomes fuller and stronger, the blood may be allowed to flow, but never to the extent of inducing the slightest approach to syncope. In the more malignant forms of the disease, attended from the onset with evident depression of the vital powers, bleeding should never be resorted to: mild aperients may, nevertheless, be demanded, together with a free exposure to the fresh air, without, however, allowing the body of the patient to become chilled. The Avarm bath will, in many cases, prove a valuable remedy; and if there be evidences of a rapid sinking of the patient's strength, even diffusible stimulants, as warm wine whey, warm Avine and water, ammonia and camphor, will be de- manded. These must, however, be administered with caution, and their effects carefully watched:—if, under their use, the skin becomes hot and dry, the tongue parched, and the pulse quick and frequent, they should be immediately discontinued. In those cases in which bleeding is indicated, the bowels should be kept open every day, by the occasional administration of some mild purgative, and the diet should consist exclusively of thin water gruel, Avith cool toast water, gently acidulated, for drink. In regard to ven- tilation, tepid sponging, &c, the same remarks will apply, as in the mild, distinct form. In all the more severe cases of small-pox, the hair should be cut close. This diminishes the amount of eruption about the scalp, the tendency to cellular inflammation of this part, to inflammation of the eyes, and to cerebral disease or violent delirium, while, at the same time, perfect cleanliness is the better secured. During the stage of maturation in mild cases, and when the eruption is perfectly distinct, Ave have little to do beyond keeping the patient cool, his apartment perfectly clean and well ventilated, and his bowels regular, by gentle purgatives; confining him, at the same time, to a 34 530 DISEASES OF THE SKIN. spare unstimulating diet; allowing him the free use of cool, aqueous drinks; keeping him perfectly quiet, and his body and mind free from exertion or excitement. Should there be much heat and dryness of the skin, with a sharp, active pulse, the infusion of senna with the addition of sulphate of magnesia, or the compound powder of jalap, or magnesia and rhubarb, should be administered in such doses and intervals, as to produce free purgation, without, however, irritating the bowels, or reducing, too rapidly, the strength of the patient:—while a free state of the bowels is all-important in these cases, very active purging is to be avoided. When the saline cathartics produce griping pains, and re- peated watery stools, calomel combined with magnesia, and folloAved by castor oil, should be substituted, or the calomel may be combined with the compound extract of colocynth. Although calomel has been condemned after the appearance of the eruption, we still believe that, in many cases, it is one of the best purgatives we can employ; it is sufficiently mild in its operation, and would appear to possess peculiar powers in moderating the violence of the disease. Saline draughts in a state of effervescence, or the liquor ammoniae acetatis, may be administered at short intervals; or, in cases unat- tended with gastro-intestinal disease, small doses of nitre and tartarized antimony, the sweet spirits of nitre Avith antimonial wine, or a combi- nation of hydrochloride of ammonia and ipecacuanha, will be found to assist in moderating the violence of the febrile excitement. R.—Pulv. hydrochlor. ammoniae, gr. xxxvj.—xlviij. " lpecacuanhae, gr. iij. " Sacchar. pur. J")j.—M. f. ch. No. xij. One to be given every three hours. When there exists considerable pain of the throat, with difficulty of swallowing, leeches should be applied to the neck, and if necessary, their bleeding encouraged by fomentations with warm water. When there is great difficulty of breathing, cough, copious expectoration of •mucus or muco-purulent matter, and other indications of inflamma- tion of the bronchi or lungs, provided there is no sinking of the pulse or symptoms of great exhaustion present, blood should be taken from the arm, to an extent sufficient to control the local disease. Subse- quently the citrate of potassa, in solution, with the addition of antimo- nial wine, may be administered; and if the cough continues to harass the patient, and prevent his sleeping at night, an opiate administered in the evening will generally afford relief. Either of the following may be given: R.—Mucilag. g. acaciae, giij. Or, R.—Pulv. ipecac, gr. iij. Syrup, scillae, gj. Magnesise calc. gr. xxxvj. Spir. nitr. 33th. giij. Ext. hyoscyami, gr. vj.—viij. Vin. ipecac. 3J. M. f. ch. No. xij. Tinct. opii camph. gj.—M. One to be given every two or three hours. Dose, a teaspoonful every two or three hours. Or, R.—Vin. antimon. njjx. Spir. aeth. nitr. njjxv. Tinct. opii camph. irgxv. Syrup, simpl. ^ss.—M. For a dose. SMALL-POX. 531 When symptoms present themselves indicative of cerebral disease, as intense pain of the head, flushing of the face, an injected state of the eyes, delirium, and violent pulsation of the carotid and temporal arteries, blood should be draAvn from the arm, leeches or cups applied to the temples and nape of the neck, and the bowels freely purged by some active cathartic, as calomel and jalap, or calomel followed by castor oil, infusion of senna, &c. When the surface is very tender and painful to the touch, cooling lotions should be applied, or a feAV leeches upon the parts where the inflammation is the most intense. Inflammation of the eyes should be treated by leeches, active purga- tives and emollient lotions. In some cases the eruption does not come out freely, and the pa- tient is affected with great irritability of stomach, frequent vomiting, a feeling of great oppression at the praecordia, and a small, feeble pulse. These symptoms will generally be relieved, and, at the same time, the eruption upon the skin promoted, by the warm bath, warm pediluvia, or hot bottles to the feet, with sinapisms to the epigastrium and extre- mities, and purgative injections. If any symptoms exist indicative of a congested state of either of the internal organs, the cautious employ- ment of blood-letting will frequently be productive of the best effects. In malignant cases, with a flaccid, dark condition of the vesicles, petechiae, hemorrhages, a livid complexion, coldness of the extremi- ties, and evident exhaustion, the treatment must be regulated accord- ing to the urgency of the symptoms in each case. The utmost atten- tion should be paid to insure a free ventilation of the apartment occu- pied by the patient, at the same time that his body is kept warm :—his bowels should be kept gently open by mild aperients or simple enemata. In the petechial and hemorrhagic cases, the vegetable and mineral acids have been highly recommended, but particularly the sulphuric, the chloric and the hydrochloric, and the juice of lemons. These may be given freely, diluted with Avater, or in combination with the decoc- tion of bark or solution of quinia. When, however, there is a tendency to a rapid failure of the powers of life, diffusible stimulants will be de- manded; the mildest should be first tried, and if they fail, recourse should be had to those of greater poAver: thus, warm wine whey, warm wine and water, ammonia and camphor should be first admi- nistered, and if stronger stimulants are required, milk punch, port Avine, or brandy may then be given. They should all, he-Avever, be used with caution, and in doses proportioned to the condition of the patient. Their effects are to be carefully watched, and if they aug- ment the heat of the surface, quicken the pulse, and render the tongue dry, or bring on a state of deep stupor or coma, their use should be immediately abandoned. Various plans have been resorted to, during the stage of maturation, to prevent pitting, and the permanent deformity thence resulting. It has been asserted by Velpeau and Meyreux, that if the pustules be opened on the first or second day of their appearance, and touched with a pointed pencil of nitrate of silver, they will be wholly destroyed, and leave no marks. The most effectual means, however, for ob- taining this desirable result, is that of keeping the patient in a dark 532 DISEASES OF THE SKIN. apartment, or covering his face with a linen mask, smeared on its inner surface with mercurial ointment. Dr. Stewardson, formerly physician to the Small-Pox Hospital at Bush Hill, instituted a number of experi- ments to test the effects of this practice; from the result of which, he remarks, it seems pretty evident that the mercurial ointment has a de- cided influence upon the small-pox pustules, preventing more or_ less completely their perfect maturation, and diminishing the concomitant swelling and soreness; the process of desiccation being completed Avithoufthe formation of thick scabs, and the resulting cicatrices being less marked than when the process of suppuration is left to pursue its natural course. It is also apparent that this influence is chiefly ob- servable in cases where the eruption has not advanced beyond the third or fourth day. Dr. Stewardson ascertained by comparative trials, that the same results do not happen when simple cerate is used instead of the mercurial ointment. In consequence of the excessive and dangerous salivation that has re- sulted from the use of the mercurial plaster, and from a conviction that it acted merely as a protective of the pustules from the air, and that any kind of plaster that would concrete on the skin would answer as well, after several trials, Dr. John Hughes Bennet found that the car- bonate of zinc made into a plaster with olive oil, applied to the face of small-pox patients, not only prevented the pitting, but had also the effect of diminishing the local and general symptoms of the disease. (Month. Journ. of Med. Sciences, 1854.) It has been proposed by Serres and Olliffe, to pencil the eruption with a strong solution of nitrate of silver, 15 to 45 grains to the ounce of distilled water, previous to its assuming the pustular form. Mida- vaine employed frictions with sulphur ointment, made of a drachm and a half to two drachms, to an ounce of lard, over the parts co- vered with pustules, and recently, Dr. CraAvford, of Montreal, and Dr. Jackson, late of Northumberland, now of this city, recommend pencil- ling the eruptions with the tincture of iodine, and relate several in- stances in Avhich abortion of the cutaneous affection was in this manner produced. The favourable results of either practice require confir- mation from a more extended series of observations. More recently the application of collodion to the pustules has been recommended as an effectual means of producing their abortion, and thus shortening the duration of the disease and preventing deformity. It has been employed to this intent by Dr. Brinkerhoff, of Pennsylvania, by Drs. Aran and Valleix, of France, by Drs. Storer and Bowditch, of Boston, Mass., all of Avhom speak favourably of its effects. Dr. Christen, Assistant Physician to the Prague General Hospital, has given to the local application of collodion a very full trial in small- pox; and the result of his observations has led him to believe that its employment is not merely useless, but also directly injurious; that, when extensively applied, it exercises an unfavourable influence on the general course of the disease, by suppressing the functions of the skin; and that by arresting the evaporation and confining a large amount of fluid matter, it promotes, in a great degree, the absorption of the pus, and thus favours that state of pyhaemia Avhich is so apt to occur when the eruption is extensive. SMALL-POX. 533 The period of desiccation, in the milder forms of small-pox, requires no particular treatment. The bowels of the patient should be kept regularly open by mild aperients; his diet should be gradually ren- dered more nourishing, care being taken, however, that it be com- posed of articles of ready digestion, and not too stimulating, and that the most trifling excess be not committed; the same rules being ob- served until complete convalescence ensues. During the period*of convalescence, the daily use of the warm bath will be advisable. When secondary fever ensues, it must be treated on general prin- ciples, and according to the nature of the complications with which it is accompanied. Violent excitement should be reduced by low diet, cool acidulated drinks, free ventilation, purgatives, and by the saline diaphoretics with minute doses of antimony, Avhen these are not con- tra-indicated by the condition of the digestive mucous membrane. The occurrence of local disease will require the use of the remedies appropriate to the character and extent of the latter; while a state of positive adynamia will demand the cautious employment of stimu- lants and tonics. The same remarks Avill equally apply to the various sequelae of small-pox. In regard to the character of the remedies em- ployed, and the extent to which they are to be carried, due attention must be paid to the greater or less degree of exhaustion, resulting from the preceding disease;—for though in many of the affections which occasionally occur subsequent to small-pox, depletion by the lancet, by cups or leeches, or by purgatives, will be demanded, yet we are seldom able to employ it with the same freedom we should in similar forms of disease, occurring under any other circumstances. When the attack of small-pox has developed symptoms of scrofu- lous disease—although in some instances, sarsaparilla, mild mercurial alteratives, or perhaps some of the preparations of iodine, may be found serviceable—a prudent course of hygienic treatment is the one most to be relied on. A change of air; appropriate clothing; a well-regu- lated diet, and daily exercise, proportioned to the strength of the patient; the warm bath, or sponging with tepid salt and Avater, fol- lowed by friction of the surface, will frequently improve the digestion, invigorate the capillaries.of the surface, render the functions of haema- tosis and nutrition more regular and perfect, and remove the danger of extensive disease of the glands, lungs, and serous membranes. As a means of rendering the small-pox milder and more manage- able, and in this manner decreasing its mortality, the inoculation of the disease had been practised by some of the nations of the East, proba- bly for a considerable period before the practice became known to Europeans. It Avas not, however, until the beginning of the year 1721, that it was introduced into England, by the energy and perseverance of the celebrated Lady Mary Wortley Montague, Avhose husband had been English ambassador at Constantinople. In June of the same year, it avus introduced into America, by Rev. Cotton Mather, under the directions of Dr. Boylston, of Boston. Inoculation was unquestionably a most valuable discovery, and had the effect, Avhen it came to be extensively practised, of disarming the disease of some of its most frightful features, and of sensibly dimi- 534 DISEASES OF THE SKIN. nishing its ravages. At the same time, however, it had a tendency to perpetuate the small-pox, and by multiplying foci of contagion, to ren- der the disease, which had previously only occurred at intervals, a frequent epidemic. Happily, the subsequent and far more important discovery of Jenner has rendered a resort to inoculation unnecessary, as a means of protection from the infection of small-pox, and as, in most of the states, the performance of inoculation is prohibited by law, while there appears no just grounds for believing that the neces- sity will ever occur for its revival, we may dismiss the subject without any more extended notice. 5.—Vaccination. It was long known, in the principal dairy counties of England, that cows are subject to a pustular eruption; and it was the popular belief in those counties, that when this was communicated to the hands of milkers, it rendered them, ever after, insusceptible of the variolous in- fection. To this circumstance, the attention of Dr. Edward Jenner became directed very early in life. In 1796, he made successful ex- periments with the matter obtained from the cow, and found that on those whom he had infected with this matter, the variolous inoculation took no effect. It was not, however, until two years subsequently, that he published the result of his investigations. Public attention became at once awakened to the subject; and although the introduction of vaccination was at first violently opposed in different quarters, it was hailed, very generally, as a means of certain security against a loath- some and dreaded disease, and that would ultimately result in an- nihilating one of the most dreadful scourges of the human species. The knowledge and practice of vaccination spread rapidly throughout Europe and America; and there is noAV no civilized nation on the earth by wrhom it has not been adopted. In regard to the origin and nature of the vaccine disease in the cow, numerous opinions have been expressed. Jenner at first ascribed its source to the grease, a disease Avhich affects the feet of horses, and Avhich is communicated to the udder of the cow by the hands of the milkers and farm servants. It has been asserted, that a pustular dis- ease, in every respect similar to the vaccine affection, may be produced in the human subject, as well as in the cow, by inoculation Avith the matter of grease. Sheep are likewise subject to a pustular disease about the head and mouth, which, it is said, when communicated to the human system, affords security against the small-pox. It has likewise been asserted by Lisa, that the inoculation of sheep with variolous matter effectually protects them from the pustular disease to which we Lave just alluded. Jenner, on the first announcement of his discovery, advanced the opinion, that cow-pox, (or the variolae vaccinae, as he termed it,) and small-pox are identical in their nature,—the vaccine infection being only a milder form of inoculated small-pox. This opinion he ever after maintained; and its correctness would appear to be confirmed by the veil-established fact, that when variolous matter is inserted in the ulder of the cow, it produces an affection identical, in all respects, VACCINATION. 535 with the cow-pox, and Avhich, communicated to the human subject, af- fords him the same protection against the variolous infection. This fact Avas early noticed by Reiter and Gassner, but for its full establish- ment we are chiefly indebted to the more recent experiments of Theile, of Russia, 1836—8; of Ceely, of London, 1839; and of Martin, of Massachusetts, performed 1835, published 1841. In his first publication, Jenner announced his conviction, that the cow-pox, Avhen it has once passed in a perfect form through the human body, leaves the constitution for ever after secure from the infection of small-pox. This was, also, the opinion generally entertained by the physicians of Europe and America, until the year 1818. During this and the succeeding year, an epidemic small-pox pervaded Scotland, and many persons who had been vaccinated were attacked with a mild form of the disease. The same thing occurred in the subsequent epi- demics of small-pox which prevailed in various parts of Europe, Ame- rica, and the East Indies; and in not a few instances, very violent at- tacks of the disease, in its most unmitigated forms, and of a fatal ter- mination, were reported to have occurred in those who had been pre- viously successfully vaccinated. These facts have very forcibly directed the attention of the profes- sion to a more close investigation of the extent of the protection af- forded by the vaccine infection. Although the result of this investi- gation has, it is believed, shaken the confidence of a few in its prophy- lactic value, the majority, notwithstanding their views in relation to vaccination have been slightly modified, still believe that, when the system has been placed fully under the influence of the vaccine virus, it is, in the greater number of cases, completely protected against a subsequent attack of small-pox; and that, even in those to Avhom it has failed to afford this complete protection, the small-pox, when it does occur, is so far modified in its character, as to become a disease of little severity, and seldom, if ever, fatal. The most accurate series of observations in relation to the protective powers of vaccination, have been recorded during the few past years by physicians in different parts of the world, possessing opportunities particularly favourable for their prosecution; all of which observations fully bear out this latter estimate of the value of vaccination. It is true, however, that in a large number of cases vaccination fails to afford full protection against the infection of small-pox, and various opinions have been advanced to account for the fact. By some, it has been ascribed to a gradual deterioration of the vaccine virus, in conse- quence of its transmission from person to person, and they strongly urge the necessity of recurring, at short intervals, to the cow, for fresh matter, in order to secure its complete prophylactic powers. That, in many instances, spurious matter may have been employed, and, in others, that which had undergone some change capable of impairing its protective influence, and that the infection resulting from such spu- rious or deteriorated matter may have been mistaken, byignorant, careless or inexperienced practitioners, for genuinevaccination, is un- questionably true. By some, however, it is maintained, that the sup- position of "the vaccine matter, in general use, having become, in any 536 DISEASES OF THE SKIN. degree deteriorated, is disproved by the fact, that the appearance of the vesicle produced by it—the period of its incubation—its progress, and the distinctive characteristics of its successive stages, are precisely the same as those obtained from the use of matter more recently de- rived from the cow. It is nevertheless certain, that, when the latter is employed, a marked improvement is perceptible in the resulting ve- sicles; the local inflammation is also more severe; and the constitu- tional symptoms more decided. In the report on vaccination made to the Belgian Academy of Me- dicine, in 1858, it is stated, as the result of the reporter's investiga- tions, that human vaccine virus becomes gradually weakened by suc- cessive transmissions, without, however, losing entirely its preservative property. It is, therefore, both useful and necessary to renew the lymph whenever true cow-pox matter can be procured. The regene- rated virus produces a more characteristic eruption, the course of which is slower and more regular than that obtained from the use of old vi- rus. The number of pustules produced by it is also greater, and they appear on individuals who had resisted the influence of the old virus. The reaction or vaccinal fever which attends the eruption is, besides, more marked and active—a condition of its preservative power. We have for some years past been in the habit of using vaccine mat- ter recently obtained from the cow, supplied to us by a friend in Eu- rope, and we have found it to be much more energetic and efficient than that in common use in this city. By many physicians of great respectability, it has been supposed, that the protective powers of the vaccine infection become gradually impaired, as the individuals who have been subjected to its influence, advance in age, until, finally, they become anew susceptible to the con- tagion of small-pox. Brown, of Edinburgh, Gregory, of London, Mohl, of Copenhagen, Heim, of Wirtemberg, and some few of the physicians of this country, advocate this opinion; all of whom insist upon the ne- cessity of revaccination, as a means of restoring to the system its im- munity from variolous infection. We have collated with no little care the leading facts which bear, either directly or indirectly, upon this question, especially those re- corded during the last ten years; all of which, in our opinion, very fully sustain the position of Jenner, that in every instance in which the sys- tem can be once fully infected with the vaccine disease, it affords a protection against the occurrence of small-pox, which is unimpaired Avith the lapse of time. The question as to the propriety and advantage of revaccination is, nevertheless, a very important one. That among a given number of those who have been apparently successfully vacci- nated, there will be found many, in whom, from some cause not well as- certained, a greater or less degree of susceptibility to variolous infection is left unextinguished, and Avhich susceptibility augments in time, is a fact that would appear to be well established; and such individuals Avill be found to be, also, susceptible to re-infection by the vaccine virus. Now, the question presents itself, Will it be possible, by subjecting such persons to revaccination, to protect them from an attack of small-pox? In order to test this question, revaccination has, for some years past, VACCINATION. 537 been very extensively practised in many parts of Europe, and the re- sults obtained thus far are curious and interesting. We have collected together the results of 721,143 revaccinations performed by different individuals in Europe and this country: in about 36 per cent, of these the revaccination is stated to have been success- ful; while in 112,061 cases, in which a second revaccination Avas per- formed, or about 12 per cent, the operation is reported as having been successful. We are not, however, to conclude, that, in every case in which re- vaccination is successful, the individual has been previously Avell vac- cinated. In, perhaps, the majority of instances, we have no other evidence of the primary vaccination, and of its character, than the report of the individuals themselves, and the presence of a more or less perfect cicatrix upon the arm, neither of which is to be received as con- clusive. But, after making a reasonable deduction for such cases as may be supposed to have been imperfectly vaccinated in the first in- stance, there still remains a large number of cases (about 33 per cent.) in Avhich the primary vaccination, though to all appearances regular and complete, fails, from some peculiarity of constitution, to afford a perfect security from subsequent variolous infection, and in which a revaccination is essential, in order to insure to the individuals a full protection. If, therefore, the facts upon record are perfectly accurate, and there is no reason for suspecting them to be otherwise, they afford conclu- sive evidence of the necessity and importance of revaccination, in all cases in Avhich persons are liable to be exposed to the infection of small-pox; not, however, from any fear that the protective power of the primary vaccination, Avhen the system has been placed fully under its influence, may be impaired by time, but simply as a test whether the susceptibility of the individuals to variolous disease has been fully extinguished. "Revaccination," in the language of the report made to the Bel- gian Academy of Medicine, 1858, " is the useful and indispensable com- plement of a first vaccination; not that it is ahvays necessary, but in order that we may be certain that all susceptibility to the occurrence of variola has been extinguished in the economy. If the revaccina- tion succeeds, we have a right to believe that protection against the in- fection of small-pox is thereby confirmed. If it fails, it should be re- peated at more or less distant intervals, so that we may be assured by these test vaccinations, of the entire immunity of the subject." Had Ave no other proof of the importance of revaccination, that de- rived from the results of the operation among the soldiers of the Prus- sian army would be sufficient, The whole army now enjoys an almost entire immunity from the contagion of small-pox, notwithstanding it has been repeatedly subjected to its influence. To the report for 1841, Ave find attached the following important statement:—The powerful influence of revaccination, in the diminution of variolous diseases, at the different military hospitals, is most remarkable. During the year 1841, there occurred but 50 cases, of which 10 were genuine variola, 24 modified small-pox or varioloid, and 16 varicella. Three of the patients died; of these, one had not been vaccinated on his admission 538 DISEASES OF THE SKIN. into the army, but his certificate indicated that he had been a short time previously; the second occurred in a recruit who had not been re- vaccinated; and the third, in a non-commissioned officer, Avho had been revaccinated some years before, but without success. Before the order for revaccination was issued, the different barracks used to be a prey to varioloid disease, which has now almost entirely disappeared. During the nineteen years ending with the 31st December, 1852, the number vaccinated upon their entrance into the army was 811,402. The first vaccination was successful in 414,595; of the remainder, on being subjected to revaccination, in 42,986 the operation was successful; vac- cination therefore took effect in a regular manner in 457,581 cases. Of these, during nineteen years, 217 were attacked with varicella, 191 with varioloid, and 13 with variola: of the latter, four died. Dr. Schilling very properly remarks (Viertel-Jahrsschr. f. gericht. und bffent. Med. 1854,) that those in whom revaccination is successful are not to be considered as invariably susceptible to the variolous infec- tion: the statistics of vaccinations performed in the Prussian army show that such is not the case. A few years since a prize was offered by the Academy of Sciences of France, for the most satisfactory essay in reply to certain queries relating to the preservative power of vaccination, the necessity of re- newing the vaccine virus from the cow, and the necessity of revacci- nation. The various essays sent in by the competitors for the prize were referred to a committee of the Academy, whose report, submitted in February, 1845, concludes with the following general summary de- duced from the facts presented by the authors of the essays. 1st. The preservative power of vaccination is absolute for the ma- jority, and temporary for a small number: even in the latter it is ab- solute until adolescence. (A position also affirmed in the report on vaccination made in 1858 to the Belgian Academy of Medicine.) 2d. Small-pox rarely attacks those who have been vaccinated in in- fancy before the age of ten or twelve; from which age, however, until thirty or thirty-five, the vaccinated are particularly liable to small- pox. 3d. In addition to its protective power, vaccination so modifies the animal economy, that it attenuates the symptoms of small-pox, abridges its duration, and considerably diminishes its danger. 4th. Vaccine matter taken directly from the cow causes local symp- toms of greater intensity, while its effects are also more certain than those of old vaccine matter, but after being transmitted for a few weeks through the human subject the local intensity disappears. 5th. The preservative power of vaccine matter does, not seem to be intimately connected with the intensity of the local effects produced by it; nevertheless, it is prudent, in order effectually to preserve its protective power, to procure new matter from the cow as frequently as possible. 6th. Revaccination is the only known method of distinguishing those of the vaccinated who remain protected, from those who do not. 7th. Successful revaccination is not a certain proof that the person in whom it succeeds was liable to contract small-pox; it merely esta- VACCINATION. 539 blishes a tolerably strong presumption that they were more or less liable to be so. 8th. In ordinary periods, revaccination should be practised after the first fourteen years, but sooner during the prevalence of an epi- demic of small-pox. At a recent meeting of the London Epidemiological Society, Dr. Waller Lewis read a highly interesting and valuable paper on the Re- lations of Vaccination and Inoculation to Small-Pox. _ From the facts and cases adduced by him the author drew the following general con- clusions, which correspond with those at which we had previously ar- rived from the results of our own observations. 1. That vaccination is a most eminent protection against small-pox. 2. That when perfectly performed it is almost, and, in some instances, more protective than inoculation or small-pox itself. 3. That it appears to render some exanthemata, as, for example, measles, milder than they would have been otherwise. 4. That neither vaccination, inoculation, nor small-pox, guaranty the individual in every instance from small-pox. 5. That small-pox attacks some persons three times, or oftener. _ 6. That there exist certain individuals who have perfect immunity from vaccination, inoculation, and small-pox. 7. That great susceptibility to, or, perfect immunity from small-pox, is sometimes found to be common to several members of the same family. , 8. That sanatory conditions have a very powerful effect on the spread of small-pox in common with other epidemics. It appears, Dr. Lewis remarks, from the cases adduced by him, and the deductions therefrom, that the laws which regulate the apparent mysteries of small-pox are as follows:— _ A. Small-pox is a disease to which almost every person is liable once in his lifetime unless protected. B. But there is a small fraction of the community who appear to enjoy an exemption from this law, no degree of exposure, either to vaccination, inoculation, or casual small-pox, causing them to take vaccinea or variola. . C. That there is a certain portion, on the other hand, in the exactly opposite condition. These individuals, whose systems appear to pre- sent a soil peculiarly favourable to the development and spread ot small-pox virus, are eminently susceptible of the disease. It is to this class that those persons belong who have repeated attacks of variola; who take small-pox after being inoculated or vaccinated, h or such persons there is no safety but in repeated vaccination. D And lastly, that between this latter class, and that favoured portion of the community that possess perfect immunity, there exists every shade and degree of susceptibility. # These laws explain the apparent inconsistency in the views held respectino- the protective powers of vaccination. Thus, all those indi- viduals, forming an enormous majority of mankind, who possess an ordinary, moderate degree of liability to small-pox, are completely guarded against the influence of small-pox virus, either by perfect 540 DISEASES OF THE SKIN. vaccination, inoculation, or a previous attack of small-pox; while others, who have a much greater susceptibility, will be protected by neither one nor the other. It is to be recollected that the protection afforded by vaccination is about equal to that derived from inoculation—while the former is un- attended with any danger to the patient, and does not, like the latter, tend to keep alive and propagate a loathsome and destructive disease. At the Royal Military Asylum, Dr. Balfour has shown that, out of every 1,000 boys admitted, protected by previous small-pox, 6.15, and out of 1,000 boys, protected by vaccination, 7.06 were attacked subse- quently by small-pox. The deaths from secondary small-pox amounted to 2.05 per 1,000 of those attacked, Avhile not a single fatal case oc- curred on those attacked with small-pox after vaccination. (Medico- Chirurg. Trans. 1852.) From records kept at the Small-pox Hospital, Mr. Marson proves, that the mortality from small-pox in persons well vaccinated, and who have more than two cicatrices, was less than 1J per cent. In those reputed to be vaccinated, not more than 3 or 4 per cent., undeV favourable, and not more than 7 under unfavourable cir- cumstances, while-the mortality from natural small-pox varied from 20 to 35 per cent. (Medico-Chirur. Trans. 1853.) Phenomena of vaccination.—On the third day after the insertion of the matter in the arm, there appears, at the point where the matter was inserted, a red and slightly elevated papula, which, on the fourth day, is surrounded by a very faint and narrow inflamed base, or areola. By the aid of the microscope, the efflorescence surrounding the in- flamed point, will be distinctly visible. On the fifth day the cuticle is elevated into a pearl-coloured vesicle, filled with a small quantity of perfectly transparent fluid. The form of the vesicle is circular or oval, according to the manner in Avhich the introduction of the virus is effected. The vesicle is somewhat flattened, and Avith a small de- pression in the centre, rather darker than the rest of its surface. It continues to enlarge in circumference, but not so much in elevation, until the eighth day, Avhen it is at its height. Its margin is then tur- gid and prominent, and it contains a greater or less amount of fluid. When closely examined, the vesicle exhibits a cellulated structure. By the floor of the cells, which are from ten to fourteen in number, is secreted the specific matter of the disease. Between the eighth and ninth days, some degree of febrile excitement very generally occurs:— the glands of the axilla become, in some cases, swollen and painful, and a state of general lassitude and drowsiness, with slight creeping chills, alternating with flushes of heat, is observed;—in other cases, the febrile excitement is much slighter, and, in many instances, scarcely perceptible. On the evening of the eighth day, the slight circle of inflammation, which surrounds the vesicle on its first formation, begins to spread, until, by the tenth day, it forms a broad areola, surrounding the vesicle, of a bright red colour, and of a perfectly circumscribed, circular form: the parts occupied by it being tense and painful. By the eleventh day, the depressed centre of the vesicle begins to assume a darker hue, and this darkness gradually extends toAATards the circumference; VACCINATION. 541 and, by the fourteenth day, the entire surface of the pock is converted into a dark broAvn scab. By degrees this becomes harder and of a darker colour; in a few days it begins to separate at the circumference, but still adheres at the centre, and does not fall off until between the eighteenth and twenty-first day,"and sometimes even later; leaving, upon its separation, a cicatrix of a form and size proportioned to the previous inflammation, and marked with radiations and indentations. In a few instances the vesicle is developed at a somewhat earlier period; and in other cases, a number of days elapse, after the inser- tion of the matter, before the appearance of the vesicle. According to Dr. Gregory, the period of retardation never exceeds sixteen days. It not unfrequently happens, that on the day after the matter is in- serted, considerable inflammation and swelling occur at the place of in- sertion, Avhich after continuing for a day or two, subside rapidly with- out leaving any local affection. Most commonly but one vesicle i3 developed at the point where the matter is inserted; occasionally, however, one or more smaller vesi- cles appear in the immediate vicinity of the primary one; and in- stances have.occurred, in which numerous vaccine vesicles presented themselves on different parts of the body, the matter taken from which communicated the disease to other persons, as effectually as that de- rived from the primary vesicle on the arm. (Report of the Central Vaccine Committee of France, for 1818-19.) In many cases, the wound made by the insertion of the matter be- comes, at an early period, very red and itching, and a small acuminated, conoid pustule occurs on the eighth day, surrounded by an imperfect, irregular areola:—the pustule is filled with an opaque, straw-coloured fluid, and forms a small, light-coloured scab, Avhich separates prema- turely. Such cases are always to be regarded as instances of doubtful vaccination. In other instances, instead of a circumscribed areola, an inflamma- tion of an erysipelatous character extends over the whole arm, from the elbow to the shoulder:—the vesicle, in place of being converted into a hard scab, causes a large ulcer, which discharges profusely, and is occasionally difficult to heal:—the resulting scar is large and irre- gular, Avithout either radiations or pittings. In these cases, also, there is a doubt whether the system is placed fully under the influence of the vaccine infection. Another irregularity is, when, about the sixth or seventh day, the vesicle becomes partially inflamed and scaly, and surrounded by a species of psoriasis in place of an areola. This is an unquestionable indication of spurious vaccination. Between the ninth and twelfth day, in robust, plethoric children, it sometimes happens that the body becomes generally or partially covered Avith a papular eruption, which, however, in no degree interferes Avith the eftects of the vaccination. Period for vaccination.—Not a little discussion has recently taken place, as to the proper age for the performance of vaccination. By some, its postponement until after the child is one year old, is strongly insisted on, under the supposition that, previously to this age, the in- 542 DISEASES OF THE SKIN. fection of the system is apt to be imperfect, or, at best, not permanent: —others have considered the disease to be more regular, and accom- panied with less febrile irritation, in infants from two to six months old; while others again maintain that it may be performed immediately after birth, and that it succeeds equally well at Avhatever age the matter is inserted. At a discussion upon this subject before the Medico-Chirurgical Society of London, Dr. Gregory gave it as his opinion, that, provided a good vesicle and areola were produced, with a due degree of consti- tutional effect, it matters not whether vaccination be performed at the second or third month, or the second, third, or fourth year. He con- sidered the true question for consideration to be, at what period of in- fantile life vaccination can be practised, so as most certainly to insure success, and avoid inconvenience to the parties. In the first Aveek or ten days after birth, before the infant has attained any degree of plumpness, it is very difficult to vaccinate, not from any want of sus- ceptibility in the patient, but from the difficulty of inserting the lymph properly: this difficulty is more or less present until about the fourth month, and hence, this is the period usually chosen; for not only is the arm then generally plump, but there are, also, no contending in- fluences, such as teething, present. Mr. Ceely agreed, in the main, with Dr. Gregory. It was stated by Dr. T. Thompson, at a discussion before the Medical Society of London, that at the Foundling Hospital, Paris, all the children were vaccinated within the month, and the operation was generally successful. From the facts recently adduced in relation to this subject, as well as from the result of our own experience, we should be inclined to agree with Dr. Gregory, as to the proper period for vaccination, when there exists no urgent necessity for its more early performance. We have found, however, that in very young subjects, there is often a great difficulty in communicating the vaccine infection; nevertheless, when we have succeeded in placing the system, at this age, effectually under its influence, as evidenced by the character and progress of the vesicle upon the arm, its prophylactic powers were as fully obtained, as when vaccination is delayed until a later period. _ While we choose, generally, the fourth month as the most conve- nient age for vaccination, nevertheless, should the prevalence of small- pox endanger the life of the infant, or a necessity present itself for the immediate removal of the latter to a situation where pure vaccine matter can with difficulty be procured, Ave never hesitate to vaccinate at any period, even within a few days after birth. No preparation of the system is demanded previously to the per- formance of the operation; nor, when a disease of a genuine charac- ter is produced, is any medical treatment necessary during its pro- gress, nor subsequently. In cases, however, in which children are af- fected with herpetic and other eruptions upon the skin, it has been supposed by Jenner, Willan, and others, that so entire a ehange is pro- duced in the character and progress of the vaccine infection,°as to de- stroy its prophylactic powers: this, however, is denied by Capuron, while Valentin and Ilusson assert, that the vaccine infection has the VACCINATION. 543 effect of completely removing whatever cutaneous disease the child may at the time be affected with. The safest course is, if there be no im- mediate necessity for vaccinating, to defer it until any eruptive dis- ease upon the skin is removed; but if small-pox is prevailing at the time, to insert the matter, and subsequently to subject the child to the test of revaccination. Vaccination adds nothing to the danger, nor in any degree inter- feres with the process of dentition; and it may safely be performed during every season of the year; though, as a general rule, where it can be done conveniently, it is better to wait until the rigours of Avinter have been moderated by the influence of spring, or until the heat of summer has given Avay to the coolness of autumn. Mode of vaccination.—By the generality of European physicians, in vaccinating, the recent lymph, obtained from the vesicle, between the fifth and eighth days, is employed: the experience, however, of the great body of the American practitioners has confirmed them in giving to the dry crust or scab the preference over the recent lymph, as a means of propagating the disease. While equally efficacious with the latter, the scab is much more manageable, and more readily preserved; its employment also obviates the necessity of interfering with the re- gular progress of the vaccine vesicle, a circumstance of very consider- able importance in reference to the certainty of the child's infection. In regard to the appearance of the scab, Avhen we are certain that it is the product of the genuine disease, and has not deteriorated from keeping, nothing of course need be said; but as this cannot always be the case, it is important to be aware of the appearance presented by the true vaccine crust. This is of a dark mahogany or walnut colour, hard, and perfectly opaque, somewhat thick in the centre, and thinner at the edges and nearly level, or only slightly concave at its under surface or base; when cut into thin slices, it presents a dirty, brownish appearance; it is rather tough—being with difficulty reduced to a pow- der, but readily soluble in water. A scab produced by a vesicle, the regular progress of Avhich has been interfered with by the irritation of the clothing, accidental violence, or other cause, or one procured from a child affected at the time with any disease of the skin, should not be made use of for vaccinating; the disease communicated by it will sel- dom be found genuine, while the virus obtained from children labour- ing under cutaneous affections is supposed to endanger the communi- cation of these to the individuals in whose arm it is inserted. In preserving the scab for use, the greatest care should be taken to keep it excluded as much as possible from the air, and from the slight- est degree of moisture. With due precaution, the scab may be pre- served throughout the year, without in the slightest degree losing its activity. Previous to its insertion, a small portion of the dry scab should be reduced, by means of pure cool water, into a paste of about the con- sistence of cream: for this purpose a square of window glass, or the bottom of a china plate or saucer, and a lancet or pen-knife, constitute every thing that is necessary. When, as is customary, the physician carries with him a portion of glass upon which to form the paste, two 544 DISEASES OF THE SKIN. precautions are absolutely necessary; which are: each time the glass is used, to clean and dry it perfectly before it is put away; and, on no account whatever, to preserve the portion of dissolved matter remain- ing from one vaccination for a subsequent one:—virus thus kept, will be a constant source of disappointment to the practitioner, and of dan- ger to the patient. The common plan of inserting the matter in the arm is, to take a small portion of it upon the point of a sharp lancet, which latter ia then introduced obliquely, for a short distance, beneath the cuticle. We have found, however, this mode of vaccinating to be very unsuc- cessful; however pure and fresh the matter may be, often no infection is communicated until after the operation has been several times re- peated. This arises from two causes;—either the matter being entirely wiped off from the point of the lancet, in passing the latter under the skin, so that not a particle is introduced; or so much blood is caused to flow by the puncture, as to wash out the matter after it has been deposited beneath the cuticle. The plan we invariably practise, and Avhich we first proposed thirty years ago, is to make, at the place where the matter is to be inserted, several parallel incisions with the blade of a common spring lancet: taking care, however, that these in- cisions penetrate no deeper than is necessary to divide the cuticle; and then to cross them at right angles, by others of a similar depth. This operation when properly performed, will be found to cause a slight blush of redness on the part, and, most commonly, the appearance of a very few minute specks of blood; the less blood, however, that is thus occasioned to flow, the better. A portion of the dissolved crust is now to be taken on the point of a lancet, and smeared over the in- cisions, and allowed to dry. To render the insertion of the matter still more certain, it has been proposed to smear it upon the arm, previously to dividing the cuticle. One recommendation in favour of the foregoing plan, independently of its certainty, is, its being productive of so little pain, that it may be performed Avhile the infant is asleep, without awaking it, or even when it is awake, almost without its knowledge,—a circumstance, however trivial it may appear, that is by no means beneath the notice of the practitioner. Subsequent to vaccination, the arm should be guarded from irrita- tion by the fingers of the patient, its clothing, or accidental violence. To effect this, the best means is, to enclose the whole arm in a wide sleeve of linen or fine muslin, drawn at the shoulder and Avrist. This is a precaution of some importance, as well to obtain a genuine, effec- tive scab, as from the fact, that the certainty of the child's being placed fully under the influence of the vaccine disease may be jeo- parded by its neglect. While in this country, physicians, generally speaking, are content with the production of a single vesicle upon the arm, many of the prac- titioners of Europe, and especially those of Germany, advocate strongly the insertion of the vaccine matter, either in both arms at the same time, or by a number of incisions or punctures in the same arm, as a necessary precaution, in order to insure the full influence of the vac- MODIFIED SMALL-POX. 545 cine infection. A very expert vaccinator, (Mr. Leese,) stated recently at one of the meetings of the London Medical Society, that he never knew a case of consecutive small-pox to occur in an individual in whose arm there were above four cicatrices from the primary vaccina- tion; and we are informed by another practitioner, (Dr. Chowne,) that in the Small-pox Hospital at London, so great a dependence is placed upon the number of the cicatrices present, that the character of the consecutive disease is generally prognosticated from that circumstance alone. It is recommended by Dr. Gregory, that with lymph of or- dinary intensity, three or four vesicles should be raised, and these at such a distance from each other, as not to become confluent in their advance to maturation. Dr. Marson, in an admirable paper on the protective influence of vaccination (Trans. Medico-Chirur- gical Soc, 1853,) adduces statistics showing that persons in whom the vaccine matter has been inserted at several places at the same time, were far less liable to subsequent attacks of small-pox than those in whom a single insertion only had been practised. Other practition- ers, of equal authority, maintain, however, that a single vesicle, if it proceed regularly through its several stages, and produce a proper degree of constitutional effect, as indicated by the occurrence of febrile excitement about the eighth day, is as effectual as twenty: many of these authorities admit, nevertheless, that the appearance of several Well-defined vaccine cicatrices affords strong presumptive evidence that the due degree of infection has been produced; and this corresponds with our own experience. In ordinary cases, nothing is necessary during the progress of vac- cination, excepting the observance of the same hygienic rules which are equally proper even had vaccination not been performed. If the febrile excitement which occurs about the eighth or ninth day is con- siderable, a slight reduction of diet, with some gentle aperient, and cool diluent drinks, is all that is required. If the inflammation spreads to an undue extent over the arm, lotions of cold water, or of a solu- tion of the acetate of lead, will, in general, speedily reduce it; but if it be of a very intense character, a few leeches may be necessary. 6.—Modified Small-pox.—Varioloid.—Mitigated Small-pox. It is noAV well ascertained, that, in many instances, persons who have been vaccinated, when exposed to the contagion of small-pox, become attacked with an eruptive disease, more or less similar, in its leading characters, to genuine variola; but generally attended with much milder symptoms, less protracted in its duration, and far less fatal in its results. This disease has been shown, by facts the most incon- testable and conclusive, to be small-pox, modified in character, and mitigated in violence, in consequence of the change produced in the constitution of the patient by the vaccine infection. As the modify- ing influence of the vaccine disease is rendered, from a variety of causes, more or less extensive in different individuals, we have, consequently, a corresponding difference in the character and intensity of the vario- loid affection; Avhich, in some cases, is of so trifling a nature, and of such short duration, as scarcely to confine the patient at home, or, at 35 546 DISEASES OF THE SKIN. furthest, not beyond a day or two; while in others, it approaches closely, in its features and in severity, to unmitigated variola. ^ On tracing back the history of small-pox to our earliest records, we find that the occurrence of the disease in a modified form has been repeatedly noticed in former years, during the prevalence of variolous epidemics, under the denomination of vesicular, abortive, or spurious small-pox; the genuine and spurious forms of the disease appearing during the same epidemic, and both ceasing with its termination. The more extensive prevalence of the varioloid affections, during the last thirty years, is evidently owing to the existence of a more extensive modifying cause, in the general practice of vaccination, which, while it affords, as we have shown, in far the greater number of cases, a full and permanent protection against the contagion of small-pox, in many, only partially destroys the susceptibility to that disease, and still leaves the system liable to be affected by it, in a more or less modified form. Soon after the introduction of vaccination, it was noticed that some of those who had undergone the disease, were attacked with a vesicu- lar eruption of a very mild character: this, however, attracted but little attention, as the disease was considered to be merely chicken- pox, against which neither inoculation nor vaccination Avas supposed to afford any security. Subsequently, however, when the disease be- gan to prevail epidemically, it was held by many to be a new malady, and to originate from a peculiar or specific contagion; but, finally, its identity with small-pox was fully established. The true character of the varioloid affections is now very generally recognised. Upon examining, with attention, the whole of the facts connected with the prevalence of small-pox, from the earliest period of its his- tory, and comparing them Avith those which have been developed since the introduction of vaccination, we find many strong reasons for attri- buting to one common origin the entire family of vesicular and pustu- lar eruptions—the small-pox, chicken-pox, sheep-pox, stone-pox, horn- pox, and a host of others; of which the distinctive characters are the result of various, and perhaps successive modifications that the ori- ginal virus has undergone, as well as of a difference in its effects upon different constitutions, resulting from causes by which their suscepti- bility to its influence is either increased or diminished. The several eruptions alluded to, run into each other by almost imperceptible gra- dations; while all, or the greater part of them, are very apt to prevail during the same variolous epidemic. Under so great a variety of grades, and accompanied by so much diversity in the appearance, progress, and duration of the eruption, and in the character of the concurrent symptoms, does modified small- pox present itself, at different times and in different individuals, that it is impossible to give any general description of it; Avhile to enter into a detail of all the varieties it presents, Avould lead to no useful practical results. Confining ourselves, therefore, to the varioloid af- fection as it occurs in persons who have been vaccinated, we shall pre- sent the more important of its leading characteristics. MODIFIED SMALL-POX. 547 The varioloid eruption is, in some cases, preceded by little or no fever; while in others, the febrile excitement is marked by a consider- able degree of intensity. The eruption may occur as early as the se- cond day, or not until the fourth or fifth:—frequently it is preceded by a transient, uniform efflorescence of the skin, or by a rash closely resembling that of measles. The eruption manifests itself in the form of minute papules, of a more or less red colour:—with the appearance of these papulae, all fe- brile symptoms almost invariably cease, and do not again recur, unless in consequence of some accidental cause, entirely unconnected with the disease. Many of the papulae become dry and disappear soon af- ter their appearance; whilst others of them become converted, in the course of the first or second day, into vesicles filled with a limpid watery fluid, which gradually becomes thicker, and of a whey-like ap- pearance. Frequently some of the more prominent vesicles (more or less in different cases,) are surrounded by a small, faint areola. About the third or fourth day, the vesicles burst, or become dry, forming small, light-coloured crusts, which soon separate, and either leave no mark upon the skin, or a slight prominence at the points occupied by the vesicles, which speedily disappears. In other cases the vesicles become filled with a puruloid fluid, and are slightly depressed in the centre. The crusts formed by the drying of the vesicles generally fall off in two or three days, though they have been known to adhere for a week, or even longer. Occasionally, the fluid contained in the vesi- cles retains its serous character for four or five days, and then be- comes puriform: in which state it may remain for several days, be- fore the desiccation of the pustules commences. It is not uncommon for papular, vesicular, and pustular eruptions, in close proximity, to exist at the same time upon the surface. The pustule and its areola, in some cases of varioloid disease, exhibit a striking resemblance to those resulting from vaccination. In other cases, during the eruptive stage, the attack approaches, in its violence and general character so nearly to one of genuine variola, as to be scarcely distinguishable from the latter; and the eruption may be even so abundant, as to resemble the primary stage of con- fluent small-pox. Varioloid may, however, be generally distinguished from unmodified variola, by the eruption appearing in successive clus- ters, and at irregular periods, between the second and fifth days; by the absence of fever in all but the most violent cases; by the smallness of the vesicles, and the whey-like character of their contents; by their early desiccation without being converted into pustules; or, when their desiccation occurs at a later period, by their not entering into com- plete suppuration, as in small-pox; by the early separation of the scabs, which are of a lighter colour than those of variola, and leave, at the parts to which they were attached, small red disks, or slight eleva- tions, instead of pits. That the disease just described results from the contagion of small- pox acting upon constitutions in Avhich the susceptibility to its influ- ence is, to a certain extent, reduced, either from previous disease, or 548 DISEASES OF THE SKIN. from idiosyncrasy, is now so generally admitted that it is scarcely necessary to enter here into a review of the arguments by which the fact is fully established. In almost every community, in which epi- demic small-pox occurs, there are many individuals who have already had the disease; a much larger number who have been vaccinated more or less perfectly; and others, again, who are wholly unpro- tected, either by variolation or vaccination. In those of the first two classes who are attacked by the epidemic, the disease will, in the great majority of cases, assume the varioloid, or modified form; while in those of the latter class, with but few exceptions, the cha- racter of the disease will be that of discrete or confluent variola, varying only in intensity. In a few instances, however, we shall meet with cases of varioloid eruption," closely resembling chicken-pox, in the unprotected. It is this latter circumstance which gave rise to the doctrine of the vario- loid disease being the result of a peculiar contagion, altogether dis- tinct from that of small-pox; the occurrence of the tAvo diseases during the same epidemic, being considered as merely accidental. The fal- sity of this doctrine is, however, fully shown by the matter taken from the vesicles of the varioloid disease as it occurs in unprotected individuals, communicating, to others similarly situated, genuine small- pox; a fact which we have verified by actual experiment. The treatment of modified small-pox is to be conducted on the same general principles as that of the disease in its unmodified form. Many cases are so slight as scarcely to require the confinement of the pa- tient to his chamber; Avhile others are marked by symptoms which occasionally call for the employment of blood-letting; in general, how- ever, all that is necessary will be, rest, a cooling regimen, a spare, unirritating diet, cool, acidulated drinks, and the administration of some active purgative, in such doses, and at such intervals, as will keep the boAvels freely open. 7.—Varicella.—Chicken-pox. Varicella may be defined, a febrile vesicular eruption; the vesicles desiccating without maturation, and often leaving cicatrices or pits upon the separation of the crusts. The eruption in varicella is generally attended with some degree of febrile excitement: in many cases, however, this is so slight as scarcely to attract attention; whilst in others, it is of considerable severity, continuing for two or three days, and attended with severe pain of the back, head and extremities. The eruption, which gene- rally appears first on the breast and back, then on the face and scalp, and finally, on the extremities, is often preceded, for a few hours, by a general erythematous efflorescence, and is accompanied, in most cases, by a disagreeable tingling or itching of the skin. The erup- tion of vesicles usually appears in succession, during three or four days; so that while some are just appearing, others are fully formed; others, again, are beginning to shrivel; and others, still further ad- vanced, are completely dry, and in the form of crusts. From a difference in the form and appearance of the vesicle, vari- CHICKEN-POX. 549 cella has been divided into three varieties, the lenticular, the conoidal, and the globular, or swine-pox. In the lenticular variety the eruption appears very early, in the form of small, somewhat oblong, flat, red, and shining elevations, having in the centre a minute vesicle, which enlarges, and by the end of the second day is filled with a whitish fluid. On the third day, the fluid in the vesicle acquires a pale, yelloAV colour; and on the fourth day, the vesicle becomes shrivelled; and in two days more, is con- verted into a small brown crust, which separates about the ninth or tenth day, leaving a red mark, which soon disappears, without any cicatrix or depression remaining. The duration of the disease is often protracted by the appearance of fresh vesicles on two or three successive days, which go through the same stages as the first. In the conoidal variety, the vesicles appear suddenly, surrounded by a slightly inflamed margin. They are elevated, pointed, and con- tain a limpid serum; on the second day, they are more distended, sur- rounded by a broader areola, and contain a pale, yellowish fluid; on the third day many of them contain a purulent matter; they now be- come shrivelled, and on the ensuing day, scabs begin to form; some having a dark broAvn, and others a yellowish, semi-transparent ap- pearance. The scabs generally separate in four or five days; those containing purulent matter leaving pits in the skin. A fresh crop of vesicles usually appears on the second and third days, each crop run- ning the same regular course;—the eruptive stage is consequently prolonged until the sixth day, and the separation of the scabs is not finished until the eleventh or twelfth day. In the globular variety, the vesicles are large and globose, with an irregular base, and surrounded by an inflamed margin. They are filled with a transparent fluid, which assumes, on the second day, a Avhey-like appearance; on the third day they begin to shrivel and assume a yelloAvish appearance, from a small quantity of pus being mixed with their contents. Scabbing commences on the fourth day, and the scabs separate in four or five days. Varicella is never attended with secondary fever. The scabs, upon separating, occasionally leave indelible cicatrices or depressions in the skin, which differ, in some respects, from those of small-pox, being whiter than the rest of the skin, and quite smooth or flat, Avith an even, rounded margin; whereas, the cicatrices from small-pox are of the colour of the surrounding skin, and uneven, like the surface of an orange, with an indented or angulated margin. Hairs occa- sionally grow within the latter, while, according to Heim, they never do in those of the former. Varicella rarely occurs more than once in the same individual. It may appear sporadically, but generally prevails as an epidemic of moderate extent. It is capable of being propagated by contagion or infection. Its subjects are usually children, although adults are fre- quently attacked by it. Much controversy has taken place as to the true nature of varicella. By Vidius, Senertus, Riverius, Morton, Sydenham, Harvey, Mead, 550 DISEASES OF THE SKIN. Hoffman, and most of the earlier writers, the disease was considered to be a spurious or bastard form of variola; while, by subsequent wri- ters, it was attributed to a contagion entirely distinct from that of small- pox, and great pains were taken to point out the specific characters by Avhich the two diseases are distinguishable. The doctrine of the independence of varicella and variola, with few exceptions, was adopted by the profession generally, until about the year 1816, when the discussion was renewed, and the identity of the two affections was again asserted, and many facts and arguments adduced in support of it, by Frank, Berard, Delavit, Thompson, and others. To disprove the common origin of varicella and small-pox, the fol- lowing arguments have been adduced: 1st. That the symptoms of va- ricella are peculiar and distinctive, and run always a regular course peculiar to that disease. 2d. That small-pox often occurs without va- ricella, and varicella independent of small-pox. 3d. That varicella occurs equally, and with the same characteristic symptoms, in those who have had the small-pox, in those who have been vaccinated, and in those who are entirely unprotected by either. 4th. That the pre- vious occurrence of small-pox does not prevent or modify varicella, nor varicella small-pox. 5th. That varicella is incommunicable by inoculation; and 6th. That varicella is more common now than before vaccination was so extensively practised, when small-pox was much more prevalent. To these arguments it has been replied, by the advocates of the identity of the diseases: 1st. That very little or no difference exists between the milder forms of small-pox and ordinary cases of varicella; and that even between cases of the two diseases of greater intensity, the difference is in the extent of violence rather than in the character of the symptoms. That in some epidemics it is frequently impossible to say Avhich cases are varicellous, and which variolous. 2d. That the varicella has almost invariably occurred either before, during, or immediately after small-pox epidemics. We have no well-authenti- cated accounts of the occurrence of varicella, unconnected with small- pox, before the introduction of inoculation; and none to be relied on previous to the general practice of vaccination. Now if the varicella be not a modified form of variola, it was reasonable to expect that sporadic cases of it would frequently occur, occasionally, indepen- dently of the latter; though the fact of the extensive independent prevalence of chicken-pox has not yet been well established. But Avhen we know that, from some inappreciable difference in its epidemic causes, the small-pox assumes a very great dissimilarity of character at different periods; some epidemics being mild, others severe, and others peculiarly malignant; and that even the character of the erup- tion has been known to differ materially, it is not unreasonable to sup- pose that in the same manner it may appear at one time as a mild or severe varicella, and at another, invariably under its more aggravated forms. 3d. Varicella, according to Bryce, Abercrombie, and Thomp- son, occurs much more frequently in those who have been variolated or vaccinated, than in the unprotected; while its symptoms differ ma- terially in different cases; the vesicles desiccating early in some, no CHICKEN-POX. 551 cicatrices being left upon the separation of the scabs; whilst in others, Borne of the vesicles are more or less fully maturated, the scabs adhere for a longer time, and on falling off, leave indelible pits in the skin. Some cases are marked by scarcely any eruptive fever; others by a febrile reaction as intense as in the severer forms of small-pox. 4th. Persons who have suffered an attack of small-pox have, according to Thompson, been observed to be seldom affected with varicella; while it has been asserted by Reil, that small-pox is generally much milder when it occurs subsequent to a severe attack of varicella, than when it occurs in those who have not been affected with the latter disease. 5th. The chicken-pox and small-pox may reciprocally produce each other. (Rayer.) 6th. Varicella, like small-pox, according to Willan, Bate- man, Thompson, and Heim, is capable of being communicated by inocu- lation. 7th. The fact that it is of more frequent occurrence since the general introduction of vaccination, is an evidence in proof of varicella being but a modification of small-pox. Previously there was a more general susceptibility to the genuine forms of variola, whereas now, by the general practice of vaccination, whole communities are, in a great measure, protected from the latter, though from various causes, many individuals still remain susceptible of the infection to a certain extent, and hence the very extensive prevalence of varicella, in com- mon with various other modified forms of small-pox known by the name of varioloid, is readily accounted for. M. Delpech considers that the separate individuality of varicella is proved, by its existing in an isolated state, free from all variolous com- plication, both sporadically and epidemically; by its occurring almost exclusively in children; by the perfect indifference with which it at- tacks all individuals, whether vaccinated or not, whether they have had variola or not, even Avhen labouring under varioloid disease, or Avhen recently convalescent from it; by the complete absence of all modification in the manifestations of the affection in those who are or have been under the influence of variolous affections; by the absence of all immunity conferred by varicella from variola or cow-pox; by the possible combination and simultaneous development of varicella and variola; by the impossibility of variola transmitting or giving rise to varicella, or of varicella transmitting or giving rise to variola; the doubtful possibility of transmitting varicella by inoculation, notwith- standing the experiments of Willan, which have been disproved by nearlv all subsequent experimentalists; and, lastly, by the decided and constant difference in the form and symptoms of the two diseases. Guersent, Alibert, Gregory, and Blache, also regard varicella as a disease sui qeneris. Upon the treatment of varicella, the same remarks may be made as were made in reference to the management of modified small-pox. The disease seldom requires much medical attention. A restricted diet, cool drinks, and gentle aperients, will be proper in all cases. If the eruptive fever is very severe, and the child robust and plethoric, a small bleeding from the arm, with saline purgatives, and a low diet, will suffice to moderate its violence. 552 DISEASES OF THE SKIN. CHAPTER II. CUTANEOUS ERUPTIONS. ERUPTIONS OCCURRING PREVIOUS TO WEANING AND DURING DENTITION. 1.—Strophulus. An eruption of pimples, generally appearing first upon the face, neck, shoulders, hands and arms, but occasionally on other parts of the body, (S. Intertinctus.) When the pimples have a florid, red appearance, the term red gum is familiarly applied to the eruption. When of a paler hue, exhibiting a less degree of irritation, it is denominated white gum, (S. Albidus.) In its simplest and most common form, strophulus consists of a few pimples irregularly distributed, and noAV and then mixed with diffused patches of redness. When, from any cause, the irritation of the skin is considerably augmented, these patches are very numerous; the pimples are of a large size, and many of them present a vesicular ap- pearance, which, however, soon disappears. When strophulus occurs during dentition, the pimples are harder, and occur in patches, with considerable redness of the skin; they are also more generally diffused over different parts of the body, (S. Confertus.) When, from any cause, there is considerable derangement of the secretions, or the child has been improperly fed, the eruption is attended with itching, pain and excoriation, resembling, on the lower parts of the body, the intertrigo of infants, or the irritation of the skin, Avith abrasion of the cuticle, produced by the stimulus of the urine; and it is, occasionally, like the latter, produced by not changing the diapers as soon as they become Avet, or re-applying those that have become saturated with the urine Avithout washing. In all cases of strophulus in which, from bad management or accidental causes, any degree of febrile excitement is produced, the eruption is increased in extent and severity, and con- stitutes the S. Volaticus. The eruption in strophulus is generally described as papular; but Plumbe would rather refer it to an over-distention of the cutaneous vessels, giving rise to the escape of minute portions of lymph beneath the cuticle. The predisposition to this affection consists in the greater degree of vascularity and irritability of the skin, and the extreme delicacy of the cuticle during infancy. The exciting causes are, over-feeding, a too stimulating diet, too rough and Avarm clothing, the irritation of teething, or any circumstance calculated to quicken the circulation, and promote undue determination to the skin. In the treatment of strophulus, the extent and intensity of the erup- tion must be taken into consideration. PRURIGO. 553 In the milder cases, and where the eruption is of little extent, nothing is required beyond a proper regulation of the patient's diet and clothing, gentle aperients, and the occasional use of the warm bath. During dentition, the gums should be attended to, and if inflamed or swollen, they should be freely scarified. When the disease is con- nected with derangement of the digestive organs, the same treatment will be required as would be proper were no eruption present. In aggravated cases, accompanied by much febrile excitement, an emetic, followed by mild aperients and minute doses of calomel, ipecacuanha and nitre in combination, with the tepid bath, and a mild, unirritating diet, will generally succeed in relieving the violence of the symptoms. If the eruption frequently recurs during suckling, it will be judicious to change the nurse. When it is attended with itching, pain and ex- coriation, much relief will be obtained.by bathing the parts frequently with any simple mucilaginous wash, as bran tea, infusion of slippery elm bark, or of the pith of sassafras. In cases in which the eruption continues for a long time, or fre- quently recurs at short intervals, the health of the patient is liable to become much deranged; and clusters of pimples of a dark colour, often arise on different parts of the body, terminating in brown ex- foliations, and accompanied by febrile symptoms; a brown, scabrous condition of the skin succeeding, often of long duration. This condi- tion is generally connected Avith more or less disease of the digestive organs, and demands for its removal minute doses of calomel, com- bined with magnesia and ipecacuanha, and some light tonic, Avith the daily use of the warm bath, and a well-regulated diet. Occasionally, change of air is attended with the best effects. 2. Prurigo.' An eruption of pimples, differing but little from those of strophulus, but usually less distinct, and flatter, and mostly confined to the outer surface of the limbs and trunk. Prurigo is attended by a sense of itching, which is aggravated by whatever induces an undue determination to the surface. By scratch- ing to relieve the intolerable pruritus which ensues when the patient is heated or excited, or warmly covered in bed, considerable heat and redness of the surrounding skin is produced, and the pimples becoming abraded, there issues from them a transparent or bloody fluid, which, concreting on the surface, forms thin crusts, of a brown or black co- lour. When the crusts separate, a dull, crimson mark often remains for some time. In children of a full, gross habit, the irritation of scratching or friction, gives rise, occasionally, to a superficial ulcera- tion, or pustule, terminating in the crust of impetigo. In the more aggravated form of this eruption, (P. Formicans,) the itching is intense and constant, resembling the crawling or stinging of insects: this is increased by heat, and by warm stimulating food. Oc- casionally white wheals and dark-brown crusts appear over different parts of the body, and attended often with a degree of tumefaction about the arms and legs, by Avhich the freedom of their movements is impeded. 554 DISEASES OF THE SKIN. Prurigo is most troublesome in the spring, and at the commence- ment of summer, and is apt to recur for months, and even years. It is usually accompanied by symptoms indicative, of more or less de- rangement of the digestive organs. It is commonly produced by ex- cess of food, or that which is indigestible, or has undergone some change by which its wholesomeness is impaired. Fish or oysters when out of season, will often produce it; it has occurred, in some cases, after a draught of cold Avater, or some acid drink. In certain con- stitutions, it will result from a very slight irritation of the stomach or bowels, and in others without any evident cause, excepting a sudden change in the temperature of the season, from cold to warm. In the greater number of the cases which occur in children, the dis- ease would readily give way to an emetic, followed by a mild cathartic, and a properly regulated diet, could we prevent the patient from con- stantly irritating the pimples by scratching and rubbing Avith his hands, which might generally be accomplished, by muffling or securing the hands, and frequently bathing the eruption with tepid water, or some mucilaginous wash. A watery solution of opium has occasionally suc- ceeded, in our hands, in allaying the irritation on the skin. In robust, plethoric habits, purgatives and a plain vegetable diet will, occasionally, be proper; and in violent cases, even the loss of a few ounces of blood may be demanded. In cases attended with de- rangement of the digestive functions, such remedies should be resorted to as are calculated to restore the latter to a healthy condition. The decoction of dulcamara, the hydrochloric acid, and the arsenite of potassa internally; touching the more prominent pimples with aro- matic vinegar, or a solution of hydrochloride of ammonia; lotions of the sulphate of potassa, the chlorate of lime, or of a solution, in water, of the extract of belladonna, or ointments of sulphur, have been re- commended for the cure of inveterate cases: we have, however, seen no case occurring in children in which we have found it necessary to resort to either of these remedies. A moderate, wholesome diet, a cooling regimen, attention to the state of the bowels and digestive organs, the daily use of the warm bath, and, as local applications to allay itching, and subdue irritation, frequent lotions with tepid water, or some simple mucilaginous wash, and occasionally with a watery solution of opium; and in cases in Avhich there Avas nothing present to forbid its use, an anodyne at night, are the remedies, which, in our hands, have never failed to subdue prurigo in children. 3.—Crusta Lactea. IMPETIGO LARVALIS VEL MUCOSA—PORRIGO LACTEA VEL LARVALIS—TINEA MUCIFLVJA— ECZEMA LACTEA. This eruption generally occurs upon some portion of the face, espe- cially upon the cheeks, and is more frequent during dentition than at any other period. It usually commences in one or more distinct red blotches which become studded with numerous, small, yellowish pus- tules, nearly confluent, and attended with considerable itching; and preceded and accompanied, in severe cases, by some degree of erysi- CRUSTA LACTEA. 555 pelatous inflammation. At the end of three or four days, and some- times earlier, the pustules burst, and discharge their contents, which dries upon the skin, forming concretions of a whitish yellow or greenish tinge, semi-transparent, and very friable. The crusts lie in laminae, some over-lapping others, or they are intersected by narrow pink or olive-coloured fissures. The discharge continues to ooze from under the scab, which grows constantly thicker. The incrustations may be confined to a small space, or occur on several parts of the face at the same time; or they may extend over nearly the whole face, covering it as with a mask. When the crusts are detached, the surface of the skin beneath them is found to be red and inflamed, and studded with numerous minute pores from which the discharge proceeds. The crusts usually remain attached from two to four weeks, when the secretion of matter diminishes, and the crusts separate, and fall off gradually, leaving a red, shining, and very tender surface, which, upon the slightest irritation, is liable again to form pustules, and re-produce the disease. In this manner, by fresh crops of pustules occurring after the separation of the scabs, the disease may be prolonged for an inde- finite period:—in such cases, deep chaps, and even ulcerations of the Bkin are liable to ensue. In prolonged cases, occurring in children of a lymphatic tempera- ment Avith fair hair, pale, delicate skin, and languid circulation, some degree of intumescence of the parotid, submaxillary, or cervical glands, will often occur. The matter discharged from beneath the scabs would appear to pos- sess some degree of acrimony, for the part of the child's breast which is brought frequently in contact with the diseased chin, when this is the seat of the eruption, soon becomes red, and exhibits an eruption of pustules, which terminate, as on the face, in a superficial ulceration. A similar effect is produced, occasionally, on the arms of the nurse who attends a child affected with crusta lactea. Even in the severest forms of the disease, no permanent marks are left upon the skin. The treatment will depend very much upon the period at which the disease is first seen by the physician. In ordinary cases, and in the earlier stages of the eruption, it will generally yield, very readily, to a proper regulation of the diet, in conjunction with mild aperients, minute doses of calomel, magnesia, and ipecacuanha, the daily use of the warm bath, and exposure to a fresh, pure atmosphere. The diet of children affected with crusta lactea should consist, either of the breast-milk of a healthy nurse, or, after weaning, chiefly of the farinacea, with or without milk, according as this is found to agree or not with the sto- mach ofjJie patient. The best local applications are emollient washes, and the watery solution of opium. When, however, from the long con- tinuance of the eruption, the general health of the patient has begun to suffer, it may be found necessary, in conjunction with a cautious course of alteratives, to administer some of the lighter mineral and vegetable tonics—as the tartrate of iron, the cold infusion of bark, or the infusion of gentian, cascarilla, or calomba. 556 DISEASES OF THE SKIN. When the inflammation has entirely subsided in the neighbourhood of the eruption, we have found one of the best local applications to be the unguentum nitratis hydrargyri, diluted by the addition of one-third portion of simple cerate. 4.—Impetigo. CRUSTED TETTER—HUMID TETTER—SCALL. An incrustation of an umber, sienna brown, or olive colour, appear- ing either in defined patches, (figurata,) or scattered over the surface, (sparsa.) This eruption appears in the form of minute pustules, collected to- gether in clusters, or dispersed irregularly over the surface. It gene- rally occurs upon the extremities; the clusters of pustules being usually smaller and more circular on the upper, and larger, oval, and more ir- regular upon the lower. The pustules appear either upon an inflamed surface, of from two to four days' duration, or in clusters, with a defined inflamed margin: they are accompanied with heat and smarting, in proportion to the extent and intensity of the inflammation. The pustules are slightly elevated, and, in two or three days after their formation, burst and discharge their contents, leaving a red and shining surface; the matter being evacuated through numerous minute orifices. When the pustules ap- pear in clusters, a crust is soon formed by the inspissation of the mat- ter ; from beneath which there is a constant oozing of a thin fluid, while around its edges fresh pustules often appear. When, from neglect or mismanagement, the disease is allowed to proceed, it may extend over the whole limb, which becomes encased in an almost continuous rugose covering, (/. Scabida.) The crust at the same time assumes a grayish brown colour, surrounded by a lake- coloured margin. There is considerable heat and itching in the limb, and its motions are impeded or completely obstructed. After a time, the incrustation presents deep cracks or fissures, through which the matter exudes, and drying, increases the thickness of the scabrous coating of the limb. When the disease extends to the hands or feet, an ulceration of a purplish hue takes place around the roots of the nails, which often drop off, and are succeeded by others of an irregu- lar form. The erythematous inflammation surrounding the eruption increasing in intensity, will occasionally give rise to slight vesications, (/. erysi- pelatoides;) and in these cases, the subcutaneous cellular membrane becoming involved in disease, the affection is one of considerable se- verity and danger. The crusts may separate as early as at the end of two weeks, or not until the termination of four or five. The healing process generally commences at the centre of the patches, and extends towards the cir- cumference. On the dull crimson surface left by the separation of the crusts, small, elevated spots occasionally occur, apparently vesi- cular, but in reality formed by indurated follicles. Impetigo is often combined with other forms of eruptive disease: thus, eczematous vesicles are often interspersed (Eczema impetiginodes;) IMPETIGO. 557 these are attended with little redness, but by great irritation, heat, and itching. The incrustations of impetigo differ from those of porrigo, by being slower of inspissation, more circular, thinner, browner, and less adhe- rent, and by their occurring, most generally, upon the extremities. The matter discharged is also purulent and glutinous—that of impetigo more thin and ichorous. The interspersion of vesicles causes some resemblance between impetigo and lymphatic scabies; the vesicles of the former are, however, slower in their progress, attended rather with heat and smarting, than with itching; while the cuticle is redder and more fissured, and the ichorous exudation more copious than in scabies. In mild cases, a simple, unirritating diet, a mercurial purgative, fol- lowed by a dose of the sulphate of magnesia, or of magnesia and pre- cipitated sulphur, with the local application of lotions of tepid water, or some mild, mucilaginous fluid, or a thin bread-and-milk poultice, Avith the occasional use of a watery solution of opium, comprises the whole treatment that is necessary. If any derangement of the diges- tive organs exists, this should be removed by an appropriate treatment. When the local inflammation in the neighbourhood of the eruption is severe and extensive, especially in plethoric habits, bleeding by leeches, or from the arm, Avill be demanded, with saline purgatives, and a very restricted diet; the inflamed part being covered with a soft linen rag,'wet Avith the liq. plumb, acet. dilut. In cases attended with considerable irritation, a few drops of the tincture of hyoscyamus may be given two or three times a day; or a pill composed of from one to tAvo grains of the extract of hyoscyamus, with the third of a grain of ipecacuanha, and one or two of carbonate of soda, may be given at bed-time. In the more severe forms of the disease, one of the best local appli- cations is the hydrocyanic acid, combined with alcohol,1 and applied, by keeping the parts covered with portions of linen constantly wet with the mixture; care being taken to remove entirely, by frequent ablutions with tepid water, the morbid secretions, so as to admit the lotion to be applied directly to the diseased surface; nothing, we are assured by Plumbe, is more efficacious in subduing the irritation ac- companying the eruption. Perseveringly employed, it will sometimes rapidly remove every vestige of the disease. 1 R-—Acid, hydrocyanic, giij. Aq. destil. .gvijss. Alcohol. £ss.—M. In the more obstinate cases, the internal exhibition of sulphur, or of the sulphuret of potassa, from five to ten grains, three times a day, in milk,—the decoction of dulcamara,—Plummer's pill, or the hydrargy- rum cum creta—with the external use of the sulphur baths, or sulphur vapour baths, should be resorted to. When, from the long continuance of the disease, a degree of debi- lity ensues, the decoction of sarsaparilla, or the infusion of gentian, cascarilla, or calomba, with the hydrochloric acid, may be resorted to. A pure, fresh air, and the utmost cleanliness of person, are important auxiliaries in all cases. 558 DISEASES OF THE SKIN. ERUPTIONS CHIEFLY CONNECTED WITH GASTRO-ENTERIC DISEASE. 5.—Erythema. A slight continuous redness of the skin, varying in extent and shape, and continuing from two or three, to ten or twelve days. Erythema may occur in patches, successively on the arms, neck, breast and face, (E.fugax.) This variety is usually observed in the progress of some febrile disease, or at the period of dentition; or it may be produced by slight irritations of the digestive organs. In other cases, the eruption appears in the form of bright red, irregular patches, chiefly on the arms, neck, breast, back part of the fore-arm, and back of the hand. The patches are at first somewhat papulated, (E.papulatum.) The slight swelling decreases within thirty-six or forty-eight hours, but the redness continues somewhat longer, and assumes, gradually, a bluish tint. The general disorder is usually trifling, though it is sometimes attended by symptoms of depression, and a quick, irritated pulse. The eruption sometimes assumes the form of a rose-coloured tuberculated swelling (E. tuberculatum;) or of a raised, indurated efflorescence: this variety generally continues seven or ei^ht days, and is attended by considerable heat of the skin, and some degree of febrile excitement. Erythema frequently occurs in large oval patches, of a deep red co- lour, upon the anterior part of the leg, in females towards the coming on of the menses, and in boys of a lymphatic temperament. The patches vary in number in different cases, and rise gradually above the level of the skin, (E. nodosum,) and are more or less painful when touched. They soften and subside in the course of eight or ten days; the redness slowly disappears, assuming in its decline a whitish tint. The tumours never suppurate. The eruption sometimes commences on the face, by a small, circular, red spot, slightly papulous, which gradually extends in circumference, and may, in this way, spread over the whole face, (E. centrifugum.) The patches are usually about an inch in diameter:—there is con- siderable redness as well as heat, principally at their margins, which are elevated, whilst the centre is depressed, and of the natural colour of the skin. They are attended with neither pain nor itching, and generally leave a slight depression of the part affected. The disease is usually of some continuance. Erythema may be produced, in children of a robust and plethoric habit, by external irritation; it is more generally, hoAvever, dependent upon some affection of the alimentary canal. Certain articles of diet, of" an indigestible or unwholesome quality, will, in some constitutions, cause its sudden appearance; it occasionally occurs, also, upon the use of some medicinal substances;—as rhubarb, balsam of copaiba, opium, &c. The eruption in these cases is generally of short duration. When it results from gastro-intestinal disease, it is commonly more severe and of longer duration. In languid and unhealthy constitu- tions, the eruption sometimes assumes a deep crimson, or a dull, dark purple hue, and is accompanied by symptoms of a typhoid character. In the slighter cases of the disease, little else is required, in the way of treatment, excepting a removal of the exciting cause, a proper ECZEMA. 559 regulation of diet, mild aperients, and the tepid or warm bath. When the eruption is attended with considerable irritation, heat, and itching, dusting the part with dry powdered starch, or bathing it frequently with tepid water, or any simple mucilaginous wash, will, usually, af- ford prompt relief. When it has arisen from an over-loaded state of the stomach, or improper food, an emetic of ipecacuanha should be administered. If it occur during teething, the state of the gums should be inquired into, and if swollen or inflamed, freely lanced. Whatever irritation may exist in the alimentary canal should be com- bated by an appropriate course of treatment. Severe cases occurring in robust, plethoric habits, and accompanied by considerable local heat, pain, and swelling, with symptoms of febrile excitement, will demand the application of leeches, or even bleeding from the arm, with saline purgatives, a restricted diet, and cooling lotions to the part affected; the patient, at the same time, being kept quiet and free from excitement. In languid habits, a course of mild alteratives, and light vegetable tonics, should be prescribed, with pure, fresh air, a nourishing diet, of plain digestible food, and the daily use of the warm bath, followed by friction of the surface. At the close of all severe cases, light tonics will be proper. 6.—Eczema. PRICKLY HEAT. An eruption of small, pearl-coloured, or brownish-coloured pink vesicles, with a very light rose-coloured base, preceded by a sense of heat or tingling. The delicate and irritable skins of children render them peculiarly liable to the production of this form of vesicular eruption on parts exposed, for a very short period, to the heat of the sun, (E.solare.) The application of heat from any other source will also produce the disease; and it frequently arises from irritations seated in the alimen- tary canal. When the vesicles of eczema occur between the fingers, especially if aggravated by scratching, they may be mistaken for those of scabies; but, the suddenness of the eruption, the more pointed vesicle, and the sensation of smarting, rather than of itching, readily distinguish them from the latter. When the eruption is more generally and extensively diffused, the vesicles, occurring in closer proximity to each other, with their inter- stices of a bright red colour, it constitutes the eczema rubrum. Between the sixth and eighth days, and sometimes earlier, the red- ness diminishes, the serosity is absorbed, the vesicles shrivel up, and a slight desquamation takes place, leaving, however, the skin redder than natural, and presenting, when carefully examined, a number of minute, round spots, surrounded by a thin, Avhite, ragged rim of cuticle, which indicates the extent of desquamation of each vesicle. The milder cases may quickly subside, Avithout the occurrence of desquamation, the lymph of the vesicles becoming opaque, and being then absorbed. In other cases, ucav vesicles arise, of larger dimen- sions; upon the rupture of which, a brownish scab forms, leaving the skin in a rugose state. In the more aggravated cases, there occur febrile symptoms and a general derangement of health from the ex- 560 DISEASES OF THE SKIN. tent and persistence of the irritation. (E. impetiginodes.) By long and repeated application of the exciting cause, the eruption may be- come more permanent, and less inclined to yield to simple remedies, (Chronic eczema.) The chronic form is, however, of unfrequent oc- currence in children. Vesicles resembling those of eczema are often produced by the ap- plication to the skin of plasters, ointments, and poultices. In the slighter cases, the treatment will consist in the removal of the exciting cause, the exhibition of mild aperients, a well-regulated diet, and the use of the warm or tepid bath, with slightly acidulated barley or toast water for drink. As local applications, tepid Avater, mucilaginous washes, or simple bread poultices are the best. Where there exists gastro-intestinal disease, this will demand its appropriate remedies. In the acute stage of the more severe forms, occurring in robust and plethoric habits, leeches, as well as bleeding from the arm, with saline cathartics, diaphoretics, and the antiphlogistic regimen gene- rally, will be often required. In protracted cases, the alkaline bath may be tried; or, as a local application, the hydrocyanic acid and alcohol, as directed in impetigo, with the cautious internal use of dulcamara. When great irritation, and loss of sleep occur, the tinc- ture of hyoscyamus may be given during the day, or an opiate at bed-time. In the impetiginous form, Avhen the eruption has become chronic, a weak solution of alum, or of the acetate or sulphate of zinc, in diluted alcohol, will be found useful. In all cases, the patient should be exposed to a pure atmosphere; his linen should be repeatedly changed, and friction of the surface carefully avoided. When, on the subsidence of the eruption, the patient remains in a languid, debilitated state, light tonics should be administered, with a plain, wholesome, nutritious diet. Change of air, under such circum- stances, will be advisable. 7.—Urticaria—Nettle Rash. An eruption of red, inflamed patches, irregularly distributed upon different, and often distant parts of the body;—sometimes small in extent and number, and at others, occupying a considerable portion of the skin. At the centre of each patch is situated a white irregularly formed spot, sometimes long and narrow, at others, broad or round, consider- ably elevated above the surrounding cuticle, and generally attended with a severe sense of itching, smarting, and tingling. The margin of the colourless tumour is very irregular, and when the finger is passed lightly over it, it presents to the touch considerable inequality of surface. The tumours, in the smaller patches of inflammation, are not unfre- quently in the form of small, distinct, circular tubercles, about the size of a spangle; but A\rhen several occur upon the same spot, they generally coalesce, and form a lengthened streak or wheal. The larger spots or wheals are mostly formed by the clustering together of a number of the circular white tubercles; and in proportion to URTICARIA. 561 their size, they are surrounded by a more or les=* vivid inflammatory redness; and a corresponding degree of heat, itching, and smarting attends them. When punctured with a finely-pointed instrument, there escapes from the white tubercles a thin, transparent fluid, and the swelling immediately disappears. The eruption, in the simple forms of the disease, seldom continues long, and is frequently so evanescent, as to disappear, after a few moments' continuance, from one part of the body, leaving no vestige of its existence; while, almost immediately afterwards, a distant part Avill be found occupied by it to a considerable extent. (U. evanida.) In very severe cases, suddenly produced by eating certain kinds of food, the tumefaction about the neck and face is often very con- siderable; not unfrequently closing up the eyes, and obliterating every vestige of the natural features. Even in these cases, the irri- tation and tumefaction will generally begin to subside at the end of thirty-six or forty-eight hours. The symptoms of the febrile form of urticaria ( U. febrilis) are much more violent, and its duration longer. In this form, the eruption is preceded by pain and sickness of stomach, headache, great languor or faintness—a sense of drowsiness and anxiety; there is increased quick- ness of the pulse, and a white coating upon the tongue. In two days, or later, a coldness and shivering are experienced, and patches of a vivid red, or even crimson hue, appear upon various parts of the sur- face, attended with a most troublesome itching or tingling, greatly increased when the patient is in bed or heated from any cause. On the appearance of the eruption, the pain and sickness of the stomach are in general relieved. The patches often coalesce, so as to produce a continuous redness, particularly on the shoulders, loins, nates, thighs, and about the knees. They are often elevated above the surrounding cuticle, and form dense tumours, with a hard distinct border—the interstices being of a dull white colour. (U. tuberosa.) The patches appear and disappear irre- gularly, first on one part, then on another; they may be excited, on any part of the skin, by strong friction, or scratching. When the patches are numerous, the face, or the limb occupied by them, appears tense, and considerably swollen. Towards the close of the disease, the eyelids are often red and tumefied, and swelling and inflammation occur on the sides of the feet. During the day, the redness of the eruption fades, and the wheals, in general, subside; but both increase, with a slight febrile exacerba- tion, in the evening. As the eruption declines, the tongue becomes clean, the pulse natu- ral, and the diseased state of the functions generally ceases: the efflo- rescence assumes a light purple or pink appearance, and then gradu- ally disappears, being followed by a slight exfoliation of the cuticle. The whole duration of the febrile nettle rash is from seven to eight days. The exciting causes of urticaria are various:—emotions of the mind; exposure to excessive heat, or over-exertion; in certain constitutions, particular kinds of food or drink, as almonds, kernels of nuts, mush- rooms, cheese, cucumbers, pie-crust, honey, different kinds of fruit, 36 562 DISEASES OF THE SKIN. or food rendered unwholesome from being out of season, or from having undergone certain changes, as mussels, clams, oysters, lobsters, crabs, and certain kinds of fish. In individuals whose skins are peculiarly irritable, slight external irritations will give rise to it: in such, par- ticularly when of a full habit of body, simple excess in any kind of food will act as its exciting cause. The treatment will depend upon the nature of the attack, and in some degree, also, upon the character of the exciting cause. The milder cases require little else than rest, a cooling regimen, diluent drinks, gentle aperients, and> tepid baths. Where the eruption has been caused by the ingestion'of certain articles of food, a brisk eme- tic, (the sulphate of copper,) followed by a dose of purgative medicine, (calomel and jalap,) should be administered; and if accompanied with severe nervous symptoms, the sulphuric ether, in doses of from five to twenty drops, according to the age of the patient, given every half hour, will generally be found very efficacious. When it becomes chronic, or repeatedly occurs in the same individual, great attention should be paid to the articles of food that are eaten, omitting first one, and then another, until the one by which the eruption is pro- duced is ascertained. In chronic cases, the alkaline baths will often be found useful; or, occasional laxatives, the mineral acids, and va- pour baths. In the febrile form, particularly when occurring in robust, plethoric habits, leeches, or the lancet, will often be required, with saline pur- gatives, and nitre, a restricted diet, and the antiphlogistic regimen generally. When from a sudden disappearance of the eruption, sickness and pain of the stomach, or faintness, or symptoms of some local affection, with an increase of the general febrile symptoms, and delirium or coma ensue—in the first instance, the warm bath, sinapisms to the ex- tremities, and small doses of ether or ammonia, will be required, and in the latter, bleeding, blisters, and pediluvia. W'hen urticaria occurs in debilitated constitutions, or when it as- sumes an intermittent type, the bark or sulphate of quinia must be pre- scribed; and should this fail, much benefit will, in many cases, be ob- tained from the use of the solution of arsenite of potassa, given in small doses gradually increased. 8.—Erysipelas. The proper infantile erysipelas of medical writers is happily of un- frequent occurrence in this country. It may occur within a few days after birth, and usually, according to M. Hervieux (L'Union Med., 1855) Avithin the first six weeks. In many instances, it is of intra- uterine origin. Although it seldom makes its appearance after the sixth week, still a few cases have been observed as late as the sixth or even twelfth month. The invasion of the disease is often extremely insidious. The in- fant appears somewhat morose; his sleep is diminished and slightly disturbed, and he is less inclined to suck than before: with these trifling symptoms, there is associated a small patch of redness, usually on the lower parts of the body, particularly about the nates, pubes, ERYSIPELAS. 563 groins, and umbilicus, which is painful upon pressure, and changes subsequently to a purplish or livid hue. In new-born infants, ac- cording to the observations of Meckel and Osiander, its origin in a large number of cases is umbilical phlebitis. The disease, it is certain, may commence on any portion of the sur- face. According to M. Hervieux the order of frequency of its oc- currence is upon the face, lower part of the trunk, and lower limbs, upper limbs, upper part of the trunk, scalp, and neck. As already re- marked, we have seen it most frequently begin on the lower part of the trunk, and on the inferior extremities. The erysipelatous inflammation spreads gradually and irregularly over the abdomen, along the back, and on the inside of the thighs: the parts occupied by it being swollen, hard, and extremely tender to the touch, as indicated by the movements and cries of the child. Generally, at the end of twenty-four hours, there arise upon the af- fected surface a few scattered vesicles, with inflamed livid bases, which terminate rapidly in gangrenous ulcerations. The vesicles ap- pear, in some cases, upon the first occurrence of the inflammation. and in others, not until this has continued several days: occasionally, vesication does not take place, and the disease is then of little danger or duration, the inflammation subsiding in two or three days. In those instances in which the inflammation is not very intense, it spreads rapidly in one direction, while it ceases in the parts originally affected; or suddenly disappearing at the part first attacked, it speed i iy reappears on some other, and, perhaps, remote portion of the surface. and in this manner, may successively invade every part of the skin. In many cases, the skin surrounding the inflammation, to the dis- tance of nearly an inch from its margin, is hard to the touch, and cannot be pinched up or moved over the subjacent parts, as in a state of health. In the majority of cases, this results from the infiltration with serum of the cellular membrane surrounding the inflammation. When vesications appear early, the gangrene generally spreads rapidly, and the case soon acquires a very dangerous and hopeless character. This is more apt to be the case when the inflammation occurs upon the abdomen; on the extremities and nates it is more liable to terminate in deep-seated suppuration, with destruction of the subcutaneous cellular structure. When suppuration occurs, the pus is of a grayish colour, and of a very thin sanious character: it penetrates through the cellular membrane, beneath the skin, and betAveen the muscles. Small portions of the skin finally slough off. and give exit to the confined matter, mixed with flocculi and large shreds of sphacelated cellular membrane. The genital organs, in some cases, sphacelate when the disease extends to them, and in many ac- quire an emphysematous appearance. In some rare instances the disease has been known to continue for fourteen or fifteen days, with but little vesication, and no diffused suppuration. Iii the more violent form of the disease, the cessation of the gan- grene is marked, in the early stages, by a white line of demarkation; and in the latter stages of the more protracted cases, by a secretion of healthy pus taking the place of the ichorous or sanious discharge. 564 DISEASES OF THE SKIN. In many cases the erysipelas would appear to be at first a perfectly local affection. Several days elapsing before any remarkable degree of general restlessness, crossness, and fever presents itself. In the early period of the disease, there is often considerable feb- rile reaction, which, upon the occurrence of vesication, assumes a low typhoid character: upon the approach of suppuration, there is always more or less depression of the vital energies—though in many cases, the tendency to sinking is evident from the commencement of the attack. Frequently the colour and expression of the countenance remain for some days without exhibiting any striking change; when suddenly an ashy, cadaverous paleness is observed ; the child cries incessantly; there is constant jactitation and complete loss of sleep, with a fre- quent pulse and increased heat of the skin. These symptoms are suc- ceeded, more or less rapidly, by stupor and death. Few cases occur in which the indications of gastro-intestinal disease are Avholly absent. There is generally more or less tenderness of the epigastrium—griping colicky pains—constipation, or frequent discharges from the boAvels of a thin, grass-green fluid, preceded and accompanied with griping. Convulsions are not unfrequent. Those portions of the surface of the body which are not occupied by the erysipelatous inflammation, often present a slightly jaundiced appear- ance, and the urine usually contains bile. The disease varies in its duration; thus it may run its course in a few days or not until the end of the fourth or fifth week. A very common form of erysipelas in infants, according to our ex- perience, is that described by Dr. Friebe in the Journal for the Dis- eases of Children, under the name of Omphalitis exsudativa. It com- mences about the umbilicus, Avithin a few weeks after birth, and is frequently accompanied with ulceration of the navel, and infiltration of lymph or pus into the subcutaneous cellular tissue, and deposits of a similar nature in the partially obliterated umbilical vessels. It is attended by great and rapidly increasing exhaustion, and occasionally convulsive symptoms of more or less severity. It usually proves fatal; often within the course of forty-eight hours, and without having extended more than three fingers' breadth around the navel. Dr. Friebe is inclined to vieAv the disease as a variety of partial induration of the cellular substance, in consequence of the cachectic condition of the infants in whom he has seen it occur, and the erysi- pelatous character of the inflammation; while the circumstance of the umbilical vessels being in part converted into fibrous cords, pre- viously to the commencement of the disease, leads him to believe that it cannot arise from umbilical phlebitis. He appears to have seen but three cases. We have met with it among the infants of the poor much more frequently, and our observations have convinced us that, in the majority of cases at least, it is dependent upon phlebitis of the umbilical veins; the evidences of inflammation of the latter were un- questionably present in almost every instance in which we have made an examination. M. Trousseau remarks that the umbilical vein is often found inflamed and filled with pus, as far as the transverse furrow of the liver, while inflammatory exudations are found on the ERYSIPELAS. 565 peritoneal surface of the abdominal viscera. M. Trousseau has ob- served that, in infants predisposed to erysipelas, the umbilical cica- trix does not form readily, and the ulceration which results-is some- times the occasional—the local—cause of the cutaneous disease. In older and more robust children, erysipelas presents itself under the same forms as in the adult. A bright scarlet, shining efflorescence appears upon some portion of the skin, preceded for a day or two by heat, and a sense of tingling, and some degree of febrile reaction. The disease occasionally declines by the third or fourth day, the skin assuming a yellowish hue, and desquamating. In other instances, the disease runs a more protracted course; vesications, more or less ex- tensive, form upon the inflamed surface, which sometimes become filled with a purulent fluid. More commonly the vesications rupture in the course of two or three days, and give discharge to a thin, glutinous fluid. In other cases, the inflammation extends more deeply, and is attended with symptoms of greater severity. Rigours and severe feb- rile reaction precede the local disease, which is attended with consi- derable swelling of an oedematous character: suppuration early occurs, and a thin, purulent sanies is formed, which travels along the cellular structure, beneath the skin, and among the muscles and tendons, mixed often with clots of thin, grumous blood. The disease, unless energetically treated in its early stages, is noAV very liable to assume a gangrenous character, attended with great depression of the vital energies, and most commonly terminating in death. In the acute stage, inflammation of the cutaneous vessels is occasionally observed, and often purulent depositions take place in the serous cavities, and in the lungs. In the examinations that have been made of infants who have died from erysipelas, phlebitis of the umbilical vessels has been occasionally met with; we have observed it in a number of cases. Inflammation of the peritoneum, with puruloid or serous effusion into the cavity of the abdomen, is more commonly met with. Pleuritic inflammation, with effusion, is more rare—pneumonia, vesicular, lobar, and lobular, is very frequent; enteritis is one of the most common morbid ap- pearances, although occasionally gastro-enteritis occurs. Various opinions have been advanced in regard to the causes of infantile erysipelas. So far as our own observations extend, the dis- ease Avould appear to originate, almost exclusively, in infants exposed to a confined and impure atmosphere, or in respect to Avhom proper attention is not paid to maintain a scrupulous cleanliness of their persons, bedding, and clothing—who are alloAved to lie for hours with diapers imbued with excrement and urine, or, if their diapers are removed more frequently, having them hastily exchanged, Avith- out the surface being properly washed and dried, for others that have been Avorn already, and merely dried. Bad nutriment, no doubt, contributes, in the majority of cases, to the production of the disease. Erysipelas of infants very commonly occurs during the prevalence of epidemic puerperal fever—children of mothers avIio become affected with the fever, are often born with erysipelatous inflammation; others are attacked almost immediately after birth. Whether, in these cases, 506 DISEASES OF THE SKIN. the disease is to be referred to a morbid matter applied to the skin in the womb, or to the same epidemic or endemic influence Avhich gives rise to the disease of the parent, it is difficult to say. Accord- ing to M. Trousseau, infantile erysipelas is principally observed when puerperal fever prevails in the wards of the lying-in hospitals of Paris. The infants appear to him to inherit from their mother a purulent diathesis, and seem to be still, Avithin certain limits, subject to the same maladies as the mother. The disease is one always of a very serious character. The larger number of young infants who are attacked by it die. Those of a more advanced age have a greater chance of recovery. The fatality of infantile erysipelas is influenced, to a great extent, according as we have it in our power or not to place the patients immediately under appropriate hygienic condition. In the treatment of erysipelas, as it occurs during infancy and early childhood, the nature of our remedies must be governed by the stage of the disease, and the character of the symptoms in each case. In a large number of cases, every remedy of a debilitating character is strongly counter-indicated, and the early symptoms of prostration which present themselves, force us at once to resort to such measures only as are calculated to support the patient's strength. In every- instance, it will be proper to pay attention, from the onset of the disease, to the condition of the bowels. A grain or two of calomel, followed in a few hours by a teaspoonful of castor oil, or laxative enemata, will be sufficient to procure a free evacuation of the intestines, without much irritation, and they may be kept in a regular state subsequently, by the exhibition, every three hours, of divided doses of calomel, combined Avith ipecacuanha and extract of hyoscyamus1—the addition of the latter is calculated to prevent or allay irritation, without interfering Avith the aperient action of the other articles. When the skin is warm and dry, the liquor ammoniae acetatis alone, or combined Avith antiraonial wine, Avill often be found beneficial.2 Under the same circumstances, the occasional use of the warm or tepid bath will prove highly advantageous. 1 J£.—Calomel, gr. iij.—iv. * R.—Liquor, acetat. ammon. ^ij. Ipecac, pulv. gr. iij. Vin. antimonii, njjxxxv.—xlv. Garb, sodse, gr. xij. • Aq. cort. aurant. 5J. Ext. Hyoscyami, gr. iv.—vj.—M. Sacchar. puris, 3'j.—M. f. ch. No. xij. Ten to thirty drops, every two or three One for a dose. hours, may be given. If, with a hot and dry skin, there should occur symptoms of cerebral irritation, as intolerance of light, screaming, or convulsions, a leech or two should be applied to the temples, and cold applications to the scalp—the boAvels should be freely opened by castor oil, with the ad- dition of turpentine, and warm pediluvia should be resorted to. There cannot be a doubt that cases frequently occur in young children, which in their early stage are accompanied by symptoms that indicate the employment of local depletion, and that in these, a few leeches applied upon the sound skin in the neighbourhood of the inflamed parts, will prove positiA-ely beneficial; we have repeatedly met with such cases, and proved the good effects of the practice. ERYSIPELAS. 567 Much judgment, however, is required to discriminate the kind of cases which are likely to be benefited by local depletion, and to de- termine to what extent it may be prudently carried:—as a general rule, a very moderate abstraction of blood will be sufficient. When a tendency to gangrene is obvious, and the disease assumes a low typhoid character, it Avill be necessary to resort, at once, to the use of the carbonate of ammonia, in doses adapted to the age of the patient, and the urgency of the symptoms; and, at the same time, the child should be nourished at the breast of a healthy nurse, or, if Aveaned, its diet should consist of animal jellies dissolved in water, beef tea, chicken water, or sago. Where the symptoms of prostra- tion are more considerable, we may combine the use of the ammonia Avith the sulphate of quinia, and the extract of hyoscyamus. R.—Sulph. quiniae, gr. ij.—iij. Extract, hyoscyami, gr. ij.—iij. Magnesias calcinat. gr. xxxvj.—M. f. ch. No. xij. One to be given for a dose every two or three hours. Hamilton Bell of Edinburgh, recommends the tincture of the mu- riate of iron in infantile erysipelas—two drops to be given in a tea spoonful of sweetened water, every two hours. We have employed the tincture of the ammoniated tartrate -of iron, in small doses every hour, so that from twenty to thirty drops, or even more may be taken every three hours, and the effect of the remedy has appeared to us decidedly beneficial. Should diarrhoea ensue after suppuration has taken place, it should be immediately checked by the cretaceous mixture, with the addition of tincture of kino and laudanum; or, if this should pot succeed, the acetate of lead, ipecacuanha and opium may be substituted. R.—Acetat. plumbi, gr. xij. Ipecac, pulv. gr. iv. Opii pulv. gr. j.—M. f. ch. No. xiv. One to be given for a dose three times a day. When the discharges from the bowels are of a vitiated character, or attended with griping or colicky pains, a few drops of turpentine, three times a day, will be found a very valuable remedy. The tur- pentine may be combined with the tincture of kino and laudanum. R.—Aq. cinnamom. Jiij. Tinct. kino, ^ij. Spir. terebenth. gj. Magnesias calc. gr. viij.—M. A teaspoonful may be given at a time, three times a day, or oftener. Various local applications have been recommended by different practitioners, as highly beneficial in the treatment of infantile erysi- pelas, while by many these are denounced as invariably injurious. Washing the parts frequently with tepid water, or some mucilaginous fluid, will, in many cases, be productive of very great relief to the patient, and we think that we have seen an abatement of the disease take place under its use; in the intervals, the parts may be dusted with poAvdered starch, or covered Avith carded cotton. When the disease is attended with considerable distention of the skin, a lotion composed of the acetate of lead and subcarbonate of ammonia, (half a drachm of each dissolved in eight ounces of water,) 568 DISEASES OF THE SKIN. has been highly recommended. Other washes have been proposed as occasionally very beneficial, but of the effects of which we have no ex- perience—as the camphorated tincture, applied by covering the dis- eased parts with rags wet with it; a solution of corrosive sublimate, three grains to an ounce of water, applied in the same manner; a so- lution of nitrate of silver, three grains to the ounce of water, similarly applied. Applying, once or twice, a very strong solution of the ni- trate of silver, by means of a pencil, upon the sound skin, for about an inch around the margin of the diseased parts, has been said to ef- fectually arrest the progress of the disease. The chloride of lime, in solution, half a drachm to the pint of water, and applied by folds of linen saturated Avith it, is said to be one of the best Avashes, in cases which early show a tendency to gangrene. A solution of the sulphate of iron, half an ounce to eight ounces of water, has also been employed with advantage by Velpeau. This is said to have subdued the erysi- pelatous inflammation in two days. We have used a wash of acetate of lead, ten grains to the ounce of water, in many cases, with the very best effects, but our favourite ap- plication, in the ordinary cases of the disease occurring in children, is fresh lard, with the addition of acetate of lead, in the proportion of ten grains to the ounce. To* those cases which exhibit, from the first, a decided tendency to gangrene, this application is not adapted. The local remedies just recited are to be employed in the early stage, pre- vious to the rupture of the vesications, and to the occurrence of sup- puration or gangrene. Among the local remedies which appear to be the most generally applicable to erysipelas occurring in children, is a blister, sufficiently large to extend over the diseased surface, and for a short distance beyond it; after vesication has been produced, the serum should be evacuated, and the vesicated surface dressed with fresh lard. When the erysipelas occurs upon the extremities, a blister applied around the limb beyond the affected surface, will frequently arrest the pro- gress of the disease in that direction. In the cases in which we have resorted to blistering, we have usually applied strips of leather, spread with blistering ointment, along the edges of the inflamed part, partly on the latter, and partly upon the sound skin, and at the end of three hours, have removed them, and immediately covered the parts with a soft emollient poultice, with the addition of lard. The most im- portant result which we have derived from the use of blisters, is the prevention of the spread of the disease. The mercurial ointment has been strongly recommended in the treatment of infantile erysipelas, as well as in that of adults, by Dewees and Metmehyr. The mode in which it is applied is to cover the diseased surface with a piece of soft linen, with the ointment spread upon it: Ave have never employed it; preferring to keep the in- flamed skin constantly covered with a coating of perfectly fresh lard. In many cases, attended with an intolerable sensation of burning, we have seen some good result from the use, as a lotion, of a watery solution of opium. In those instances in which the disease is attended with conside- PHLEGMONOUS TUMOURS. 569 rable restlessness, and when the patient is prevented from sleeping at night, a few grains of the Dover's powder, or a dose of the cam- phorated tincture of opium, adapted to the age of the patient, should be given at bed-time. When erysipelas terminates in gangrene, washes of a solution of the chloride of lime or soda, of a few drops of creasote, diffused in Avater, or of a strong decoction of galls or black oak bark, should be immediately employed; or the sphacelated surface may be covered with either the charcoal or yeast poultice. Pencilling the edges of the gangrenous ulceration Avhich often ensues, with the creasote wash, or the balsam of tolu, will occasionally arrest its progress. We have seen, we think, good effects result, in some instances, from Avashing the gangrenous surface with a very strong solution of the sulphate of copper. In all cases in which the cellular membrane is involved in disease, free incision should be early made, as well to unload the vessels, and relieve the swelling and distention, as to give exit to the purulent fluid and dead portions of cellular structure. The pus, if allowed to remain, by making its way beneath the skin, and between the mus- cles and tendons, has a tendency to increase the extent of the disease, and to cause the death of the patient, by the irritation and exhaus- tion to which it gives rise. After the incisions, the parts should be covered with a soft emollient poultice. The patient, or the affected limb, should be kept at rest, and the inflamed part, if possible, some- what elevated, so that the flow of the blood from it may be facilitated by gravity. Should indications of pulmonary or cerebral disease occur in cases of erysipelas, these will demand their appropriate remedies. When convalescence has been established, and a degree of weak- ness and languor remains, some light mineral tonic, with the mineral acids, should be administered, and the child should be allowed a nu- tritious, but mild and easily digested diet; he should be immersed daily in the warm or tepid bath, and enjoy a dry, fresh, wholesome atmosphere. 9.—Phlegmonous Tumours. These occur on various parts of the surface of the body, either as indications of internal disease, or of some constitutional derangement. They are often critical when they occur at the decline of acute febrile diseases. They have received a great variety of appellations, but may all be included under the general denomination, phlegmon. There are two leading species: the one involving the cutis, and the cellular tissue beneath, often to a great extent; while the other is con- fined to, and only involves, in the suppurative process, the substance of the cutis. The first appears in the form of a painful, dark-red, circumscribed tumour, of a somewhat conical form, excessively painful to the touch, and often attended with more or less febrile excitement. At the apex of the cone, a little white speck or slough is generally observed, which 570 DISEASES OF THE SKIN. when picked off, is not followed by the discharge of matter, but leaves an excavation of a corresponding size and shape. It is very probably, Plumbe remarks, that the matter is formed, in this species of phlegmon, within a very few days after the occurrence of the disease, deeply im- bedded in the cutis, and is prevented from making its way to the sur- face, in consequence of the thickening of the superincumbent structure from adhesive inflammation. The second species is in the form of a dark-red, lenticular swelling, very painful to the touch, and slow in maturating. When pressure is applied to the sides of one of these small tumours, soon after suppura- tion has commenced, a transparent serum exudes. Pus first appears in a minute yellow elevation on the centre of the tumour, the surround- ing parts of the latter being hard, solid, and painful. The abscess sel- dom gives discharge to much matter, and in most cases, where the in- flammation is not very obvious at the surface, a small portion of the cutis is destroyed and comes away in the form of a slough. After the excavation, formed by the separation of the latter, is filled up, and the inflammation has subsided, a thickened and hardened condition of the part, which is of a bluish colour, remains, and is only slowly re- moved. These phlegmons appear in the greatest number upon some portion of the trunk, particularly the abdomen, while the first species occurs most commonly on the arms, thighs and nates. (Fosbrooke, Plumbe.) We have very frequently seen the latter in children of a gross habit of body, upon the back part of the neck, and between the shoulders. They are always of a chronic character, and very generally a new crop makes its appearance as fast as the first subsides, and they con- tinue thus to occur until the diseased condition of the system, by which the local affection is produced, is overcome. Children of full, gross habits, and who are fed upon coarse and rich food, are most subject to phlegmonous tumours. They are more common during the spring and summer than at the other seasons of the year. When extensive, they often give rise to a greater or less degree of fe- brile excitement. The proper treatment consists in placing the patient upon a plain vegetable diet; the evacuation of the bowels by a dose of calomel, fol- lowed by a saline cathartic, and free exposure to a fresh, pure atmo- sphere ; and when the phlegmonous tumour is very extensive, hard, and painful, particularly when accompanied by febrile symptoms, the appli- cation of a few leeches to its centre. The early suppuration of the tumour should be encouraged by the application of large emollient poultices, of which the best are those composed of the crumb of stale bread, or linseed meal, boiled in milk, with the addition of lard. When suppuration has taken place, and the matter does not readily find its way to the surface, the abscess may be opened with a lancet, and the application of the poultices con- tinued. In general, in a few days, the excavation will be filled up with healthy granulations, and completely cicatrized. If, after the abscess bursts, or is opened, it exhibits no disposition to heal, it should be dressed with the common resinous ointment. PHLEGMONOUS TUMOURS. 571 In the second species of phlegmon, the use of the sulphuric acid in- ternally, continued for a length of time, has been said to prove pecu- liarly efficacious. It should be used largely diluted with water, and in as large doses as is compatible with the age of the patient. Under its use, we are assured by Fosbrooke, that the pain of the tumours is deadened, and the latter gradually absorbed, without suppuration. An alterative course of treatment, continued for many weeks, with the use of the compound decoction of sarsaparilla, will, in general, be required. Children, who are subject to boils, should be restricted to a light, unirritating diet, composed chiefly of farinaceous substances; they Bhould use daily exercise in the open air, and be daily immersed in the warm or tepid bath. Children are often affected with a phlegmonous inflammation of the glands of the neck and groin, unconnected with indications of scrofu- lous disease, and occurring under the same circumstances as the cuti- cular phlegmon. Its treatment differs in nothing from that recommended for the more extensive forms of the latter; low diet, saline purgatives, and the ap- plication of leeches, and of cooling applications when a considerable degree of inflammation is present; and when the tendency to suppu- ration is evident, emollient poultices frequently repeated. In many cases the inflammation and swelling of the glands are of an indolent character, and will often remain for a considerable time without either increase or diminution. In these cases we have gene- rally found the application of a blister to cause a rapid suppuration to ensue. When an abscess forms, it should be early opened by a free inci- sion, and the application of the poultices continued, until the cavity is filled up by granulations, and a disposition to cicatrization is ap- parent. There is a form of phlegmonous abscess of common occurrence in children which we have not seen noticed by any writer. It is conse- quent upon a deep-seated inflammation beneath the fascia, upon the anterior part of the thigh, or upon the lower part of the back; some- times immediately above the hip. It may, perhaps, appear in other parts, but the above are the only ones in which we have seen it. The disease is generally met with in children of a lymphatic temperament. The first symptoms are usually deep-seated, dull pains at the part Avhere the inflammation occurs, Avhich are often'increased at night, and always upon the application of pressure. If the inflammation take place in the thigh, or upon the hip, the child walks lame: in many cases, Avhen in the latter situation, the symptoms bear a strong resemblance to those of morbus coxarius, for which the disease may be mistaken by an inexperienced physician. There is at first no redness or increased heat of the part, and but little or no swelling:—by degrees, however, a swelling is perceived, which gradually increases in extent, and finally, upon a cautious examination, a fluctuation of matter may be detected. The skin over the tumour is smooth and shining, and very tense, and a deep-seated, throbbing pain, increased by paroxysms, is complained of:—it is often so severe as to deprive the child of his rest. 572 DISEASES OF THE SKIN. In children over four years of age, we have seen, after suppuration has occurred, a well-marked hectic fever, with two exacerbations in the course of the twenty-four hours, profuse perspirations at night, and occasionally colliquative diarrhoea. We have never observed any dis- position in these abscesses to approach the surface; this has usually been prevented by the matter forming beneath the aponeurosis or fascia enveloping the muscles. Occasionally, the matter in the thigh has travelled downwards, and given rise to a swelling in the neighbour- hood of the knee; and in one case in which the abscess formed in the lower part of the back, the matter found its way to the groin, Avhere it formed a fluctuating tumour of considerable size. When the con- tents of these abscesses is discharged by an incision, it is of a healthy appearance, though occasionally containing flocculi, and large frag- ments of dead cellular matter. The treatment Ave have pursued in these cases is, in the early stage, the application of leeches over the seat of inflammation, followed by blisters—a dose of calomel, succeeded by saline cathartics, and if the discharges from the bowels are of an unhealthy appearance, the admi- nistration, three or four times a day, of small doses of calomel, in com- bination with ipecacuanha, extract of hyoscyamus, and magnesia. The moment matter is formed, we consider it all-important to make a free incision down to the abscess, and then to dress with emollient poultices. This gives relief to the pain, and the patient, in general, very quickly recovers his usual health; though, in cases in which there exists considerable exhaustion, the administration of some light tonic will be proper. In one case, occurring in a lad between eight and nine years of age, attended with hectic fever, night sweats, and a profuse diarrhoea, the stools being thin, dark-coloured, and very fetid, upon a free incision being made to give discharge to the contents of the abscess, which was seated upon the anterior surface of the left thigh, a manifest improve- ment in the condition of the patient was almost immediately manifested. For the relief of the diarrhoea, a powder composed of the sixth of a grain of sulphate of copper, subsequently increased to one-fourth of a grain, the third of a grain of opium, and two grains of the extract of quinia, was administered every three hours. On the fourth day, the evacuations from the bowels were reduced to two in the twenty-four hours, and became of a natural appearance; all symptoms of fever were gone, and the appetite and strength of the patient considerably improved. In a week, he was able to walk about, and quickly regained his normal degree of health. The left thigh, however, remained, for some time longer, less in size, and the whole limb much weaker than the other. Inflammation, followed by suppuration, frequently attacks the ciliary and follicular glands of the eyelids, in which case a small dark-red tumour forms upon the tarsal edge of one of the eyelids, attended with some SAvelling and redness of the lid, redness and injection of the eye, aversion from light, and considerable soreness, increased by the mo- tions of the eye or eyelids, (hordeolum, stye.) The disease usually oc- curs under the same general circumstances as the other phlegmonous PHLEGMONOUS TUMOURS. 573 tumours. After the inflammation has continued for a shorter or longer period, a white or yellow speck forms at its centre, which, on bursting, gives discharge to a small quantity of pus, Avhen the inflammation and [swelling quickly subside, and finally disappear. It is very usual for a succession of these little phlegmonous tumours of the eyelids to occur; no sooner one set disappears, than another makes its appearance, and runs the same course. When the inflammation and swelling are considerable, a leech or two should be applied to the lid, and calomel, followed by saline ape- rients, administered, so as to procure a free discharge from the bowels; the diet being at the same time carefully regulated. Aery warm Avater applied frequently to the inflamed lid, by means of a sponge, or a soft poultice of crumb of bread and milk applied over the closed eye, maybe used to promote suppuration:—as soon as this takes place, the minute abscess should be opened by means of a fine sharp-pointed lancet, and the stye then cautiously touched with the point of a pencil of lunar caustic. This causes the quick subsidence of whatever inflam- mation and swelling may remain, and prevents the induration and red- ness, which often continue for a considerable time, especially in chil- dren of a weakly or lymphatic temperament. Should the latter, how- ever, occur, they may be moderated by a poultice, composed of crumbs of bread, a grain or two of the extract of belladonna, and the campho- rated tincture; or, perhaps, what is better, by touching the part with lunar caustic. A chronic inflammation of the ciliary bulbs not unfrequently takes place, which by degrees pervades the entire ciliary circle, and, if not checked in its early stage, terminates in a chronic inflammation of the edges of the eyelids, accompanied by a slight glutinous discharge from the ciliary glands. In time the bulbs lose their power of secreting the eyelashes, which fall out; and the loss of these, with the permanent red circle which surrounds the eye, causes no inconsiderable deformity. (Tinea ciliaris, lippitudo, chronic stye.) This affection most generally occurs in children of a weakly, un- healthy constitution, and of a lymphatic temperament, and it is very commonly conjoined with a more or less disordered condition of the digestive organs. In the early period of the inflammation, leeches should be applied in the vicinity of the lashes, folloAved by the application of Avarm water, or soft emollient poultices, and after the disease has assumed a chronic form, the unguentum hyd. nitratis diluted, or the cautious use of the nitrate of silver, will generally effect a cure. But these local remedies will be of little service, unless attention be directed to the condition of the general health of the patient, and to the state of the digestive organs. The first should be strengthened and invigorated by a proper diet, daily exercise in the open air, the warm or tepid bath, followed by friction of the surface, or by sponging the skin daily with salt water of tepid warmth, followed by friction, and by the administration of light tonics and alteratives. The healthy functions of the digestive organs should be restored by a course of treatment adapted to their particular condition, which it is unnecessary here to particularize. 574 DISEASES OF THE SKIN. 10.—Herpes. An eruption of transparent vesicles, varying in size from that of a millet seed to that of a pea; either distributed like a belt around, or partly around the body, (H. zoster, zona,) or in defined clusters, (H phlyctaenodes,) or in circular patches around an inflamed area, the surface of which desquamates as the vesicles decline, (H circinnatus;) or, very rarely, in three or four concentric circles, or rings of varied and beautiful colours, and elevated above the surface of the surround- ing skin. When the eruption takes place around the lips, as it often does towards the decline of catarrhal fevers, or in the course of va- rious disorders of the digestive organs, it has been denominated herpes labialis. The herpetic eruption may occur on various parts of the body, and is generally preceded by some degree of febrile excitement, which is often so slight as scarcely to attract attention; or by pain in the epigastrium, and other symptoms of disease of the digestive organs. The fever and other symptoms,—particularly languor, loss of appetite, headache, nausea, pain of the abdomen, heat of the surface, and hur- ried circulation,—generally remain as long as fresh vesicles continue to be produced. The abdominal pain usually pursues the course of the eruption, being felt at the regions of the stomach, liver, &c, when around the waist; and when upon the shoulder, deep-seated pain of the scapula, spine, or, as the eruption extends down the arm, of the os humerus, is complained of. The eruption makes its appearance in the form of a bright red efflo- rescence, accompanied by a sense of heat and tingling. The redness is distributed in patches, varying in size, and separated from each other by a greater or less extent of the surface retaining its natural colour. Upon the largest of these patches, near its centre, a few small vesicles arise, and still fewer upon the adjoining patches, and upon the next perhaps none, or only a minute pimple, which in an hour or two, becomes a perfectly formed vesicle. Slight pressure at this period produces a sensation of prickling; but, as the disease advances, it is attended with a severe smarting pain. Within tAventy-four hours, the vesicles that first appeared attain the size of small pearls, and se- veral of those Avhich are the closest together, coalesce, and form a large irregular blister, the areola of inflamed skin being also increased. The eruption extends, in an irregular line, from the spot where it first commenced, to distant parts of the surface, by the occurrence of a succession of inflamed patches and vesicles, which continue to appear for four or five days: at the end of this period, the first formed vesi- cles become opaque, shrivel up, and terminate in a brown scab, that is gradually extended by a similar change taking place in the other vesicles of the same cluster:—the inflamed patch upon which they are situated at the same time acquires a bluish tint, and loses all appear- ance of heat and irritation. In about two weeks from the appearance of the eruption, the scabs separate, and leave a tender, discoloured state of the skin, which gradually disappears: in some cases, however, the disease is protracted to twenty or twenty-seven days. HERPES. 575 When the constitution of the patient is much diseased, or the erup- tion has been improperly treated, small white sloughs occasionally form at the points occupied by the vesicles, leaving permanent pits or scars upon the skin, after the healing process is completed. A slight eruption of herpes, and one limited in extent, is apt to as- sume a circular form, and hence has obtained the popular appellation of ringworm. In such cases the vesicles are sometimes extremely minute, and they generally soon dry up, the cuticle falling off in a few days, in the form of small exfoliations, leaving a reddened scurfy areola. This form of herpes occurs on different parts of the body, and seldom requires much attention. Herpes labialis is not often a very troublesome form of the disease; it generally goes through its course in a week or ten days; the vesi- cles first becoming turbid and yellow, then drying up, and ultimately falling off, in the form of scales. The posterior part of the fauces is sometimes affected, when the disease appears suddenly, after checked perspiration and cold; a feAV vesicles being distributed upon this part, surrounded by an erysipelatous redness. The causes of the herpetic eruption have not been very accurately determined. It is most commonly met with in persons of a lymphatic temperament, and is most prevalent in warm climates and seasons, and in the neighbourhood of marshes. It sometimes prevails epidemi- cally. We have already noticed the occurrence of one variety, to- Avards the close, or during the course of catarrhal and gastro-intesti- nal disease. It is often observed in infants, during the period of den- tition. Sudden suppression of perspiration—sudden changes in diet and regimen—the habitual use of food of a fatty or oily nature, or of fish, and inattention to personal cleanliness, have been enumerated, as common exciting causes of herpes. Like erysipelas, the disease is said, by some authors, to occur after violent paroxysms of anger. The different varieties of herpes require but little treatment. It would be useless, if not dangerous, to attempt to suppress the erup- tion. The tingling, smarting, aching and burning by which it is ac- companied, may, however, be allayed, and in this manner the patient rendered more comfortable, by lotions composed of a solution of ace- tate of lead, with a slight addition of alcohol, or by the application to the part of the ungt. plumbi acetatis. In the more severe cases, the strictest rest should be enjoined, with the antiphlogistic regimen ge- nerally, the tepid bath, and occasional doses of some mild aperient, as sulphur and bitartrate of potass, or sulphur and magnesia. When the eruption is confined to a very small space, and the vesicles are very minute, the application of substances possessing slightly caustic or powerfully astringent properties, will often speedily effect its re- moval, as the juice of the green rind of walnuts, tincture of galls, or a strong solution of the sulphate or acetate of copper; but, under all other circumstances, such applications will prove decidedly injurious. If each vesicle is carefully punctured, so as to allow the escape of its fluid contents, the pain will be much diminished, and the irritation more speedily subside; but the vesicles must not be cut or rudely broken. 576 DISEASES OF THE SKIN. It is stated by Plumbe, that the spreading of the eruption may be prevented, and the progress of the disease shortened, by the applica- tion of a small blister upon the uninflamed skin, at the part to which the eruption seems disposed to extend. The blister should never be applied upon the vesicles themselves, as this may cause a sloughing of the integuments at the seat of the latter, followed by small irritable ulcers, which heal with difficulty and leave permanent marks upon the skin. When herpes occurs as a concomitant of other diseases, the treat- ment should be exclusively directed to the removal of the latter, Avith- out any attention being paid to the eruption. The decoction of dulcamara, and, in very severe cases, the arsenite of ammonia dissolved in distilled Avater, in the dose of the one-twenty- fourth of a grain, have been recommended as peculiarly efficacious. In some cases of uncommon seA'erity, or where the disease has been improperly treated in its early stages, a rupture of the vesicles takes place, folloAvedby ragged ulcers, which spread, often with great rapidity, (II. Exedens.) These ulcers should be treated by carrot poultices, or touched with a weak solution of nitrate of silver, or chloride of soda. 11.—Psoriasis. SCALLY TETTER--DRY SCALL--LEPRA ALPHOIDES. This form of squamous eruption consists in a rough and scaly con- dition of the cuticle, sometimes in separate patches, varying in size, and of irregular form, and sometimes occupying continuously a large portion of the surface. For the most part, psoriasis is accompanied with rhagades or fissures of the skin. Soon after the appearance of reddish points or projections on the skin, small white or pearl-like scales appear, either separate or in clusters, or surrounding a central pink-coloured space, with a slight discoloration of the surrounding skin. In other cases, the patches are of a reddish or brownish colour, interspersed with fissures, and ac- companied with intense itching, or a sense of burning, increased by heat or friction; sometimes producing ulceration, and the discharge of a purulent fluid, which, intermixed with the scales, on becoming con- crete, forms a more elevated crust. The scales are usually surrounded by a circle of deep rose-colour, which is increased in intensity by ex- ertion, or by food of a stimulating quality: beneath the scales, the skin is red and irritable. When the patient is in bed, the scales often be- come detached in great quantities, and, by their friction, aggravate the tingling and itching. When the disease occurs in the neighbourhood of joints, or parts en- dowed Avith considerable motion, blood frequently issues from the fissures, accompanied by severe pain and smarting. Psoriasis is, occasionally, at its commencement, formed of small dis- tinct patches, with irregular circumferences, (P. guttata.) These ap- pear on almost every part of the body, even on the face. In other cases, the patches are of some extent, and also irregularly circum- scribed, (P. diffusa.) The patches, in other cases again, present a tortuous or serpentine appearance, (P. yyrata;) while, in some in- psoriasis. 577 stances, the patches, at first separate and irregular, become, in a short time, confluent, until at length the disease covers the greater part of the surface of the body, with a universal scaliness, interspersed Avith deep furrows, and a harsh, stiff, and thickened state of the epidermis, (P. iurcterata.) In infants, the disease very commonly affects the cheeks, chin, fore- head, nates, abdomen, &c. When the face is affected, the eyes some- times partake of the inflammation, and generally the mucous membrane of the nose becomes inflamed and thickened, causing snuffling, difficulty of respiration, and some discharge from the nostrils. In protracted cases, there is often great emaciation, which rapidly increases until death takes place. The disease, in early life, is com- monly attended Avith more or less affection of the alimentary canal, which may have been the primary cause of the eruption, and may im- pede its cure. Psoriasis generally occurs among the children of the poor, who in- habit unhealthy localities, and is mainly to be attributed to bad food and bad nursing, in conjunction with the morbific influence of an im- pure and confined atmosphere, and a neglect of personal and domestic cleanliness. In its treatment, a change to a more wholesome atmosphere, an im- proved diet, proper clothing, and frequent tepid bathing, with a course of treatment adapted to restore to their healthful condition the func- tions of the digestive organs, are the first steps to be taken, and, with frequent ablutions of the more irritable parts with warm water or mu- cilaginous fluids, will, in general, be sufficient to accomplish a cure. If there be much irritation, with constant fretfulness, and Avant of sleep, the parts may be bathed with the watery solution of opium, and the same, with the addition of the carbonate of soda, may be administered internally, should there be nothing to forbid its use. When severe local inflammation exists, leeches around the edges of the squamous patches will be proper. On the subsidence of the local irritation, the sulphur-bath may be employed, and repeated every two or three days, provided it is not found to increase the irritation of the skin. If the latter effect result, the bath should be at once suspended, and gentle purgatives adminis- tered, at such intervals as will be sufficient to preserve the bowels freely open: the following has been recommended, as one well adapted to these cases: R.—Sulph. prsccip. 3J. Magnes. calc. ^ss. Pulv. rhsei, gr. xxiv. Bi-tart. potassae, gr. xxiv.—M. f. ch. No. xy. In the chronic stage of psoriasis, the decoction of dulcamara, and small doses, three times a day, of the solution of the arsenite of potassa will be proper; or in cases attended with considerable derangement of the alimentary canal, with unhealthy discharges from the bowels, in which of course, the arsenical solution would be improper the decoc- tion of dulcamara may be employed, in conjunction with the spirits of turpentine: three to eight drops or more of the latter, according to 37 578 DISEASES of the skin. the age of the patient, may be given three times a day, dropped on a piece of mint candy. When the scales do not readily separate, they may be carefully touched with the liquor potassae, or dilute hydrochloric acid; or the ointment of the nitrate of mercury may be used, taking care to wash off that already applied before it is reneAved. If the disease is attended with a state of considerable prostration, and especially if the skin, at the seat of the eruption, acquires a dark or violet hue, the sulphate of quinia should be administered, or some one of the preparations of iron or the tincture of iodine in doses of from two to eight drops, twice or thrice in the course of the day. A pure, fresh atmosphere, and the daily use of the warm bath, are, in these cases, all-important. When it occurs simply as a concomitant of other diseases, our whole attention should be directed to the removal of the latter; as the dis- appearance of these will very generally be followed by that of the cu- taneous affection. This is a rule which will apply generally to all of the diseases of the skin. 12.—Follicular Warts. Hard, white, and rather shining elevations of the skin, usually oc- curring on the cheeks and forehead; they are often stationary for some time, but, in some instances, one or more of them become en- larged, of a pale pink colour, and surrounded by an inflamed margin. These tumours ordinarily result from an obstruction of the cuticular follicles, preventing the discharge of their sebaceous secretion, which, accumulating in the follicles, and concreting, causes their distention, and, ultimately, excites an inflammation, that often involves for a short distance the neighbouring skin. Soon after the inflammation occurs, a suppurative process commences in the follicle, and the seba- ' ceous matter is dislodged; and speedily all disease disappears; but, oc- casionally, the matter accumulates w'ithin the follicles, and an abscess of considerable size is produced; from a small opening in which, an exudation of cheesy matter, mixed with pus, continues for some time, or, concreting upon the surface, forms a crust. This affection generally occurs towards the close of childhood, in both sexes, but more commonly in boys, and is ordinarily produced by derangement of the digestive organs; in females, it is frequently connected with that condition of the digestive and assimilating func- tions which gives rise, at a later period, to chlorosis. A proper regulation of the diet, brisk but gentle purgatives, pure air, and the warm or tepid bath, followed by brisk friction of the sur- face, are the only remedies required; excepting in cases in which the derangement of the bowels is of a more serious and extensive cha- racter, when the proper treatment adapted to the particular character of the intestinal disease present in each case will be demanded. When the tumours are large, few in number, and of an indolent character, they may be seized with a pair of forceps, and excised by a sharp scissors; or the inspissated matter by which they are filled may be expelled by gentle pressure. When inflammation takes place, sup- PORRIGO. 579 puration should be promoted by warm fomentations, or a small poul- tice; and as soon as matter is formed, it should be allowed early to escape by a slight incision. In some cases, towards the period of puberty, these tumours become the seat of chronic inflammation, and the face then becomes studded with hard, dull, red, and painful pimples, (A. indurata,) which con- tinue for a long time. They are generally connected with very con- siderable derangement of the digestive organs; and until the latter are restored to a healthy condition, very seldom disappear. Various local applications have been recommended for these pimples, but we must confess we have, in no instance, seen any advantage derived from their use. A course of treatment adapted to the condition of the alimentary canal, with an appropriate diet and regimen, is the only means which, in our hands, has succeeded in freeing the patient from the deformity consequent upon acne indurata. 13—Porrigo. TINEA FAVOSA—FAVUS—TINEA CAPITIS—SCABIES CAPITIS FAVOSA—TEIGNE FAYEUSE— HONEYCOMB SCALL—SCALD HEAD. This is one of the most obstinate, disgusting, and infectious, of the simple cutaneous affections of childhood. There are several varieties of the disease. In one, (P. lupinosa,) an eruption of minute, flat, um- bilicated vesicles of a yellow colour, occurs upon the scalp, attended by more or less itching. The contents of these pustules, by speedily desiccating, form a number of small circular scabs, of a yelloAV or fawn colour; each scab being hollowed in its centre, and raised at its edges, and having its base deeply imbedded in the skin,.and strongly adhering to it. The scabs gradually increase in size, but still preserve their circular and cupped form. When the pustules of porrigo occur in clusters on different parts ot the scalp, the edges of the scabs formed by them approach each other, and by their aggregation give rise to crusts of considerable extent; in which, however, the cup-like form of the individual scabs is readily detected srivintr to the crusts some resemblance to honeycomb. Some- times the cutis°is deeply involved in the irritation of the disease, and fissures of considerable extent are formed, from which an ichorous or purulent matter is discharged; and occasionally, according to Ahbert in severe and protracted cases, the cutis and subcuticular cellular membrane are destroyed, and the bone of the skull laid bare. Be- rween the different clusters of scabs the skin is covered with furfura- CTn\Some^ndividuals the disease extends to the forehead temples, and neck * or it occurs upon other and remote parts of the body. The attendant itching is, in some cases, almost intolerable, and causes the patient to scotch himself incessantly and severely Pedi- poH which multiply in great numbers under the edges of, and between Ito^toMbl* to this irritation The smeU emitted by the scalp is peculiar and disgusting, resembling that of the urine of the mWhCen\he crusts are removed by the application of emollient poul- 580 DISEASES OF THE SKIN. tices, the epidermis is found to be destroyed, and the reticular structure beneath red and inflamed. A yellow, viscous, and fetid discharge ex- udes from numerous ulcerations;—a number of small abscesses are seen dispersed over different parts of the scalp, of a lenticular form, and appearing as so many centres of inflammation. When the disease is neglected and allowed to proceed, it is finally attended by an almost universal falling out of the hair, leaving the skin smooth and shining; the few hairs that remain being thin, languid, and altered in colour and structure. When the scabs in this form of porrigo are allowed to become per- fectly dry, they assume a white appearance, wear off, break, and de- tach themselves from the scalp, their remains presenting no regular form. In another, and very common form of the disease, (P. furfurans,) there is, at first, a slight desquamation of the cuticle of the scalp, often attended Avith considerable itching. There is discharged from the af- fected surface an ichorous matter, which dries, and forms a scurfy covering to the scalp: the disease gradually and slowly spreads over the greater part of the scalp; the layers of scurf thicken, and resemble a coating of bran, or coarse flour, the lower surface of which is satu- rated with fluid. Upon freeing the scalp from this adhesive substance, it is found to be divested of its cuticle, presenting a smooth shining sur- face, like, varnish, and usually of a pink colour. The hair, in this form of porrigo, becomes matted and glued together; and, when the finger is pressed upon it, the whole mass has, in nearly every part, a soft yielding feel. The disease is chiefly confined to the scalp, but sometimes extends to a slight distance upon the forehead, in the form of crusts, resem- bling a portion of bran, cemented by some adhesive fluid, the edges of which are sometimes dry, and perfectly Avhite. Much itching attends the disease, and great numbers of pediculi range freely over the affected parts; ulcerations to a small extent occur here and there, from which a fluid is discharged. The scalp emits the smell of sour milk. In other cases, the disease presents itself in the form of numerous small, deeply-seated, yellow pustules, of a circular form, and umbili- cated, seated upon a circular red patch, which precedes them. The pustules are crowded together, especially around the circumference of the patches. They are commonly each traversed by a hair, and are at- tended by intense itching (P. scutulata;)—their contents soon con- crete, forming a small cupped scab, which adheres by its edges to the adjoining scabs, producing thus a continuous crust, of the form and dimensions of the patch upon which the pustules arose. The indivi- dual scabs, in coalescing, lose their cupped form. Around the circumference of the patches, new crops of pustules suc- cessively arise, and forming scabs, cause the greater portion of the scalp to become covered with a continuous, thick incrustation, of a whitish colour, around which, portions of the original blotches, in the form of semicircles, or segments of circles, are perceived. In these cases, there is no hair, except around this incrustation, where the feAV remaining hairs form a sort of crown, (P. decalvans.) Portions of PORRIGO. 581 the scnlp are frequently covered with circular patches, varying in size, showing the disease in a more or less advanced stage, with here and there a white and shining space, entirely bald;—the intervening por- tions of skin being covered, to a greater or less extent, with a furfura- ceous desquamation. This form of porrigo may extend to the fore- head and neck. In other cases, the disease is more circumscribed: the pustules, on drying, form small brownish, or dark-gray crusts, varying in form and size, and strongly resembling fragments of old mortar, or the plaster from walls discoloured by damp and dust;—they are often very hard, even of a stony consistence, (P. granulata.) The patches of disease are generally separated from each other, and are not so deeply im- bedded in the dermoid tissue, as those of the P. lupinosa; they are sometimes surrounded by thin, dry, furfuraceous scales. The disease is attended Avith severe itching; and, upon the separa- tion of the crusts, the parts beneath are found to be red and inflamed, Bmooth, polished, and often swollen. Here and there, small, depressed, whitish abscesses occur, from which issues a small quantity of a viscous, colourless fluid, which thickens and dries, forming new crusts, analo- gous to those which preceded. Before the matter becomes perfectly dry, it exhales a nauseous smell, someAvhat resembling rancid butter, or milk beginning to turn. (Plumbe.) This form of porrigo is con- fined to the scalp and parts immediately adjacent. When porrigo furfurans occurs in children possessed of a less de- gree of irritability of skin, the disease is of a much more chronic cha- racter; there is less disposition to pustulation, or to the exudation of fluid. A constantly repeated exfoliation of the epidermis, in the form of minute, dry scales, takes place; and the cuticular sheath which en- velops each hair for a short distance beyond its exit from the scalp, becomes more elongated, opaque, dry, and shining; giving to the hair near its root, a shining silvery appearance, resembling the fibres ot asbestos. (Teigne amiantacee of Alibert.) When the diseased hairs are cut off with the scissors, the skin appears furrowed, and somewhat red and inflamed. The itching sensation is considerable: as the dis- eased parts are usually destitute of moisture, no unpleasant smell is emitted. , , , - In severe or neglected cases, the lymphatic glands at the back ot the head, and of the neck, sometimes become enlarged; occasionally the tongue has been seen studded with patches and vesicles. (Dendy) When it spreads in the direction of the eyes, porrigo will occasionally produce severe ophthalmia. Tinea ciliaris will in other cases, be pro- duced with an cedematous state of the puncta lachrymaha, and a dis- charge of the tears over the cheek; or even, in very protracted cases, cctropium, especially of the lower lid, may finally ensue. Porrigo is capable of being propagated by inoculation or contact: the disease, however, frequently occurs spontaneously in children of unhealthy constitutions, fed upon coarse, fat food, and in whom no at- tention is paid to preserve the head, and body generally, perfectly clean It is under these circumstances, and particularly when the dis- ease in its early stage, has been neglected, or treated by improper re- 582 DISEASES OF THE SKIN. medies, that the most obstinate and aggravated cases occur. The dis- ease is said to be of most frequent occurrence in low, marshy, and otherwise unhealthy situations. In the children of those in comfort- able circumstances, to whose personal cleanliness daily attention is paid, the disease is generally produced by contagion, or results from a deranged state of the digestive, assimilating, and nutritive functions, the consequence of excess in the use of rich, fat, or oily food:—in such children, the eruption is generally small in extent, and without much difficulty removed. With respect to the treatment of porrigo, in every case the condi- tion of the patient's general health, and the state of the digestive or- gans particularly, should be first attended to; and whatever indications of internal derangement or disease exist, should be met by their ap- propriate remedies; the local treatment being restricted to frequent ablutions of the head with warm water, the hair being previously re- moved from and around the affected portions of the scalp, by a pair of sharp scissors, and any loose hairs detached by the forceps. This simple treatment, in recent cases, and where the general health, or that of the assimilating organs, is not extensively impaired, will very often succeed in effecting the complete removal of the cutaneous affec- tion. The entire removal from the scalp of the incrustations produced by the desiccation of the morbid discharges, and the matting of the hair, is all-essential to the entire and speedy eradication of the disease; and, hence, when these have been allowed to accumulate, the head should be repeatedly washed with tepid water, and the diseased parts covered with simple emollient poultices. When, by these means, however, we do not readily succeed in softening and detaching the crusts, alkaline washes may be employed, made stronger or weaker according to the greater or less thickness and firmness of the crusts. From one drachm, to two, three, or even four drachms, of the subcarbonate of potassa, to the pint of water, may be employed, according to circumstances. In detaching the crusts, no violence should be employed. The removal of the dead and loosened hairs is also a matter of some importance, and should not be neglected; the best plan is to pull them out by means of a small forceps. After all local irritation has been removed by emollient washes and poultices, we have seldom failed, in slight and recent cases, to cause the speedy removal of the disease, by the application, night and morn- ing, of the unguentum hydrargyri nitratis, or of an ointment of the iodide of potassium, (one drachm to two ounces of lard,) applied in the same manner; the parts being well washed with tepid water in which a small portion of Castile soap has been dissolved, previous to the re- application of either ointment. In some recent cases, touching the diseased parts with the nitrate of silver, will often cause an immediate arrest of the disease. The ointment of the ioduret of sulphur has been recommended by Biett and Schedel as a very efficacious local applica- tion; improving the condition of the scalp, preventing the formation of fresh pustules, and causing a healthy growth of hair. But so long as any irritation of the scalp exists, all irritating applications are in- PORRIGO. 583 jurious; emollient poultices, and washes of tepid warmth, are then alone proper, and they should be immediately resorted to, should any degree of local irritation occur during the employment of any of the ointments or lotions recommended. Care should be taken to prevent the contact of the diseased dis- charges from the scalp with the healthy skin; as, in this manner, the disease may be extended and kept up for a considerable time. During the treatment, the patient should be put on a diet composed principally of farinaceous substances; he should be afforded the benefit of a pure atmosphere, and have his bowels regulated by the occasional use of mild aperients; while the healthy action of the cutaneous capil- laries is promoted and maintained by the daily use of the warm or tepid bath, according as the heat of the surface is deficient or increased. In many cases, sulphurous baths, and gentle sulphurous douches every morning, Avill prove very useful adjuvants. In chronic cases, a variety of lotions have been recommended; as solutions of the sulphate of copper or of zinc; of the deuto-chloruret of mercury, or of the nitrate of silver, or the sulphuric, nitric or hy- drochloric acids, more or less diluted. Quickly washing the diseased portions of the scalp with diluted nitric or hydrochloric acid by means of a feather, and then pouring water on the parts, to prevent the ac- tion of the acid from penetrating too deeply, we are assured by bcnedei will very certainly cause the removal of the disease. By the same au- thority, touching the diseased parts with a small hair pencil, dipped in creasote, and subsequently applying an ointment of creasote (twenty grains to an ounce of lard,) is asserted to have succeeded in the eradi- cation of the malady, in cases Avhere many other means had been in- effectually employed. . Bv Dr A. L. Wigan, of London, a plan of treating the disease has been proposed, which is described as prompt in its effects, and uniformly successful. The whole of the scalp is, in the first place, to be care- fully shaved twice, unless the quantity of hair is very small, and offers no obstacle to the complete examination of the skin This, according to Dr Wi-ran, is all-important, inasmuch as when the scalp is covered with even°a moderate quantity of hair, in parts that have become in- Led, the disease may gradually progress, whilst the whole attention s paid to those in which it is already apparent. A narrow circle ot hair may be left around the face, as a concession to parental a anity, if"tl "re be no indications of the disease at this part, and it is care- fullv washed with hot vinegar. . The scalp being denuded of hair, is to be washed with the pyrolig- neou. or ooPncentStted acetic acid. In its first application, Dr. A\ igan employs the acid diluted with three times its weight in water. This '™sh eenerally causes a number of red patches to appear upon portions of tescaTp which before its application looked perfectly hea thy- showint that these parts had become infected, but without the disease Sng'g ne through its stages, which Dr. AVigan supposes from a Wt number of observations, to require a space of eight days The whole extent of the disease being thus determined, with a piece of fine sponge tied to the end of a stick, or held in a pair of silver 581 DISEASES OF THE SKIN. sugar tongs, each spot is to be thoroughly imbued with the concentrated acid, for the space of three or four minutes; when, according to Dr. Wigan, the disease will be fully arrested. He has often applied the acid a second time, but he firmly believes that this is unnecessary whenever the scalp has been completely denuded of its hair, and the extent of the infection tested by the preliminary application of the di- luted acid. The crusts are gradually raised up with the growth of the hair, which soon sprouts again if the eruption be recent. As soon as a pair of fine scissors can be inserted beneath them, they should be re- moved by clipping the hair; but we are warned not to do this prema- turely, lest a sore place be produced. We confess, we have seldom met with much trouble in curing cases of porriginous disease of the scalp, excepting in constitutions of a very unhealthy character, particularly those strongly predisposed to scro- fulous or tubercular disease. Our success we have mainly attributed to the attention we pay to the complete cleansing of the scalp, by re- peated ablutions with warm water, and the occasional use of alkaline lotions; to the early removal of the hair by the scissors, and the re- moval of loosened and diseased hairs by the forceps; to the constant attention we direct to the condition of the digestive, assimilating and nutritive processes, with the view of detecting and removing any de- rangement which may exist in either. This course, with perfect cleanliness of the patient's person and habiliments, free exposure to pure, fresh air, with a well-regulated diet, and appropriate exercise, has enabled us, in a very large number of cases, to succeed in the re- moval of the diseased condition of the scalp, with no further local ap- plication than the emollient washes and poultices above referred to; or the application for one or two days of the citrine ointment, diluted or undiluted; or of the ointment of the iodide of potassium. The disease, however, is not one of very frequent occurrence in Philadel- phia, at least in its more aggravated forms. ERUPTIONS CONNECTED WITH LANGUID CUTANEOUS ACTION. 14. Pityriasis. DANDRIFF. Morbid exfoliations of cuticle in different parts of the body, but in infants chiefly occurring on the hairy scalp, unaccompanied by much irritation or fluid secretion. We are to recollect that in all infants, for some days after birth, an exfoliation of the cuticle takes place; which is always to be considered a healthy natural process. Dandriff, however, is the progressive des- quamation of thin scales from the scalp, succeeding light, pink, unele- vated patches; attended, in most cases, by a trifling degree of chronic inflammation of the vessels secreting the cuticle, but without the dis- charge of fluid. If the infant in whom this affection occurs is not very much neg- lected in regard to cleanliness, it usually disappears in a few weeks; but now and then, under different circumstances, and particularly, when, at the same time, there is derangement of the alimentary canal, ICHTHYOSIS. 585 from improper or unwholesome food, it is followed by considerable ir- ritation of the scalp, a fluid secretion and scabbing, (P. scabida,) or a state resembling the porrigo furfurans. Under circumstances of peculiar aggravation, according to Plumbe, there is, in fact, no real difference between the two affections. In these severe cases, too, the hair often falls off, and the eyelids, likewise, occasionally become dis- eased. On the breasts of children, about the tenth year, there are often seen a few light, yellowish scales, scattered here and there, and sometimes so indistinct as scarcely to be perceived, (P. versicolor.) In this situa- tion, they sometimes resemble freckles, or light yellow stains; upon more minute examination, however, their squamous character will be readily detected. In children of unhealthy constitutions, the spots will occasionally assume a dark, or livid hue, (P. nigra, melasma;) this will often be observed in children, more especially, who have become debilitated by a residence in warm or tropical climates. When the dandriff occurs upon the scalp of infants, it is, no doubt, in very many instances, dependent on the disposition to determination to the head, so common at this age; and it is not improbable, when attended by much irritation and fluid secretion, hyperaemia of the ce- rebral vessels may be prevented by it. (Plumbe.) The condition of the patient's health, therefore, requires to be closely considered, in deciding upon its treatment. Sedative applications are seldom advi- sable, or even safe; and those of an irritating character should never be employed. . ,„ . Upon whatever part of the body the disease may present itself, it will demand little attention beyond what may be necessary to restore the patient's general health, and the regular action of the digestive functions, with strict attention to cleanliness of the surface generally. The exfoliation will usually be quickly checked, by simply washing with warm water. In more obstinate cases, a weak alkaline solution, as one drachm of the liq. potassae to four ounces rose water, may be gently rubbed upon the part. 15.—Ichthyosis. FISH-SKIN DISEASE. A morbid thickening, with a dry and hard condition of the cuticle, evidently dependent upon chronic inflammation of the vessels by which the cuticle is produced. , Ichthyosis is unattended, at first, by any uneasy sensations, but as the thickening of the cuticle increases, a sensation of increased heat, with redness, and other marks of more or less irritation are ob- served on the healthy skin, around the margin of the diseased part. When the thickening of the cuticle causes it to rise above the surround- in tr surface, it begins to exhibit the appearance of minute and innume- rable figures, which soon increase in length; and extensive cracks form, intersecting each other, and dividing the surface into innumerable fragments of which each, considered separately, exhibits a great simi- larly, in structure, to the common wart. The diseased cuticle now assumes a dusky, dark-brown colour, which gradually approaches to 586 DISEASES OF THE SKIN. blackness. This discoloration results from the entanglement of dirt by the rough and fissured surface of the skin, which even frequent ablutions will not prevent. On drawing the finger over the diseased surface, the sensation is the same as though the part was covered with large warts of long standing. The arms and legs are the most common situations of this disease; it very rarely occurs upon the face. The skin of those infants in whom the disease is subsequently de- veloped, instead of the usual smooth and soft texture, has, according to Rayer, a sallow, dry, shagreen-like appearance. The cuticle, during the first or second month, becomes more rough, and of a grayish lme, communicating to the touch a feeling like that produced in many cases by the skin of the aged. This condition may continue throughout life, or it may increase with the progress of years. The appearance of the skin in cases of ichthyosis is more like that of the legs of fowls, than the scales of fishes, or of serpents; and, when the thickening of the epidermis is very considerable, it has been likened by Rayer to the bark of certain trees. The skin may become, in some cases, so rough that the hand, when passed over it, experiences a sen- sation similar to what is felt when a file or shagreen, or the skin of certain fishes is handled. The squamae formed by the diseased cuticle may, with the excep- tion of the largest, be detached without causing pain, or any unplea- sant sensation. When detached by friction, or in any other manner, they are speedily reproduced, with the same characters as before. Desquamation of the diseased cuticle often takes place during the summer season; but the disease again constantly recurs, on the return of autumn. On the separation of the squamae, the skin is found to re- tain its natural colour; its furrows, however, are more marked than natural, and its exhalations and secretions are found to be entirely suspended. The disease is often congenital; and is then seldom got rid of during life. Its remote and exciting causes, are equally involved in obscurity. In numerous cases, where it has been studied with the utmost care, it was found impossible to trace it to any pre-existing derangement of health, or local irritation. According to Girdlestone, Martin, and Rayer, it is frequently hereditary; but it as frequently occurs in child- ren whose parents, and grandparents, have presented no traces of the disease. Neither climate, nor season, nor locality, nor mode of life, would seem to exercise any marked influence upon its production. When local, of small extent, and occurring subsequent to birth, in the children of healthy parents, there is some hope of effecting a cure. Repeated blisters, and topical stimulants, have succeeded in removing the disease in some cases. In two instances, in which it was limited to the legs, Plumbe succeeded in effecting a cure by strapping the af- fected parts tightly with adhesive plaster, and applying a long roller, kept constantly moistened with cold water, the straps being renewed every fourth or fifth day. When the disease is of greater extent, we must content ourselves with the frequent use of emollient washes, mucilaginous and soothing RUPIA. 587 fomentations, the warm bath, frequently repeated, the vapour-bath, and the occasional use of alkaline baths. Internal remedies have not been found to produce any good effect. • In a practice of over forty years, we have met with but six cases of well-marked ichthyosis; in one, the disease was evidently hereditary, and resisted every means employed; in the others, it was of compara- tively small extent: the parts affected were daily washed with diluted nitric acid, by which the squamae were rendered much thinner; a suc- cession of blisters was then resorted to, and in from eight to ten weeks from the commencement of the treatment, a complete cure was effected. In one case, twenty-six years have now elapsed without any indica- tion of the disease returning. 16.—Ecthyma.—Rupia. ATONIC ULCER. Ecthyma is an eruption of hard, red elevations, painful upon pres- sure, and with inflamed bases; the elevations, in a few days, increase irregularly in size, and pus is formed at their apex. The eruption is occasionally attended by a violent smarting pain. The pustules occur in irregular groups of various dimensions, and suppuration proceeds, with greater or less rapidity, in different cases. In some, we have a large inflamed base, with a small pustule in the centre; in others, the pustules are in the form of blebs, with a central spot. In three or four days, the matter of the pustules becomes dry, and forms thick, brown scabs, which fall off in the course of a week or ten days, leaving a dark-red stain, or superficial cicatrix. In in- fants, the'elevations slowly disappear, without suppuration, by cuticular desquamation. When confined to a particular part of the surface, the eruption of ecthyma may come out at once; but in other cases there is generally a succession of pustules. The duration of the disease, in the first case, is from one to two weeks, but in the latter it may continue for months. It occurs most frequently upon the extremities, shoulders, and nates. Several varieties of the disease are described by Willan and others, as the E. vulgare, the E. infantile, the E. luridum, and the E. ca-^ checticum: but as these varieties are the mere results of different de-' grees of constitutional debility, or of irritability of the skin, it is un- necessary to describe their individual characteristics. Rupia is the eruption of one or more flattened blebs, of the size of a shilling, containing a serous, transparent fluid. The blebs soon be- come flaccid, their contents increase in consistence, and become tur- bid, and finally drying, form scabs of a dark-brown colour, rough on the'surface, thick and prominent in the centre, and adhering, at their edges, to the surrounding cuticle, which is there slightly elevated. (R. simplex.) On the separation of the scab, a superficial ulceration of the skin remains, which usually heals rapidly, though it may remain for a time open, sometimes covered with a scab, and sometimes with- out one. The ulcer generally leaves behind it a deep red stain.* In some cases the blebs are much larger, and are surrounded by an 588 DISEASES OF THE SKIN. inflamed margin, several lines wide. The blebs are very quickly con- verted into rough scabs of a very dark colour, which are also sur- rounded by an inflamed areola; from this the cuticle is raised by suc- cessive formations of matter and bloody serum, which, upon drying, add to the size and thickness of the scab, with the increase of Avhich the areola advances, and, by continually forming new rings of matter, increases the primitive scab in width and thickness, until it acquires the size, and almost the shape and appearance of the outer surface of a small limpet or oyster shell, (R. prominens.—Bateman.) The scabs in this variety, which is usually confined to the lower extremities, often adhere for a long time: Avhen they separate, they leave an ulce- rated surface, which has often a bad appearance. Sometimes the scabs are reproduced; in other cases, the ulcer remains open, extend- ing constantly in depth, and is with difficulty healed; and when cica- trized, leaves a dark-coloured, livid mark upon the skin, Avhich dis- appears very slowly, if at all. In other cases, the disease commences with slightly raised patches of a dark livid colour, upon which flattened, irregular-shaped blebs soon form, surrounded by a dusky red margin. The fluid contained in the blebs is thick and dark-coloured, which, in place of drying, escapes by the bursting of the blebs, and an excoriation of the skin remains, attended with pain, which soon degenerates into an ill-con- ditioned ulcer, that spreads rapidly in extent and depth, (R. escha- rotica.) Successive blebs arise and burst, and in this manner multiply the points of unhealthy ulceration. Cicatrization is always slow and protracted. This variety generally occurs on the loins, thighs, and lower extremities. Ecthyma and rupia occur only in children who have been subjected to causes, the operation of which has a tendency to reduce the ener- gies of their system, and to produce a languid state of the vitality of the skin; hence impure and confined air, a cold and damp atmosphere, and deficient or impure food on the one hand, or a state of debility from preceding diseases, on the other, are their usual predisposing and exciting causes. Both forms of disease are very apt to occur after measles, scarlatina, small-pox, and other severe affections of _ childhood; and in nearly every case of any severity, they are accom- panied by a low, irritative fever,—frequently assuming a hectic cha- racter—by a general wasting of the body, and by the utmost languor and debility. In the treatment of these affections, our attention should be chiefly directed to the restoration of the general health and vigour of the patient's system. When this restoration can be effected, the local dis- ease will seldom demand much attention, it being generally soon arrested, the scabs separating, and the ulcerations assuming a healthy aspect, and rapidly cicatrizing. The means by which this object is to be obtained, will, in some measure, be governed by the circum- stances of individual cases: as a general rule, they will consist in pure, Iresh air, cleanliness of person, appropriate clothing, a wholesome, nourishing diet, consisting of meat, gravy or jellies, chicken, beef, or mutton broth; and when the exhaustion of the patient is extreme, wine RUPIA. 589 whey, or wine and water. The cold infusion of bark, the sulphate of quinia, and other vegetable tonics, may, in some cases, be employed Avith advantage; they are best adapted to the more severe and pro- tracted forms of these diseases. In the early stage of most cases, gentle purgatives, occasional doses of a mercurial alterative,1 and the warm bath daily, will generally be required. In more protracted cases, if the discharges from the bowels are of a vitiated character, the spirits of turpentine will often be found to produce a beneficial effect. In such cases, we must be cautious in the administration of mercury in any form. Good air, wholesome food, and the sea-air and sea-bathing, with, perhaps, some light tonic, will generally succeed in effecting a cure, unless the health of the pa- tient is completely impaired. A cautious use of weak alkaline baths has, in numerous instances, been found of benefit. 1 R.—Mass. f. pill. hyd. gr. iv. ad xij. Or, R.—Calomel, gr. vj. Ipecacuanhas, gr. ij.—iij. Magnesise calc. gr. xxiv. Ext. hyoscyami, gr. iij.—vj. Ipecac, pulv. gr. iij. Ciirb. sodae, J*)j-—oss-—^- ^ P^- ^xt. hyoscyami, gr. iij.—M. f. No. xij. chart. No. xij. One to be given for a dose, every evening. To be given as the preceding. In regard to the local treatment, so long as the pustules or ulcera- tions present a decidedly irritable condition, emollient washes and ap- plications are alone to be employed. When the ulcers are tardy in cicatrizing, a lotion of red wine and water, or of red wine and honey, may be employed. When the ulcerations of rupia are of an indolent character, a wash of the bitartrate of potassa, or dusting their surface with this substance in a dry state, is said by Willan to answer very well. If the above ap- plications do not succeed, the ulcers may be washed with a solution of nitrate of silver, or of sulphate of copper. If much itching or pain is present, an ointment of hydrocyanic acid and sugar of lead has been recommended.2 The ointment of the nitrate of mercury has, in our hands, very generally proved successful. Washing the ulcers with diluted nitric or hydrochloric acid, will often be a means calculated to improve their condition, and promote their cicatrization: the degree of dilution necessary will depend upon the more or less indolent and un- healthy condition of the ulceration. Ointments of the proto-ioduret, or of the deuto-ioduret of mercury have likewise been used, according to Biett, with great success in obstinate cases. 2 R.—Acid, hydrocyanic. £J. Plumbi. acetat. gr. xv. Ungt. cetacei, ^ij.—M. For the more malignant ulcerations, the chlorides of lime and soda, as an external application, and the latter internally may be tried. But we are to recollect, that in no case, but especially in those in which the disease is of an extensive and aggravated character, will external applications be of much avail, unless the general health of the patient be at the same time improved by a proper diet and regimen, and by the cautious employment of invigorating remedies: in many cases, when this can be effected, the local disease very readily disappears, 590 DISEASES OF THE SKIN. with very simple applications. When we fail in our attempt to restore the vigour of the system, the most active topical applications Avill be unproductive of good. 17.—Pemphigus. POMPHOLTX.—BULL-E FEBRILIS.—PEMPHIGOID FEVER. The eruption of large bullae, preceded and accompanied by febrile phenomena, which generally assume a typhoid character; the disease, in its progress, having many features in common with the gangrenous form of infantile erysipelas. The eruption is usually preceded, for several days, by a, sense of chilliness or shivering, followed by pain in the head and epigastrium, increased heat of the surface, and a frequent, feeble, irritable pulse, with great languor and fretfulness. A dull erythematous blush, or patches, sometimes of a livid hue, and slightly elevated above the sur- rounding parts, appears on various parts of the body, but chiefly on the neck, upper part of the breast, inner surface of the thighs, and the groins; a very common situation for them is behind the ears. Large, irregular vesications now quickly make their appearance; they are generally flattened on the top, and at first filled with a trans- parent fluid, which, as the vesicles enlarge rapidly in size, becomes turbid, and of a purplish hue. The vesicles are usually surrounded by an inflamed border, of a livid red colour. Tlje fever now assumes a typhoid character, with a dry, brownish tongue, and a rapid sinking of the pulse. When the vesications break, and discharge their con- tents, an ulcerated surface is left, which is extremely painful, and spreads over the surrounding surface, often with great rapidity. 'The discharge is often fetid, and large in quantity, and the edges of the ulceration acquire a livid hue. When situated behind the ears, the connexion of the posterior cartilage with the cranium may be destroyed, the ulceration extending often to the meatus auditorius, to the eyes,— the sight of which becomes destroyed,—and even to the vertex. (Stokes.) When the disease occurs upon the hands, exfoliation of the bones of the fingers sometimes takes place. In other cases, vesications arise in rapid succession, on different parts of the body, followed by gangrenous ulcerations, and the patient sinks in a few days, from pain, loss of sleep, and intense fever. Death, it is stated by Dr. Stokes, generally takes place about the tenth or twelfth day; it is often preceded by convulsions. Pemphigus may occur at any period, from a few days after birth to the ninth year:—it is most frequent, however, according to Willan, within the first year. Its causes are evidently impure and confined air, neglect of domestic personal cleanliness, deficient or unwhole- some nutriment, and the effects of cold and damp;—it is hence almost exclusively confined to the offspring of the poorest classes, among whom it often prevails epidemically. There is reason to believe, how- ever, that like infantile erysipelas, the disease is in some way connected with puerperal fever, affecting particularly the offspring of mothers who become attacked with the latter disease. It is said by Stokes to be more prevalent in summer than in winter. PURPURA. 591 This, however, is contrary to our experience; the few cases we have met with—the disease being one of comparatively rare occurrence in Philadelphia and its vicinity—all occurred in the winter. The treatment of pemphigus, as it occurs in children, should be commenced by the removal of the patient, whenever it is possible, to a pure, fresh atmosphere, cleansing his skin by the use of the warm or tepid bath, and if there is no affection of the digestive organs present to forbid it, furnishing him with wholesome, nourishing food. If the disease is seen in its earliest stage, and tenderness of the epi- gastrium, with derangement of the bowels, is found to exist, a few leeches should be applied to the abdomen, followed by warm fomen- tations or the application of a warm emollient cataplasm, and inter- nally, small doses of calomel, ipecacuanha, and extract of hyoscya- mus, and an occasional dose of castor oil may be given; if, at 'iLo same time, there exist much heat and dryness of the surface, some gentle diaphoretic will be proper, with frequent tepid sponging. R.—Acetat. ammoniae, gviij. Aq. camphorse, ^ij. Vin. ipecac. 3J. Tine, hyoscyami, £j. Syrup, limon. ^ij.—M. Dose, a teaspoonful every three hours, for a child two years old. On the formation of vesications, the warm bath and fomentations of an infusion of chamomile, with the sulphate of quinia internally, in con- junction with the mineral acids, if the state of the bowels will permit of their use, should be administered. If the vesications are very large, they should be punctured, and the ulcerated surface washed Avith a very weak solution of the nitrate of silver:—at the same time the patient should be put upon a mild, but nourishing diet. In the gangrenous or phagedenic form of the disease, an ointment prepared from the great fig-AVort (Scrofularia nodosa) has, we are as- sured by Maunsell, been found particularly successful in causing the ulcers to assume a healthy condition, and cicatrize. This remedy was introduced by Dr. Stokes, the elder, of Dublin, Avho found it in use among the Irish peasantry. His practice was, at first, to apply a car- rot poultice or one of porter and oatmeal: this was kept on for about eight hours; when removed, the ulcerated surface was gently wiped Avith lint, and the ointment of scrofularia, previously melted, was spread over it carefully, by means of a soft feather; the ulcer was then dressed Avith the ointment, to which an eighth part of wax had been added, the dressing being repeated, in severe cases, every fourth or sixth hour. Dr. Stokes also directed the internal use of yeast, which he believed tcf be of service. In a comparatively chronic form of pemphigus, Dr. Maunsell states that the employment of iodine has been found to be attended with the most decided benefit. 18.—Purpura. A subcuticular extravasation of blood, occurring without external violence, and not disappearing upon pressure; sometimes accompanied 592 DISEASES OF THE SKIN. with hemorrhage from one or other of the internal organs, and ap- pearing either with or without febrile reaction. The appearance of the skin, at the parts at which the extravasation takes place, differs in different cases; thus, the extravasation may ap- pear in the form of minute red, or violet-coloured spots, (petechice,) or of patches of a ruddy violet colour, often livid, and sometimes quite black; generally of a deeper hue in the centre than at the circumfe- rence, and varying in diameter from a few lines to several inches, (ecchymoses.) Both varieties of extravasation are very generally ob- served in all cases of purpura. In some cases, purpura occurs without being preceded by any marked disturbance of health, though usually the patients exhibit for some days previous to its appearance considerable lassitude, dejection, and fretfulness, with indications of general debility. It is unattended throughout with any degree of febrile excitement, (P. simplex.) The subcuticular extravasation may consist entirely of petechias, having some resemblance to flea-bites, but not quite so large, unsur- rounded by an areola of inflammation, and uneffaceable upon pressure; or the petechiae may be intermixed with ecchymoses—occasionally, but very rarely, the extravasation appears only in the latter form. The petechiae may occur only upon particular regions, or be disseminated over nearly the Avhole surface of the body; they may occur in every part at the same time, or appear successively during several days— when in place of being all of the same hue, they will vary from a red- dish-purple, or brown, to a clear or faint yellow. Petechiae occur prin- cipally upon the legs, but often appear upon the face also, in which case, a number of ecchymoses are frequently seen upon the conjunc- tivae. The extravasations constituting P. simplex are always unattended with local heat or pain, or any febrile excitement, and occasionally, without the least apparent disturbance of either of the principal func- tions of the system. Soon after their formation, the petechias undergo a change of colour, passing from reddish-brown, through various intermediate shades, to yellow; and most commonly, the blood is entirely reabsorbed in twelve or fourteen days. Occasionally, as remarked by Rayer, the spots of extravasation form a slight eminence, of the size of a pin's head, caused by a minute drop of blood being effused immediately beneath the cu- ticle, which it raises. On the drying of the blood, a small dark crust appears. When the petechiae are very numerous, they are sometimes, at par- ticular parts of the surface, collected into irregular clusters. In a few very rare cases, there is observed, interspersed among the petechiae, a kind of marbling of a light violet colour, like the eruption in rubeola nigra. Occasionally, there are very feiv or no petechiae, but ecchy- moses, in considerable numbers, are disseminated over the body and limbs, particularly OA'er the dorsal surface of the feet and hands, and the inner surface of the extremities. They resemble often the marks left by the strokes of a whip: their colour, which is of a dark or livid blue, fading very slowly. These ecchymoses are, in some cases, sue- PURPURA. 593 ceeded by an exfoliation of the cuticle, particularly when the latter has become detached by the quantity of sanguinolent serum effused beneath it. In some instances, the effusion is to so great an extent as to pro- duce bullae or phlyctenae. The blood, in certain cases, is effused into the subcutaneous and in- termuscular tissues, and then the skin commonly presents a number of broad, slightly prominent spots, dark in the centre, and of a greenish- yellow towards the circumference, and unattended with pain. Some- times the backs of the hands are affected with a species of oedema. In a few instances, the subcuticular extravasation is preceded by somewhat prominent, reddish, oval, or circular spots, accompanied by a smarting or tingling sensation, similar to, but not so decided as that of urticaria. (P. Urticans.) These spots, at the end of two or three days, sink to a level with the surrounding skin, and acquire a dark- red, or liver colour; new spots at the same time making their appear- ance. They are sometimes intermixed with true petechiae. P. urticans occurs most frequently upon the legs, which are often at the same time cedematous, or affected with a sensation of stiffness or heaviness. The eruption generally continues for a month, but may be of longer dura- tion. Immediately after the disappearance of the petechiae and ecchy- moses, in cases of P. simplex, they in some cases return suddenly, in a single night. These hemorrhagic phenomena may be repeated se- veral times at very short intervals, prolonging the duration of the dis- ease to several months. When P. simplex presents itself under the form of ecchymoses, it is generally a more serious disease than when it appears under the pe- techial form; the P. urticans is the least important of all the forms of the disease. A much more serious form of purpura is that accompanied with hemorrhage. The body is often covered with livid spots, similar to those that follow bruises; actual thrombus occasionally forms under the hairy scalp, and the blood has even been seen exuding from behind the ears, and from the vertex; the subcuticular and cutaneous effusion covering nearly the whole surface. The disposition to hemorrhage in some patients is so great that the mere act of feeling the pulse, the pressure of a loose ligature, or the weight of the body in sitting, leaning, or lying down, is sufficient to cause actual ecchymoses. In such cases, the slightest puncture, the mere grazing of the skin, is followed by a copious and continued dis- charge of blood; and most commonly, either from the commencement, or in the course of the disease, hemorrhage occurs, to a greater or less extent, from the nose, bowels, stomach, or lungs, P. hemorrhagica. In some of these cases, the whole of the fauces are of a dark-red colour, and blood issues from every part of them. P. haemorrhagica is some- times, according to Rayer, complicated with angina membranacea; oc- casionally, the gums are livid and spongy, and blood exudes from their surface; the tongue is swollen, livid, and blackish; the inner surface of the cheeks presents some blackish and soft patches, with which the palate is also covered. On all these parts, irregular phlyctenae, or 38 594 DISEASES OF THE SKIN. bullae appear, filled with dark-coloured blood; when these burst, a dis- charge of blood takes place from the excoriated surface; deeper ulce- ration sometimes occurs, with hemorrhage to a much greater extent. Children have been known to die in a single night, from the hemor- rhage, in such cases. When the discharge of blood is very considerable, or recurs fre- quently, the feet and legs become oedematous, the face blanched, and the surface of the body, generally, of a yellowish, or livid hue; the petechiae and ecchymoses increase in number, and acquire a deep brown tint; the blood becomes more and more serous; the temperature of the body, but particularly of the extremities, sinks, the pulse becomes small and feeble, and the strength of the patient completely prostrated. Convulsive movements, tremors of the whole body, or fainting fits, sometimes occur. The patient finally dies ex-sanguine, unless febrile symptoms, or serious internal disease, should ensue previously to death. Purpura is occasionally accompanied by febrile reaction. P. febri- Us. The occurrence of petechiae and ecchymoses, in this form of the disease, is preceded by a sense of extreme lassitude and depression, and by shivering fits, of longer or shorter duration, succeeded by in- creased heat of the skin, pains in the back and limbs, headache, quick- ness of pulse, nausea, retching, or vomiting. The subcuticular extra- vasations appear between the third and sixth days, sometimes with hemorrhage from the mucous membranes, and at others, preceded by exanthematous spots, similar to those of urticaria febrilis. Febrile purpura may appear under the form of ecchymoses. In some cases, it is attended with hemorrhage from the nose, throat, stomach, intes- tines, &c.; in other cases, the latter occurs without the subcuticular hemorrhage. It may present, from the commencement, very serious symptoms, and prove fatal in a few days, in consequence of sanguineous effusion in the lungs, or substance of the brain; or it may terminate in death more slowly, in consequence of the extent of the hemorrhage, or the gradual draining away of the blood. The causes of purpura are extremely obscure. It is of much more frequent occurrence before than after the period of puberty, and at- tacks, as remarked by Willan, Graves, and others, most generally, such children as are exposed to the debilitating influence of an impure and confined, or cold and damp atmosphere, and who are badly fed, or on improper food, and debarred from sufficient exercise; it is, never- theless, not unfrequently met with in robust children, of full habits, and apparently in the enjoyment of perfect health. Some children appear to be peculiarly predisposed to its attacks, and this often hap- pens in all the children of the same family, as we have repeatedly ob- served. It has been supposed, in some cases, to be hereditary. It occasionally occurs subsequent to small-pox, measles, and other acute affections. It has been maintained by Mills, Parry, and Combe, that in all cases, venous plethora is necessary to the production of purpura; and in many cases, there certainly exist strong evidences of an overloaded PURPURA. 595 state of the portal system, Avith more or less derangement of the di- gestive organs; the bowels are often torpid, or in a state of constipa- tion, and when evacuations are procured, these are often of a most vi- tiated character. Pain of the epigastrium, or hypochondria, or ten- derness upon pressure, with swelling and tension of these parts, are also frequent symptoms of the hemorrhagic cases. In mild cases of purpura simplex, a proper regulation of the diet and regimen, with the warm or tepid bath daily, a full dose of calomel, followed by castor oil, or the citrate of magnesia; and when, by these means, the bowels have been fully evacuated, small doses of calomel, calcined magnesia, and ipecacuanha, in combination, repeated three times a day, with free exposure to a fresh, pure atmosphere, will, in general, be sufficient to effect a cure. In the more severe cases of P. hemorrhagica and P. febrilis, the re- medies must be adapted to the circumstances of each case. Where there exist evident indications of hyperaemia, or venous plethora; or much local pain or tenderness, with fulness and tension of the abdo- men generally, or at the epigastrium, or hypochondria, a cautious ab- straction of blood from the arm, or locally, by leeches, will occasion- ally be advisable. It must be admitted that, in young children, bleed- ing is a remedy not generally adapted to this disease: when leeches are employed, we have often knoAvn them to give rise to a long-con- tinued hemorrhage, by which, probably, a fatal result was caused, in cases, where, had the leeches not been applied, the disease miglit have been cured; on the other hand, when blood is drawn from the arm, we have known the loss of a few ounces to be followed by so great a degree of exhaustion, as to demand an immediate resort to stimulants, to prevent the death of the patient; at the same time, in children over ten years of age, we have certainly seen the very best effects result, in the early stage of the disease, from the cautious abstraction of blood, particularly by the lancet. In every case, our chief attention should be directed to the condition of the bowels. Full doses of calomel, in combination with magnesia or jalap, and followed, in a few hours, by a mixture of castor oil and turpentine, will have the effect, very generally, of bringing away large quantities of vitiated secretions: of unloading the portal system, and exciting a more healthy action throughout the entire extent of the gas- tro-intestinal mucous membrane; and by the continuance of the tur- pentine, in tolerably large doses, with an occasional dose of calomel, Ave shall soon correct the character of the intestinal evacuations, and at the same time effect a cure of the disease. Under the purgative treatment, we have seen the most rapid change produced in all the more serious phenomena of purpura haemorrhagica, and a striking amend- ment in the condition of the patient generally occurs the moment that large evacuations are procured from the bowels, of dark olive-green, and highly offensive faeces. The drinks of the patient may be acidulated with lemon juice, and they should be given perfectly cold; the diet shouldbe light and un- irritatincr, and composed of articles of a nourishing kind. When° decided debility exists, the sulphate of quinia, the dilute 596 DISEASES OF THE SKIN. mineral acids, and a nourishing diet, with, perhaps, in extreme cases, wine whey, or Avine and water, or diluted malt liquors, will be demand- ed; attention being, at the same time, paid to the bowels: in such cases, the spirits of turpentine and castor oil will form the most efficient and appropriate purgative. Care must be taken, however, not to mistake mere oppression of the vital functions for debility, or to commence Avith tonics or stimulants too early in any case: when this is done, we have repeatedly seen the tonic treatment increase the number of petechiae, augment the hemorrhage from the mucous membranes, and excite a violent febrile reaction, quickly followed by collapse and death. FROM INFECTION INDEPENDENT OF VISCERAL DISEASE. 19.—Psora—Scabies—Itch. The itch makes its first appearance, usually, between the fingers, about the wrists, and upon the backs of the hands, in the form of minute ve- sicles, filled with a colourless, transparent fluid, intermixed with small papulae, which latter likewise assume, in a short time, the vesicular character. The eruption is attended by intense itching, which is al- ways increased by whatever elevates the temperature of the part. Fre- quent friction and scratching, to allay the itching, produce speedily an inflammation and rupture of the vesicles, by which means the disease is extended to the surrounding skin. When the skin is very irritable, the vesicles of psora soon assume an opaque appearance, and are converted into true pustules, which sometimes attain a very considerable size. Hence, when the malady is of some standing, there may exist, at the same time, papulse, vesi- cles, and pustules, of various dimensions, interspersed: a feature which, in connexionwith the excessive itching and irritation, will readily dis- tinguish the itch from the other cutaneous affections. Though in its commencement, the disease, in the majority of cases, is confined to the fingers, wrists and hands, it may, however, extend to nearly every part of the body; in such cases, being most severe and troublesome about the trunk, margins of the arm-pits, and flexures of the joints, in consequence of the warmth generated by the clothing, and the friction excited by the motions of the body. The papula?, vesicles, and pustules often give rise to dark points, or dark-brown crusts, caused by the desiccation of the matter discharged by them. The pustules sometimes, when neglected, coalesce, and when ruptured, form ulcerations, upon which dark-brown scabs are apt to form. Psora, in the great majority of cases, is unquestionably produced from the direct contact of the fluid matter of the vesicles, by the touch of an infected person, by the handling or wearing his clothes, sleeping in the same bed, &c. It is increased in extent and virulence by a neg- lect of personal cleanliness, either in regard to repeated ablutions of the surface, or frequent changes of linen; and, by this means, many suppose that the disease may be generated, independent of infection. In its early stages, psora is entirely unconnected with any other dis- ease. When, however, it occurs in children who are debilitated, or otherwise unhealthy, it not unfrequently gives rise to a troublesome ITCH. 597 impetiginous affection of the skin, which may continue long after its specific character has been destroyed, (S. cachectica.) It is said never, or at least very rarely, to terminate spontaneously; when not subject- ed to a proper remedial treatment, it may continue during the lifetime of the patient, which it seldom tends to shorten. The disease presents itself under its most aggravated forms almost exclusively among the miserably poor; it is, however, met with more frequently in some countries, and situations, than in others. It is, in some degree, endemic in all cold and mountainous regions. In many cases of psora, particularly when neglected, an insect is to be seen, in or near the vesicles (scabies vermicularis, acarus vel sar- coptes scabiei.) It is usually found beneath the cuticle, in a small spot close to a vesicle, to which it is connected by an irregular dotted line, that marks its burrowing course. If this spot be punctured, upon careful ex- amination, the insect, somewhat resembling a cheese mite, may be de- tected, and abstracted upon the point of a needle. Of the existence of these insects there can be no reasonable doubt; but how far they are essential to the disease, and Avhether the latter is produced by them, are questions not so readily solved. The affirmative has been, recently, strongly maintained by several of the French and German physicians; while there are others who consider the insect as a mere parasite, in no way concerned in the production of the disease; the supposed cases in which the itch has been communicated by transferring the acarus to the skin of sound persons, being ascribed alone to the virus adhering to it. This latter we feel disposed to adopt as the correct view; for it is extremely difficult to reconcile the ease with which the disease is communicated by mere contact, with the notion that the transfer of one of the insects is necessary to produce it; especially when we are told of the difficulty of extracting these from their burroAvs beneath the cuticle. It is said by Mouronval, Lugol and Gras, that the dis- ease cannot be communicated by inoculation with the fluid of the vesi- cle: this we believe, however, to be an error:—we knew the disease to be produced, in one case, by an individual who put on a pair of gloves that had been Avorn four months previously by a person affected with the itch, and which had lain in a drawer from that period. It is supposed by some, that itch may be communicated to man from the dog and other domestic animals. Several workmen at the Jardin des Plantes, of Paris, are said to have contracted the disease, by at- tending upon a diseased camel, (Andral, Cazenave.) The disease may be communicated to infants and children at any period from birth to puberty; it generally occurs about four or five days subsequent to exposure to its contagion. A great variety of external as well as internal remedies have been proposed for the cure of this affection. They have all, no doubt, fre- quently succeeded: they are all, however, inferior in certainty, in the ordinary forms of the disease, to the external application of sulphur, either in the form of ointment or fumigation; and its internal use, in the form of the precipitated sulphur, mixed with milk or molasses. In the cases that usually occur in children, the ordinary unguentum 598 DISEASES OF THE SKIN. sulphuris of the shops will answer every purpose; but in more obsti- nate cases, the compound sulphur ointment of the United States Pharmacopoeia, may be employed. An ointment composed of one part carbonate of potassa, two of sulphur, and eight of lard, is pre- ferred by many of the French practitioners. Whichever of these ointments is used, it should be well rubbed into the affected parts, night and morning, for the space of one week; by which time, or perhaps earlier, in slight cases, the disease will be en- tirely cured. On ceasing the use of the ointment, the child should be immersed in a warm bath, and the entire surface of the body well washed with soap. In children of four or five years, and upwards, the common soft soap may be used, which, by some of the recent German physicians, is asserted to be itself an excellent remedy in cases of in- veterate itch. During the external employment of the sulphur, a portion of it— from ten grains to half a drachm, according to the age of the child— should be given, night and morning, in milk or molasses. In plethoric or robust children, over two years of age, an equal portion of the bitartrite of potassa may be added to the sulphur, and given in simple syrup or molasses. The diet of the patient should be perfectly plain and easy of digestion. After the cure is effected, no portion of the clothing or bedding that was in contact with the patient whilst he la- boured under the disease, should be used, until it has been thoroughly purified, and well aired. In many cases an ointment of the iodide of potassium made by adding one drachm to one ounce of lard, will prove a very efficient remedy; we have used it with complete and prompt success, in nume- rous instances. An ointment composed of half a drachm of sulphuret of lime, mixed with a little olive oil, and rubbed upon the palms of the hands, twice a day, for ten or fifteen minutes each time, will, it is said, prove, also, an efficient remedy. (Joy.) The sulphurous water-bath has occasionally been employed; but is by no means so prompt and certain in its effects, as the sulphur va- pour-bath ; this constitutes the principal remedy of Gates, and it has been strongly recommended by Horn, De Carro, Wallace, and other physicians, who have subsequently employed it. In children of eight, ten, and twelve years of age, we occasionally meet with cases of the disease, in which from neglect, and personal uncleanliness, it has been alloAved to spread over a considerable portion of the body, and in a form of considerable severity;—to these cases, the sulphur vapour- bath is well adapted. The number of fumigations necessary will de- pend very much upon the character of the disease in each case, the degree of irritability of the skin, &c. When a proper apparatus can be procured, this should be invariably employed; but if this is not at hand, blankets may be saturated with the vapour of sulphur, by means of sulphur strewed upon burning coal3, enclosed in a warming-pan; the patient being placed between the blankets, naked, and covered closely up to the throat. A great variety of other modes of treatment, and various forms of ointment, have been proposed, none of which, however, in the case of SYPHILITIC ERUPTIONS. 599 children, are equal in efficacy to those detailed. It is asserted by Pentzlin, that an ointment composed of one part of tar, and two parts of salt butter, melted together, with the addition, while fluid, of one part of carbonate of potassa, will remove the disease in seven days, if applied once every twenty-four hours. The following ointments have been found occasionally very useful, in the treatment of psora in infants. We annex them, not because we prefer them to those we have already given, but because cases may occur, in which, from a variety of circumstances, it may be useful to resort to one or other of them. R.—Creasot. tijjxxx. R.—Calcis Chlorid. fij. Cerati, Adipis, J viij.—M. 01. Amygdal. dulc. aa gj.—M. R.—Carb. potassae, ^ij. solve in R.—Hyd. Oxyd. alb. Qj. Aquae, gj. dein adde, Adipis, giv.— M. 01. Olirae, ^iv. Camphors, 3'j.—M. In every case of the disease occurring in robust and plethoric chil- dren, if there exists considerable irritation of the skin at the parts af- fected with the disease, it will be proper to commence the treatment by emollient poultices, warm fomentations, and brisk purgation; and should the local symptoms be very considerable, the application of leeches, or even the drawing of a few ounces of blood from the arm. The same treatment will be proper, should any considerable degree of local irritation or inflammation occur during the use of the sulphur or other ointments. These latter will always be found to act more effec- tually, by the reduction, in this manner, of the irritation. If the child affected with itch be debilitated, or labour under any other disease, the remedies adapted for the latter should be combined with the treatment required for the removal of the former. 20.—Syphilitic Eruptions. Infants are liable to become infected with syphilis, either before birth, during birth, or during lactation. Infants born of mothers who are labouring under the venereal disease may exhibit indications of syphi- lis at birth; or the disease may not appear for many days, weeks, or months subsequently. Syphilitic children are frequently born pre- maturely or dead, with the cuticle separated, or peeling from different parts of their bodies, or in a state of gangrene: abortion is a very fre- quent consequence of intra-uterine infection. It is a curious circumstance, that during the entire period of gesta- tion, at the period of conception, or even for some time previous, neither parent may have exhibited any symptoms of disease, and yet the foetus may become infected in consequence of an attack of syphilis, in one or other parent, Avhich had, to all appearances, been fully eradi- cated years before marriage. In cases like these, where there exist so many powerful motives for concealment or deception, there must, of course, always remain considerable doubt as to the fact of the entire freedom from disease of the parents; we have nevertheless met with repeated instances, in which we had every reason to believe that such was actually the case; and a similar statement is made by Burns, Veggio, Maunsell, Dendy, and others. It is probable, however, that 600 DISEASES OF THE SKIN. in some of the numerous cases recorded in the continental journals, of syphilitic children born of parents in whom no vestige of the disease existed, eruptions of the skin of a non-venereal character may have been mistaken for those of syphilis. How far confidence is to be placed in the statements made of the foetus being liable to infection, in con- sequence of the father being, or having been diseased, while the mother is, and always has been, perfectly healthy, we are not prepared to offer any positive opinion: we have, however, certainly met with cases which would appear to establish very fully the fact; and Mr. Acton, surgeon to the Islington Dispensatory, England, adduces three cases, in which constitutional syphilis in the father was the cause of repeated abor- tions, and, subsequently, of infection of the foetus born at the full pe- riod—the mother remaining throughout wholly free from disease. He gives an abridged account of two other cases of secondary syphilis in men, whose wives were free from all disease, but had miscarried. Dr. Behrend (Journ. f. Kinderkrankheiten, xvii.) states that the disease is most frequently imparted to the foetus by the father. Intra-uterine syphilis generally presents itself in the form of red, brown, or fawn-coloured blotches varying in size, and slightly raised above the level of the surrounding skin. From the surface of these blotches, a very slight moisture exudes, which, in parts exposed to the air, on drying, gives to them a scaly appearance, and at length forms thin scabs, of a dark yellow, or brownish colour, which reappear as often as they are detached. The eruption usually occurs first upon the lower extremities, buttocks and loins, but subsequently extends to the rest of the body, as well as to the face. When the blotches appear about the verge of the af us, between the buttocks, and in the folds of the thighs and neck, the continual moisture and friction of the parts prevent the formation of crusts, but irregular tubercular swellings (condylomae,) occur. With the progress of the disease, the skin becomes throughout of a reddish-brown or fawn-colour. The infant is, at the same time, fever- ish, fretful, and gradually wastes away; its voice becomes feeble and hoarse, and there is a constant discharge from the nostrils of a yel- low, viscid mucus, which quickly dries about the external orifices; the nose becomes swollen, and perpendicular fissures occur in the lips, giving a very peculiar appearance to the mouth. The whole counte- nance assumes at length a wrinkled, dejected appearance, and the in- fant exhibits evident indications of suffering, from deep-seated pains in the cylindrical bones; it becomes more and more feeble and ema- ciated; ulcerations present themselves upon various parts of the skin; the inside of the mouth and surface of the tongue are often covered Avith aphthae, and the patient finally dies, in a state of extreme .de- bility and excessive emaciation. Such are the usual phenomena and progress of syphilitic eruptions, from intra-uterine infection; though we have known infants born of diseased parents to present irregular ulcerations, or large vesications on different parts of the surface, filled with a yellow, turbid or dark- coloured fluid, and which, upon rupturing, left ulcerations of the skin, that became quickly covered with thin, dark crusts, and surrounded with a dark-red or purplish margin. SYPHILITIC ERUPTIONS. 601 It has been doubted whether the venereal disease is ever communi- cated to the infant during birth; the vernix caseosa being supposed to afford a sufficient protection to the skin against infection. It is certainly not very common to find the disease communicated in this manner; and we believe, that when such is the case, it will present itself, most generally, under the form of purulent ophthalmia. Transmission by the nipple of a diseased nurse is a very frequent mode in which infants are infected with syphilis. Ulcers, in this case, are generally formed in the mouth of the child, which are often entirely overlooked; or, when first noticed, are liable to be mistaken, even by the physician, for the ordinary eruption so common in infants during lactation. Thus, the true character of the disease not being recognised in its first stage, it seldom comes under treatment until blotches and ulcerations have made their appearance upon the skin, Avhen its characters are the same precisely as those described above. It is very common for syphilitic eruptions in infants to entirely dis- appear under an appropriate treatment, but again to return, sooner or later, after the treatment is suspended, and thus to recur repeatedly, until, finally, every vestige of the disease is eradicated. This should serve as a caution to the young practitioner not to pronounce the child entirely cured, until several months have elapsed without any symptoms of the disease reappearing. The diagnosis of syphilitic eruptions in infants is not always very easy; they, in many cases, resemble very closely psoriasis or lepra, or some of the more inveterate forms of scabies. The physician Avho has seen a good deal of the disease will seldom be deceived; but the young practitioner must depend altogether upon a cautious investigation of its history, at the same time, without, if possible, exciting suspicion in the minds of those interested: an incautious hint, or imprudent ques- tion, might have the effect of destroying domestic peace, or, at least, of deeply wounding the feelings of a mother, in cases where the con- duct of neither parent is in the slightest degree concerned in the pro- duction of their infant's malady. In every instance, indeed, the ex- pression of opinion should be very guarded. The treatment of infantile syphilis is extremely simple, and, when judiciously carried into effect at an early stage of the complaint, is, very generally, successful in its eradication. One or two grains of hydrargyrum cum creta, two, three, or four times a day, according to the age of the child; or a third or fourth of a grain of calomel, com- bined with chalk, ipecacuanha, and extract of hyoscyamus;1 with the external application of the black wash, or dilute citrine ointment,2 to the crusts, ulcers, or condylomae, twice or thrice a day, should be di- rected, and continued until the eruption and the discharge from the nostrils disappear; and at longer intervals, for one, two, or three weeks subsequently. 1 R.—Calomel, gr. iij.—iv. 2 R.—Ungt. hyd. nit. ^iij. Pulv. ipecac, gr. ij.—iij. Cerat. simpl. 31J.—M. Cretoe ppt. %*s. Ext. hyoscyami, gr. iij.—iv.—M. f. chart. No. xij. One to be given twice a day, or every 3 or 4 hours, according to the age of the patient. 602 DISEASES OF THE SKIN. By this plan of treatment, we have generally succeeded in the re- moval of the disease in one month, in recent cases; but in those which have been neglected in their earlier stages, it will seldom effect a cure under two, three, or even four months. We are to recollect, also, the liability of the eruption to recur, after, to all appearance, it has been entirely eradicated; when the same treatment is to be again resumed. Should the mercury, when given by the mouth, produce griping and purging—which, however, we have seldom found it to do Avhen com- bined with the chalk, ipecacuanha, and hyoscyamus—a small portion of Dover's powder may be added to each dose; carefully, however, watching the effects of the opiate, which, in infants, often gives rise, even in the smallest doses, to very serious effects. When the gastro- intestinal irritation produced by the calomel cannot be controlled by such doses of opium as it would be prudent or safe to administer to an infant, it has been advised to omit its use, and resort to the external application of mercury, in the form of ointment. Fifteen grains of the unguentum hydrargyri mitis may be rubbed upon the inner surface of the thighs alternately, once in tAvo days, until the mouth becomes hot, when it is to be intermitted, and again resumed after a proper inter- val, should it be necessary. In children under two years of age, salivation is rarely, if eA'er, pro- duced; it is necessary, nevertheless, to watch the effects of the mer- cury upon the gums, and if these become hot, slightly swollen, or livid, its use should be at once suspended, as in some cases gangrene has been known to result from its continuance under these circumstances. This result, however, is seldom witnessed excepting in very feeble children. When the external sores are very indolent, they may be washed with a weak solution of the sulphate of copper, or of the nitrate of silver. If we have reason to suppose that the mother or nurse is labouring under disease of a syphilitic character, (and we must recollect, that for very obvious reasons, it would be imprudent either to wean the infant, or to suckle it at the breast of a healthy nurse,) we should administer to her the ioduret of mercury, with the decoction or syrup of sarsapa- rilla. It is true, that the milk may be thus rendered less adapted for the nourishment of the child, but it seems, nevertheless, absolutely necessary for the effectual eradication of the disease in the infant. We would remark, however, that we recommend this course only in the case of the mother being actually syphilitic: we are opposed to the plan of attempting the cure of the infant by giving mercury to the nurse, as was formerly practised. During the course of treatment, both mother and child should enjoy the benefit of a pure, fresh atmosphere; the diet of the former should be plain, mild, and sufficiently nourishing, and her drink, water alone: it is important, also, that she take sufficient daily exercise in the open air, and observe regularity in her hours of repose. SCROFULA. 603 SECTION V. DISEASES OF THE NUTRITIVE FUNCTION. SCROFULA. Scrofula is a very common affection of infancy and childhood, being itself often the cause of various morbid phenomena: more fre- quently, however, it acts as a predisposing cause of disease, or imparts to the several affections, common to the earlier stages of life, a peculiar character, as well in reference to their symptoms, as to their progress and termination. It is very difficult to give a correct, and at the same time a concise and comprehensive definition of scrofula, and hence the somewhat vague term scrofulous or strumous diathesis, has been very generally adopted by physicians; the various manifestations of this morbid con- dition being usually described as individual disease. This plan, while it is productive of no little confusion, is but illy calculated to lead to correct views in regard to either the pathology, prophylaxis, or thera- peutical management of that particular morbid condition of the orga- nism in which scrofula consists. In children in whom the scrofulous predisposition is strongly marked, there is a deficiency of fibrine in the blood; there is a pre- dominance of the white fluids and tissues over the red; the several organs are pale, small in size, loose in texture, and perform lan- guidly their respective functions. There is usually a peculiar fra- gility of the whole frame; the skin is, in most cases, thin and deli- cate, and by allowing the vessels beneath to be distinctly seen, gives to the complexion an appearance of great delicacy and beauty: the limbs are often small, soft and rounded, but with large joints; the fingers are long and slender, but commonly broad and flat at the extremities; the chest is contracted; the head is usually large, and the hair fine, silky, and often light-coloured; the eyelashes are long, the eyes prominent, though languid in expression, and the pupils large; the lips are ordinarily thick and prominent. The whole frame exhibits an appearance of languor and debility; exercise of every kind quickly tires. Notwithstanding there is generally a want of muscular deve- lopment, yet, in many cases, the body and limbs have an appearance ot plumpness, resulting from the infiltrated state of the cellular tissue. The action of the heart, though usually languid and feeble, is easily excited, and a degree of febrile excitement will be apt to result from the slightest causes. The feelings are quick, warm, and ardent; and in many cases there is very decided quickness and precocity of intellect. 601 DISEASES OF THE NUTRITIVE FUNCTION. Not unfrequently the countenance is swollen, and of a sallow hue; the cheeks full, tumid, and flaccid; the hair coarse and dark-coloured; the lips thick, coarse, and liable to chap; the skin thick, harsh, and subject to eruptions; the eyes dull and watery; the eyelids full and drooping, and the general expression dull, heavy and stupid. Digestion is ordinarily slow and imperfect, and liable to frequent derangement. The bowels are torpid or irregular; cold and heat are alike borne with difficulty; while the effects of any of the usual mor- bific causes are more certain to be experienced by an organization such as we have described, than by one of greater health and vigour; evinced, however, in the production rather of chronic than of acute disease. Inflammation occurring in scrofulous habits is slow in its progress, and often unattended by very manifest symptoms, unless when it is externally seated. When adhesions occur, the adhesive matter, in- stead of being firm, is of a curd-like consistence and appearance, very soft and easily broken, and with few, if any, blood-vessels pene- trating it. Suppuration is attended with the formation, instead of genuine pus, of a thin, puruloid fluid, containing curd-like matter. Ulceration is slow in its progress; granulations are tedious in form- ing, and unequal; and cicatrization, which is very tardy in taking place, leaves an uneven, deep, and unsightly scar. Softening of the internal tissues is very common, as well as tumefaction, suppuration, or disorganization of the lymphatic glands. Throughout almost every tissue of the body there is a tendency to tuberculous depositions, varying somewhat in their character, pro- gress and termination, according to the different tissues in which they occur; whilst in the bony structure we have a disposition to softening from the defect of the ossific process, and in the skin a pre- disposition to various chronic eruptions. It is evident from the foregoing general sketches of the characteris- tics of the scrofulous diathesis that they are all dependent on an abnor- mal condition of the organic functions, giving rise to imperfect sangui- fication and nutrition, and consequently, a defective organization of the several tissues. Children are often born with this defective organization, or with so decided a tendency to it, as to render its development certain, if the infant be subjected to those influences which are calculated to impede or render imperfect the functions of digestion, assimilation and san- guification. Under such circumstances, tubercular depositions take place at an early period, and a decided and very peculiar modification is manifested in the phenomena, progress, and tendency of the ordi- nary diseases of infancy. Under opposite circumstances, or by a judicious course of hygienic treatment, the organic functions may be roused into greater activity, and the organization of the tissues so far improved, as to destroy their tendency to disease, or to allow the individual to pass through life with a delicate constitution, but without the occurrence of any morbid phe- nomena calculated to produce suffering, or materially to impair his comfort. The question has been long discussed as to the hereditary charac- SCROFULA. 605 ter of scrofula. Upon a cautious review of all the facts that have been adduced, and a reference to the recorded experience of every observing physician, it appears to us to be a question very easy of solution. There cannot be a doubt, that the children of parents who have laboured under the disease are more peculiarly liable to its occurrence, all other things being the same, than those born of indi- viduals Avho were free from it. In the foetus in utero, scrofulous affections have not unfrequently been developed, when one or other of the parents have been diseased; but, ordinarily, all that the child inherits is that particular organization, which predisposes it subse- quently to birth to affections of this character. This diathesis or predisposition may be derived not only from scrofulous parents, but from such as have never manifested, during their whole lives, any trace of the disease. Thus, the predisposition in the child may result from a morbid condition of the parents, pro- duced either by disordered digestion, chronic disease, intemperance, of various kinds, a luxurious and indolent life, too late or premature marriage, or the habitual indulgence of any of the depressing passions. Intermarriages between near blood relations have probably, also, a very powerful tendency to produce a predisposition to scrofula in the offspring. While children born with the organization, and consequent pre- disposition just alluded to, will, under all circumstances, be most liable to the occurrence of scrofulous disease, it is, nevertheless, true, that the scrofulous tendency may be developed subsequent to birth, even in children exhibiting no traces of a lymphatic temperament, and born of perfectly healthy parents. The causes which produce this development are various: the most important are improper or deficient food—impure and confined air— defect of exercise—cold and dampness—imperfect clothing—neglect of personal cleanliness—over-fatigue—and the depressing passions generally. Improper or deficient food is probably of itself sufficient to produce that particular condition of the organic functions upon which the de- velopment of scrofulous disease depends. The origin of scrofula in disorder of the digestive organs is indeed of so frequent occurrence, that many pathologists have considered this to be its invariable cause. . . Improper or deficient food must necessarily give rise to imperfect di- gestion, defective assimilation, and incomplete sanguification; the blood in consequence becomes deficient in fibrine, and the nutrition of all the tissues suffer. The child becomes pale and loses flesh, its strength sinks, and a general unhealthy condition of the whole organism quickly ensues. , .. This may occur to the infant at the breast, from the bad quality or insufficient quantity of the mother's milk; it is more likely, however, to take place when the deficiency is attempted to be supplied by rear- ing the child, partly or entirely, by the hand, and still more so, after weaning, by the unappropriate character, the insufficient amount, the indigestibility, or the unnutritious properties of the diet upon which it 606 DISEASES OF THE NUTRITIVE FUNCTION. is attempted to be nourished. Poverty may prevent a greater quantity or a better quality of food being allowed, and, in such cases, other causes very generally concur to undermine the health and vigour of the constitution. But, even in families where food is plenty, " child- ren are often starved into disease," by that which is given to them being altogether unadapted to the condition of their digestive organs, and, in consequence, not undergoing, to a sufficient extent, those changes which are essential to afford an adequate supply of materials fitted for nutrition. A robust, healthy child, in the enjoyment of pure air and active exercise, may often, for a considerable time, exhibit, in no very striking degree, the bad effects of an improper or insufficient diet; but even such a one must eventually suffer under it; whilst the feeble and delicate child, or one exposed at the same time to the in- fluence of an impure, damp, and confined atmosphere, and debarred from sufficient exercise, will quickly evince all the phenomena of defec- tive nutrition. We do not mean to say that in every instance scrofula will be developed; but only that this is one of the causes which con- cur in its development. In the predisposed, it is often the chief cause. Impure and confined air is also an efficient agent in the production of scrofulous disease. It acts not only in preventing the due oxygena- tion of the blood by the lungs, but also the important changes which are effected in it by the functions of the skin. Children confined in ill-ventilated apartments, particularly when the air of such apartments is still further vitiated by the numbers who breathe it, or by the neglect of cleanliness, are uniformly pale, delicate, and unhealthy; and if, at the same time, the apartments are badly lighted, the baneful influence exerted upon the health of its inmates is still more manifest. The effect which the solar rays exercise upon the atmosphere, or upon the functions of life, it is perhaps impossible to discover; all we know is, that they are, in some manner, essential to the wholesomeness of the first, and to the due performance of the latter. From the many causes by which, in large and crowded cities, the purity of the atmosphere is impaired, and its free circulation impeded, the children who are brought up in them have invariably paler com- plexions, and very generally smaller muscles, less developed forms, and a far inferior degree of vigour than those reared in open, healthy situ- ations in the country. When the deleterious tendency of the city air is not fully counteracted by a sufficiency of wholesome food, regular active exercise out of doors, and personal and domestic cleanliness, a scrofulous tendency is very apt to be generated. A want of sufficient exercise is likewise to be ranked among the causes of that defect of nutrition, upon which the tendency to scro- fulous disease depends: its effects are very generally increased by its being combined with those of an impure and confined atmosphere. It is chiefly by these two causes that the health of those children is so quickly impaired, who are confined for many hours, daily, in crowded school-rooms, or are made to toil from morning until night, and often late in the night, in sedentary occupations. Nutrition, in children so circumstanced, is quickly and deeply impaired, by defective digestion, SCROFULA. 607 by imperfect assimilation, by deficient oxygenation of the blood, and by a too languid circulation through the capillaries. Cold and damp are invariably injurious to the infant. In the pre- disposed, they are among the most powerful exciting causes of scro- fula, and even in the healthy, when long continued, they impair, to a very considerable degree, the nutrition of the bodies; and this, too, when in a degree far below what is necessary to produce a sensation of chilliness in the adult. In the damp and chilly hovels of the poor, during the colder season of the year, the children seldom escape more or less suffering and disease, and if death is not the speedy consequence, the health and energy of their systems are impaired, and some form of scrofula being developed, they ultimately become its victims. But it is not among the poor only, that cold and damp exert their morbific influence; even the children of the more opulent are made to suffer from them, in consequence of fashion rather than good sense dictating the form and material of their clothing, and leaving entirely bare, or only flimsily covered, portions of the body that require at least equally with the others to be kept warm. The effects of the cold to which the child is thus exposed are not less certain, because produced often slowly and insidiously. Conjointly with a bad or insufficient diet, foul and stagnant air, and deficient exercise, personal uncleanliness is a powerful cause of that state of impaired health in children, which lays the foundation for scrofulous disease. Children are, we suspect, but seldom subjected in this country to over-fatigue from laborious occupations. In Europe they are frequently, however, exhausted by being kept steadily upon their feet, for many hours, day and night, at occupations, which, without being laborious, fatigue as well by their monotony, as by the constant attention they demand. We have known the health of the boys or girls in some of our neAvspaper offices, Avho wait upon the press, often during the en- tire night, to become seriously impaired; and in certain of our schools, where young children are kept seated at their desks, engaged in unin- teresting tasks, for many hours of the day, a degree of fatigue is in- duced, often very serious in its results. Fatigue in children impairs the energies of the system, increases the irritability of all the organs, and thus concurs in the production of the scrofulous predisposition. The depressing passions, happily, are not easily excited in children, and yet they are more frequently a cause of impaired health, at this period of life, than is generally supposed. Neglect or ill usage on the part of parents, ridicule for personal defects, constant thwarting of their childish but natural inclinations; the rude repulsing of their affections, and a variety of other errors and improprieties, in the moral education of children, will often, in those of peculiarly suscep- tible minds, produce a state of such deep depression as sensibly to impair their health, and with the seclusion and inactivity to which such depression most generally leads, lay the foundation for disease, which will be very liable to assume the scrofulous character. In the predisposed, almost any one of the causes enumerated will be sufficient to produce some one or other of the forms of scrofula, 608 DISEASES OF THE NUTRITIVE FUNCTION. while even in those born with the marks of health, the combined ac- tion of several of them may produce the predisposition to its occur- rence. Children who possess, from their birth, a strongly marked lymphatic temperament, and in whom the predisposition to scrofulous affections is consequently congenital, may, in the majority of cases, by a proper course of hygienic treatment, be preserved from the attack of disease, and have their health and vigour greatly improved. Unless, however, such a course is early commenced, and perseveringly carried out, they will be constantly liable to a variety of ailments, until some confirmed and serious malady is finally developed. Their digestion becomes, from slight and often inappreciable causes, frequently deranged; their ap- petite, though often excessive, is, in numerous instances, deficient or ir- regular; their bowels are often confined, the discharges being un- healthy in colour and consistence; or a torpid condition of the intes- tines will alternate, at irregular intervals, with diarrhoea, the stools being light-coloured and slimy, or dark and of a jelly-like consistence. The flesh becomes soft and flabby, and the bones indisposed to perfect ossification. The child is late in assuming the erect position, or in its attempts to walk, or if put upon his feet, the bones of the lower ex- tremities become curved and distorted. The joints are large and pro- minent, but loose and infirm. Dentition is protracted, sIoav, and diffi- cult, and the teeth soon become black and decayed. The child is often fretful and peevish, has a languid, heavy appearance, is indis- posed to play, and readily becomes fatigued. His sleep is often dis- turbed, and broken by signs of distress, or by startings, as if from fright. The functions of the skin are imperfectly performed, and, frequently, eruptions of a transient or permanent duration occur. The tongue is either soft, flabby, and repeatedly covered with a thick tenacious mucus, or uniformly red, or maculated. In many instances the child exhibits early symptoms of intelligence, but is more often dull, heavy, and stupid. As the child advances in years, the throat, fauces, and tonsils ex- hibit symptoms of disease. The latter, especially from slight attacks of inflammation, become greatly swollen, and of a ragged, uneven shape, and often remain permanently enlarged for a considerable length of time, though seldom very painful; the only immediate in- convenience resulting from the enlargement being an impediment to the freedom of respiration, particularly when the child is asleep, some slight difficulty in swallowing, a dulness of hearing, and a peculiar in- tonation of the voice in speaking. The eyes are often the seat of slow inflammation; the edges of the eyelids are affected with chronic disease, increased exudation from the follicles, stye, &c. The glands of the neck become enlarged, and after remaining long in an indolent state, frequently inflame, suppurate, and give rise to ulcerations, slow in healing, and which often leave fistulous openings, from which a thin discharge takes place, for many months, or even years. The term scrofula has generally been restricted to a chronic en- largement of the lymphatic glands, terminating finally in their inflam- mation, and a species of imperfect suppuration, forming abscesses filled SCROFULA. 609 with a pale, whey-like fluid, that gradually becomes thicker, of a yel- lowish colour, and intermixed with portions of curd-like matter. When the abscess is opened or ruptures, it gives rise to an irregular, ragged ulcer, in which large, spongy granulations slowly form, of different heights at the different parts of the ulcerated surface, and when cica- trization finally takes place, an uneven, puckered, and often deep, indelible scar is left. The swelling of the lymphatic glands may be detected when they are no larger than a pea. They are then, hard, movable, and without pain or even tenderness when touched or handled. They often con- tinue, for a great length of time, without increase, forming a chain of small tumours, extending from ear to ear. Occasionally, one of the salivary glands, or the thyroid body becomes affected. When the glands commence to augment in size, the progress of the swelling is, generally, extremely slow, and often months or years elapse, before the skin over the tumour inflames. Occasionally, the swelling sub- sides before this takes place; but, in general, it has a tendency to soften, forming a species of encysted tumour filled with a whey-like or curdy fluid. Even at this stage, absorption will sometimes take place, and the SAvelling disappear. Usually, however, suppuration pro- ceeds slowly; the Avhole structure of the diseased gland becomes de- stroyed, and a large abscess is formed, that finally bursts, forming an ulcer, varying in size, with indurated edges, and uneven surface, from which is discharged a thin Avatery fluid, mixed with flakes of curdy matter, and occasionally small masses of a tuberculous appearance. In other cases, the diseased gland is less uniformly softened, and becomes converted into a curd-like substance, intermixed with a softer, less opaque matter, of a light yellow colour, with a small collection of pus near its centre. Sometimes a number of small abscesses occur in the body of the diseased gland, each filled with curdy matter. The gland finally becomes a large abscess. Inflammation subsequently attacks the tissues surrounding the gland; which latter is eventually entirely destroyed by suppuration;—suppuration sometimes taking place around the new-formed matter within the gland. The gland may continue, however, for a number of years in a diseased state, without suppuration taking place. The scrofulous ulcer is always slow and difficult to heal; it may often remain open for months; or it may heal in one part and extend in another. When cicatrization does take place, it is irregular, puckered, often crossed by projecting bands, and of a peculiar white, unhealthy colour. The intumescence of the glands is frequently the effect of exposure to cold, or occurs in conjunction with more or less disease of the diges- tive organs. It is sometimes connected with cutaneous eruptions about the head and face; but occasionally comes on without any very evident exciting cause. It is generally confined to the glands about the neck, thouo-h the lymphatic glands of the axilla and groin may become dis- eased in the same manner. We have seen well-marked scrofulous dis- ease of the axillary glands, but have never met with a case in which those of the groin were affected. 39 610 DISEASES OF THE NUTRITIVE FUNCTION. Scrofulous disease of the glands of the neck most commonly occurs after the fourth year; it may occur, however, much earlier; we have seen it previously to the first year, and repeatedly between the second and fourth. It seldom, however, tends to suppuration in children un- der two years of age. When the disease occurs in this form, uncon- nected with any serious affection of the internal organs, though tedi- ous and troublesome, and often resulting in very considerable defor- mity, it is seldom, if ever, fatal. It has even been proposed, in cases in which a tendency to tuberculous depositions in the lungs presents itself, to overcome this by exciting disease in one of the glands of the neck, by the insertion of vaccine matter in numerous points over the gland; and instances are related, by the late Dr. Parrish, of Philadel- phia, of the presumed successful result of this procedure. Scrofulous Ophthalmia.—Inflammation of the eye is a very com- mon affection in children of a strongly marked lymphatic temperament; and is often the first indication which presents itself of the scrofulous predisposition. Very generally, the edges of the eyelids are first affected with a degree of soreness, and soon become red and slightly thickened; the secretion from their follicles is increased, and drying during sleep, causes the lids to become agglutinated. Upon everting the eyelids, their inner surface is found to be somewhat reddened, and a few red vessels are observed upon the globe of the eye. The redness of the conjunctiva is at first slight, and, in many cases, confined entirely to the lids. There is generally, however, an abundant secretion of the tears, and very great intolerance of light, so that the patient cannot be persuaded to raise his eyes to the light, but walks with the face in- clined downwards, and often shades the eyes with the hands. This intolerance of light is usually most severe in the early part of the day; in the afternoon it will, occasionally, so far remit as to per- mit the patient to open his eyes. The presence of daylight, as Taylor remarks, would appear to produce a spasmodic action of the orbicularis muscles, so that even when the child is willing, he is unable to unclose the eyelids during daylight; or, if he does succeed, by a kind of con- vulsive effort, the cornea is immediately rolled upAvard beneath the margin of the tarsus, so as to be completely hid from view. As the disease augments, the redness of the conjunctiva increases in extent and intensity. In the commencement, the disease is not attended with much pain; though, occasionally, severe pain is experienced during the night, by Avhich sleep is often broken or prevented. In some cases, the vessels running from the conjunctiva to the cornea are somewhat injected, whilst in other cases, several enlarged vessels are perceived; the red- ness of the conjunctiva of the eye itself is, however, not usually very strongly marked. In recent and acute cases, an effusion of serum sometimes occurs beneath the conjunctiva immediately around the cor- nea, forming an elevated cedematous circle, of a peculiar reddish-brown appearance, and about a line or more in thickness. In all cases of true scrofulous ophthalmia, there exists a strong dis- position to the formation of pustules, which appear upon many points SCROFULOUS OPHTHALMIA. 611 of the eyelids, and along the edge of the tarsus, and often produce ul- cerations, attended with considerable irritation. The skin immediately beneath the eye is also very commonly inflamed and covered with a minute pustular eruption. In the majority of cases, small vesicles or pustules appear upon the conjunctiva and cornea. They vary in number and size, but are gene- rally smaller upon the cornea; at the same time, a pencil of red vessels is often developed on the latter. The vesicles or pustules, upon rup- turing, form small, round, superficial, or funnel-shaped ulcers. The vesicles or pustules, may be absorbed previously to bursting, and then they leave, in the cornea, a slight degree of cloudiness, which disap- pears in time. Sometimes, upon the removal of this, a transparent dimple remains, which is long in filling up. In some cases, the cloudi- ness spreads over the cornea, and large red vessels run into it, form- ing a vascular speck, which is always a very tedious and troublesome symptom. Occasionally, a general cloudiness or a permanent opacity of the cornea may also be produced. Dr. Maunsell describes the ulceration of the cornea as sometimes presenting an appearance, as if a small portion of its conjunctival layer had been removed by a sharp chisel, leaving a distinct facet, some- times level, and in other instances concaA^e: this condition may remain unaltered for a considerable length of time, and is unattended with opacity of the cornea. We have met with this form of ulceration in many cases. The ulcers of the cornea, particularly when superficial, often cica- trize, leaving an opaque, permanent cicatrix, which may become les- sened in time, but never entirely obliterated. When the ulcerations are of some depth, they are often attended with considerable irrita- tion and pain upon every motion of the eyelids. They sometimes penetrate entirely through the cornea, and a protrusion of the mem- brane of the aqueous humour takes place, in the form of a small vesi- cle : Avhen this gives way, the aqueous humour escapes, the iris is pro- lapsed, and a dense, opaque cicatrix is the result; or the ulcer may at once penetrate the anterior chamber, with a similar result. When the ulceration of the cornea is of considerable size, and the iris extensively prolapsed, the pseudo-cornea which forms over the protruded portion of the iris, sometimes give way before the pressure of the humours, forming a partial staphyloma. A general protrusipn of the whole cornea may take place from the same cause, when its texture has become weakened by inflammation, and the iris is adhe- rent to its posterior surface. The transparency of the cornea may also be impaired by a ramification of red vessels, forming a vascular net-work in its conjunctival layer. The inflammation may be propagated from the cornea to the scle- rotica and iris, or even to the more deeply-seated structures of the eye, producing extensive disorganization of the interior of the globe, par- ticularly when the disease is of long standing, or has repeatedly re- curred. Hydrophthalmia may be induced by increased secretion of the humours; or, occasionally, the eye may become atrophied, appa- rently from interrupted nutrition. 612 DISEASES OF THE NUTRITIVE FUNCTION. Scrofulous iritis is generally'of a chronic form, and unattended with symptoms of any severity: it may, in the course of time, extend to and cause disorganization of the surrounding tissues, terminating in amaurosis and atrophy of the globe. Scrofulous ophthalmia occasionally assumes a much milder form. Its principal feature is the occurrence of pustules upon the conjunc- tiva, usually a line or two from the margin of the cornea. (Pustular ophthalmia.) These pustules are generally of considerable size, and filled with an opaque, yellow matter: they are accompanied with a fascicular injection of the conjunctiva in their immediate vicinity: oc- casionally, the injection of the conjunctiva is more diffused, and ac- companied with ecchymoses. On the pustules bursting, they form broad, elevated ulcers, which, after a time, cicatrize. There is little or no intolerance of light, and an entire absence of the spasmodic con- traction of the lids observed in the more severe form of scrofulous ophthalmia. The transparent textures of the eye are unaffected. Pustular ophthalmia is often combined with catarrhal conjunctivitis. This form of scrofulous ophthalmia is, according to our experience, of much more common occurrence, than the more violent one described above. The local disease is generally attended with some degree of febrile reaction—a fretful and irritable temper, and a disordered condition of the alimentary canal. Frequently, the abdomen is tumid and tense, the breath very offensive, and the alvine discharges of an unnatural appearance. When the case is one of long continuance, there is con- siderable emaciation, particularly of the extremities, with a general manifestation of feebleness and irritability. Scrofulous ophthalmia is frequently preceded by eruptive affections of the head and face, and ulcerations behind the ears, which disappear soon after the inflammation of the eye is fully developed. When as- sociated with these eruptive affections, the disease has been described by Wardrop and Christian, as exanthematous, orporriginous ophthalmia. Scrofulous ophthalmia usually attacks both eyes, though seldom in an equal degree; or the disease may occur, first in one eye, and then extend to the other; or, it may attack the two eyes alternately. The disease most generally occurs during childhood: it is rarely met with in adults, never, unless they have previously suffered from it. The most common period for its attack is between the first and four- teenth years of life. It is produced by the usual causes of ophthalmia—cold, irritating vapours, or other substances admitted into the eye. It frequently oc- curs, also, about the period of dentition, *or subsequently to an attack of one or other of the febrile exanthemata. Scrofulous Otitis.—This is a very common affection during child- hood. The inflammation may be confined to the lining membrane of the external meatus, Avhen it very generally assumes a chronic form. The inflamed membrane becomes, sooner or later, studded with minute pustules, upon the rupture of which, ulcers form, and give discharge to a thin, unhealthy, and often very fetid pus. The discharge from the ear usually continues for a great length of time, and the lining SCROFULOUS OTITIS. 613 membrane of the meatus very frequently assumes a thick, spongy, and highly irritable condition, and presents an appearance as though it were covered with a kind of curdy exudation. In other cases, the dis- charge ceases for a longer or shorter period, and then again suddenly recurs. Sometimes the suppression of the discharge is followed by scrofulous ophthalmia, porriginous eruptions upon the scalp, intumes- cence of the glands of the neck, &c. The disease may cause finally a destruction of the membrana tympani, and of the ossicula of the ear, and thus occasion permanent deafness. In other cases, the inflammation affects the deep-seated structure of the ear; or this may become affected in consequence of the extension of the disease from the external meatus. This form of otitis is at- tended with more or less dull pain, which often extends over the side of the head, alternating, occasionally, with very severe paroxysms of more acute suffering; with deafness, singing, humming or other noises in the ear; disturbed sleep, fretfulness, and irritability of temper, and, occasionally, with some degree of febrile reaction. When a discharge takes place, it ia of a thin, grayish, dirty-coloured fluid, often more or less sanguinolent, and exhaling a peculiar, but, generally, very fetid odour. It is often acrid, and causes irritation, and more or less swell- ing of the lobe of the ear, and of such parts of the skin as it comes in contact with. In the progress of the disease, the discharge from the ear Avill occasionally contain small fragments of carious bone. The mastoid cells are occasionally affected in cases of scrofulous otitis. When this occurs, a dull pain is felt over the mastoid process, which is tender upon pressure;—the skin covering this part becomes reddened, slightly swollen, and an accumulation of matter takes place beneath it. After a time, the skin assumes a more dusky or violet hue, becomes gradually more and more thin, and, finally, ulcerates, giving discharge to a fluid similar to that from the ear. The cellular structure of the mastoid process is now found to be destroyed, to a greater or less extent, and infiltrated with matter, while a fistulous communication is formed between the external surface and the cavity of the tympanum. Occasionally the matter travels downwards, between the muscles attached to the mastoid process, and opens low down in the neck. In other cases, the whole cellular structure of the mastoid process becomes disorganized and broken down, and is discharged from the external meatus, mixed with a sanious fluid, and the mastoid projection disappears without the skin becoming affected. In other cases, again, the pus and disorganized matter of the cells, find their way from the mastoid process through the Eustachian tube;—the ar- rival of the matter in the fauces being attended with coughing and ex- pectoration, a nauseous, disgusting taste, loss of appetite, and occasion- ally vomiting. In some cases, the mastoid process is enlarged, and converted into a soft, homogeneous mass, readily cut, like cheese, with o Jen if6 The petrous portion of the temporal bone is occasionally affected.. In some instances, the facial nerve is involved in the disease, and* acute pains in the ears are experienced, with spasmodic contractions of the muscles of the face, on the side affected, terminating, finally, 614 DISEASES OF THE NUTRITIVE FUNCTION. in paralysis. Several cases of this kind are noticed by Lallemand, Berard, and others, and Ave had one under our care, in which, besides paralysis of the muscles of the left side of the face, there was a loss of the power of articulating. In this case, which was in a boy seven years of age, the otitis occurred subsequent to a severe attack of scarlet fever. In many instances, the disease of the petrous portion of the temporal bone extends to the brain, or its membranes, and va- rious symptoms of cerebral disease are developed. One or two cases are referred to by Lallemand, in Avhich the disease extended to the occipital bone and involved the first two cervical ver- tebrae. Caries of the bones, at the basis of the cranium, has likewise been observed by Krukenberg. Scrofulous otitis is, most generally, a disease of childhood; it com- monly affects but one ear, though we have seen a few cases in which it occurred simultaneously in both. It may be produced by any of the ordinary causes of inflammation. It is frequently observed about the period of dentition; and, in a large number of instances, subse- quent to attacks of one or other of the acute exanthemata. The dis- ease is frequently preceded by ulcerations behind the ears, erysipelas of the face, porriginous eruptions about the head and face, and, as these frequently disappear when the inflammation of the ear takes place, it has been generally attributed to their being suddenly dried up or repelled—in most instances, however, as Krukenberg very justly remarks, with very little foundation. Scrofulous otitis is frequently accompanied by more or less febrile reaction, and by the same disordered condition of the alimentary canal, noticed when treating of scrofulous ophthalmia. Discharges from the Vagina.—These not unfrequently take place in female children, even at an early period of infancy, and, occasion- ally, about the fifth year. They result from a subacute inflammation of the mucous membrane within the labia, and are, in many cases, at- tended with an aphthous ulceration. The matter discharged is various in its character, being often a thin sanious fluid, containing small floc- culi, of a curdy appearance: not unfrequently, however, the discharge is of a thicker, more opaque, somewhat purulent appearance, and is often so acrid as to produce redness and irritation, and a slight pustu- lar eruption of those portions of the skin with which it comes in con- tact. The discharge is sometimes very slight. It would occasionally appear to prevail as an epidemic. These purulent discharges are of common occurrence among girls who have been exposed to an unwholesome atmosphere, and to the ef- fects of personal uncleanliness. It has been'repeatedly mistaken for go- norrhoea, communicated by infection from the parents; or, in older children,—for the disease, when neglected, may even continue, accord- ing to Dewees, up to puberty—it is apt to give rise to suspicions of a very grave character, which the physician is occasionally called upon by his professional opinion, to remove. A number of striking cases are related by different physicians, which show the importance, in a medico-legal point of view, of a correct knowledge of the nature of i this affection. Mr. Wilde, of Dublin, has, in a very able paper, pub- SCROFULOUS DISEASE OF MESENTERIC GLANDS. 615 lished in 1853, fully investigated the subject of infantile leucorrhoea in its proper medical, as well as in a medico-legal point of view. The history of every case should be carefully inquired into. The nature of the child's constitution will afford some clue to the character of the disease, inasmuch as it is of most frequent occurrence in those of a scrofulous diathesis, particularly during the period of dentition, and when the children are placed under bad hygienic influences, or suffer from the irritation of ascarides in the rectum. The disease just described is, it may be proper to remark, a very different one from that noticed by Boivin, Dugls, Kinderwood, Mac- kintosh, and others, as affecting the labia of female children, and ter- minating most commonly in gaugrene. Tabes Mesenterica.—Scrofulous disease of the mesenteric glands. The glands of the mesentery are said to be, after those of the neck, the most common seat of scrofulous disease. From the frequency with which, in those predisposed to scrofula, subacute or chronic in- flammation of the alimentary mucous membrane occurs, there can be no doubt that disease of the mesenteric glands is a very common in- dication of such predisposition. The error committed by most pa- thologists, until a very late period, has been, in attributing to the diseased condition of these glands the entire chain of symptoms by which it is preceded and accompanied; when the affection of the glands is probably, in the majority of instances, the consequence of gastro- intestinal irritation. Contrary, however, to the generally received opinion, Rilliet and Barthez do not consider tuberculization of the mesenteric glands to be a frequent affection of the first period of childhood. It occurred to a considerable extent in only about one-seventh of the cases where the mesenteric glands were affected, and in only about one sixteenth of all the children who presented tubercles in other parts of the body. In but one-half the cases of tuberculous children, the mesenteric glands were found affected, and then only slightly. Rilliet and Barthez state that the disease scarcely ever attacks children under three years of age—that it is slighter the younger the child is, and that it reaches its maximum of development between five and ten years, after which it is very rare. The reason why it has been generally considered so frequent among children, is, they conceive, because other diseases as tuberculous peritonitis, enteritis, &c, have been mistaken for it. The most common characteristic of tuberculization of the mesen- teric glands is prominence of the abdomen, with emaciation, particu- larly of the limbs. Its onjy certain diagnostic, however is the per- ception of the enlarged glands, by manual examination, through the parietes of the abdomen. It may, however, be suspected, whenever chronic disease of the alimentary canal occurs in children of a strongly marked lymphatic temperament, especially if such disease becomes at- tended in its course with a fulness and irregular hardness of the 1 T°iTglands exhibit, in the various stages of the disease, nearly the same chants that occur in scrofulous glands of other parts; m some case* beinJm™jt tens 'the cerebral substance. In cular membrane, ™®"«f P contrarv Green describes the surround- a few rare examples on the contrary, U,ee ^ ^ ing nervous t.ssuc as be ng more palean ^ ^ rtnUrSTptrint; —ate vicinity of cerebra. tube, C,eTu9bercm;y'of t^VaT^'very generaLy associated with othc, 630 DISEASES OF THE NUTRITIVE FUNCTION. scrofulous indications. The first dentition would appear to be their principal epoch, though in many cases they will be found to suc- ceed to acute or chronic affections of the gastro-intestinal mucous membrane, or to the exanthematous fevers. Treatment of Scrofula.—There is no specific for the cure of scro- fula. If we are correct in our views, in regard to its pathology—if the morbid condition of the system depends upon defective assimila- tion, and sanguification, by which the blood is rendered deficient in its healthy organization, and nutrition is, in consequence, imperfectly performed:—if the whole of the organic functions are inactive; it is evident that our endeavours should be entirely directed to improve the condition of the blood, and render nutrition more active and perfect, and in this manner, to correct the morbid constitution of the body, which constitutes the essential foundation of the disease. Medicinal agents, however important and essential they may often become, for the removal of certain prominent symptoms, are not to be considered as those upon which our chief dependence is to be placed in effecting that change in the condition of the organic functions which is essential in order to improve the general tone and vigour of the system:—this can only be done by placing the body under the influence of those natural agents by which alone its healthful action is to be promoted and sustained. From alteratives and tonics we can expect but little, but from a proper diet, pure fresh air, sufficient exercise, cleanliness, and proper clothing, in conjunction with a due regulation of the moral and intellectual powers, when sufficiently early resorted to, the most prompt and decided benefit will be inva- riably derived; and without their influence, under no circumstances can we expect to prevent the inroads of painful and destructive dis- ease, or to arrest its progress, after it has occurred. In regard to every child, the same hygienic agents are essential to preserve and promote the health, vigour, and regular development of its frame; but in one who is delicate from birth, or who exhibits, at an early period, the striking characteristics of the lymphatic tem- perament, with languid circulation, and a predominance of the white fluids and tissues, they become doubly important; their neglect will then endanger the occurrence, sooner or later, of serious and even fatal disease, while proper and unremitting attention to them will seldom fail to improve the constitution of the blood, and render nu- trition more active and healthy. We have, in the commencement of the present treatise, entered, with sufficient minuteness, into a consideration of the hygienic ma- nagement of children, to render it unnecessary, in this place, to go into further details:—we need only add a few remarks in regard to it, so far as it respects such patients as already present indications of the invasion of scrofulous disease. Air, exercise, and proper nourishment are, in these cases, our chief remedial agents. Animal food, with a proper mixture of the more readily-digested farinaceous vegetables, will, in general, be essential, after the child is weaned; but previously to this, the only appropriate diet is the breast-milk of a perfectly healthy nurse. The proper spe- SCROFULA —TREATMENT. 631 cies of animal food, and the manner in which it is cooked, require, also, to be attended to. Beef, mutton, venison, chicken, turkeys, and most kinds of game, fresh-laid eggs, and fresh milk, with stale bread, crackers, potatoes, and rice, should constitute almost the exclusive diet, in the cases referred to. In regard to cookery, the meats should be plainly roasted, broiled, or boiled, or the beef may be eaten in the form of steak, and the mutton in that of chops. The milk may be taken without any preparation, or simply boiled, according as it is found to agree Avith the patient's stomach; it may, also, be taken occasionally with mush, boiled with rice, and sweetened, or with eggs, in the form of plain custard, or with rice, or bread, in the form of plain pudding. The eggs should be boiled, but not hard. The bread should be of wheat, or of Avheat and Indian, and not eaten until twenty- four hours after it is baked. The potatoes should be roasted, in which form they are easier of digestion, and agree better with the stomach, than when boiled. In regard to condiments, these should consist of salt and Cayenne pepper, for the animal food, and of sugar, and per- haps cinnamon or nutmeg, for the preparations of milk. The condi- ments, however, should be used in moderation, and rather with the view of imparting an agreeable relish to the food, than for the pur- pose of stimulating the appetite. While a sufficiency of food is allowed properly to nourish the sys- tem, caution must invariably be exercised to prevent its being par- taken of in too great quantities at a time, or too frequently. No general rule can be laid down in respect to these important points; much will depend, in regard as well to the quantity of food, as to the frequency of the meals, upon the condition of the patient's stomach, his age, and the particular circumstances of his case. For drink, nothing should be allowed but pure water or toast water: we say pure water, for there can be no doubt, that impure water is decidedly prejudicial to health, and some have even sup- posed that hard Avater is a cause of scrofula. The effects of the Avater habitually used as drink, like that of the air we breathe, though insensible, are not the less certain and poAverful:—the quality of the water made use of, during health as well as in disease, merits more attention than has generally been paid to it. By most of the English physicians, an occasional glass of good beer, porter, or wine is recommended, but to this we must positively object. Alcoholic drinks, whether fermented or distilled, are not, in any de- gree, calculated to promote digestion, nor to improve the nutrition of the organs, while they have a decided tendency to promote habits, Avhich, in after life, may even prove a greater curse than the Avorst effects that can result from that defective state of the organic structure in Avhich Ave have presumed the tendency to scrofulous disease mainly, if not entirely, to consist. Pure and fresh air is as essential as proper and sufficient nourishment. It is too much the custom to confine, Avithin doors, the weak and deli- cate, Avhereas of all persons they the most demand frequent exposure to the open air; and, with proper clothing and due precaution, such ex- posure may, with great propriety and decided advantage, take place 632 DISEASES OF THE NUTRITIVE FUNCTION. in children of four or five years of age, even in the colder season of the year, during perfectly clear weather. Even when the weather is such as to prevent the child from being taken out, the advantages of a fresh and pure air may be afforded it by proper ventilation, the strict- est attention to domestic cleanliness, and by guarding against over- crowded apartments, by night as well as by day. Where Ave can com- mand it, the atmosphere of a dry elevated situation in the country should always be preferred to the atmosphere of a large or crowded city. In connexion Avith the subject of air, is that of exercise, a proper daily amount of which should invariably be taken out of doors. The exercise must, of course, be adapted to the strength and age of the child, but should always be as active as can be allowed, without the fear of its inducing undue fatigue. Sir Astley Cooper states, that he has seen five hundred cases of scrofula, in the course of a single year, with scarcely a boy among them, and this, from the circumstance that boys will take exercise, while girls are not allowed to do so. As a substitute for exercise, in cases in which the debility of the patient is so great as to render a sufficient amount of such as is of a more active kind impossible, friction of the surface, repeated daily, either with the hand, or a proper flesh-brush, or cloth, will be useful; and, in all cases, it will be proper, even in connexion with exercise; but it can never supply fully the place of the latter, when it can be taken in a pure fresh atmosphere. For young children, the usual sports of their age—riding occasion- ally in an open carriage—short walks or jaunts, with some pleasing and moderate occupation of the mind, in the intervals, will suffice. For older children, various recreations present themselves, of an inno- cent character, which call into sufficient exercise the muscles of the body. Riding on horseback is a very admirable mode of exercise for those sufficiently old to partake of it with safety; especially for girls, who cannot easily obtain a sufficient amount in any other manner. Frequent bathing will be necessary, as well for the maintenance of personal cleanliness, as to promote and sustain the regular actions of the cutaneous exhalants. The warm bath should be employed when the temperature of the surface is deficient, with considerable languor of the circulation; but in patients possessed of greater vigour, and in whom the temperature of the skin is better maintained, the tepid bath may be substituted. Sponging the surface with tepid water, or with salt and water, followed by brisk friction, will also be highly bene- ficial. A bath of sea-water, when practicable, may be taken three times a week, at eleven o'clock in the morning. The temperature of the bath should be seventy-four degrees, and the child may remain in sixteen or twenty minutes; after which friction to the skin may be employed, or a walk taken. A child may be brought to bear the bath by sponging or sprinkling the surface daily with tepid water. Bathing in the open sea, when it can be borne Avithout producing languor or chilliness, will unquestionably be proper, in the generality of cases. SCROFULA—TREATMENT. 633 Against cold bathing, which is recommended by writers of even a recent date, we most positively protest; the idea of its exerting a direct tonic effect has originated in false views, as well of the action of cold upon the human system generally, as of the particular circum- stances under Avhich the reaction it gives rise to invariably occurs. To immerse a weakly child in cold water, would be more likely to produce and increase the tendency to scrofulous disease, than to pre- vent it, if it did not cause more immediate, and even more dangerous results. In regard to clothing, this should be accommodated to the tempera- ture of the climate and season, and adapted in quantity, material, and form, to preserve, as far as possible, a uniform temperature of the sur- face;—guarding against the slightest sensation of chilliness in cold or changeable weather, and too much heat or excessive perspiration during the summer. As a general rule, liable, however, to some exceptions, flannel next the skin should be worn during the autumn and winter, and late in the spring: for the remainder of the year, coarse muslin may be substituted. The mind should be occupied and amused, without being fatigued, or too much excited; and every means calculated to promote cheer- fulness, buoyancy of disposition, and equanimity of temper, should be put in requisition, and every depressing influence carefully re- moved. When there exist considerable torpor of the digestive functions, and constipation of the bowels, with dark-coloured, or pale, clay-like, unhealthy evacuations, it will be proper, at an early period, to endea- vour to excite the whole alimentary canal to a more healthy action. Purgatives will, in general, be required. Rhubarb and magnesia, the compound powder of jalap, or, in older children, the blue mass, com- bined with rhubarb and ipecacuanha, will generally answer our pur- pose, or an occasional dose of calomel combined with magnesia, and followed by moderate doses of senna tea, of the compound powder of jalap, or of the sulphate of magnesia, may be employed. The article which has answered best in our hands has been the compound powder of jalap. This was a favourite prescription with Dr. Physick, in scro- fulous disease of the hip joint:—he gave it every day or every second day, so as to keep up a steady and tolerably brisk action upon the bowels* under its use we have known the health and strength ot the patient rapidly to improve, and his attenuated limbs to become aug- mented in bulk, and increased in firmness. Of course, the doses of the purgatives employed, and the frequency of their repetition, must be governed entirely by the age of the child, the condition of the bowels, and the effects produced. In many cases, after the bowels have become more regular and the stools of a more healthy appearance, some light tonic may be given, with the view of improving the digestive powers of the stomach. The proto-carbonate of iron maybe administered in the dose of a few grains combined with the sulphate of quinia daily, for a short time; or we may give the carbonate of iron with rhubarb, and a little orange 634 DISEASES OF THE NUTRITIVE FUNCTION. peel;1 or the following, which is a good preparation for the same pur- pose.2 The ammoniated tartrate of iron will in many cases be found particularly beneficial. Preparations of iron would appear to be our very best tonic, in that state of the constitution which predisposes to scrofula. 1 ]£.—Carb. ferri, gr. xxxvj.—£j. 2 R.—Sub. carb. sodae desiccat. gr. xlviij.— Pulv. rhaei, gr. xxiv.—gss. "^iijss. ----cort. aurant. Qij.—M. f. Pulv. calombsc, 3'j. chart. No. xij. ----rhaei, ^ss.—M. f. One for a dose daily, or twice a day. ch. No. xij. (A. Cooper.) To be given as the last. We have, heretofore, presumed that symptoms of local disease have not presented themselves; that the child is merely labouring under a state of general debility, the result of imperfect assimilation and hsematosis, and deranged or deficient nutrition; and that our only in- dication is to improve digestion, render sanguification more perfect, and the nutrition of the solids more regular and complete. It is true, that in every case and stage of scrofulous disease, this indication is still to be fulfilled; but the mode of fulfilling it will demand some important modifications, according to the particular circumstances of each indi- vidual case. When the usual symptoms of gastro-intestinal disease are present— tenderness of the epigastrium or right hypochondrium, loss of appetite, nausea, irregularity of bowels, dryness and increased heat of the sur- face, and a red, dry tongue—animal food should be forbidden—a mo- derate quantity of some of the lighter farinaceous preparations—weak chicken Avater or whey, with gum, barley, rice, or toast water for drink —should constitute the diet, until the above symptoms are removed. The treatment of the gastro-intestinal disease is to be conducted on general principles—leeches, according to circumstances—warm fomen- tations—minute doses of calomel and ipecacuanha, with the occasional interposition of a saline purgative, among which one of the best is pro- bably the citrate of magnesia. The nitrate of potassa has been highly spoken of as a remedy in cases of gastro-intestinal disease occurring in subjects presenting a tendency to scrofula, and it is asserted by Todd, that, when combined with mercurials, the efficacy of the latter is increased. We have used it, in many cases, in small and repeated doses, with certainly very good effects. During the continuance of disease of the digestive mucous mem- brane, active exercise will be improper; indeed, friction of the surface, repeated daily, will, in the majority of cases, have to be substituted for exercise of every species. After we have succeeded in completely removing the irritation or subacute inflammation of the alimentary canal, the diet of the patient should be gradually and cautiously improved—chicken water, beef tea, afterwards the gravy of meat, then broths, then small portions of chicken, or mutton, or beef, may be allowed until a full animal diet can be taken Avith safety. At the same time, the use of tonics may be entered upon with benefit, when, if they had been given previously, they would have rather tended to augment and confirm than to remove SCROFULA—TREATMENT. 635 effectually the debility of the system. The chalybeates, as already re- marked, either alone or conjoined with weak cold infusions of bark, infusion of chamomile, or the colomba in substance, will be among the best tonics, in these cases. The proto-carbonate or the ferrura tartar- isatum, or a combination of the latter with small doses of carbonate of iron, or the nitrate or sulphate of potassa, may be given, or the tinc- ture of the sesquichloride of iron combined with iodine;1 or Ave may employ the iodide of iron. 1 R.—Tinct. ferri sesquichlor. Tinct. iodini, aa,. 55 ij. Aquae purse, ^ss.—M. (Todd.) Dose,—thirty drops, three times a day, for a child ten years of age, and a smaller portion for those younger. These articles should be administered for several days in succession, and then intermitted for a day or two, the bowels being, in the mean time, kept regularly open by means of occasional doses of some mild purgative; and at the same time the child should be placed upon a proper hygienic treatment, without which tonics, however judiciously selected or long continued—and in general, to derive from them their full effects, they must be persevered in for a length of time—will be pro- ductive of little or no good. The cod-liver oil is a remedy from which, in most cases, decided advantage will be derived, when its use can be continued perseveringly for a sufficient length of time. According to Rilliet and Barthez, it possesses at once tonic and discutient properties. Notwithstanding its disagreeable taste and odour, children exhibit to it no great repugnance. It may be given to children three years of age in the dose of from one to two dessert-spoonfuls, and from three to four, to older children, com- bined with some aromatic. The following are the formulae recommended by Tourtual. R.—01. jecoris aselli, 31J.—^iij. R.—01. jecoris aselli, t*f j. Gum acaciae, q. s. Liq. carb. sod33, ijij. . Aq. foenelic. 3J. 01. calam. aromat. trg iij. Syrup, cort. aurantii, ?ss.—M". Syrup, cort. aurantii, ^j.—M. Dose, a teaspoonful every three hours. Dose, one to two teaspoonfuls, morning and evening. R.—01. jecoris aselli, jij. Vitell. ovi. No. j. Syrup, menthi, " flor. aurant. iiS. 31J.—M. Dose, a dessert spoonful three times a day. The remedy should be continued, in order to derive fromjt its re- medial effects, for many weeks, or even months. There is scarcely any form of scrofula Dr. Phillips has not seen to improve under the use of cod-liver oil, but he seldom was able to carry it far enough to produce any considerable amelioration: he considers that its good effects result from its improving digestion and nutrition, which is the opinion of the generality of those physicians who have given to the remedy the most extensive trial. When enlargement of the lymphatic glands occurs, so long as the swellings remain indolent, no other treatment is required than that which is calculated to improve the general condition o£ the system. 636 DISEASES OF THE NUTRITIVE FUNCTION. Iodine, both internally and locally, has, by many writers, been con- sidered almost a specific, in these, as well as in most of the local affec- tions of a scrofulous character, while others consider it of very little value in any of them. We have never, certainly, seen those striking effects produced by its use, reported to have been observed by others: the evidence in its favour is too strong, however, to allow of our doubt- ing its curative powers in many cases. The solution of Lugol is, perhaps, the best form in which the iodine can be given internally,1 or we may employ the iodide of iron.2 Ex- ternally, iodine may be used in the form of solution3 or of ointment.4 i R._Iodin. ^j. 2 R.—Ferri iodid. gr. v. Potass'i iodidi, 9'j. Aquae destUlat. |j.—M Aquae destillat. ^viij.—M. Dose, a teaspoonful, three times a day, in For children under seven years, the dose is sugared water; gradually increased by two drops, twice a day, gradually increas- adding ten drops, daily, to each dose, ed to five drops. From the age of seven until the dose amounts to two teaspoon- to fourteen, sixteen drops, twice daily, in fuls. sweetened water. 8 R.—Iodin. gij. * R.— lodin. gr. xij. Potassi iodidi, giv. Potassi iodidi, Jjss. Aquae destillat. ,§v.—M. Axung. ^ij.—M. By Dr. Phillips, the curative powers of barium, in scrofula, is con- sidered as little, if at all, inferior to that of iodine. Its field of use- fulness is, however, more limited. The barium seems to him to be a more certain stimulant, or he might even say irritant, than iodine, and consequently its use is clearly contra-indicated where there is much in- flammatory excitability of the system; but in cases marked by a tallow- like complexion, pale tongue, languid circulation, and irritability of the mucous surfaces, its good effects will often be very decided. Dr. Phillips usually gives it in solution, one grain to an ounce of distilled water, with ten drops of compound tincture of gentian. Of this solu- tion he commences with half an ounce, twice a day; on no occasion has he exceeded three grains in the day, and he has never experienced any check in the administration of the remedy. The solution of caustic potassa, the same gentleman is satisfied, has, in many instances, exercised a salutary influence, and these are mostly cases in Avhich much acidity pervaded the secretions, and acted upon the general economy. The state of the bowels should be attended to agreeably to the di- rections already given. When the enlarged glands become painful and sore to the touch, the ordinary local applications for the removal of inflammation should be resorted to. In many cases, a few leeches will be useful; but, in ge- neral, we may trust to cooling or evaporating lotions, or the solution of the acetate of lead. As soon as a tendency to suppuration is evinced, an ordinary emol- lient poultice should be applied, and Avhen a distinct fluctuation is de- tected, an opening, transversely, in the direction of the folds of the neck, should be made with a lancet:—this will often prevent extensive ulcerations, and its consequent unsightly scar. It is true, that even after suppuration has taken place, the contents of the abscess will oc- SCROFULA — TREATM ENT. 637 casionally be absorbed, and the tumour disappear without rupturing: Ave are not, however, perfectly convinced, that this result is always to be desired:—after matter is formed in a scrofulous gland, we confess that Ave should prefer its discharge to its absorption. After the open- ing of the abscess, a common poultice is one of the best applications that can be made to the part. When ulcerations form and show no disposition to cicatrize, a solu- tion of the sulphate of zinc—one grain to the ounce of water—will often be found useful to promote their healing: in some cases, however, it will be necessary to touch the edges of the ulcer with the nitrate of silver. When very irritable, the ulcer may be washed with a weak solution of the nitrate of silver, and then covered with a poultice of bread and water. In these cases, poultices of the leaves of hemlock, or of sea-Aveed, have been recommended, but our great object should be to correct the condition of the general system, for until this is effected, the ulcers seldom, if ever, are found to assume a healthy ap- pearance, and to heal perfectly. A hard, indolent tumour will sometimes remain subsequent to the cicatrization of the ulcer, the discussion of Avhich may be attempted by some one of the various ointments of iodine: so long as any pain or tenderness remains in the part, however, the use of these Avill be im- proper; and, if pain or irritation arise during their use, they should be immediately discontinued, and soothing applications resorted to. In cases of Scrofulous Ophthalmia, if the affection of the eye is recent and acute, the application of a feAV leeches to the temples, and to the external angles of the eye, Avill often be advantageous; but in cases of a decidedly chronic character, or which have already existed for some time, leeching will not only be useless, but often decidedly injurious. In cases of a very acute character, in Avhich there exist considerable redness and pain of the eye, and a decided febrile reac- tion, it may be even necessary to repeat the leeches; but, in every in- stance, Ave must be cautious not to carry the depletion too far. The best local application, when the eyes are very red and painful, is the crumb of bread wet with cold water, during the day, and a por- tion of alum curd, enclosed in a fine muslin bag, during the night. The eyes should be invariably shielded from the direct rays of light by a broad, deep-green silk shade, so shaped that it may stand out well from the forehead, and admit the access of air to the eyes. This management of the shade is of great importance; as those usually emploved, which are small and lie close to the eyes, do more harm than good. (Maunsell.) All local applications of an astringent or sti- mulating character are not only wholly useless, but decidedly impro- per: we°have repeatedly seen them keep up the pain and redness of the eyes, which have rapidly improved in appearance so soon as such ap- plications were discontinued, and a poultice of bread and water sub- stituted. . , • , i , i i • When the appetite is variable and capricious, with a hot, dry skin, quick pulse, and coated tongue, considerable advantage will often be derived from an emetic early administered. An aqueous solution of tartar emetic would appear to be the best article in these cases; the t 638 DISEASES OF THE NUTRITIVE FUNCTION. emetic may be followed up with minute doses of tartarized antimony combined with the sulphate of magnesia.1 This treatment, however, is more particularly adapted to the acute form of the disease, occur- ring in children over ten years of age. In place of the combination just mentioned, we may administer minute portions of calomel and pulvis antimonialis, to which, when there is very great irritability, and want of rest at night, a small portion of Dover's powder may be ad- vantageously added.2 1 R.—Sulph. magnes. yij. 2 R.—Calomel, gr. ij. Antimonii tart. gr. j. Pulv. antimonialis, Aquae, giij.—M. " Doveri, aa gr. vj.—M. f. ch. Dose.—A teaspoonful every two or three No. xij. hours. . One of which may be given every three or four hours. In many cases of the disease, there is a loaded and torpid condition of the alimentary canal, with a hard and tumid abdomen, irregularity of the bowels, and an unnatural appearance of the discharges. In these, active purgatives will be found of advantage; by their action a large amount of unhealthy-looking faeces is often brought away, to the manifest improvement of the condition of the patient. A dose of calomel, combined with rhubarb and magnesia, may be given, and repeated every two or three days, so as to produce a brisk action upon the bowels; or we may administer a few grains of calomel in the evening, and on the succeeding day, the compound powder of jalap, castor oil and turpentine, or an infusion of senna, with the ad- dition of the sulphate of magnesia. After the bowels have been well evacuated, they should be kept regularly open by occasional small doses of calomel, followed by the compound powder of jalap, or by the use of this latter alone. We are to recollect, however, that, while the most decided advantage is to be derived from the judicious employ- ment of purgatives, too violent or long-continued purgation is invaria- bly prejudicial. After a more healthy and regular condition of the alimentary canal has been produced, the carbonates of soda and potassa, either by them- selves, or combined with rhubarb, calomba, or a weak infusion of cha- momile, quassia, or bark, will often be productive of the best effects. The sulphate of quinia is, however, probably the tonic best adapted to these cases,3 and when administered after the disordered condition of the digestive organs has been removed, will, generally, very quickly effect a complete cure. The preparations of iodine will also, in the more chronic cases, be found beneficial, particularly the iodide of iron. The hydrochloride of barytes is very strongly recommended by a few writers in the disease before us, as well as in the other forms of scrofulous disease: it may be employed in solution.4 We know no- thing of its effects from our own experience. 3 R.—Aq. cinnamom. ^iij. * R.—Hydrochlor. baryt. ^j. Sulph. quinise, gr. vj.—x. Aq. destillat. ^ij.— M. Acid, sulph. dilut. ngiv.—vj. Dose.—From ten to twenty drops, two Sacch. alb. giij.—M. or three times a day, to a Dose.—A teaspoonful every four hours, for child between three and se- a child from three to seven years ven years of age, in the sy- of age. rup of sarsaparilla. SCROFULA — TREATMENT. 639 The diet of the child should be carefully attended to during the acute stage. In the more violent forms of the disease, he should be confined exclusively to some simple farinaceous article of food, with toast, barley, or rice water for drink. He should be immersed daily in a tepid bath, or have the whole surface sponged daily with tepid salt Avater. Friction of the surface, with the hand or flesh-brush, will also be important. The purity and dryness of the air which the patient breathes is a matter of very great importance, and should never be neglected; a patient with scrofulous ophthalmia will rapidly improve in a dry, fresh atmosphere, with very few remedies beyond those of a hygienic cha- racter, while one confined in a close, impure, and damp atmosphere, will exhibit but slight indications of amendment, under whatever plan of treatment we nnay adopt. The body of the patient should be sufficiently, but not too warmly clothed; the hair should be cut short, and the head and neck sponged with tepid Avater every morning, and then thoroughly dried. He should not, when we can preA'ent it, be allowed to keep his bed during the day, nor, at night, to lie with his face buried in the pillow. It is not proper to confine the patient, for any length of time, to a darkened room; with the shade for the eyes already described, free exposure to the open air, whenever the weather is perfectly clear and mild, is of advantage, and will contribute very powerfully to the cure. It is one of the best means of removing the morbid sensibility of the retina which forms so prominent and troublesome a symptom of scro- fulous ophthalmia. Blisters to the nape of the neck or behind the ears, kept on for a feAv hours, and then removed; the blister being reapplied as soon as the inflammation produced by the first has subsided, are directed by Travers, and will, in most cases, be found advantageous. In mild, recent cases, the occasional use of a collyrium, composed of a solution of the sulphate of zinc or alumine in rose-Avater, from three to five grains to the ounce, "will occasionally be found useful; or we may employ a very weak solution (one grain to eight ounces) of the bichloride of mercury, in pure water, or rose-water. When the pain and intolerance of light are very severe, warm fo- mentations to the eye, as hot as they can be borne, will often afford very decided relief; a pledget of soft muslin, or of lint, or a piece of soft sponge, saturated with warm water, or an infusion of poppy-heads or chamomile flowers, may be applied upon the eye during the day, and replaced by warm bread-and-water poultices during the night. The anodyne effects of the vapour of Laudanum, or of a vinous tincture of belladonna will often prove beneficial; either of these being mingled with a cupful of hot Avater, the eye should be exposed to the vapour two or three times a day. After the intolerance of light and spasmodic contraction of the orbi- cular muscle have so far subsided as to permit the patient to unclose his eyes in a moderate light, scarification of the conjunctiva of the lids will often be folloAved by very considerable relief; the operation may eATen be repeated several times, after intervals of two or three days, 610 DISEASES OF THE NUTRITIVE FUNCTION. until the increased fulness of the vessels, and the thickening of the lid are removed. Subsequent to the scariflcation, benefit Avill generally re- sult, in cases of a very obstinate character, from inserting a small piece of the ointment of the peroxide of mercury, fifteen grains to the ounce of lard, within the eyelids. The introduction of the ointment may be repeated at bed-time, every night, or every second night. In severe and obstinate cases, this will be found a useful practice, even Avhen scarification has not been resorted to; or, a few drops of the solution of nitrate of silver, two grains to the ounce of water, or of the vinous tincture of opium may be instilled into the eye, daily, or every other day. These applications have a very decided effect in diminishing the irritability of the diseased organ, in promoting the healing of the ulcerations of the cornea, and in dispersing any opaci- ties which these may have occasioned. When a granular condition of the conjunctiA'a occurs in chronic cases, collyria of a solution of the nitrate of silver or of a solution of sulphate of copper, (four grains to the ounce of water,) will be re- quired. When there exists considerable disease of the tarsal edges of the eyelids, this may be relieved by the application of the ointment of the peroxide of mercury, or, what is still better, of the ointment of the nitrate of mercury, diluted with one-half or one third of its weight of fresh lard: this being rendered soft, should be applied, by means of a hair pencil, along the edges of the lids every evening. Large ulcerations of the cornea, Avhich exhibit any tardiness in healing, may be touched by means of a hair pencil, with a solution of nitrate of silver; or, when the ulcer is small, deep, and funnel-shaped, with a pencil of lunar caustic, cut to a fine point. When prolapsus of the iris occurs, the protruding portion should be touched every second or third day with the caustic. In cases of deep central ulceration, with adhesion of the iris, the ex- tract of belladonna, reduced by the addition of Avater to the consist- ence of a thin paste, and smeared upon the forehead, over the eye- brow, by causing the dilatation of the pupil, will either have a ten- dency to free the iris or to elongate to such an extent its attachment, as to prevent the loss of vision. When a vascular speck occurs, its progress may often be arrested by removing a portion of the enlarged vessels running into it. Let it be recollected, however, that in every case of scrofulous oph- thalmia, and during every stage of the disease, our chief attention should be directed to correct the morbid state of the general system: unless this can be effected, remedies directed solely to the local dis- ease are Avorse than useless; while, by restoring health and vigour to the organic functions, and thus improving the strength and tone of the whole body, cures have been repeatedly effected, without a single local application, or so called specific remedy. Scrofulous inflammations of the ear require the same unremitting attention to the condition of the digestive organs; the same course of treatment directed to render assimilation, hsematosis, and nutrition more active and complete, as is demanded in the disease we have just SCROFULA—TREATMENT. Gil considered. The same general remedies—purgatives, when the bowels are loaded and sluggish, followed by mild laxatives, or small, repeated doses of calomel, with the occasional interposition of a mild laxative, and succeeded, when a more healthy and regular condition of the bow- els has been obtained, by similar tonics to those directed in cases of scrofulous ophthalmia, will be called for. In regard to the treatment of the local disease, this must be con- ducted upon general principles. In cases attended with symptoms of a good deal of severity, leeches, a mild, unirritating diet and the use of the tartarized antimony, with nitre and calomel, or with the sul- phate of magnesia in solution, as directed in scrofulous ophthalmia, will be proper. The local applications consist in the injection into the ear of simple tepid and emollient fluids, and the application externally, of an emol- lient poultice. When the meatus externus is hot, and its lining mem- brane red and swollen, warm fomentations should be assiduously ap- plied to the ear and side of the head, and leeches behind the ear. Blisters to the nape of the neck, or behind the ear, frequently re- peated, are all-important remedies. In the more deep-seated inflammations of the ear, the tartar emetic ointment may be rubbed upon the mastoid process, until local irrita- tion is produced. In the more chronic cases of the disease, slight astringent injections may be resorted to, at first of tepid rose-water, and subsequently of a very weak solution of the acetate of lead, two or three grains to the ounce of water, or of the acetate of zinc, of similar strength, or of the nitrate of silver, one grain to the ounce. The strength of these injections may be gradually and cautiously increased; but in all cases we must be careful not to arrest too early or suddenly the discharge from the ear, nor until the health of the general sys- tem is considerably improved. If the discharge becomes offensive, a few drops of the chloride of soda, in an ounce of water, may be injected. Whenever, during the use of astringent injections, the discharge be- gins rapidly to diminish, it is as well to desist for a time from their use, and resort to those of a simple emollient character. Should the arrest of the discharge be followed by any unpleasant symptoms, warm fomentations and simple bread poultices should be applied to the ear, as hot as they can be borne. At the same time we should give inter- nally the iodide of potassium, cod-liver oil, and the vegetable tonics. The Discharges from the Vagina, in scrofulous girls, require little treatment beyond that which is demanded for the improvement of the general health of the system. Frequently washing the parts with some mild emollient, or slightly astringent fluid, will be proper. In most cases, the condition of the alimentary canal will indicate a course of purgatives and alterative doses of calomel, followed by tonics as in the locf two (11SG3.S6S Tabes Mesenterica.—The particular treatment of scrofulous enlarge- ment of the mesenteric glands is of secondary importance to that of the gastro-intestinal disease, with which it is almost invariably con- nected. This demands precisely the same remedies as when it occurs in a patient in whom no predisposition to scrofula exists, with this only 41 642 DISEASES OF THE NUTRITIVE FUNCTION. exception,—that depletory remedies must be resorted to with the utmost caution. It must be constantly borne in mind, that in patients in Avhom there exists a decided tendency to scrofulous disease, remedial measures of a debilitating character, even with the same violence of symptoms, cannot be carried as far as in a patient in whom no such predisposition is present. As soon as the disease of the mucous membrane of the alimentary canal is subdued, the child should be put upon an improved diet. Meat- broths, prepared with particular reference to their nutritive and di- gestible properties, may be given as soon as prudence will permit, and at the same time a course of purgatives should be commenced with. The carbonate of potassa or soda, with some light bitter infusion, or where there is a tendency to constipation, combined with rhubarb and nitre, may be commenced with at an earlier period, perhaps, than more active tonic remedies, and will be very useful so far as the disease of the glands is concerned. Iodine, both internally and externally, would appear to be the re- medy best adapted to the cure of enlarged mesenteric glands, occurring in children of scrofulous habits. Lugol's solution may be given, in doses of from three to six drops, two to three times a day; or we may employ the iodide of potassium, in the dose of half a grain to a grain, in a spoonful of the decoction of sarsaparilla, two or three times a day. The iodide of potassium is the preparation that will, in most cases, agree best with the bowels:—if these are in the least degree irritable, the addition of a small portion of the syrup of white poppy, or of the tincture of opium to each dose, will lessen its liability to disagree. The iodide of iron may, in many cases, be advantageously employed instead of, or in alternation with the foregoing. If, however, under the inter- nal use of iodine, irritation of the digestive organs should ensue, it must be at once suspended, and the means for allaying the irritation resorted to. The best form for the external application of iodine is that of the ointment of the iodide of lead, (half a drachm to the ounce of lard.) When, however, its use can be persisted in sufficiently long, without inducing considerable irritation of the skin, we have experienced the very best effects from the ointment of the iodide of potassium, (half a draehm to the ounce of lard.) The ioduretted baths we have never employed; of their effects, therefore, we know nothing from our own experience: they are, however, highly recommended by others, and will, in some cases, no doubt, be found of benefit. These baths are formed by dissolving one grain of iodine and two of iodide of potassium in a gallon of water. In protracted cases, change of air, frequent bathing in tepid salt water, or daily sponging with simple warm or salt water, followed by brisk frictions to the surface, a cautious course of chalybeates, and a well-regulated diet, constitute the plan of treatment to be pursued. When, however, the disease has been of long continuance, little hopes are left of effecting a cure. Very generally the patient sinks under hectic fever, night sweats, and colliquative diarrhoea, or tubercular depositions take place in the lungs or other important organs, and, sooner or later, terminate the life of the patient. SCROFULA .—TREATMENT. 643 In the Scrofulous Disease of the Bones denominated rickets, little else is demanded than a strict attention to those hygienic measures that are adapted to improve digestion, and render more vigorous and perfect the whole of the organic functions. A proper diet, pure air, the tepid bath, and sponging with tepid salt water, together with fric- tion of the surface, daily but cautiously performed, are the agents from which the greatest amount of good is to be anticipated. The diet of a rickety child should be light, easy of digestion, and abounding in nu- tritive matter. Previous to weaning, the breast-milk of a healthy nurse is invariably to be preferred; and, subsequently, meat broths, with the farinaceous vegetables, or beef and mutton plainly cooked. Children suffering from rickets are unfortunately precluded from active exercise; the utmost care should indeed be taken, not to allow them too soon to assume the erect position, or to attempt to walk. They may, however, be passively exercised, by being carried abroad in a carriage, or in the arms of an attendant. They should be taken frequently in the open air, during clear bright weather. Exercise, as Bouchut has well remarked, reanimates their ap- petite, and the solar influence, by exciting the functions of the skin, imparts to all the tissues and organs a vigour which they would never acquire in the shade. In carrying or even handling a rickety child, or one strongly pre- disposed to become so, great pains must be taken to avoid undue pres- sure upon any part of the body, or to place it in any position by which th« spine or either of the long bones may become distorted. Its clo- thing, also, should be perfectly free and loose. In the soft and yield- ing condition of the entire bony structure, any part of the clothes being allowed to bind, or to compress unduly the chest or limbs, by preventing the full development of the first, and producing a change of shape in the latter, may, independently of the deformity to which it gives rise, cause permanent decrepitude, or a serious interference with the free and regular action of important organs. The child should not even be allowed to lie too long in the same position, in order to guard against too much and constant pressure on particular bones. Any symptoms of local disease which may occur in patients affected with rickets, must be combated by their appropriate remedies. The sluggish and deranged state of the bowels will very generally call for purgatives, and the employment of calomel in alterative doses; care- fully, however, guarding against the production of its specific effects. As soon as the regular and healthy condition of the alimentary canal has been established, tonics, as in other cases of scrofulous disease, may be administered, and will often be productive of very decided advan- tage. The chalybeates and iodine, with cod-liver oil, and occasionally, the sulphate of quinia, constitute our best tonics in these cases:—it is in these, also, that the hydrochloride of barytes is said to be particu- larly beneficial. During the whole treatment, the tepid salt-water bath, sponging with salt-water, and brisk friction to the surface, should be daily resorted to. m . . Trousseau employs the cod-hver oil in all cases ot rickets, in the dose of from six to eight drachms, increasing for older children the 644 DISEASES OF THE NUTRITIVE FUNCTION. dose to two ounces, and it is said, that his experience is most decidedly in favour of the good effects of the remedy. Various plans of support and of machinery have, at different times, been proposed to prevent the occurrence of distortion and deformity in the bones, and to remove it after it has taken place; we believe them all, however, to be worse than useless; indeed, every mechani- cal means adapted to effect the former object, will be absolutely perni- cious—invariably increasing the evil it was intended to avert. Those which have been resorted to to effect the second object, are generally unsuccessful, and are occasionally attended with mischievous effects. It has been recommended, upon the authority of Dupuytren, to place children whose breasts have become wedge-shaped, from the effects of rickets, against a flat resisting surface, and then to press with the palm of the hand upon the projecting sternum, so as to flatten the thorax in its antero-posterior diameter, and by increasing thus the convexity of the ribs, to augment its capacity laterally. In the success of such a procedure, we have not the least confidence. We believe with Dr. Maun- sell, that much more may be effected by a course of well-regulated gym- nastic exercises, commenced with after the strength of the patient is well established, and he is sufficiently old to permit of their being put in practice. It will be evident to any one acquainted with the mechan- ism of the human frame, and the mechanical effects produced upon it by the continued action of particular muscles, that modes of exercise could be easily devised, which, if repeated sufficiently often, Avould have a very powerful tendency to remedy many of the distortions con- sequent upon rickets. In scrofulous disease of the ends of the long bones, independently of the general treatment adapted alike to all cases of scrofulous disease, it is essential that the limb be kept in a state of perfect rest, which can scarcely be effected without the aid of appropriate splints and ban- dages;—and, although these, when the disease is seated in the bones of the lower extremities, will prevent the patient from taking exercise, they cannot be avoided. When inflammation takes place, this is to be removed by moderate local depletion in the commencement, aided by evaporating lotions, as a mixture of water and alcohol, or water and camphorated spirits, or a solution of the acetate of lead. In many cases, blisters, applied in the immediate neighbourhood of the affected joint, frictions with a solution of iodide of potassium, or with the oint- ment of the latter, or with the tartar emetic ointment, will often prove beneficial. It has been recommended to keep open the blister, by dress- ing it with the unguentum sabinae, or other irritating applications: we are persuaded, however, that a frequent repetition of the blister is a far preferable practice. Purging will be found, in most instances, to be demanded, in consequence of the torpid and loaded condition of the bowels; and, in general, it will produce, also, a good effect upon the diseased condition of the joint. So long as a disposition to suppuration continues, it is probable that blisters to or in the neighbourhood of the joint, with the use of iodine internally, will constitute the most prudent and judicious practice. "N hen the disposition to suppuration has subsided, gentle pressure upon SCROFULA—TREATMENT. 645 the joint, by means of strips of soap-plaster, should be applied, and continued for some time. Motion of the joint must not be attempted bo long as the least degree of irritation remains, or the slightest pain is excited. In all scrofulous diseases of the joints, motion should be delayed for a much longer period than in almost any other of the affections in which the bones of the extremities are implicated. As soon as the limb becomes perfectly free from irritation, it is ne- cessary to subject it daily to gentle friction. In the management of the scrofulous affections of the joints, the utmost patience, caution, and perseverance will invariably be demand- ed ; a too early desire to permit the natural use of the affected limb, may eventuate in complete anchylosis, or more serious injury; while, in even severe cases, by prudent and judicious management, a com- plete cure may sometimes be effected. The treatment of White Swelling consists in perfect rest of the affected joint. When this is hot and painful, or tender upon being handled, leeches, lotions of a solution of the acetate of lead, or evapo- rating washes, brisk purgation, and a light, unirritating diet will be demanded. When the swelling is indolent, presenting no increased heat, nor tenderness upon pressure, blisters will, in general, be found the most efficacious application; though, in some cases, benefit has been derived from dry friction, or by friction with the iodine in solu- tion, or in the form of ointment. According to Latta, applying a blis- ter, first upon one side of the joint, and then upon the other, and thus repeated alternately, until the pain and swelling are reduced, has, in many cases, been found more successful than when the blister is made to envelop the whole joint. When blistering induces an increase of the heat and pain, an issue upon each side of the joint may be sub- stituted. p In cases in which the parts involved in the swelling become infil- trated with matter, encircling the joint with strips of adhesive plaster, applied pretty tightly, has been found, in many cases, highly beneficial. This practice is equally proper after abscesses or sinuses have formed. In many patients a cautious use of opiates will be demanded, to re- lieve the pain, and procure sleep at night, and in the latter stages of protracted and severe cases, to arrest the copious diarrhoea Avhich then so generally prevails: in this latter case they should be combined with the acetate of lead. Splints, in cases where the disease is seated in the knee, are neces- sary, as well to prevent motion, as to counteract the tendency which exists in these cases to permanent flexure of the joint When the elbow joint is affected, and anchylosis cannot be prevented, angular splints should be applied, in order that the limb may become flexed so far as to render it as serviceable as possible to the patient. The question of the propriety of amputation in cases of white swell- ing, is a purely surgical one; its discussion does not fall within the Bcope of the present treatise. . Hip Disease-morbus coxarius.—In relation to the special treat- ment of this affection, nearly the same remarks will apply as in the case of white swelling. The most perfect rest of the affected joint is 646 DISEASES OF THE NUTRITIVE FUNCTION. absolutely necessary to the accomplishment of a cure in all cases; and this can only be maintained by a splint, so carved or modelled, as to fit accurately the side of the pelvis, as well as the thigh and leg of the side on which the disease exists: such a splint, properly padded, while it prevents motion, produces no injurious pressure about the joint, nor at any part of the limb. Whenever there is much heat, pain, or tenderness, leeches will be proper, with the same cooling and evaporating lotions as were directed in cases of white swelling. Some surgeons prefer the application of cups to leeching. In many cases, in the earlier stages of the com- plaint, previous to the soft parts about the joint becoming affected with any considerable amount of inflammation, we have been more pleased with the effects of cupping, than Avith those derived from leech- ing; but we have been repeatedly called to cases, at a later stage of the complaint, in which, although local bleeding was demanded, the extreme tenderness of the diseased joint prevented the application of cups, and obliged us to resort to leeches. In this affection, we know of no practice which will be found more generally beneficial, than pretty active purging with the compound powder of jalap, as pursued by the late Dr. Physick. Under this treatment, with perfect rest of the limb, leeches, and cooling lotions, we ha\re repeatedly seen the general health of the patient rapidly im- prove, and a perfect cure effected. The diet of the patient, in the early stages, should be light and easy of digestion. Milk, with any of the farinaceous substances, or light meat broths, in moderation, may be allowed. Blisters are unquestionably useful in the early period of the disease. We prefer repeated blisters, to keeping up a discharging surface by stimulating ointments. In very chronic cases, a caustic issue, just before and below the great trochanter will probably be more beneficial than blisters. Frictions with iodine in the form of solution or ointment, in conjunc- tion with its internal use, will often produce very happy results. When suppuration is about to occur, or an abscess or abscesses have already formed, the effects of gentle, continued pressure may be tried. We think that in a few instances we have seen it beneficial. When abscesses form, it is better to avoid, if possible, opening them, lest we cause the cavity of the joint to become exposed. In regard to general treatment, this is to be conducted upon pre- cisely the same plan as in any other case of scrofulous disease. Disease of the Spine.—Children of a delicate, enfeebled frame of body, particularly females, when approaching the period of puberty, are liable to curvature of the spine, entirely independent of disease of the vertebrae; though, when long-continued, disease of these, as well as of the intervertebral cartilages, is liable to take place. The species of curvature we now refer to is the result of a defect of power in the muscles by which the erect position of the trunk is maintained. It is often increased, if not produced, by improper articles of dress, which furnish an artificial support to the upper part of the body, and thus deprive the muscles of the trunk of their proper office; these conse- SCROFULA—' •TREATMENT. 647 quently obey the general physiological law—by which muscles long disused diminish in bulk, and finally lose entirely their power of act- ing. Stays, corsets, and braces produce this effect, under all circum- stances, when worn during the period of youth, and, in too many in- stances, the mischief is increased by the undue pressure they exert upon the muscles and bony structure of the chest. The general plan for giving increased vigour and tone to the whole system, by improving its nutrition, must be pursued in these cases; at the same time a loose style of dress should be adopted, and artificial supports of every kind abandoned. The power of the muscles about the spine and chest may be very materially increased, and even considerable curvatures of the spine removed, by a proper course of calisthenic exercises, daily practised, and firmly persevered in. Such exercises as gradually accustom the patient to support the entire weight of the body by the arms, in climb- ing, swinging, and the like movements, have a tendency to give de- velopment, strength, and activity to the muscles upon the chest, as well as to those of the back and spine, concerned in maintaining the body in its erect position, while, at the same time, when carried on in the open air, they promote the general health of the system. Frictions with the hand or flesh-brush over the entire surface of the back, em- ployed daily, as well as sponging with tepid salt water, a well-regulated diet, and daily general exercise, are all-important measures, which [should never be neglected. In the proper spinal disease, from an affection of one or more of the vertebrae, exercise, either general or regulated, is out of the question: perfect rest in the recumbent position must be enjoined, and perse- veringly maintained, until the disease of the bones is fully arrested. Various contrivances have been devised to take off the pressure of the head and upper portion of the trunk from the spine, when the patient is in the upright position, and by this means to allow him to exercise his body by walking about. We confess that we have seen but little good result from these contrivances, and, in many cases, positive in- jury:—yfQ prefer the recumbent posture, until the cure of the local dis- ease is considerably advanced, when, probably, the machine invented for cases of diseased spine by Dr. J. K. Mitchell, of Philadelphia, may be resorted to, for a short time daily, with advantage. From diseased vertebrae, a certain amount of angular curvature is inevitable; though, by a prudent and judicious course of treatment, early commenced with, we may be enabled to diminish, very materi- ally, the extent of the deformity. The great object of the practitioner, in these cases, should be, to give, as quickly as possible, increased tone and vigour to the whole system; for when this can be readily effected, the disease of the ver- tebras is very generally arrested, and their complete consolidation pro- duced. The morbid condition of the system is to be removed by a nourishing diet, friction of the surface, and the internal use of tonics;— the different preparations of iron, as the carbonate, proto-carbonate, ferrum tartarisatum, the tincture of the sesquichloride of iron, the iodide of iron, the hydrochloride of barytes, iodine, and the sulphate of quinia, are to be preferred. 648 DISEASES OF THE NUTRITIVE FUNCTION. Iodine, externally and internally, has, unquestionably, in a large number of cases, been attended Avith the most happy effects; even Avhen the disease of the bones has made considerable progress, its use has appeared to arrest the disease, and allow anchylosis to take place. With the administration of iodine by the mouth, the diseased portion of the spine should be rubbed daily with the ointment or solution. M. Piorry (Gazette des Hbpitaux, 1856,) has long been in the habit of employing phosphate of lime in cases of rickets attended with cur- vature of the spine, and he states with decided advantage. It is only employed by him, hoAvever, in conjunction with a highly nutritious diet, exposure to the light and to a dry and warm atmosphere, but the good effects of the remedy he nevertheless considers as unquestionable. He gives it in the form of very fine filings of fresh bones; about one ounce daily, in milk, or rice milk. The insolubility of pure phosphate of lime has heretofore prevented its employment as a therapeutic agent; according to M. Kuchenmeister of Zittau by uniting the phos- phate with carbonate of lime at a temperature of F. 70°—a soluble combination of valuable remedial powers results. During the treatment, the bowels should be kept freely open by mild aperients. In the early stage of many cases of the disease, active purgatives, particularly the compound of jalap and bitartrate of po- tassa, will be found of advantage. After all, however, we believe that the plan of treating the disease with caustic issues, formed along the spine, on each side of the dis- eased vertebras, as originally recommended by Pott, should not be neg- lected; we have unquestionably strong evidence in favour of its suc- cess. We have seen the most decided benefit result from it in nu- merous instances; and by resorting to it, we in no degree preclude ourselves from whatever advantages are to be derived from rest in the recumbent position, purgatives, the local application of iodine, or its internal use, either alone, or in conjunction with tonics. The time necessary for the cure of diseased vertebrae is very various in different cases: in some, complete consolidation of the spine may take place at the end of a month or two; in others, not until after many months. In all cases it is important that the patient should not resume the upright position until we are certain that anchylosis has made considerable progress; nor should it be retained, at first, for any length of time, and on no account should much active exercise be at- tempted. So soon, however, as anchylosis has taken place, gentle daily exercise, at first by the aid of crutches, subsequently without any support but that derived from a cane, and finally, entirely with- out support, should be commenced: by this means the natural strength and movements of the muscles of the loAver limbs will be gradually re- gained, and the general health of the body improved. In cases marked by a strong predisposition to tubercular deposi- tions, the best that the physician has it in his power to do, is to endea- vour to prevent the formation of the tubercles by means adapted to restore health, strength, and vigour to every portion of the system; or when they have already formed, by the use and proper regulation of the same means, to endeavour to prevent their subsequent development, DYSURIA. 649 and the irritation produced by them in the tissues in which they are seated. Whatever symptoms are produced by them, when they are seated in the lungs or brain,.must be treated upon general principles; always recollecting, however, that the particular constitutions in which tubercular depositions ordinarily take place, will not bear either de- pletion being carried to so great an extent, nor so restricted a diet, as many of the symptoms which arise would often seem to demand, or which would be proper, were they to occur in other constitutions. We have no means of positively judging of the presence of tuber- cles in the brain, and most of the other organs, during the lifetime of the patient: Ave may suspect their presence, however, whenever chro- nic and anomalous affections of any of the organs occur in individuals who exhibit a very strong predisposition to affections of a scrofulous character. SECTION VI. DISEASES OF THE URINARY ORGANS. l.—Dysuria—Painful and Difficult Micturition. Infants and young children are not unfrequently affected with pain and difficulty in voiding urine. It is often observed, to a slight ex- tent, as a symptom of any febrile excitement under which they may labour, and is very common about the period of dentition. The child has a frequent desire to urinate, but passes only a very small quantity at a time, and with evident distress and uneasiness. This, though ge- nerally a temporary inconvenience, may nevertheless continue for a considerable length of time, and result, ultimately, in severe and dan- gerous disease. In some cases the discharge of urine is attended with such severe paroxysms of pain as to throAV the child into violent agitation, and cause him to utter uninterrupted shrieks, until the discharge is com- pleted, when the pain instantly ceases, and the child, if old enough, returns to his play as though nothing had occurred. Dysuria in children is very generally attended with a morbid condi- tion of the urinary secretion; most commonly the urine contains an excess of lithic acid, though, in some cases, it is highly charged with phosphatic sedimentous matter. • There is a form of dysuria which is of frequent occurrence in young infants, and always a source of intense suffering during its continu- ance,—if it do not, sooner or later, terminate in a complete suppres- sion of the urinary secretion: it is described by some of the conti- nental writers, under the denomination of urodialysis neonatorum. In this form of dysuria the urine is passed in very small quantities, often only a few drops at a time, and, evidently, with intense pain, as indicated by the screams of the patient, the drawing up of his legs to- 650 DISEASES OF THE URINARY ORGANS. wards the abdomen, the flushing of the countenance, and the general agitation of the whole body. The urine is always very high-coloured, and stains the diaper or linen of the child, of a deep reddish-yellow, or orange hue. It produces an irritation or scalding of the surfaces over which it passes, and, finally, excites inflammation of the lining membrane of the bladder, and probably of the urethra also, as indi- cated by the mucus with which the urine becomes charged. The patient usually exhibits more or less febrile excitement;—the skin is increased in temperature, and dry, the thirst augmented, and the bowels constipated. When a discharge of faeces is obtained, these are commonly in the form of small rounded masses, like marbles. The digestive function is invariably deranged;—the breath having a very decided acid odour. There is, generally, considerable irritability of the skin: while inflammation and superficial ulceration, attended with a thin, acrid, fetid discharge, by which the mischief is extended to the neighbouring parts, are almost certain to occur, wherever two surfaces are in contact. Cutaneous eruptions of various kinds, are also very common; sometimes assuming the form of psydracious (im- petiginous) pustules, scattered over different parts of the body, and especially in the folds of the neck, axillae, groins, &c, giving rise to superficial ulcerations of a very troublesome character. The more violent forms of dysuria occurring in children, are, very generally, accompanied with more or less derangement of the diges- tive process, and the formation of acid in the alimentary canal. Se- vere attacks of the disease will, most commonly, be met with in those children who have been indulged, from an early period of infancy, in animal food, rich gravies, and similar highly azotized articles, and in whom, with imperfect digestion, there coexists an insatiable appetite for food of a rich, stimulating quality,—"Children," to adopt the lan- guage of the elder Schmidt, "who, according to the short-sighted estimate of their parents, are in the enjoyment of the most robust health, while, in fact, disease, already commenced, only awaits in them some trifling cause to rouse it into more open and rapid action." There is no doubt that deranged digestion, and the consequent pro- duction of an excess of acid in the fluids of the body, giving rise to increased secretion of lithic acid by the kidneys, and thus changing the normal constitution of the urine, may, during childhood and in- fancy, be the cause of a very considerable degree of irritation about the neck of the bladder—then easy to be excited, from the physiolo- gical condition in early life of the mucous tissue generally—attended by pain and difficulty in passing the urine; and that the urine will, in these cases, indicate, by its physical properties, and the usual tests, a predominance of the acid in question. But this is not the only cause of painful and difficult micturition in children. In many cases, parti- cularly in those which occur during dentition, or during slight febrile attacks, the dysuria is evidently the result of the increased irritability which the lining membrane of the bladder experiences, in common with the other mucous tissues, and, although the urine may also con- tain a slight excess of acidity, this is too small a quantity to produce the degree of dysuria experienced, without the former. DYSURIA. 651 Various intestinal irritations are an occasional cause of difficult and painful micturition in young children. We have seen it often con- nected with the presence of oxyures in the rectum: in these cases, the urine generally forms deposits of an alkaline character. We have known, also, an ordinary attack of dysentery in a child, to be accom- panied with severe dysuria. In a few cases that have fallen under our notice, we have had rea- son to believe that dysuria depended upon a degree of inflammation about the neck of the bladder. The urine, in these cases, notwith- standing the calls to void it were very frequent, was passed with more or less pain, in very small quantities, and loaded with mucus. Partial retention of urine is common in such cases. According to Eberle, in female children, a very common cause of dysuria, and one very often overlooked, is an inflamed condition of the orifice of the urethra. This is often red, swollen, and so extremely sensible, that it cannot be even lightly touched, without causing the child to shrink, and shriek with pain. In cases of this kind, the urine presents nothing abnormal, and the pain, accompanied by considera- ble smarting, remains for some short time after the discharge of urine has ceased. We have met with this state of the female urethra so frequently, that we are never called to a case of dysuria occurring in a girl, without making an examination. There does not appear to be any source of difficulty in the diagnosis of dysuria. Even in the youngest child, its symptoms are sufficiently evident to prevent the disease from being mistaken for almost any other; and yet we have known it to be confounded with colic, and treated for several days accordingly. If, however, a child is found to become affected with spells of severe suffering only during the pe- riod it is voiding its urine, the pain commencing and ceasing with the act, the true cause of the paroxysms is at once pointed out. Happily, in the majority of cases, the remote and exciting causes of dysuria are only of temporary duration, and hence the affection is Beldom productive of any very serious or permanent injury. When however, the disease is connected with long-continued disturbance of the assimilative process, it may produce disease of the kidneys, ureters, or bladder, giving rise to a complete suppression of urine, or it may be the cause of gravelly or calculous concretions. Gravel, in children, is of more frequent occurrence than is gene- rally suspected; and, when formed in the pelvis of the kidney, its occasional passage through the ureters is attended with sudden in- tense attacks of pain, which continue until the particle of gravel has found its way into the bladder. These attacks, the cause of which is at first not very evident, may give rise to convulsions. Occasional y the urine voided immediately after the cessation of the pain, is slightly Tn tiie treatment of dysuria, we must be governed by the peculiar character of each case. When dependent upon disordered assimila- tion, it is important to employ such means as are calculated to render the digestive process more prompt and regular Previous to weaning, the breast-milk of a healthy nurse, pure air, the warm bath daily, fol- 652 DISEASES OF THE URINARY ORGANS. lowed by friction to the surface, will in general effect this. In older children, beef tea, or chicken water, should constitute, pretty much, their ordinary diet, and all articles of a saccharine and acescent kind should be entirely prohibited; at the same time, daily exercise should be taken in the open air, cold and dampness being carefully guarded against, and the functions of the skin promoted and maintained by the tepid bath and friction. In all cases, the boAvels should be at once freely evacuated, by suf- ficient doses of magnesia and rhubarb, aided by emollient enemata, and their regular action subsequently maintained by small doses of calomel, magnesia, and ipecacuanha, with or without the addition of extract of hyoscyamus, repeated once, twice or thrice a day, as may be necessary. R.—Calomel, gr. vj.—xij. Pulv. ipecac, gr. iij. Magnes. calc. gr. xxxvj. Ext. hyoscyami, gr. iv.—vj.—M. f. ch. No. xij. When there is a strong tendency to acidity of the stomach and bowels, the best prescription will be, either magnesia and milk, in small, fre- quently repeated doses, or, what is calculated in these cases to produce the greatest amount of benefit, the bi-carbonate of soda. This may be given in doses of from two to six grains, according to the age of the child, once, twice, or thrice daily. It should be dissolved in about half a drachm of a weak infusion of calomba, or chamomile, and then diluted with barley, rice, or gum water. When dysuria occurs during dentition, the state of the gums should be carefully watched, and inflammation, distention, and pain of these promptly removed, by free incisions repeated daily, if necessary. The bowels should be kept freely open, by occasional doses of magnesia and rhubarb; and if any febrile excitement exists, as it generally does, the daily use of the tepid bath, and, internally, the acetate of ammo- nia, with the addition of a small quantity of the sweet spirits of nitre, will be proper. During the paroxysms of pain, should they he of any continuance, the best means of alleviation is the hip-bath, used tolerably warm, and, internally, a few drops of turpentine, sweet spirits of nitre, and the camphorated tincture of opium, in combination.1 In ordinary cases, however, the duration of the paroxysms is too short to allow time for the preparation of the bath; we must content ourselves, therefore, with the administration of the latter. 1 R.—Aq. cinnamom. gij. Spir. terebenth. 3Jss. Magnes. calc. gr. viij. Spir. aeth. nitr. giij. Tinct. opii camph. ^ij.—M. When dysuria is attended with a copious secretion of the phosphate of magnesia and ammonia, with pale or light-coloured urine, which de- posits, upon cooling, a whitish or yellowish sediment, and becomes ra- pidly putrid when suffered to remain at rest, the diet of the child, if weaned, should be mild but nutritious, and taken in moderate quanti- DYSURIA. 653 ties, so as not to endanger the overloading of the stomach, or the dis- turbance of its functions. In addition to milk, and the usual farina- ceous preparations, the child may, with propriety, be allowed a mode- rate portion, daily, of beef, mutton, venison, chicken, turkey, or any other meat of easy digestion; which should be fresh, not too fat, and plainly cooked, without much seasoning. For drink, we may direct weak lemonade, or water sweetened with the acidulous lemon syrup. The bowels, in these cases, are generally irregular, and the func- tions of the entire alimentary canal more or less deranged. To re- move this condition of the digestive organs, the bowels should be freely evacuated with rhubarb, castor oil, and turpentine, or the compound infusion of senna, and kept freely open by the occasional use of the ■ latter, or by mild, purgative enemata. To allay the general irritability of the system, by which this form of dysuria is generally accompanied, either the Dover's powder,1 in small doses, or a combination of ipecacuanha and extract of hyoscya- mus,2 will, very frequently, be found beneficial. 1 g.—Pulv. Doveri, gr. vj. 2 R.—Pulv. ipecac, gr. iij. Pulv. valerian, gr. xij.—M. f. ch. Ext. hyoscyami, gr. iv.—vj.—M. f. No. xij. (Eberle.) ch. No. xij. Of these one may be given every six hours, One every three hours. to a child between 2 and 5 years of age. After the bowels have become regular, and their discharges natural, benefit may be derived from the administration of the tincture of the sesquichloride of iron, in small doses, or of the protocarbonate of iron. Daily exercise in the open air, the tepid bath, and frictions of the Burface, are all-important measures, and should never be neglected. All alkaline substances are improper. When dysuria appears to be dependent upon a morbid degree of ir- ritability in the lining membrane of the bladder, the condition of the urine being normal, or very nearly so, the treatment should consist of a mild, unirritating diet, the use of the warm or tepid bath daily, and the plentiful use of diluents, of a mucilaginous character. The free- dom of the bowels should be maintained by occasional doses of castor oil or by laxative enemata; and if there is nothing present to forbid its use, a dose, adapted to the age of the patient, of Dover's powder may be given at night, or the extract of hyoscyamus and ipecacuanha, as directed above, three or four times a day. A weak infusion of the seeds of wild carrot, or of the root of parsley, mixed with an equal por- tion of the mucilage of the inner bark of the slippery elm, has been found, in some of these cases, peculiarly beneficial. R. Sem dauc carotre, *ii. Or, R.—Rad. apii petroselini, gij. K.—bem. dauc. caroire, 3ij. Aqure bullient. gviij. Aq. bulhent. 3v.ij.-M. ^ ^ ^ ^ ^ ^ ^^ &nd add half a pint of the mucilage. Very active exercise will not be proper; but a short walk or ride in a carriage, should be taken every day, when the weather is dry, and sufficiently mild. In this, as well as in all the other forms of dysuria, it is important to defend the surface against cold and damp, and hence the importance of flannel being worn next the skin. 654 DISEASES OF THE URINARY ORGANS. When dysuria is connected with inflammation of the neck of the bladder, a leech or two may be applied to the perineum; the bowels should be kept freely open by the mildest laxative enemata, and the warm hip-bath should be used every evening. In other respects, the treatment differs in nothing from that directed for irritability of the bladder. In the cases of painful micturition, occurring in female children, from inflammation of the orifice of the urethra, we have frequently found speedy relief to be derived from washing the parts, three times a day, with a solution of acetate of lead, keeping the bowels freely open by mild laxatives, putting the patient upon a mild, unirritating diet, and using the warm or tepid bath daily. Covering well the inflamed part with perfectly fresh lard, or spermaceti ointment, by protecting it from the contact of the urine, will often enable the inflammation to heal, if it be of a simple erythematous or phlegmonous character. Some prefer, as a wash, a strong solution of the borate of soda. In many cases, there exists a slight pustular eruption around the orifice of the urethra, often occupying the whole of the fossa in which the urethral orifice is situated: in these cases the application to the part of the citrine ointment, diluted with an equal quantity of fresh lard, will seldom fail to effect a speedy cure. In every case in which there occurs dysuria, or any other symptom most generally connected with a change in the composition of the uri- nary secretion, it is all-important to pay strict attention to the condi- tion of the urine voided, and to ascertain with accuracy its prevailing character, and according as this indicates an excess of the lithic acid, or of phosphatic matter, to direct such a course of treatment as will be calculated to arrest the secretion of either. By these means, perse- veringly carried out, the formation of stone in the bladder may be al- most certainly prevented; while, by their neglect, or the careless man- ner in which they are pursued, the child may be subjected, even before he attains to adult age, to all the pain and suffering attendant upon calculous formations. 2.-^Anuria.—Suppression of Urine. The kidneys perform their secretive function previously to birth; and, very generally, the moment the child is born, or, at least, within a very short time subsequently, a discharge of pale-coloured, inodorous urine takes place from the bladder. It occasionally happens, however, that six, twelve, twenty-four, thirty-six, and even forty-eight hours elapse, before any urine is passed by the infant: in these cases, it is reasonable to suppose that the function of the kidney has not been established. The infant exhibits no uneasiness whatever, that can be referred to the absence of the discharge, which, Avhen it occurs, gene- rally goes on regularly. The physician need give himself little uneasiness, in consequence of the child's not urinating for the first twelve hours after birth. If the dis- charge does not then take place, however, it will be proper, in the gene- rality of cases, to endeavour to excite the action of the kidueys by some simple means. The bowels should be freely evacuated, by a dose of castor SUPPRESSION OF URINE. 655 oil, or by laxative enemata, the child should be immersed to the hips in a warm bath, and a few drops of the sweet spirits of nitre, may be given every half hour, in a dessert-spoonful of the infusion of parsley root, or of wild carrot seed. When these simple means fail, we confess that we have seldom seen any good result from those of a more active character. We are recommended, however, to employ frictions over the loins and hypogastric region, with warm vinegar of squill, or a mixture of juniper oil and sweet oil, or with the expressed juice of onions, diluted with water; and, internally, to exhibit a few drops of the vinegar of squill, or a drop of spirits of turpentine, in a teaspoon- ful of milk, or four or five drops of the expressed juice of roasted onions, every thirty or forty minutes; in conjunction with warm bathing, lax- atives, and if necessary, laxative enemata. So long as the child exhibits no unusual drowsiness, or restlessness, there is a possibility that the kidneys will commence their secretory function, and the child do well. We have repeatedly known the uri- nary discharge to be suspended for upwards of tAventy-four hours, with- out the least injury resulting. In some cases, however, the suppression of the urinary discharge in young infants is the result of congenital malformation of the kidneys, ureters, or bladder, or a disorganization of the kidneys from intra- uterine disease. Absence of the kidneys, ureters, or bladder, though of very rare occurrence, has been occasionally observed: occlusion of the ureters, or of the urethra, is more common, and many cases are re- lated, in which, at birth, there was softening of the kidneys, or the pelves were entirely filled with calculous concretions; or the kidneys were converted into cysts, or filled with hydatids. The absence of the urinary secretion has, in many cases, been dependent upon congenital disease of the spinal marrow. We have met Avith one or more of these cases. When the suppression of the urine is dependent on malformation, extensive disease, or disorganization of the kidneys, or of the urinary organs generally, of course nothing can be done for the relief of the patient, who seldom survives more than a day or two; he quickly falls into a state of stupor, which sooner or later terminates in death. Anuria may occur at any period during infancy and childhood, from disease of the kidneys. In many of their acute febrile affections, the secretion of urine is very considerably diminished, or, for a time, en- tirely suspended. Complete anuria is a common symptom of the latter stage of hydrocephalus, as Avell as of other affections of the brain, or of the spinal marrow. In such instances, of course, the reinstatement of the function of the kidneys is dependent upon the reduction or re- moval of the disease Avith which it is connected. In a very interesting case, related by Fosbroke, of suppression of the urinary discharge in a child, preceded by diarrhoea, aphthae of the mouth, cough, strabismus, stupor, and convulsions; the kidneys were found upon dissection, to be very vascular, the papillae projected through the infundibula, and were of a bright red colour, while the pelves and ureters contained a quantity of sabulous matter and tena- cious mucus. 656 DISEASES OF THE URINARY ORGANS. 3.—Ischuria.—Retention of Urine. In ischuria, the urine is regularly secreted by the kidneys, and con- veyed into the bladder, but its discharge being prevented by some affection of the latter organ, or of the urethra, it accumulates in the bladder, causing it to become greatly distended, with other very serious, and often painful consequences. Complete or partial retention of the urine may occur in the new- born infant in consequence of an obstruction existing at the neck of the bladder, or in the course of the urethra, from inspissated mucus. This species of retention is said to be very common; but we should not infer it to be so from our own experience, having met with but one or two cases of it, in upwards of forty years' practice as an ob- stetrician. A much more common cause of retention in new-born in- fants, is that from occlusion of the urethra, either by a thin, semi- transparent membrane, situated at its orifice, or a short distance within it, or by an adhesion of the lips of the external orifice. In some cases, the retention is caused by a complete closure of the prepuce. In other cases, the cause of retention has appeared to be a spasmodic contrac- tion of the bulb of the urethra. In cases of ischuria in the new-born infant, as the urine gradually accumulates in the bladder, this becomes more and more distended, and may, at length, be distinctly felt, forming a circumscribed tumour above the pubes. The infant very soon exhibits indications of more or less pain and distress, which are increased by pressure upon the hypo- gastrium. The little patient becomes very restless and fretful, his coun- tenance has an expression of suffering, and his legs are constantly drawn up towards the abdomen; while the latter, if the impediment to the discharge of urine be not removed, becomes often enormously distended, and the skin covering it acquires a smooth shining appear- ance, as in cases of ascites; the superficial veins being, at the same time, greatly enlarged and gorged with blood. If the accumulation Avithin the bladder be allowed to go on, rupture of the latter may, sooner or later, take place, and quickly destroy the patient; or the urine, after enormously distending the bladder, may accumulate Ayithin, and produce distention of the ureters also, and finally, of the pelves of the kidneys. In some of these cases, the kidney itself becomes expanded into a kind of cyst, filled with urine. Inflammation of the peritoneum, effusion into the cavities of the brain, and other serious consequences may result from irremediable obstructions to the discharge of the urine—altogether independent of rupture of the bladder, which we have not found to be a very common occurrence. It is surprising to Avhat an extent, in some of these cases, the blad- der will become distended: it has been found by Billard, to fill the whole cavity of the abdomen, and by Howship, Parrish, and others, to contain from eight to twenty ounces of urine, sometimes mixed with mucus or albuminous flocculi. The ureters have, in some cases, been so far dilated as to present a diameter of from half an inch to one or more inches. RETENTION OF URINE. 657 In all cases where a permanent and irremediable obstruction to the exit of the urine from the bladder exists, death must necessarily, sooner or later, take place. In those, however, which depend upon oc- clusion of the external orifice of the urethra, or the want of an opening in the prepuce, the obstruction may be readily removed by a very simple operation. In every instance in Avhich a new-born infant is found not to have an evacuation of urine within twelve hours, at the furthest—or sooner, if any indications of pain or distress exist—the physician should make a cautious examination of the urethra, by the careful introduction of a Bmall bougie, by which any obstruction in that part will at once be detected; and if this result from inspissated mucus, it will at the same time be removed. If the urethra is found to be pervious, and the in- troduction of the bougie is not followed by a flow of urine, a small flexible catheter should, with the utmost caution, be passed into the bladder—for there is reason to believe, that, in some instances, the re- tention is caused by a spasmodic action of the membranous portion of the urethra, or, Avhen the bladder has been allowed to become greatly distended, that its contractile power may have become temporarily impaired. In this latter case, it will, in general, be prudent to pass the catheter daily, until it is found that the bladder has regained sufficient power to completely evacuate itself without artificial assist- ance, and no tendency to a reaccumulation remains. When no obstruction to the exit of the urine can be detected in the urethra or at the neck of the bladder, the bowels of the patient should be freely opened by purgative enemata, after which he should be im- mersed to the hips in a warm bath, and, at the same time, gentle fric- tion may be made over the pubic region with the hand, or with a little camphorated oil. This will often be sufficient to procure the discharge of urine, especially should it happen to depend upon a spasmodic af- fection of those muscles of the urethra which act as a sphincter vesicae. During the whole of infancy, and the earlier period of childhood, suppression of urine is liable to occur from this latter cause. The in- ability to evacuate the bladder may take place suddenly after exposure to cold, but, more commonly, it results from some irritation seated in the rectum, as the oxyures, or other worms. In these Cases, the warm bath, an active cathartic, as castor oil or infusion of senna, followed by an anodyne injection, and frictions over the perineum with cam- phorated oi'l, with the addition of a very small portion of extract of belladonna, will be the proper treatment. We have met with a num- ber of cases of suppression of urine in children about the period of den- tition, arising evidently from this cause; and the practice detailed has always been productive of prompt and entire relief. Occasionally, the retention of urine results from an inflammation of the neck of the bladder. When this is the case, leeches to the pe- rineum emollient and laxative enemata, the hip-bath, and small doses of Dover's powder and ipecacuanha, or of extract of hyoscyamus and ipecacuanha, are the remedies indicated. If by these means the re- tention is not quickly relieved, the urine must be drawn off by the cautious introduction of a small catheter. 42 658 DISEASES OF THE URINARY ORGANS. It is scarcely necessary to say, that in all cases remedies which act directly upon the kidneys, are improper; they augment the distress and danger of the patient, by increasing the amount of fluid secreted, and consequently the distention of the bladder. Under ordinary circumstances, there is scarcely a possibility for any mistake being made in the diagnosis of ischuria; nevertheless, when the obstruction to the discharge from the bladder is only partial, after the latter has become distended to a certain extent, small portions of urine are, occasionally, evacuated, notwithstanding a constantly in- creasing accumulation is, in fact, taking place; and, unless the physi- cian makes, himself, an examination of the condition of the bladder, he will be very liable to be deceived by the report of the mother or nurse, and attribute the suffering of the patient to other causes. Cases have occurred, in which the bladder was finally ruptured by over dis- tention, and death ensued from peritoneal inflammation, when relief might have been afforded, had a retention of urine been suspected to exist: a small discharge from the bladder deceived the attendants, and by incautiously depending upon their report, the physician was led to form a very erroneous, and unhappily fatal diagnosis. Whenever we are called to a young infant, who is restless and fret- ful, and persists in keeping its legs drawn up towards its abdomen, we are scarcely free from censure, if, notwithstanding the assurances of those about it, that it passes its urine regularly, we neglect to make a cautious examination of the abdomen, by which, if retention of urine exists, the fact may be readily detected. 4.—Enuresis.—Incontinence of Urine. In early infancy, the discharge of the urine, as well as of the faeces, takes place involuntarily. As the infant increases in age, and soon after it assumes the erectposition and has learned to walk alone, with a very little precaution, it will acquire a command over the sphincters of the rectum and bladder, and be able to retain the contents of either, until a proper place and opportunity is offered for their evacuation. Children who have not been taught regular and cleanly habits in re- gard to their evacuations, will often, even after they have arrived at two or three years of age, void their urine and faeces the moment the desire is felt; and what at first resulted from a mere inattention of parents to restrain, under any circumstances, the natural calls, will at length degenerate into a partial loss of the controlling power of the will over the sphincters of the rectum or bladder—more particularly over the latter—and the children finally may become affected with ha- bitual incontinence of urine. Happily, however, a sense of decency, Avhich children early acquire, the ridicule of companions, and other in- fluences, prevent this latter occurrence, excepting under very peculiar circumstances. Still, incontinence of urine is of very common occurrence among children of all ages, even up to the period of puberty, and sometimes until late in life. In some cases, it evidently originates from paralysis of those muscles by which the expulsive action of the bladder is re- sisted; or perhaps from paralysis of the bladder itself: in these cases, INCONTINENCE OF URINE. 659 of which we have seen many, the urine dribbles away constantly, being discharged, guttatim, as it reaches the bladder. Some of the patients thus affected passed from under our notice; some survived until their fourteenth, sixteenth, and eighteenth years, and then died of other diseases,—in the majority of cases of a tubercular character,—while others became early affected with paralysis, hemiplegia, or paraplegia; and after death, exhibited extensive lesions of the brain or spinal mar- row: one died with all the symptoms of genuine tetanus, more proba- bly, however, the result of an overdose of strychnia, exhibited by an empiric of the homoeopathic school. But the most common form of incontinence of urine is that which presents itself in a discharge of urine at night, while the patient is asleep in bed. There are few young children, who, during the intense nocturnal slumber peculiar to their age of life, do not occasionally pass their urine in bed, particularly if care has not been taken to cause them to urinate just before going to sleep; or, if they have been indulged in the use of tea or other fluids late in the evening. But this does not constitute a case of incontinence, properly speaking, though it may be- come so by neglect. Children affected with enuresis, at first occasionally, but very soon habitually, and very generally at a particular hour of the night or morning, discharge their urine in their sleep. Incontinence of urine is not always, however, confined to the period of sleep. In many cases not only are the calls to urinate at all times more frequent and pressing than in health, but the urine, according to Willis, is always more copious, and of lower specific gravity; and does not contain the due proportion of characteristic animal ingredients, but is colourless and watery. This condition of the urine is unquestionably present in many cases of enuresis in children:' but by no means in all. In numerous instances, as Prout remarks, the urine contains an excess of sedimentitious mat- ter, particularly lithic acid and its compounds, which impart to it an acrid and irritating character. It is often the case during childhood —and the same thing may continue during the whole of after life— that the calls to urinate are invariably of so urgent a character that the moment the inclination is experienced it must be yielded to with- out delay. It in such cases is felt also at very short intervals during the day-time as well as at night. . .... It is probable that the discharge, during sleep, in children, particu- larly when it has become habitual, is often entirely involuntary and takes place without the patient being at all conscious of the act. In numerous instances, however, there is no doubt, as Prout very just y remarks, that the discharge is a voluntary effort, excited by a lively dream; the dream being prompted either by the distention of the blad- der, or by the stimulating properties of the urine. It has been said, that during sleep * discharge of urine never takes nlace executing when the individual is lying on his back; the urine, Fn i 2, gravitating in such a direction as to press directly upon the "sensible spot-the master spring, of the muscles of the 600 DISEASES OF THE URINARY ORGANS. bladder, "situated a little behind and below its orifice." (Charles Bell.) This statement is by no means correct; from personal obser- vations, made under circumstances peculiarly favourable for arriving at correct conclusions, we know—and the same thing has been re- marked by Willis—that children affected w-ith nocturnal incontinence of urine, pass their water while lying in any position, probably even more frequently when they happen to be lying on their face, than in any other posture. Whoever, therefore, trusts to position alone for the cure of incontinence of urine in children, will be sure to be disap- pointed. That the affection, from whatever cause it may have originated, is in many cases continued and confirmed by habit, is proved by the fact, that by Avatching the patient, to ascertain the particular hour at which the discharge takes place, and waking him just before it arrives, to enable him to evacuate his bladder, he will in a very short time either awake of himself, and make use of the proper utensil, or he will ac- quire, in time, the power of retaining his urine during the entire night. Though a trifling malady in itself, so far as the general health of the individual is concerned, incontinence of urine is often one of se- rious importance, from the physical suffering and moral misery it oc- casions, Avhen the child arrives at an age capable of feeling the shame so generally attached to his infirmity, and the scorn and ridicule heaped upon him for what he had perhaps as little agency in the production of, as he has the power to prevent its continuance. Boys, remarks Willis, have been known, who had been beaten unmercifully for wet- ting the bed, to sleep, or rather pass the night, in their clothes, on the floor or in a chair, for several nights afterwards, till, worn out by fa- tigue, they found themselves compelled to undress, and take natural rest; hoping, as they had escaped one or two nights, passed between sleeping and waking, they might possibly get through another, and yet sleep soundly. But in vain: the very first night after betaking themselves to their bed, they were as unfortunate as ever; and then came the renewed beating, and, far worse to bear, the ridicule and scoffing of companions, or the other members of the family. It is the duty of physicians to point out, on every proper occasion, the serious consequences which such improper and cruel means, originating in an entire misconception of the nature of the complaint, are capable of producing. It is curious, that in relation to an affection of every-day occurrence, so great a difference should exist as to the sex in which it is most commonly observed; thus, by Wardrop, it is said to occur only in boys; by Steward that girls are more subject to it than boys; while Millar affirms that it is equally common in children of both sexes. Noav the fact is, that neither sex is exempt from its occurrence; according to our own experience, however, it is certainly far more frequent in the male than in the female. In regard to the treatment of nocturnal incontinence of urine we believe that the general want of success, attendant on the various plans which have been proposed for its cure, has arisen from an entire mistake in regard to the true nature of the disease, and from the remedies being INCONTINENCE OF URINE. 661 directed to remove some supposed morbid condition of the bladder, which seldom, if ever, exists. Our own observation has taught us the entire correctness of the views of those writers who refer the disease, primarily, to a derangement of the digestive and assimilative organs, and a consequent morbid change in the constitution of the urine._ We have seldom seen a case of nocturnal incontinence of urine, without its being accompanied by more or less derangement of the digestive organs; and have very generally found, that when this is removed, the involuntary discharge of urine ceases. In those cases in which the urine contains an evident excess of lithic acid, the course of treatment directed, under similar circumstances, for the cure of dysuria, will be equally proper here. Daily exercise in a pure dry air; avoidance of cold and dampness; a diet composed of a moderate portion of plainly cooked beef, mutton, or chicken, with the least acescent of the farinaceous preparations, and the daily use of the warm or tepid bath, with friction to the surface, and a prudent use of alkaline carbonates, as magnesia, the bicarbonate of soda, or the carbonate of potassa, with light bitters and tonics, and a gentle purga- tive and well-directed alterative course, will in most cases be found sufficient to improve the condition of the digestive organs, as well as of the urinary secretion; and as these changes take place, the invo- luntary discharge of urine during sleep will become less frequent, and finally cease entirely. m When the condition of the urine is that pointed out by Willis— namely, pale and watery, of diminished specific gravity, and deficient in its usual saline ingredients, the same attention should be directed to restore the healthy function of the digestive organs, and bring back the urinary secretion to its normal state. Any light bitter infusion acidulated with hydrochloric acid, with the addition of a very small proportion of the tincture of opium, will be found a useful remedy in these cases; or we may administer, as directed by Willis, a couple ot tablespoonfuls of the concentrated decoction of uva ursi, with the addi- tion of ten drops of the tincture of the sesquichloride of iron, two or three times a day. The dose of the latter remedy here directed, is that adapted to a child of five or six years of age; but a younger pa- tient will seldom bear more than a teaspoonful at a time of the decoc- tion, and from three to five drops of the tincture of the sesquichloride of iron, Avhich may be repeated, if necessary three times m the course of the day. Cold, or in very young and delicate children repeated tepid sponging of the perineum and pubes, has been found beneficial insomeP cafes8 In others, according to Willis a blister to the sacrum has succeeded in relieving the complaint; we have used the blister fre- quently, occasionally with complete success; in others, with no advan- 18 Success'has more than once followed the use of sedatives, as cam- phor digitalis, nitrate of potassa, benzoic acid, &c where tonics and stimulant, which at first appeared to be rationally indicated, have ^ Children should, under no circumstances, but more especially when they are affected with nocturnal incontinence of urine, be allowed to 662 DISEASES OF THE URINARY ORGANS. partake of large quantities of water, tea, or any kind of fluid diet, during the latter part of the afternoon and evening. 'They should in- deed be prohibited from drinking, or partaking of any kind of food just before retiring to rest. They should be made to evacuate the bladder on being put to bed; and awoke for this purpose at regular intervals during the night. Cases occasionally occur, in which whatever means are employed, no permanent benefit is produced. In such instances, it has been sup- posed that the infirmity is traceable to a congenital deficiency of con- trol over the sphincter of the bladder, the children wetting themselves whenever sharply spoken to, or frightened:—we have repeatedly met with such cases in children of an eminently nervous constitution. The most obstinate cases have appeared to us, however, to occur in very profound sleepers, and to be kept up by the bladder having acquired a confirmed habit of evacuating its contents at a particular hour; so that, even in the day-time, when the patient is perfectly awake, he finds the utmost difficulty to retain his urine beyond the particular period when its discharge has been accustomed to take place. It is in these cases that the exhibition of the tincture of cantharides will be found beneficial. By the irritation it produces about the neck of the bladder, the moment the urine begins to flow, a degree of stran- gury occurs, sufficient to awaken the patient, and thus prevent the evacuation taking place in bed. This effect being repeated for several nights in succession, the habit upon which the involuntary discharge takes place, is entirely broken up, or the child will become accus- tomed to awake when the desire to urinate occurs, and thus all the disagreeable consequences resulting from his unfortunate infirmity be prevented. From three or six, to ten or fifteen drops of the tincture of cantharides, according to the age of the child, may be given three times in the course of the day, and the dose should be gradually in- creased, until a degree of strangury is experienced in voiding the urine. The moment this effect is produced, the medicine should be given only in small occasional doses, so as to keep up, for a few nights, a slight degree of irritation at the neck of the bladder. Of course the employment of the cantharides is proper only in protracted cases, un- connected with derangement of the digestive organs, and a morbid state of the urinary secretion. Should too violent a degree of strangury ensue from the action of the cantharides, it may be abated by the free use of emollient enemata and mild mucilaginous drinks, small doses of camphor in the form of emulsion, and the warm hip-bath. If these means are not immediately successful, an anodyne enema may be given. Morand has long been in the habit of employing belladonna, in- ternally, in nocturnal incontinence of urine in children, and with very satisfactory results. He gives it in gradually increased doses. A pill containing three-fifths of a grain is at first given to children between four and six years of age, night and morning. If no effect is produced at the end of a week, a third pill is given at noon; and, after fourteen days, a fourth, if necessary. In this manner the remedy must some- times be continued for two, three, or four months in succession. In INCONTINENCE OF URINE. 663 cases of children between eight and fifteen years he begins with three pills, increasing the number as above. If signs of narcotism super- vene, the medicine must, of course, be for a time suspended. The belladonna was first brought into general notice as a remedy in nocturnal incontinence of urine of children by Trousseau; and in proof of its efficacy a large amount of testimony has been presented by various practitioners—more, certainly, than in favour of any other of the numerous remedies which have been proposed for the removal of this infirmity. We have, ourselves, found it to be more generally successful than any other we have employed. A similar statement in reference to it is made by Dr. Hewson, who gave it in a large num- ber of cases occurring under his notice among the inmates of the House of Refuge for juvenile offenders. (Trans. Philad. College of Phys., 1858.) Trousseau found it inapplicable to cases in which the enu- resis was present during the day as well as at night. Such has been, also, our experience. Dr. Berengieur, in cases of incontinence of urine succeeding to obstinate attacks of intermittent fever, in children between seven and fourteen years of age, found the most successful remedies to be a combination of copaiba, laudanum, and protoxide of iron, made into pills, in the proportion of three parts by weight of the former, to six of the latter. Of this mass one pill, weighing from two to three grains, was given morning, noon, and evening; and after every two or three days, an additional pill, until the patient takes ten daily. Along with the pills, an infusion of the folia juglandis was ordered as a common The employment of strychnine has been recommended by Moudiere, Cherchiare, Lendrich, Schnatz, and others. We have given it a trial, but found it when administered in very small doses, to do no good; and when given in larger doses, its effects upon the nervous system have been too violent to Avarrant a continuance of its use. In that form of the disease in which the enuresis occurred habitually during the day as well as at night, we have found, however, the use of the tincture or extract of nux-vomica to be often productive of beneficial results Dr. Deiters (Preus. Vercin-Zeitung, 1854) has found cubebs more effectual than any other remedy in cases of enuresis. He gives it in doses of a few grains to infants, and to older children, of half a tea- spoonful, twice or thrice daily. To effect a radical cure he has found it necessary in some cases to continue the use of the cubebs for a period of from three to eight weeks. . When everything else fails, we may resort, in the male, to mechani- cal contrivances for compressing the urethra, and thus prevent the escape of the urine. The best is that recommended by ^ ihis, m which a firm, but not hard pad, is kept applied by means of a spring to the membranous portion of the urethra. This should not, however be permitted to be worn habitually; it may be used, occasionally, with perhaps considerable benefit; and when chidren are visiting from home will insure them from the shame and mortification incident to this infirmity Ligatures to the penis, or the use of jugums should never be permitted, as much mischief is liable to result from them. 664 DISEASES OF THE URINARY ORGANS. In not a few instances, incontinence of urine is kept up by the irri- tation of the oxyures worm in the rectum. When this is the case, an enema of aloes, or assafoetida, dissolved in milk, or of turpentine dif- fused in mucilage, will destroy the worms, and a well-regulated diet, daily exercise, the warm or tepid bath, and friction of the surface, will in general tend to prevent their return. Should, however, the rectum become again infested with them, a repetition of similar enemata should not be neglected. 5.—Diabetes. There can be no doubt that children are occasionally affected with a species of hyperuresis, in which the urine discharged differs but little in its sensible qualities from common water, being perfectly limpid, entirely colourless, with scarcely any odour, and after standing for ten or twelve hours, becoming slightly opalescent or milky. This affection usually occurs in children of debilitated constitutions, emaciated, or quickly becoming emaciated, with soft protuberant abdo- mens, and listless, torpid, indolent dispositions. The appetite is gene- rally voracious, and the thirst incessant and insatiable. The child de- sires every thing of an eatable kind that he sees, and is constantly cry- ing for water, large quantities of which he will swallow at a time, if not restrained. The bowels are usually constipated or irregular, and the digestive process is disturbed, as well by a diseased condition of the stomach, as by the amount of food, often of a crude and insoluble kind, with which this organ is always overloaded. It is not uncom- mon for the discharges from the bowels to be mixed with portions of undigested aliment, particularly of the vegetable substances that have been swallowed, whether cooked or uncooked. Mellituria.—Diabetes mellitis is a much more rare disease during childhood. Dr. West has not met with a single case, and Dr. Prout has seen but one instance of it, in a child of five years old, and only twelve in patients between eight and twenty, out of a total of seven hundred cases of diabetes. It has been observed by M'Gregor and Willis, in boys of three and five years of age, and in both boys and girls about tAvelve. In one of the cases referred to by Morton, (Phthisisologia,)we are expressly told that the urine was mellea dulcedo; while in the disease described by Venables as tabes diuretica, the urine was evidently insipid. Diabetes in children seldom occurs during lactation. It would ap- pear to depend, very generally, upon derangement of the digestive and assimilative functions, consequent upon the use of improper food, subse- quent to weaning. A confined, damp, or impure atmosphere, the want of sufficient exercise, and a congenital infirmity of constitution, are, no doubt, also, very common exciting or predisposing causes. The child exhibits at first no striking symptoms of disease, but be- comes gradually dull, listless and fretful; loses its usual playful and active disposition, and exhibits an uneasy, discontented and anxious expression of countenance. The bowels are generally regular, with little or no deviation from the natural and healthy appearance of the discharges. The tongue has a natural appearance. At an early pe- DIABETES. 665 riod, however, there is an increased discharge of urine, increased thirst, and a more craving appetite than usual; and these symptoms, with the gradual emaciation, and dry, harsh state of the skin, are in general referred to the presence of worms in the intestines, for which the child is treated—the real nature of the disease being entirely over- looked. The emaciation goes on increasing, while the abdomen becomes more tumid, but Avithout much tenderness or tension. The tongue becomes coated with a thick layer of mucus; the bowels become constipated or irregular, and the stools acquire an unnatural appearance, being occa- sionally slimy and green, or mixed with portions of undigested food; while occasionally they are frothy, light-coloured, and apparently in a state of fermentation. The thirst rapidly increases, as well as the craving for food, and at the same time the discharge of urine augments rapidly in quantity, be- coming often enormous; exceeding, at times, perhaps very generally, the amount of fluid taken. The emaciation goes on with increasing rapidity, and is attended often with extreme debility; while the skin becomes uniformly dry and very harsh. There is almost invariably a gnawing sensation at the pit of the stomach, and increasing dul- ness, inactivity of disposition, and depression of mind. The pulse, which was at first somewhat accelerated, now becomes small, quick and hard. The latter stage of the disease is often accompanied with a consider- able degree of febrile excitement, frequently attended with headache, vertigo and temporary delirium. In cases of long continuance, cedema- tous swellings of the lower extremities, or even general dropsy, have been known to occur. The child gradually sinks, apparently from an entire suspension of the nutritive process; in other cases, a state of deep coma precedes the fatal event. The urine discharged is generally pale, perfectly limpid, without the least trace of sedimentitious matter; in some cases, however, it is of a milky appearance, and slightly turbid, and occasionally of a very light- yellow or greenish hue, having a very close resemblance towhey. Dr. Prout refers to a modified form of diabetes, occasionally met with in quite young children, to which the attention of the profession was first formally directed by Dr. Venables. There is a profuse flow of urine, containing frequently albuminous matters; in other instances, either an excess or deficiency of urea, and in a few cases, saccharine matters, more or less perfectly developed. The specific gravity of the urine ranges, according to the form of the disease, from l*02o to 1-005, or even less. It is generally transparent, and occasionally of a greenish hue. It is often associated with the tuberculous diathesis. Diabetes is always to be considered a serious disease. VVhen de- tected in its early stages, it is very possible that, by a proper course of treatment, its fatal termination may be very generally prevented; but unfortunately, it is seldom that the disease falls under the notice of the practitioner, until it has existed for some time—the discharge of urine increases so slowly in amount, that it is entirely overlooked by the parent* of the child, or if noticed, is ascribed to the enormous 666 DISEASES OF THE URINARY ORGANS. amount of fluids which bis morbid thirst prompts him to take. Even when a physician is consulted, the case is too often considered as one of worms, mesenteric disease, marasmus, or dropsy of the brain; and an improper course of treatment adds then to the fatality of the disease. The first attention of the physician should be directed to restore the healthy action of the digestive and assimilative organs; for unless this can be accomplished, there is very little hope of arresting the inordi- nate and unhealthy action of the kidneys. The child should be put upon a strictly regulated diet, composed of the more digestible kinds of animal food, plainly cooked, with prepa- rations of milk, eggs, and rice or oatmeal, without sugar; crackers should be given in preference to bread, or if bread be eaten, it should be well toasted. In the quantity of food taken, the patient should be so far restrained as to prevent the stomach from becoming at any time overloaded; probably four meals a day, at stated hours, a very mode- rate quantity being eaten at each, will be most advisable. The patient should be positively restrained from the use of all crude, acescent, or saccharine vegetables or fruits; and for his drink, he may take toast- water, slightly acidulated with hydrochloric or nitric acid, but in no larger quantities than is absolutely necessary to allay thirst; tea, coffee, lemonade, thin gruel, whey, and the like, must be absolutely prohibited. With this diet, a due amount of exercise should be taken daily, in a dry, pure, temperate atmosphere:—the patient should be allured out of doors for a short walk; or if too torpid or debilitated for walking, he should ride, or sail upon the water every day, when the weather will permit. The functions of the skin appear to be, in a great measure, sus- pended in cases of diabetes; hence, the warm bath, and friction of the surface, become important measures, and should be daily repeated. The bowels should be freely purged, and kept open, subsequently, by gentle aperients. In the first instance, we may give a combination of aloes, rhubarb, and the bicarbonate of soda;1 or aloes, gamboge, carbonate of soda, and extract of hyoscyamus.2 When the boAvels have been fully evacuated by either of the foregoing purgatives, they may be kept regularly open by a combination of calomel, extract of hyoscyamus, magnesia, and ipecacuanha.3 1 R.—Aloes, gr. xij. 2 R.—Aloes, gr. xij. Pulv. rhaei, gr. xxxvj. Gambog. gr. xij. Bi-carb. sodse, gr. xxiv.—M. f. Bi-carb. sodae, gr. xxxvj. pil. No. xiij. Ext. hyoscyami, gr. xij.—M. f. Of which one, or two, or three may be given, pil. No. xiij. according to the age of the child, every This forms a very prompt, gentle, and ef- three hours until they operate freely. fectual purgative, when one pill is given every three hours. s R.—Calomel, gr. xij. Magnesias, gr. xxxvj. Ipecac, pulv. gr. iij. Ext. hyoscyami, gr. vj.—M. f, ch. No. xij. One to be given once or twice a day, as may be necessary. In some cases, according to Richter, emetics of ipecacuanha, re- DIABETES. 667 peated daily, for two or three days, in the commencement of the dis- ease, have been found beneficial. Occasional small doses, say one grain to a child betwciu one and two years old, of the compound powder of ipecacuanha may be given tAvo or three times a day, after the bowels have been fully evacuated. Combining the opiate with uva ursi, or the carbonate or phosphate of iron,1 is said by Venables and Reirson, to be attended, in many cases, with the most decided benefit. A combination of uva ursi, carbonate of soda, extract of hyoscyamus, and carbonate of iron, will likewise be found a very valuable remedy;2 or the uva ursi, extract of hyoscy- amus, and iron may be prescribed in a fluid form,3 which is prefer- able, generally, in cases of the disease in children. 1 £—Pulv. ipecac, comp, gr. xij. 2 R.—Pulv. uvas ursi, 533. Pulv. uvce ursi, ^ss.—3J.—M. f. Bi-carb. sodas, gr. xxiv. Pulv. xij. Ext. hyoscyami, gr. xij. Carb. ferri, gr. xxiv.—M. f ch. Or, R.—Pulv. ipecac, comp. gr. xij. No. xij. Carb. ferri, ^ijss.—3J.—M. f. One to be given three times a day. pulv. xij. 3 R-—Extract, hyoscyami, Qj. Or, R.—Pulv. ipecac, comp. gr. xij. Aquas, gj.—M. Phosphat. ferri, gr. xxiv.—xxxvj. Five drops of this solution, and the __M. f. pulv. xij. same quantity of the tincture of the One of either of these formulas may be given sesquichloride of iron, may be given to a child between one or two years of age, three times a day, in a teaspoontul of every four hours. »n infusion of uva ursi, one ounce to the pint of boiling water. Infusions of calomba, gentian, or quassia, may be used occasionally, with very good effect. > During the period of dentition, careful attention should be paid to the condition of the gums, and if these be swollen, painful, and red, they should be freely scarified. By Dewees, the external application of the spirits of turpentine is recommended in cases of diabetes in children. There can be no doubt, that in nearly all the diseases of childhood dependent upon a highly deranged state of the alimentary canal, of a chronic character tur- pentine constitutes, when judiciously employed, one of our most bene- ficial remedies; and, so far as the disease of the digestive organs is concerned, we have no doubt it would prove an appropriate remedy internally, in the species of hyperuresis under consideration. We have been deterred from prescribing it, however, lest its action upon the kidneys might prove prejudicial. The tannin has been used by Giadorou in some cases of diabetes Avith success; and is worth a trial, in a disease, which, in children, it is particularly difficult to control. R.—Tannin, ^j. # ,, * i. *- Ext. hyoscyami, gr. iv.—M. f. ch. .No. xij. One of these may be given to a child over one year of age every three hours, the quan- tity of Sn in each dose being gradually increased to ten or fifteen grains. 668 CONGENITAL AFFECTIONS, ETC. n. SECTION VII. CONGENITAL AFFECTIONS, AND ACCIDENTS OCCURRING, MOST GENE- RALLY, WITHIN THE MONTH. 1.—Fractures. Fractures of the bones of the extremities are sometimes produced during birth, especially in cases where, from a mal-position or presen- tation, turning, or other manual interference, is required: we have knoAvn the fracture of the humerus repeatedly take place by improper and unskilful attempts to bring doAvn the arm after the protrusion of the head in cases of ordinary labour. In all instances in which this accident has unfortunately taken place, the fact should be at once explained to those who have the care of the infant, and measures immediately taken, after the child is washed, to secure the fractured extremities in apposition, by a proper bandage and splints. What we have found to answer perfectly well, even in fractures of the thigh in the new-born infant, are, narrow strips of thin pasteboard, well moistened in w*arm water, then neatly enveloped in soft linen, applied to the limb, after the proper adjustment of the latter, and secured in their place by a proper bandage. These splints, if made sufficiently soft, mould themselves to the shape of the limb, and when they again dry, present a sufficient resistance to the feeble action of the infant's muscles. It is necessary, however, to watch carefully the limb until the drying of the splints, lest in handling the child it be accidentally bent at the place of fracture, or the fractured extremities of the bone be otherwise displaced. Fractures of the bones of the extremities occasionally occur, in chil- dren after birth, either from blows or falls, or more generally from improper handling or lifting. These fractures are usually simple, often oblique, and in many cases incomplete. As was first clearly pointed out by Dr. John Rhea Barton, of Philadelphia, the correctness of whose observations are confirmed by those of Marjolin, Sanson, Campaignac, and others, it is often found that in the fracture of the long bones of children, while some of the osseous fibres are broken, others are merely bent, similar to what takes place in the incomplete rupture of a fresh reed. For the treatment of fractures occurring after birth, a light reten- tive apparatus is required, similar to that employed in the fractures of the adult. Fractures in infants heal rapidly and promptly, and give little in- convenience, if properly secured. As nutrition at this period is rapid, malformations of the intestines. 669 reparation takes place also readily: a child may suffer more, observes Blundell, and incur more danger from cutting a tooth, than a new-born infant from fracture of the femur or of the humerus. 2.—Congenital Malformations of the Intestines. Congenital malformations of the intestines being of frequent occur- rence, and capable of being removed or relieved, in many cases, by an operation, a treatise on the diseases of children would seem to be incomplete Avithout some notice of these affections. The malformation may consist in the constriction of the caliber of the intestine, at different points above the anus—in the entire closure of the canal by transverse membranes—in its division into separate parts—in the absence of the lower portion of the rectum, in its termi- nation in the vagina in the female, or in the bladder in the male—or in the greater or less contraction or stricture of the anus or its closure, by a membrane of greater or less thickness. The first three of these species of malformation are necessarily and promptly mortal. Neither meconium nor excrement is voided—the milk and other fluids taken, are speedily vomited, and in many in- stances, there is discharged from the stomach a yellowish or dark- brown fluid or meconium. Death may occur in a few hours, or not until the termination of several days—the child often becoming ex- tremely emaciated. Strictures of the rectum, in the immediate vicinity of the anus, or of the latter opening alone, differ in extent in different cases; some- times being sufficient to prevent the contents of the bowels from being discharged, while in other cases they merely render the act ot defeca- tion difficult and painful. In cases of partial stricture whether of the rectum or anus, a permanent cure may often be effected by the introduc- tion of a bougie or a portion of prepared sponge. When the stricture is considerable and endangers the life of the patient, it has been advised to divide it by the knife, and prevent its return by the use of tents or bouses. Such an operation can of course only be resorted to when the Stricture is at, or in, the immediate vicinity of the anus. Lnder such circumstances, it will, when properly performed, be very gene- ^A more'frequent species of malformation is the closure of the anus by a membrane, differing in density and thickness, in different oases This malformation is readily detected by the absence of any external opening-and the distentionof the anus by the meconium accumu- iS in the rectum: "this distention is more parent when the child cries; at which time, also, a fluctuation can be very readily felt be- ^s st^aS i. detected, a crucial incision should be made with a sharp-pointedbistoury, through the ^mb^e by which the anus is closed—care being taken not to divide the sphincter ailras this may give rise to a troublesome and long-continued invo- anus' the Tattc* being perfectly formed. V henever no discharge takes 670 CONGENITAL AFFECTIONS, ETC. place from the infant's bowels within a few hours after birth, a careful examination should be made into the state of the rectum; and if the imperforation exists at the lower portion of the gut, it will generally be detected by the introduction of a gum elastic catheter. The ob- struction may, in many cases, be removed by an operation; the nature of which will, in a great measure, be governed by the circumstances of each case—whether by the introduction of a trocar and canula, as directed by some, or by the straight-pointed bistoury, as directed by others. The greatest caution should be observed in the introduc- tion of the instruments, as well as in the division of the obstructing membrane, lest the sides of the intestine be wounded, or an opening be made into the bladder or the vagina. I We have seen a case of this species of malformation, in which the obstruction, consisting of a transverse membrane, existed about an inch and a half within the anus, the lower portion of the rectum being in all respects perfectly formed. The child lived four days, and, until within a few hours previous to its death, presented no indication of the existence of the obstruction, excepting the absence of all discharges from the bowels. Shortly before death, great tumefaction of the ab- domen from the development of gas took place, with evident pain on pressure of any portion of its parietes: no operation was permitted by the parents. An examination of the body revealed the nature of the obstruction—a firm, membranous partition, existing about one and a half inches above the termination of the gut, and forming a complete obstacle to the further passage of the contents of the bowels. The small intestines were perfectly empty, greatly contracted, and free from the least trace of disease; the colon was enormously distended with gas, and, throughout its whole extent, injected with blood; the upper portion of" the rectum was likewise greatly distended, and con- tained nearly eight fluid ounces of meconium and thick, ropy mucus; its mucous coat presented very decided marks of inflammation. The colon, as well as the rectum, was found congenitally deficient in a case recorded by Lehman; the ileum, on arriving at the place where the colon should have commenced, terminated in a blind sac filled Avith meconium. Another common malformation of the rectum is a firm adhesion of its sides, often for many inches above its natural termination, with a total absence of any trace of anus or of sphincter muscle. The skin retains its natural colour ^over the Avhole space between the parts of generation and the coccyx, without being elevated in one place more than in another, and having the same firm, fleshy feel throughout. In such cases, the intestines sometimes terminates in a cul de sac, about an inch above the ordinary situation of the anus, or it may not descend lower than the projection or upper portion of the sacrum; occasion- ally, it opens into the bladder or vagina. We have seen a case in which the gut, upon reaching the top of the sacrum, suddenly became contracted to the size of one of the ureters, and passed obliquely for- wards and downwards to the fundus of the bladder, into which it opened by an orifice that would scarcely admit a large bristle. In these cases, it has been advised to make an incision, about an TONGUE-TIE. 671 inch long, in the situation where the anus ought to have existed, and then gradually to deepen it in the natural direction of the rectum, by successive strokes of the scalpel, the index finger of the left hand being used as a director. By this means, the end of the rectum may be often reached, and a discharge of the faeces procured; and, by keep- ing the artificial passage permanently dilated by tents of oiled linen or bougies, of a proper size, the life of the child may be preserved. It is seldom, however, that the patient will acquire the power of retain- ing the faeces, or that the use of the tents can be abandoned, at any time subsequently, without a contraction of the passage speedily taking place. If the termination of the rectum cannot be reached by the operation just described, it has been advised—as death must inevitably follow— after the incisions have been carried as far as the finger can reach, to introduce upon the latter a long trocar, in such a direction as will be best calculated for finding the termination of the rectum. We have seen this tried in several cases, but never Avith any success. When an outlet for the faeces cannot be procured by either of the above means, it has been proposed by Littre and Sabatier, to make an opening into the abdomen above the pubes; near one of the groins: by Duret in the left iliac region; by Callisen and Amussat in the lumbar region between the posterior border and crest of the ilium, parallel with the posterior edge of the quadratus muscle, or perpendicularly, in order to get at the colon, and form an artificial anus, in one or other situation. Duret is said to have performed the operation in the iliac region, and Amussat in the lumbar region, with success, in several cases. A case is related by Roux, in which the rectum opened in the ure- thra, and others by Dubreuilh, and by Steele of New York, in which the rectum was entirely wanting, the colon opening into the neck or summit of the bladder. The case of Roux was successfully treated by incisions from the natural position of the anus, in the direction of the rectum. . ... It has been supposed by many surgeons of eminence, that inconti- nence of faeces must be an inevitable result of an artificial anus esta- blished in the perineum or coccygeal region, not in connexion with the sphincter ani. The inaccuracy of this supposition is proved by the case of a patient operated on some years ago by Amussat of Paris. This patient has been under the care of Sir P. Crampton, up to the present period, and he states that no such infirmity exists. 3.—Tongue-Tie. Physicians are frequently called upon to relieve, by an incision, the tied tongue of infants; an accident supposed to be produced by a mal- formation of the freenum linguae. It often happens, that in young in- fants, the frscnum approaches very near to the apex of the tongue; and it is possible that, in some instances, the impediment to the free motion of the tongue thence resulting, may render sucking very diffi- cult, or even impossible. We confess that we have never met with such a case; though, if nurses are to be believed, it is a thing of the 672 CONGENITAL AFFECTIONS, ETC. most common occurrence. Infants occasionally appear to suck with difficulty, frequently letting go and reseizing the nipple; in other cases, the act of sucking is accompanied with a kind of clucking sound:— this is almost invariably attributed to the tongue being tied. We have, however, repeatedly examined the tongue in such cases, and have de- tected no malformation of it, or of its fnenum:—nothing, in fact, to interfere with its movements. Burns declares that he has not seen two instances in which a malformation of the frsenum rendered any operation really necessary. Marley has seen but one; the operation Underwood declares to be very rarely necessary; and the same obser- vation is repeated by Maunsel. The tongue is sufficiently free for all its functions, if the tip can be advanced beyond the outer margin of the lip, or placed upon the roof of the mouth. An operation is requisite only in cases where the confinement is such as to prevent either of these movements. When an operation is absolutely necessary, it consists in dividing, with a knife or scissors, the anterior edge of the freenum; taking care that the incision be not Carried so far as to endanger a division of the lingual vessels, and thus give rise to a troublesome and dangerous he- morrhage. The head of the child being held firmly, with the face upAvards, the operator, standing behind the top of the head, inserts the first and second fingers of the left hand into the mouth, beneath the tongue, and places one on each side of the frsenum, when the latter may be cau- tiously divided, to the extent deemed necessary. Of the accidents that have been said to result, in some cases, from this operation, we need not speak;—by proper caution and skill on the part of the operator, they can, in every instance, be very readily avoided. 4.—Hemorrhage from the Navel. Hemorrhage may take place from the cut end of the cord, in con- sequence of the imperfect manner in which this has been tied, or the improper materials of which the ligature is composed, or from improper handling on the part of the nurse on adjusting the dressing of the navel, by which the ligature is displaced; or, more rarely, from the thick, firm, gelatinous matter with which the vessels of the cord are enveloped, preventing the ligature from acting with sufficient force upon them to cause their closure; the prevention and remedy in this form of hemorrhage are sufficiently evident. The hemorrhage does not, however, always result from the divided end of the cord. We have, in several instances, found the umbilical vessels perfectly secured, but a constant oozing or percolation of blood to take place around the root of the cord, at the part Avhere it is im- planted in the walls of the abdomen, and in only one instance were we able to arrest the flow of blood; in all the other cases the patients perished exanguious. In the instance alluded to, we directed a pow- der to be formed of starch, two parts, sugar one part, with an addition of powdered acetate of lead, amounting to one-half the quantity of sugar: this powder was applied around the cord, at the seat of the he- HEMORRHAGE FROM THE NAVEL. 673 morrhage, and an additional quantity constantly added as the blood penetrated through the former. After three hours' close watching, a firm crust was formed, through which the blood no longer penetrated: at the end of twenty-four hours the crust separated, without the he- morrhage returning. We tried this plan in another case without suc- cess; the blood flowed too freely to allow of the proper hardening and adhesion of the paste formed by its mixture, but flowed through, as well as beneath it. Another, though more rare, still not uncommon form of umbilical hemorrhage in young infants, is described by Dewees: in this, the flow of blood takes place from the side of the cord, in consequence of a rupture or ulceration of one of the varicose dilatations of the umbi- lical veins. We have seen one or two such cases. The arrest of the hemorrhage is, in general, very easily effected by the application of a ligature around the cord, below the place at which the blood is dis- charged. In one instance, however, from this being situated near the base of the cord, we found a good deal of difficulty in applying the ligature, and only succeeded, finally, by drawing out the cord until the skin surrounding" it Avas put upon the stretch. The ligature appeared at first to cause no inconvenience to the infant, but towards the close of the second day, so great a degree of pain was evidently produced by it, that we were induced to divide it; the hemorrhage, however, did not return. There is still another form of hemorrhage that occasionally occurs at the navel, and is always attended with a good deal of trouble and danger. This takes place after the separation of the cord. In place of the navel cicatrizing, it remains open, and soft fungous granulations rise from its centre, from which there is a constant oozing of blood that may continue for a long time, causing, by the extent of the he- morrhage, the utmost debility of the child, and putting his life always in imminent danger. The application of lunar caustic may stop, for a time, the discharge of blood, but we have never known it effectually to arrest it. We have occasionally succeeded by pursuing the plan recommended by Underwood, namely, the application of a dossil of lint, kept in its place by cross strips of adhesive plaster, and secured by the proper adjustment of the belly-band; more frequently, however, we have found that covering the navel with a powder of starch, sugar, and acetate of lead, and then applying over this a graduated com- press, secured by a broad bandage passing around the child, will more effectually prevent the discharge of blood, and allow the navel to cica- ' In other cases the exudation of blood takes place from the margin of the umbilicus, or directly from the umbilical vessels: it is at first readily arrested by compression or styptics, but returns in a few hours and cannot be permanently arrested by any of the ordinary astringent or caustic applications, the child finally sinking from exhaustion If the hemorrhage be controlled by a ligature, and in other cases where no \\ZZe\l been applied, extravasations of blood often appear upon various parts of the surface of the body and the mucous membranes-; 43 671 CONGENITAL AFFECTIONS, ETC. and after the separation of the ligature, the hemorrhage usually re- turns. However trifling these hemorrhages may appear when described in books, and hoAvever easy it may seem to the inexperienced to arrest them, they, nevertheless, are among the most troublesome accidents occurring in young infants that the practitioner is called upon to treat, and will often foil the best-directed efforts for their removal. A most interesting paper on this subject was read before the Boston Society for Medical Improvement, April 20, 1852, by Dr. Francis Minot. It comprises the analysis of forty-six cases of idiopathic hemorrhage from the umbilicus in new-born infants, reported in the journals, or furnished to the writer by those under whose observation they had occurred. The time at which the hemorrhage commenced in these cases was exceedingly irregular, varying from a few hours to the eighteenth day after birth, the average of forty-one cases being the eighth day. In four cases, it began before the separation of the cord; in three imme- diately after; in others, at periods varying from one to thirteen days; the average of nineteen cases being five and a half days. There is no apparent connexion between the condition of the child, and the length of time which elapses before the commencement of the hemorrhage. Thus, in one child which was quite feeble, there was no bleeding until the thirteenth day after birth, and the fifth after the cord fell off. In another feeble child, the hemorrhage began on the second day, before the separation of the cord. A child which was "plump and hearty" at its birth, began to bleed at the umbilicus on the third day; a "stout and healthy" infant on the sixteenth day. A large proportion of the children (twenty-six out of thirty-two) were to all appearance perfectly well at birth. Many are described as being "stout and healthy," "large, plump, hearty," &c. Six were feeble at birth. "Accompanying the hemorrhage, and occasionally preceding it, there is often Avell-marked jaundice, and unfrequent, light-coloured dejec- tions from the bowels, indicating derangement of the functions of the liver. The subjects of the disease appear to suffer little or no pain. A majority are of the male sex, and born of healthy parents. There Avould appear to be a predisposition to the hemorrhage in certain fa- milies. In nine of the cases on record no morbid symptom preceded the oc- currence of the hemorrhage, which in one case did not commence until the eighteenth day after birth. In general, however, previously to death, a jaundiced condition of the surface occurs; this was noticed in twenty-two cases. A "saffron hue" was observed four hours after death, in a patient who had constipation and clay-coloured stools during life, and in three others the skin is described as sallow, or light yellow. One of the latter had profuse hemorrhage on the evening of the day on which the cord separated, which Avas finally arrested, and the child lived. Six years afterwards she had an attack of jaundice from which she recovered. Only one patient with well-marked jaundice recovered. Along with the jaundice, there was, in most cases, constipation and HEMORRHAGE FROM THE NAVEL. 675 clay-coloured stools, the former symptom being noticed six times, and the latter nine times. The character of the flow of blood is not generally described, al- though it is easy to infer that in most cases it was a continuous oozing, rather than a jet. Out of eleven cases in which this particular is re- corded, the former state of things occurred eight times, the latter three times. The appearance of the blood during life is noticed eight times. In one instance only did it coagulate. In seven it did not coagulate, and in most cases it was thin and light-coloured. In one instance it contained bile, as was evident from the yellow stain which it imparted to linen. Ecchymoses were noticed in twelve cases. They generally existed in considerable numbers in various parts of the body, and also on the tongue, and inside of the mouth. In one case they preceded the bleeding, in one they followed it, and in four they appeared imme- diately after the arrest of the bleeding by the ligature. Pain was noticed in four instances: in two it appeared to be caused by extend- ing the legs. The observations are necessarily very imperfect in this particular. Cerebral symptoms occurred four times: in three, the patients, one of whom recovered, appeared almost comatose. One child died with symptoms of compression of the brain. As already re- marked, clay-coloured stools and constipation usually accompanied the appearance of jaundice. In three instances, the dejections were bloody; in two, they were green, and in one "regular." Vomiting was recorded in one case only. The results of thirteen autopsies show that there is no one lesion which is constantly present; consequently the morbid anatomy of the disease sheds no light whatever upon its pathology. Dr. Minot is of opinion, that idiopathic umbilical hemorrhage is one of the various manifestations of the hemorrhagic diathesis, which, in other cases, is exhibited in bleeding from the gums, mouth, stomach, intestines, &c, and in the appearance of purpuric spots beneath the skin, on various parts of the body. In proof of the correctness of this opinion, the concurrence of these several phenomena with umbilical hemorrhage is adduced. Thus, nothing is more common than a pur- puric eruption. In three of the cases referred to by Dr. Minot, there were bloody dejections, and in one bleeding from the gums. Another evidence is the thin and watery condition of the blood, and its great deficiency in fibrine, whereby mechanical means become almost wholly inefficacious to arrest its flow. Dr. Minot very truly remarks, that the dependence of the disease on a constitutional cachexy should never be lost sio*ht of, especially in connexion with the subject of treatment; for unles? means be adopted for correcting the constitutional difficulty, local applications offer but a slender chance of saving the patient. To Avhat extent the condition of the parents is concerned in the pro- duction of umbilical hemorrhage, Dr. Minot has not been able to as- certain Of the health of the fathers, in the cases on record, little or nothing is said. Of tAvelve mothers, eleven were healthy, one was feeble It is evident, however, the disease may be the result of some inherited peculiarity, because in several instances, two or more chil- 076 CONGENITAL AFFECTIONS, ETC. dren in the same family have been affected in the same way. "At the same time, as Dr. Manley remarks, these cases differ from the or- dinary rule in the history of bleeders, for in none of them is the direct transmission of the hemorrhagic constitution clearly proved. He al- ludes, however, to one case—not included in my collection—in Avhich a woman, who had been liable to copious epistaxis, and whose mother and sister were also subject to hemorrhage from various parts, lost a male infant on the third day after birth, in consequence of hemorrhage from the navel and the gums. The same law obtains in this as in other transmitted diseases, namely, that while some of the children succumb to the malady, others escape it altogether; thus, in four instances, the mothers each lost two children from umbilical hemorrhage, and each had two living and healthy; another lost two, and had three living. Other similar cases are also alluded to by the reporters of some of these observations. Nothing has been observed in the condition of the mother, which could account for the disease transmitted to her offspring, nor does her health appear to differ during successive preg- nancies, which have resulted in healthy children, and in those born with the hemorrhagic tendency." "Out of fifteen cases in which the nature of the labour was noticed, it was natural in fourteen, and difficult in one." "The predisposition of infants of the male sex to this disease is re- markable, and is particularly alluded to by Mr. Ray. The comparison of a large number of observations has shoAvn, however, the dispro- portion to be less than he thought it. Unfortunately, in a number of the cases, the sex was not noticed; but out of thirty-two cases in Avhich it is alluded to, twenty-two, or 68| per cent, were males, and ten fe- males. Whether this difference be any thing more than accidental, can only be ascertained by more ample statistics. "The remarkable proportion of cases in Avhich jaundice was noticed —twenty-two out of thirty-nine, or fifty-six per cent.—shows it to be something more than a mere coincidence. Whether, to use the Avords of Dr. Cheyne, the bleeding proceeds 'from the unhealthy change pro- duced in the blood by the reception of the bile into the mass of fluids, becomes a question of interest, especially Avhen considered in connexion with a class of cases in which icterus was accompanied by a remark- able tendency to obstinate and even fatal bleeding from slight Avounds, such as scarifications or leech-bites.' The jaundice itself Avas satis- factorily explained in three instances, by the absence or obstruction of the bile ducts, but in four cases the ducts were pervious. It is plain, however, that the derangement of the biliary function does not play an indispensable part in the production of the disease, since in three cases it was noticed that there was no yellowness of the skin, and in five the autopsy showed the liver to be, to all appearance, healthy. Moreover, a remarkable case is reported by Dr. Campbell, in which icterus commenced on the day after birth, and the child died at the age of six months. The liver was so large as to fill the greater part of the abdomen, and neither a gall-bladder nor bile-ducts could be dis- covered. Yet, in this case, there was no hemorrhage. The associa- tion of these two phenomena, and, at the same time, their indepen- HEMORRHAGE FROM THE NAVEL. 677 dence of each other, are shoAvn in the following cases, communicated to me by Dr. A. Hooker of East Cambridge, who says: 'I attended a Avoman, to all appearance healthy, and who has good labours. She has lost four children from umbilical hemorrhage. She has since had a child, which presented a slightly jaundiced look, but no hemorrhage took place, and it did well.' The other case is as follows: 'A mother had two children, who are now alive and well; but one of them had jaundice at the age of four or five. She has since had two others, both of whom died of umbilical hemorrhage, preceded by jaundice.' The state of the umbilical vessels has been supposed to be quite suf- ficient to account for the hemorrhage in many cases. Dr. Minot is, however, far from thinking that a pervious state of these vessels, a few days after birth, ought to be considered as a pathological condition, and, in this opinion he is supported by Mr. Ray, who says he has fre- quently found them pervious in children of a month or six weeks, who died without bleeding. In regard to the prognosis in cases of umbilical hemorrhage, Dr. Minot remarks:— "Out of forty-six cases, thirty-nine, or more than eighty-four per cent., were fatal, at periods varying from six hours to six weeks after the commencement of hemorrhage, the average of twenty-seven cases being six days. Six of these children died on the day after the bleed- ing began; five on the second day after; three on the fourth day. From this we see that umbilical hemorrhage is an extremely fatal af- fection. Even in those children who are apparently robust, and seem to offer the best chance for recovery, the prognosis must be very guard- ed, while in feeble infants it is almost inevitably fatal. We must not forget, however, that many cases which recovered, are perhaps not re- ported. The descriptions given of the favourable cases, prove that they were genuine examples of the disease; hence, although the chance of recovery is excessively small, the prognosis is not absolutely fatal in every case. Jaundice appears to be a very grave symptom, since only a single case recovered, in which it had been observed." The hemorrhage was permanently arrested in ten of the cases in- cluded in Dr. Minot's paper; in three by compression; in three by li- gature, and in the four others, respectively, by collodion, plaster ot Paris, scrapings of sole-leather, and nitrate of silver. In three of these cases death occurred eventually, from exhaustion, or diseases evidently caused by the feeble condition of the child. It is recommended by some writers to cut down upon the bleeding vessel, and tie it. Dr. Minot considers this to be a very difficult, if not impracticable operation, even in the small number of cases in which the bleeding comes from a single vessel He thinks the ligature en masse is easier, safer, and more effectual The ligature will, however, he remarks, succeed in a very small number of cases, unless, the dia- thesis upon which the malady depends, be corrected The same may be said of styptic and caustic applications, which in four cases actually appeared to increase the hemorrhage. _ Dr Minot recommends the use of the mineral acids internally, with other'astringent and tonic remedies. He finds but a single instance 678 CONGENITAL AFFECTIONS, ETC. of their employment among thirty-three cases, the treatment of which is reported. In this instance, the patient entirely recovered. "As to local treatment," he remarks, "we have seen that the liga- ture and pressure were each successful in three cases, and that caustic and styptic applications generally failed. The most that can be hoped from local applications, is a temporary arrest of the bleeding, until the condition of the blood can be improved. The ligature appears to me the most likely to effect this, and the sooner it is employed the better, since every drop of blood is of importance in such young sub- jects. I believe the best mode of employing it is to transfix the um- bilicus by two needles at right angles, and to wind the thread tightly underneath them." 5.— Cephalsematomia. Upon the head of the new-born infant there is often present a tu- mefaction, varying in size, from a slight swelling at a particular part of the scalp, to one of such an extent as to alter materially the natural shape of the child's head. This tumefaction is most generally the result of the pressure to which the head of the foetus is subjected during a difficult and pro- tracted labour—especially when the membranes have been ruptured and the liquor amnii discharged at an early period. It is then in- variably seated at that part of the head which first presents itself at the outlet of the pelvis. The tumefaction in the cases here referred to is soft to the touch, without fluctuation, and preserves for some time the impression of a finger applied to it. The skin which covers it is always dark-co- loured, often of a deep violet hue. This species of tumefaction is caused by either an extravasation of serum, of a mixture of blood and serum, or of blood alone into the cellular tissue of the scalp, beneath the aponeurosis and above the pe- ricranium. It demands scarcely any treatment—absorption takes place rapidly, and the sAvelling quickly disappears. Dr. Churchill has, in a few rare cases, known inflammation to occur in the tumour, folloAved by ulceration or the formation of an abscess. WThen we find inflamma- tion of the tumour has set in, and that the use of evaporating lotions is inadequate to its control, Dr. Churchill directs the application of a soft warm poultice, frequently repeated. When an abscess forms, the pus should be early evacuated by a free incision, after which the poultice is to be reapplied. The head of the new-born infant is the seat, occasionally, of another much more important and dangerous tumefaction—the cephalaematomia of practical writers. It is in the form of a tumour, of greater or less extent, situated upon one of the parietal bones, most commonly the right. It is usually kidney-shaped; its semicircular edge being to- wards the sagittal border of the bone, with its concave side embracing the parietal protuberance. The tumour has a doughy or fluctuating feel with a hard, sharp, well defined margin, giving to the finger the sensation of a bony edge, such as would result from an entire loss or considerable CEPHALHEMATOMA. 670 depression of the skull at the part occupied by the swelling. The co- lour of the scalp enveloping it is unchanged. The tumour cannot be diminished in size by pressure, and no motion is communicated to it during deep respiration, or by crying or coughing. On its first forma- tion it is said to be occasionally pulsatory, but only for a very short period. The fact of this pulsatory movement is, however, by no means well established. Levy of Copenhagen, (Journ. fur Kinderkrankhei- ten, 1854,) who has studied the subject with much care, sets down an en- tire absence of pulsation throughout its course as among the character- istics of cephaloematomia. The size of the tumour differs, as we have already remarked, very much in size in different cases. It may be no larger than a hazel nut, or of sufficient magnitude to cover the entire bone upon which it is seated, and of proportionate elevation. The right parietal bone is its most common location. It has been occasionally seen, however, occupying the frontal, and more rarely the occipital. The swelling seldom passes beyond the one bone; Levy states that its base never approaches nearer than a line or a line and a half to the edges of the bone, and never intrudes upon a suture or fontanelle. In the larger number of instances there is but a single tumour—they have nevertheless been met Avith in a few instances upon both parie- talia, or upon one or other of these, and also upon the frontal or occipital bone, or upon all three, in the same case. Bednar, in seventy-four examples of cephalaematomia observed by him, states that the tumour occupied the right parietal bone in 40; the left, in 22; both parietals, in 6; the occipital in one; both parietal and occipital bone, in one; and the frontal bone, in one. In the six cases seen by Naegele; in three, the tumour was on the right parietal bone; in two, on the left; and m one on both. In one hundred cases which occurred at the Prague Hospital, according to Dr. Bohm (Scanzoni. Geburtshidfe,) the tumour was on one or other of the parietal bones in 92; on both, mfour; on the occipital, the frontal, and the temporal, each one. < There can be no doubt as to the cause of the swelling in cases of cephalsematomia; it is invariably the result of a circumscribed effusion of blood beneath the pericranium upon the surface of the skull, from a rupture of the vessels which pass upon and into the bones of the cra- nium, from the pericranium without, and the dura mater within ; which rupture and effusion give rise to a circumscribed separation differing in extent in different cases, of the pericranium from the skull. The amount of the effused blood varies from a few drachms, to one, two, or three ounces. , . . In a few cases, besides the effusion of blood beneath the pericranium, on the outer surface of the skull, there exists at the same time a cor- responding extravasation beneath the skull, between it and the dura mater. As a general rule, the latter is the least extensive; sometimes, however, the reverse is the case. Cephala^matomia is of extremely rare occurrence. According to the ttistics collected by Churchill in the last edition 1858) of his work the Diseases of Children, it appears that Naegele met with seven- statist on 680 CONGENITAL AFFECTIONS, ETC. teen cases during a practice of twenty years. Palletta, (De Abscessu Sang. Cap. Mediot. 1810,) saw but a few cases among a large number of children. M. Baron (Dictionnaire de Med.) estimates its occurrence at about once in every 500 children. M. P. Dubois (Nouv. Diet, de Med.) during a service of many years at La Maternite, where from 2500 to 3000 children are born annually, saw but six cases. Dr. Doepp (Annates de Chirurg. Franc, et Etrang., 1844,) states, that, in the Foundling Hospital of St. Petersburgh, during eleven years, it oc- curred in 262 cases, or, in one among every 190 of the whole number of children in the institution. M. Valleix (Malad. des Enfants,) at the Foundling Hospital of Paris, during five months, met with but four cases among 1937 children, or about one in every 387. M. Velpeau refers to only five cases. To these we may add, that the observations of Bednar (Die Krankh. der Neugebornen) are based on 74 cases, and those of Dr. Levy on fourteen cases; while, according to Dr. Bohm, it occurred in the Prague Hospital in 96 instances among 21,045 in- fants, or in the proportion of one to about every 219. These statistics refer only to those cases of cephalaematomia, in which the effusion of blood occurs between the pericranium and skull: cases where there is effusion between the skull and dura mater are much more rarely met with. According to Rokitanski, whose account of the pathology of cepha- laematomia is the most clear and accurate, the extravasated blood is loosely coagulated, and of a dark colour. A pale red fibrinous co- agulum frequently adheres to the inner surface of the detached peri- cranium and the denuded surface of the bone. When it has existed for some short time the tumour presents ap- pearances precisely similar to those which are consequent upon every separation of periosteum from the bone it invests. An inflammatory process commences around the margin of the detachment, and bony matter is deposited in the form of a velvety and finally filamentous osteophyte. This deposit extends, for the breadth of a few lines, be- yond where the pericranium still retains its connexion with the bone. It is thickest just at the margin of connexion, where it forms a ridge that rises abruptly around the basis of the tumour. Upon the denuded surface of the skull, and the inner surface of the detached pericranium, a fluid now exudes, at first of a gelatinous consistence, but becoming gradually more and more dense, and finally, continuous with the bony deposit surrounding the base of the tumour. The hard, sharp, abrupt ring which encircles the base of the swell- ing in cases of cephalaematomia, is constantly present in mature cases. Sometimes, as Levy has remarked, it is formed on the first day after birth, in other cases it is not complete in its entire circumference un- til several days subsequently. It begins to be formed as soon as the separation of the pericranium from the bone is arrested, and the cir- cumferential extension of the tumour ceases. Krause, Valleix, Rokitanski, and Levy, all refer the ring or pad around the base of the tumour, to the ossification of a plasma-exuda- tion, poured out by the cranial periosteum whilst in a state of irrita- tion, from the constant distention and pressure it suffers, when it is CEPHAL^MATOMIA. 681 separated from the hone by the extravasated blood within the tumour. Doepp refers the marginal ring to a coagulation of the blood, at the edge where the periosteum, elevated by the effusion, is still adherent to the skull, while a few others, with Busch and Bartsch, believe it to consist entirely in a mere deception of the sense of touch. It is pro- bable that, at an early period after its formation, the hard ring en- circling the base of the cephalgematomia is the result of a coagulation of the blood, but after a short time there can be no doubt that a fibrinous exudation is poured out and accumulates at the place where the ring is felt, and that, in this exudation, bony matter is often deposited in the course of the reparative process that spontaneously ensues. If the extravasated blood is removed by absorption, or evacuated by an artificial opening, according to Rokitanski, union of the detached pericranium with the bone is effected by means of the exudation which is poured out upon their opposing surfaces. If, however, neither absorp- tion nor evacuation of the extravasated blood takes place, very gene- rally, suppuration occurs Avithin the tumour; the blood contained in it changing to a fluid pulp, and acquiring a chocolate-brown colour. In these cases, ulceration of the soft parts, and caries or partial ne- crosis of the bone often ensue. If the soft parts remain entire, and are not divided by the knife, the bone becomes more deeply carious, a deposition of pus takes place beneath it, and causes a separation of the dura mater from its inner surface, when the bone perishes in its entire thickness. Extensive suppuration in the pericranium and soft integuments above the skull now generally ensues, these becoming discoloured and easily torn. Such cases mostly prove fatal, either from exhaustion of the patient's strength, or more frequently by the occurrence of inflammation of the membranes of the brain, or of the brain itself—occasionally the fatal event is the result of pyemia. But even in this advanced stage, re- coveries from inflamed cephalsematomia occasionally take place. In some instances, when the extravasated blood is not absorbed, nor evacuated by an artificial opening, the layers of exudation cover- ing the denuded bone and the inner surface of the separated pericra- nium, become gradually ossified, and form a finely reticulated bony net-work, enclosing the extravasated blood, which latter acquires a dirty, rusty, brown colour. Sometimes, however, in place of this bony net-work, small plates of bone are scattered over the inner surface of the tumour. The latter then exhibits a certain rigidity, and when firmly compressed, gives an impression of crepitation, like the crack- ling of parchment. Cephatematomia, though not always attended with danger never- theless requires to be carefully watched, in consequence of the liabi- lity there is of the development of unpleasant, and, occasionally, very serious symptoms. Whenever there is present an effusion of blood upon the dura mater, as well as beneath the pericranium the conse- quent rupture of the blood-vessels passing to the bone, both from with- out and Avithin, and the danger thence arising of its entire death, ren- der of course the prognosis unfavourable, and the more so in propor- tion to the extent of the subcranial effusion. 682 CONGENITAL AFFECTIONS, ETC. Cephalaematomia has been supposed to depend upon some abnormal condition or disease of the bones, or upon some vice in the constitu- tion of those in whom it occurs. By recent and more careful investi- gations into the true pathological character of the tumour, it is clearly shown that neither anomalies of development nor morbid conditions of texture of the cranial bones have any thing to do with its pro- duction ; when these do occur they can be viewed in no other light than as occasional and exceptional phenomena. There is, however, according to Rokitanski, pretty constantly ob- served in the early stage of cephalaematomia, a manifest congestion of the bones of the skull, upon the presence of which the hemorrhage in- timately depends. At the place of extravasation the bone appears, however, pale and exanguious, especially when there is an effusion of blood, both beneath the pericranium and upon the dura mater. There are good reasons for believing that cephalaematomia is de- pendent upon a peculiar constitutional hemorrhagic tendency existing at birth. Rokitanski refers to the circumstance of the tumour upon the head, in some cases, existing with effusions of blood between tissues which have the same relation to each other as bone and periosteum. Thus, extravasation of blood beneath the peritoneal coat of the liver, is not an unfrequent accompaniment of cephalaematomia; effusions of blood in other localities, also, are of occasional occurrence. In the great majority of cases, Rokitanski thinks it most probable that the extravasation giving rise to the tumour, commences during birth, and is increased so as to produce a palpable tumour, soon aftenvards, by the establishment of respiration and the increased impetus of the cir- culation.—(Naegele.) Instances are recorded, hoAvever, in which the tumour is not perceived until several days after birth, and it is pro- bable that it then first originated. We believe, however, that, in every instance, the tendency to cephalaematomia—the particular con- dition of things necessary to its production, is congenital. It is said to be most frequently observed in first-born children, and more often in boys than in girls. Dr. Levy, however, believes that too much stress should not be laid on the assertion of different writers, that cephalaematomia is chiefly met with in priiniparae, since out of fourteen cases which fell under his observation, four were not such, and that there is even less reason for believing that its frequency of occurrence in boys, much exceeds that in girls, as the ratio in his cases was only 8 : 6. By the larger number of writers, the formation of cephalaematomia is referred to the pressure exerted upon the fcetal head during la- bour. Valleix and Weber, both consider it the result of circular pres- sure—a pressure that can only be exerted by the neck of the uterus. Dubois attributes the development of the tumour to a simple sepa- ration of the pericranium, from some violence, which, by tearing asunder the numerous vessels passing between the pericranium and bone, allows the blood to escape from them, and accumulate beneath the scalp. It is probable, we think, that cephalaematomia has been incorrectly CEPHALHEMATOMA. 683 attributed to the pressure upon the child's head during a tedious or diffi- cult labour. NaegeU, Dubois, and others, have seen it to occur after perfectly easy labours, in which the head of the foetus had not experi- enced any undue pressure. From the frequency with which it occurs after easy, normal labours, M. Pauli refers its production to the shocks caused by the abrupt contact of the foetal head with the bony parietes of the pelvis. Dr. Levy denies that circular pressure by the neck of the uterus is the cause of cephalaematomia—such pressure can only produce, he remarks, supracranial ecchymosis, between which and cephalaemato- mia the difference, although in one respect, scarcely more than in de- gree, is, nevertheless, symptomatically, very great. We cannot help believing, however, that the pressure which the foetal head experiences in even the easiest labours, in children labouring under a peculiar he- morrhagic predisposition, is sufficient to produce cephalaematomia, and that without this predisposition, the utmost pressure of the head during labour will fail to produce it. Dr. Levy, himself, admits that the tumour is the result of a strong resistive force applied to a particular portion of the foetal head by some part of the bones of the pelvis, varying according to the point of greatest frictional pressure, in the progress of labour. In the majority of cases, cephalaematomia will do very well under a very simple treatment; confined pretty much to the application of cold evaporating washes to hasten the resorption of the extravasated blood. The ordinary spirit-wash, or a solution of the hydrochlorate of ammonia in camphor-water are among the best. Halmagrand re- commends the hydrochlorate of ammonia in red wine; others, a solu- tion of the acetate of lead, or the acetate of zinc in rose-water. A slight, graduated and uniform compression of the tumour will, in all cases, be proper. The production of suppuration in the tumour, by caustic applications or a seton, as practised by Moscati, Goelis, and Palletta, is a plan of treatment uncalled for in any case, and calculated to produce greater suffering and more unpleasant results than, in the great majority of cases, would be liable to occur, even were the tumour left entirely to itself. . . . „ , By Michaelis, Naegele, and P. Dubois, an early incision for the purpose of evacuating the effused blood, and allowing the detached pericranium to be brought and retained in contact with the bone, is recommended. They direct a simple incision to be made, extending the whole length and depth of the tumour, down to the bone. After the removal of the effused blood, the edges of the incision are to be drawn together and secured by straps of adhesive plaster-the head being enveloped in a suitable bandage or cap, so adjusted as to make moderate pressure at the seat of the tumour. But, as remarked by Bouchut, incision should be resorted to only, when a tumour of large extent has remained stationary in size for ten or twelve days after its formation. Levy directs the hair to be shaved from the entire surface of the tumour and for some distance around its base, and a puncture then 684 CONGENITAL AFFECTIONS, ETC. to be made with a lancet at a depending point, and equable pressure exerted by the fingers, so as to expel as much of the effused blood as possible: afterwards a compress is to be applied, secured by proper straps and bandages, and kept on for about six days. When suppuration occurs and an abscess forms, this is to be treated on general principles; an early opening for the discharge of the pus should, however, always be made. If the bone becomes necrosed, the dead portions should be removed as they become detached, and the appropriate dressings applied. 6.—Cyanosis—Morbus Coeruleanus—Blue Disease. Cyanosis is marked by a blue, purple, or leaden tinge, more or less deep, of the entire surface of. the body, but particularly marked in the lips, cheeks, and nails; accompanied with a reduction of tempe- rature, and occasional paroxysms of difficult respiration, approaching to complete asphyxia, during which the blueness of the skin becomes more intense, and more generally diffused over every part of the surface. The paroxysms are brought on by whatever hurries the circulation —as a quick motion of the body, crying, and, when the infant survives long enough to be able to walk, by going up or coming down stairs, by emotions of the mind, &c. When the paroxysms are severe, there is a cessation of respiration and circulation, the extremities become per- fectly cold, and the patient falls into a state resembling death. After a few moments' rest, however, the infant again breathes, the circula- tion is restored, the colour of the skin becomes lighter, and he recovers his ordinary state of health; finally, however, a paroxysm more severe than usual occurs, during which life is extinguished. In some infants even the effort of sucking often induces so great an embarrassment of the respiration and circulation, as to bring on paroxysms, which are occasionally accompanied with convulsive movements. When the patient affected with cyanosis has arrived at the age of childhood, he is indisposed, and often unable to participate in the sports of other children, but even in summer crouches over the fire, languid, chilly, and dispirited. The ends of the fingers and toes are often bul- bous as well as discoloured: there is a tendency to cough, on the least muscular exertion, and the congestion of the lungs very frequently manifests itself, under the influence of slight exciting causes. The discoloration of the skin and interior of the mouth is sometimes as deep as the stain of the small black cherry. Notwithstanding the majority of cases terminate fatally at an early period of infancy, or at the furthest during childhood, there are in- stances on record, in which patients labouring under cyanosis have lived twenty, forty, and even fifty-seven years, death being produced by the supervention of some other disease. Cyanosis is, in the majority of cases, evident from the moment of birth, or presents itself within a day or two subsequently. There are cases, however, upon record, in which it first made its appearance in the adult, after severe falls, or blows, prolonged fits of coughing, or violent and fatiguing muscular efforts. One very curious case is re- CYANOSIS. 685 lated by Hufeland, in which the disease occurred suddenly on the ninth day after birth, subsequent to a convulsive attack, and completely dis- appeared upon the twelfth day after its invasion. The production of cyanosis has very generally been attributed to an admixture of the arterial and venous blood, in consequence of a per- sistence of the communication which exists, in the foetal state, between the auricles, or of some malformation of the heart or of the main arte- rial or venous trunks. That in the great majority of the cases of cya- nosis, there exists an abnormal structure of the heart or blood-vessels, or a mal-arrangement of the latter, is proved by the results of nume- rous dissections. The most common lesions of the heart and great vessels, are, the origin of the aorta from both ventricles; a patulous condition of the ductus arteriosus; imperfection of the ventricular septum; obliteration of the pulmonary artery; a transposition of the origin of the aorta and pulmonary artery, with an open state of the fora- men ovale, and in a few, of the ductus arteriosus also: in one case the aorta was obliterated. The right cavities of the heart are frequently found dilated, hypertrophied, or both. The hypertrophy is always most considerable in cases in which there exists contraction of the pulmonary orifice. The total absence of .the ventricular septum has been noticed in some cases. The heart has been found to consist of a single cavity; the pulmonary artery to arise from both ventricles, and send off the descending aorta; the right auricle to open into the left ventricle, and a free communication to exist between the two ven- tricles, and the two auricles; in other cases, the right ventricle was bifid; in others the arch of the aorta was double; the coronary veins have been found to open into the left ventricle; the inferior or the superior cava into the left auricle. The foramen ovale has been found closed in the foetus. In some cases the valves of the heart adhered along their edges, and were consolidated into one mass, leaving only a small central aperture, or they were perforated by numerous holes, or altogether absent. The instances of a single auricle and single ventricle are very numerous. Considerable contraction of the pulmo- nary artery, particularly at its origin, is also a very common lesion. In a few cases, the pulmonary artery has been found completely im- pervious, or the artery has been found entirely absent, the bronchial arteries appearing to supply its place; and in one case, the aorta ter- minated near the heart, in a cul de sac. In one case there was an en- tire absence of the right lung, the septum between the ventricles of the heart was imperfect, the foramen ovale and ductus arteriosus were both open: the aorta communicated with both ventricles the pulmonary artery was imperforate at the base of the heart; the lung being sup- plied with blood by the arteriaUucf.-the child lived six weeks. (11 o- chenschrift fur die qesammte Heilkunde, ISol.) M Aberie, of Vienna, gives the following conclusions as the result of the analys'is of 180 cases of cyanosis. In 100 cases there was a defect in the partition of the ventricles; in 87 of these cases, there was also an abnormal communication of the ventricle with the aorta; in 22, the foramen ovale was closed and in 65 it was open. In four cases only, the pulmonary artery arose from 686 CONGENITAL AFFECTIONS, ETC. both ventricles. In the 87 cases in which the aorta arose from both ventricles, the pulmonary artery was 37 times strictured, or even quite closed. Of the 180 cases two-thirds were males. Sufficient evidence is thus afforded, that abnormal communications between the cavities of the heart, particularly the auricles, by the non- closure of the foramen ovale, and various malformations of the heart, and of the main arterial and venous trunks, occur, in perhaps the ma- jority of cases of cyanosis. The mixture of the arterial and venous blood, which is supposed to result from the free communication between the two auricles, in con- sequence of the patency of the foramen ovale, is evidently inadequate to explain the blue colour of the skin, inasmuch as no such discolora- tion takes place in the foetus; while the communication exists in the majority of infants for many days after birth, without a single symptom indicative of cyanosis being present. The foetal openings in the heart, and the communication between the aorta and pulmonary artery, by means of the ductus arteriosus, are not usually obliterated for some time subsequent to birth, and have been found open as late as the third week in infants who have died of disease totally unconnected with any disturbance of the respiratory apparatus in the slightest degree resem- bling that which occurs in cyanosis.1 It has been shown, that in re- peated instances the foramen ovale has remained open for a very con- siderable period, without the occurrence of cyanosis; while the foramen has been found closed before birth, the foetus nevertheless presenting all the symptoms of cyanosis. An interesting case is related by Mr. H. J. Johnson, in the London Lancet, for February, 1843, of an adult female Avho died in St. George's Hospital of erysipelas, and in whom, upon dissection, the foramen ovale was fouud so patent as to admit of two fingers being passed through it from one auricle to the other. The heart was large, flabby, and somewhat dilated. During the lifetime of this patient she presented no symptom from which the nonclosure of the foramen could be inferred. It has indeed been denied by Clo- quet and Louis, that any admixture of venous and arterial blood can take place, even with a free opening between the two auricles, from nonclosure of the foramen, so long as the communicating cavities are of equal strength or provided all the orifices are free. It has been supposed by Louis, Frank, and others that the contrac- tion of the pulmonary artery, which is so commonly met with in those who have perished after labouring under symptoms of cyanosis, is the chief cause of the non-closure of the foramen ovale, in consequence of the constant state of over-distention which it keeps up in the right cavities of the heart. In a paper contained in the Edinburgh Medical and Surgical Jour- 1 Dr. Elsasser of Stuttgard, (Rente's Zeitschrift, iv. 1852,) after 870 examinations of the condition of the foetal openings and blood vessels at different periods subsequent to birth, states that in regard to the closure of the foramen ovale and ductus arteriosus, great varieties occur. The completion of the process in much the greater number of in- stances, takes place within the first six weeks, and the obliteration of one or other duct before birth, or previously to the fourth or sixth week after birth, are exceptions, chiefly interesting in a forensic point of view. CYANOSIS. 687 nal, for October, 1843, this point is very fully considered by Dr. Cragie. This gentleman states, that from the facts of the case related in the paper referred to, and of several others, he is satisfied of three circum- stances, namely: first, that the open state of the foramen ovale is rarely a primary and solitary lesion; secondly, that when it is a solitary lesion it is not attended with any injurious effects, and that the venous blood of the right auricle is not thereby necessarily mixed with the arterial blood of the left auricle; and, thirdly, that in opposition to what has been hitherto usually taught, the open state of the foramen ovale is, in a large proportion of cases, the means of prolonging life. HoAvever paradoxical, Dr. Cragie remarks, the latter conclusion may appear, and however opposed to the usually received dogmas, it flows almost directly from the facts which may be traced in every case of open foramen ovale. It is not, in fact, the primary lesion. From the phenomena of the cases on record, on the contrary, and from the frequency of the arctated or contracted state of the pulmonary artery, it must be inferred that the primary lesion is the obstructed state of that artery; and that it is this which is the cause, not only of the open state of the foramen ovale, but of the hypertrophy, also, of the right ventricle. This is the result, whether the pulmonary artery is only greatly narrowed in caliber, or terminates in a cut de sac, or is ob- structed by a membranous partition formed by a coalition of the semi- lunar valves. The effect of such an impediment is manifest. The blood cannot pass into the pulmonary artery with the requisite freedom and facility; there is, consequently, over-distention, first, of the right ventricle, and excessive labour of its muscular apparatus; secondly, of the right au- ricle, and excessive labour of its muscular apparatus, with extreme dilatation of its membranous portion; thirdly, over-distention and con- gestion of the whole venous system throughout the body. The lungs, meanwhile, receive little or no blood, and, consequently, the blood is not duly aerated. This is doubtless a very serious evil; but Bichat has obscurely suggested, and Drs. Williams and Kay have clearly shown, that dark-coloured blood, or that which is venous, is adequate to maintain vital action. Every thing that we now know of the cases of cyanosis shows that the obstruction to the circulation through the pulmonary artery, must be the main cause of the uncertain and tran- sitory existence of persons labouring under this severe lesion, and that the open state of the foramen ovale, instead of being as William Hunter imagined, and most subsequent writers have taught, the cause of death, furnishes, in fact, the only means by which life can be pro- longed, while a function so important as that through the lungs is impeded. . , , . „ . Dr. Cragie considers himself further entitled to infer from various facts in the history of the development of the ovum, that the obstruct- ed or it may be, the undeveloped state of the pulmonary artery, is the anatomical cause of the perforated septum, and of the origin of the aorta from the two ventricles when that malformation is observed. Dr M Still<5, in a very able paper on cyanosis, contained in the ime'rican Journal of the Medical Sciences, (vol. viii. p. 25,) maintains, 688 CONGENITAL AFFECTIONS, ETC. that in every instance cyanosis is dependent upon congestion of the general venous system resulting from a partial or complete contraction or obstruction, or upon an imperforation of the pulmonary artery; that this lesion alone will account satisfactorily for the discoloration of the skin and the dyspnoea; that it is present in almost every case of cya- nosis—or, if absent, that there is ahvays some other efficient cause for the disturbance of the pulmonary circulation; and, finally, that the lesion referred to never exists without the concurrence of cyanosis. These several positions are very fully borne out by the series of facts adduced in the paper referred to. That the disease is caused invariably by delay to the passage of the blood through the lungs, resulting from the presence of a fixed impe- diment to the circulation, is the opinion advocated by the leading pa- thologists of the present day. Morgagni appears to have been the first who attributed the intense lividity of cyanosis to obstruction in the trunk of the pulmonary artery. Louis ascribed it to some obstacle to the circulation of the blood through the veins, and MM. Bertin and Berard, and more recently, Professor Rokitanski, of Vienna, agree in referring the blue appear- ance of the surface, in those affected with abnormal apertures in the cardiac septa, to a stasis of the blood in the right cavities of the heart, and the consequent difficulty with which the venous blood circulates. Though it be complicated, in many cases, Avith the admixture of the venous and arterial blood, still it is very evident that the disease is not produced by this admixture. Dr. Chevers, in a very able paper published in the London Med. Gaz., March, 1847, states that the results of his investigations into the causes of cyanosis, are almost entirely confirmatory of the gene- ral conclusions of Dr. Stille'. The latter, he remarks, has, perhaps, referred somewhat too exclusively to the right side of the heart and the pulmonary artery as the seats of the mechanical obstacle to the circulation of these cases; for it will occasionally, though rarely, be found that the physical impediment to the circulation exists in the pulmonary tissue, or is even external to the lungs, as in Dr. Marcet's well-known case, (Edinburgh Medical and Surgical Journal, vol. i., p. 412;) and in some few instances the cause of obstruction is seated either in the left heart, or in the aorta, Still, in every case of cyanosis, there will be found to exist some cause or other which tends essentially to prevent the free and complete circulation of the blood through the lungs, to retard its passage through the venous system, and, conse- quently, to render the process of its arterialization slow and incomplete. Dr. Stille' has also argued that obstruction to the pulmonary artery is never found without the concurrence of cyanosis. This is perfectly true as regards most of the cases of congenital narrowing of this vessel, but it does not hold good in all; thus, when congenital im- perfection of the pulmonary valves does not become seriously obstruc- tive until late in life, the symptoms which it produces are not neces- sarily those of cyanosis. Dr. Chevers cites an instance in which ex- treme narrowing of the pulmonary orifice, the result of endocarditis, occurring at the adult period, was not attended with the slightest CYANOSIS. 689 appearance of lividity of the surface; in fact, it appears that, for the complete establishment of that generally dilated condition of the en- tire venous system which attends cyanosis, the obstruction to the cir- culation must have been present either at or before birth, when the capillary vessels are naturally more capacious than they are in the adult; or it must become confirmed previously to the full development of the body, Avhile the entire vascular system is pliant and dilatable, and is still capable of readily adapting itself to permanent changes in the circulation. It is well known, that in adults, the occurrence of various kinds of disease productive of obstruction in the heart and lungs, is liable to give rise to extreme venous congestion, and considerable lividity of the surface; but Dr. Chevers is not acquainted with any instance in which an impediment of this kind, occurring subsequently to the age of twenty-five years, has produced that general and intense blueness of the entire surface which forms the characteristic feature of true cya- nosis from congenital malformation of the heart. In extreme cases of original defect of the cardiac apparatus, such as those in which the ascending pulmonary trunk is obliterated or ab- sent, the cyanosis appears to be due less to the circuitous course by which the lungs are supplied with blood, than to the unnatural nar- rowness of the pulmonary vessels, which are almost invariably far less capacious than in the ordinary condition; hence the pulmonary veins and left auricle are usually more or less contracted in these cases, while the lungs are either badly developed and imperfectly ex- panded, or present the evidences of chronic impediment in the dilated condition of their tubes. There are still a few pathologists who adhere to the old opinion that cyanosis mainly depends upon the circulation of carbonized blood through the arterial system, insisting upon the fact that, in the great majority of cases of cyanosis, the septa of the heart are more or less deficient. It is now established that cyanosis may exist quite inde- pendently of imperfection of the cardiac partitions, or of admixture of the venous and arterial blood; Dr. Chevers, however, apprehends that M. Berard and Dr. Stille* are somewhat too exclusive in main- taining that admixture of the two currents has in no instance any in- fluence in the production of cyanosis. It appears to him by no^ means unreasonable to conclude, that, in extreme cases, where the impedi- ment to the pulmonary circulation is great, and where a large quan- tity of venous blood evidently passes into the aorta at every systole of the ventricles, the discoloration of the surface, and especially the lividity of the mucous membrane, which is so frequently observed in these erases, is in part, at least, due to the dark hue and impure con- dition of the arterial blood. It must nevertheless be borne in mind that the principal reason why cyanosis is generally present in cases of extensive communication between the cavities of the heart, will be found in the fact, that a cause of obstruction capab e. of prevent- ing the natural closure of the septa, will rarely fail to occasion permanent and severe impediment to the circulation. A\ here an ab- normal opening is discovered in the cardiac apparatus of one who 44 690 CONGENITAL AFFECTIONS, ETC. has only lately become cyanosed, or where such an aperture presents traces of recent enlargement, it must not be at once concluded that the presence or augmentation of this communication has occasioned the cyanosis; the first cause of the disease must be sought for, and this will generally be discovered to be some manifest impediment to the circulation which has determined the patency of the opening from birth, and which, having become recently aggravated, has produced the cyanosis at the same time that it has increased the size of the abnormal foramen. Cyanosis, whether congenital or acquired, is very rarely recovered from. If, as already remarked, the infant survive the first few days or weeks, it may live on to puberty. An aggravation of the symp- toms every now and then will take place, and these paroxysms are liable to be very severe at the period of weaning, during dentition, or when the child begins to walk, and at puberty; if this latter period be passed, the patient may live to eighteen, twenty, thirty, forty, sixty years, or even to extreme old age. The chances of life depend pretty much upon the nature of the organic disease present, and of the ac- cessory morbid phenomena: thus, in a child whose pulmonary artery was found completely obstructed, death took place on the thirteenth day from birth; while in three patients, in whom the foramen ovale and ductus arteriosus were simultaneously patescent, one lived seven- teen, another, tAA*enty-nine, and the last forty-two years. The duration of life in the cases of cyanosis analyzed by M. Aberle, was as follows:— In four cases, death occurred within the first twenty-four hours; in 16, within the first fourteen days; in 7, before the end of the first month; in 6, from the second to the third month; in 8, from the third to the sixth month; in 12, from six to twelve months; in 7, from one to tAvo years; in 9, from two to three years; in 11, from three to six years; in 11, from six to eight years; in 13, from eight to eleven years; in 12, from thirteen to sixteen years; in 8, from sixteen to twenty years; in 10, from twenty to twenty-five years; in 6, from twenty-five to thirty years; in 5, from thirty to thirty-five years; in 5, from thirty-five to forty-five years; in 4, from forty-five to sixty years; and in one case, at eighty years. In 10 cases, the age is not indicated. A few cases are on record, in which the phenomena of cyanosis, after continuing for a very considerable time, finally, entirely disap- peared; and in cases connected with certain affections of the lungs, intestinal canal, uterus, and brain or spinal marrow, the cyanosis has disappeared with the cure of the pulmonary, gastro-intestinal, uterine, and cerebral disease. As a general rule, however, the disease is en- tirely beyond the control of medicine. It is said to prove more quickly fatal in males than in females; and the mortality is certainly greater in winter than summer. (Jour. Hebdom., No. 113.) It is unnecessary to say any thing on the treatment of cyanosis. If the pathology of each case be attentively and carefully examined, and the true character of the disease be kept in mind, it will be easy to adapt our palliatives to the most urgent distress. The patient, in every INTESTINAL HEMORRHAGE. 691 instance, should be kept as much as possible in a state of rest, and every thing should be avoided, liable to produce mental or physical excitement, or which in any manner has a tendency to hurry the res- piration or circulation. He should enjoy a pure, fresh atmosphere, gentle, passive exercise, and be allowed a mild, easily digested diet; his bowels should be kept perfectly free, and his body be carefully pro- tected from cold or damp. When cyanosis appears in a new-born child, and persists after res- piration is established, it has been recommended by Corvisart to em- ploy gentle frictions over the head and body with a warm, soft cloth, while the infant is held near the fire. The frictions should be perse- veringly continued, attention being, at the same time, paid to procure a free evacuation of the meconium. 7.—Intestinal Hemorrhage. In the new-born infant we occasionally meet with a copious discharge of blood by stool, and in a few cases by vomiting also. It usually occurs between the first and tenth day after birth, but may take place at any time within the first two or three months, and is said to be more frequent in males than in females. The discharge of blood from the bowels may occur suddenly and without the slightest premonition, or it may be preceded by paleness of the countenance or a rapid fluctuation in its colour; somnolency, slight spasmodic twitchings of the muscles, convulsive respiration, a diffi- culty of sucking, great prostration, vomiting, or frequent discharges by stool of a thin yellow fluid; and tympanites. All of these symp- toms, however, are seldom observed to precede the intestinal hemor- rhage of infants in one and the same case. In the new-born infant the disease may commence by the meconium being, at first, mixed with more or less blood: the stools usually, hoAV- everfconsist of blood alone, even from the first. The hemorrhage from the intestine is in many cases accompanied by a vomiting ot blood, and in a few instances the latter only is present. The amount of blood discharged is often very considerable, rendering the child, in a short time excessively pale, prostrated and unable to suck—and its pulse to become small and feeble, and its breathing difficult; it some- times induces an attack of convulsions Etlmger refers to a case in which over one pound of blood was discharged within a short time by stool and vomiting. „ , „„„„„* j„„ The hemorrhage usually ceases by the close of the second day, though it has been known to continue for five days, and even longer. It°is sometimes the case that the blood poured out into the cavity of the intestines, is not immediately discharged, either by stool or vomiting but undergoes a change whilst it remains within the alimen- LrTcanal • under such circumstances when evacuated it is of a dark or bkck cofour and, occasionally, converted into a blackish matter mixed w tfsi me-having lost all the characteristics of blood; by the aid howeve^of the microscope some altered blood corpuscles may still Vnlhe cases collected by Dr. Rahn-Escher (Gazette 3ICdicale, 1835,) after tt permanent cessation of the hemorrhage, the patients re- 602 CONGENITAL AFFECTIONS, ETC. mained for a long time pale, thin, and feeble, and strongly predisposed to convulsions. One became subsequently rachitic, and another, at the age of twelve months, died from tabes mesenterica and hydroce- phalus. In cases of hemorrhage into the alimentary canal of infants, the blood continues, occasionally, to be effused, but instead of being dis- charged by stool or vomiting, accumulates internally, the patient perish- ing with all the symptoms of death from profuse loss of blood without any appearing externally. A discharge of blood from the bowels during infancy may take place in cases of purpura, which has been known to occur in an infant one month or even three days old. (Richard, Billard, Bouchut.) Bloody stools may also be a symptom of intestinal inflammation or invagina- tion, of polypus of the rectum, or of anal fissures; the intestinal he- morrhage, however, to which we desire to call especial attention, is evi- dently due to a morbid hyperaemia of the mucous membrane existing at birth, or occurring immediately afterwards. Billard has observed twenty-five cases of simple hyperaemia of the intestinal tube, without hemorrhage, in children who had perished Avithin a few hours or days after birth. Fifteen of these had all the external characters of the apoplectic condition of the newly-born—with symptoms of congestion of the lungs and heart. In fifteen other cases the congestion was attended with intestinal hemorrhage; of these, eight Avere from one to six days old, four, from six to eight, and three, from ten to eighteen days. Six were boys and nine girls. The greater number were remarkable for the plethoric condition of the tissues, the general congestion of the integuments, and the engorged state of the large blood vessels and principal viscera. The intestinal canal contained blood in all of them—which was more or less changed— being of a pale or dark red or blackish colour—appearing in the form of a thin layer on the mucous coat, or of specks or clots in different parts of the digestive tube. Intestinal hemorrhage has been supposed to result in the young in- fant from the compression its body has experienced during a tedious labour; that this cannot be so, hoAvever, is evident from the fact that the hemorrhage has occurred as frequently, or nearly so, after easy and rapid labours as after such as were difficult and protracted. Ril- liet refers the disease, 1st, to the congestion of the intestinal tube, a con- dition Avhich is normal in the new-born infant, and 2d, to some im- pediment to the speedy and complete establishment of respiration; in consequence of which, the blood, unable to pass freely through the lungs, engorges the other organs, especially the intestines, the vessels of which, already loaded with blood, are unable to support this new tax. A somewhat similar explanation of the mode of production of the intestinal hemorrhage of the infant is given by Billard. These hemorrhages are always to be viewed as serious occurrences in early infancy, and the more so the sooner they occur after birth. They are not, however, necessarily fatal, recovery having frequently taken place and, occasionally, under circumstances the most unpro- mising. Out of thirty-one cases, adding those we have found upon record to those in our own case book, and others furnished us by pro- SPINA BIFIDA. 693 fessional friends, recovery took place in thirteen, and a fatal termina- tion in eighteen. The fatal result often occurs with great rapidity. In regard to the treatment, Bouchut recommends that, when the hemorrhage appears at the moment of birth, which, v,*e may remark, is but seldom the case, and the infant is plethoric, all the tissues ap- pearing to be in a state of engorgement, blood should be allowed to escape from the divided cord previously to the application of the liga- ture. When the hemorrhage does not appear until some time after birth, with the same plethoric condition of the child, he advises a leech to be applied to the anus, and even a second, should the congestion not be sufficiently subdued by the first. If, however, no indications of plethora are present, the smallest abstraction of blood will be improper. In the few cases of intestinal hemorrhage in young infants that we have met with, blood-letting was the last remedy that would have suggested itself. Drs. Rahn-Escher and Rilliet direct the use internally of diluted sulphuric acid in cinnamon water, or, in cases attended Avith prostra- tion, an emulsion of alum and musk. Both these, however, are of ex- tremely doubtful propriety in patients of so tender an age as those in whom the disease so generally occurs. Diluted alum whey in rose water we have found to act beneficially. We think more favourably of the directions given by the gentlemen just referred to, to place the patients in a cool and frequently changed atmosphere, to apply cold compresses to the abdomen, and to keep the extremities comfortably warm. i Enemata of cold water may also be resorted to, but we have htte confidence in the various astringent injections that have been recom- mended—such as solutions of tannin, catechu, extract of rhatany, acetate of lead, or nitrate of silver. In extreme cases, and where the danger of a fatal termination is imminent, they may, however, be tried. iS every instance, the child, if it have strength enough to suck, should be put to the breast; if too weak, it must be fed with the mo- ther's milk drawn in a spoon. 8—Spina Bifida—Hydro-Rachis. Hydro-rachis is, strictly speaking, an abnormal accumulation of fluid within the spinal column; it is, in almost every instance, a congenital affection, and may be associated with either hydrocephalus or spina blIna'the latter case, one or more tumours will be found to exist upon the spine generally in its lumbar, occasionally in its dorsal and sacral, and v ry rarely in its cervical portion. These tumours vary in size, frn m tbJt of a hazel-nut to that of the adult head, or the entire spine being bfi, thtumour may occupy its whole length. The tumour is usually globular or ovoid in shape, having either a large base or narrow neck in one case, recorded by Brewerton, it was bi-lobed It may Se invested by the common integuments, in a healthy uninflamed con- dition o ' th/skin covering it may be thin, almost transparent, and cosTed by purplish lines, and as if about to rupture, with a sero-san- guineous fluid exuding through it; or, the tumour may be ruptured, its G94 CONGENITAL AFFECTIONS, ETC. contents having escaped through a very small, ulcerated opening, Avhich is surrounded by a red, rugose, unequal elevation of the skin and sub- cutaneous tissue. The two latter conditions of the tumour are much more common than that in which it is covered by healthy skin, and far more dangerous. The tumour is always situated over a deficiency in the vertebrae, arising, most commonly, from an imperfect development of the late- ral arches; occasionally, however, the lateral arches may exist, hut re- main ununited, or, still more rarely, there may be a complete division of the whole vertebrae, body as well as processes. The opening in the vertebrae may be confined to one bone, or extend to two or more, or it may occur at different parts of the spine, giving rise to several tumours, or as we have already seen, it may exist throughout the whole extent of the spine. The tumour itself is formed by a cyst, communicating with the spi- nal cavity, and filled by a fluid secreted within the latter. In the most favourable cases, its parietes are composed of one or two layers, con- sisting of the arachnoid membrane, the dura mater, and the common integuments, in a natural condition; more generally, however, its pa- rietes are thickened, inflamed, ulcerated, gangrenous, or covered with fungous granulations, or tufts of hair. To the touch, the tumour is tense and protuberant, whenever the position of the infant is such as to allow the fluid from within the spi- nal canal to gravitate towards it, but it is more or less soft and flaccid under opposite circumstances. By gradual pressure, its bulk may be diminished, and if of small size, the whole of its contents may be forced back into the spinal cavity, when the margin of the opening through the vertebrae may be felt with the finger. Pressure upon the tumour very frequently induces a state of coma, or convulsions, and in one case referred to by Dr. M. Hall, pressure, even that resulting from the supine recumbent position of the child, invariably produced attacks similar to the croup-like convulsions of laryngismus. In some cases, the tumour has been observed to expand during ex- piration, and sink during inspiration. The contents of the tumour may be either a limpid, colourless serosity, or a turbid fluid, often con- taining albuminous flocculi, or a purulent matter. The fluid of the tumour communicates freely with that collected within the cavity of the spine; and in many cases, there is a free communication between the ventricles of the brain, the intercranial arachnoid cavity, the entire canal of the spine, and the cavity of the external tumour, so that pres- sure made upon the latter may force the fluid back upon the brain, and cause more or less compression of that organ. Children affected with spina bifida often present other malforma- tions, as imperforate anus, imperfect or irregular development of the alimentary canal, &c. When there exists no external opening in the tumour, it being co- vered by the common integuments, and when the accumulation of fluid within the vertebral canal does not exercise upon the brain, or spinal marroAv, a degree of pressure sufficient to interfere with the free exer- cise of their functions, patients with spina bifida, though generally of a SPINA BIFIDA. 095 weak and infirm constitution, may exhibit no particular symptoms of disease, and even live to an advanced age, without the occurrence of any serious evil that immediately results from the spinal tumour. Cases of individuals labouring under spina bifida of almost every age, from ten years to fifty, and upwards, have been observed. Generally speaking, however, from a greater or less deficiency in the spinal cord, or other morbid conditions of it or of the brain, the infant is liable to be affected with paralysis of the loAver extremities, convulsions, an open state of the sphincters, and difficulty of respira- tion. He is occasionally unable to take the breast, and becomes gra- dually more and more exhausted, his feet and legs become cold and cedematous, his cries more and more feeble, his pulse extremely quick and feeble, his breathing more and more difficult, and often stertorous, and, finally, death takes place, preceded by convulsions or coma. The larger the tumour, the more intense and rapid is this train of symp- toms. When the tumour bursts, inflammation of the membranes of the cord in general very rapidly ensues, and we have then all the symp- toms of spinal meningitis, and, in most cases, the patient is very quickly destroyed. If, however, the opening in the tumour is very small, notwithstand- ing a portion of fluid is constantly escaping, no very important suffer- ing may result for a length of time. Druitt mentions a case Avhich came under his notice, of a female, twenty-seven years of age, in whom the tumour relieves itself when distended by the exudation of a watery fluid through an exceedingly minute aperture. But, very commonly, the fluid discharged becomes more or less turbid, purulent, or even fetid, and symptoms of spinal inflammation soon occur. When the tumour is of considerable size, its sudden rupture may produce a paroxysm of convulsions, terminating almost immediately in death. It has been asserted by Duges, that a rupture of the tumour has taken place in utero, and the opening has again closed, previously to birth. This appears to us, however, to be very doubtful; the case cited in confirmation of it is certainly very far from being conclusive. After death, the most common appearance met with is a more or less copious effusion of serosity, either between the pia mater and the arachnoid membrane of the spinal marrow in the arachnoid cavity, or between the dura mater and bony wall of the spinal cavity. When in the first two situations, the effused fluid very generally communicates freely with the ventricles of the brain, and with the arachnoid cavity within the cranium, in which there also exists a morbid effusion of serum Occasionally, when the tumour is small in size, and covered with the common integuments, in a normal state, the brain is found to be per- fect healthl the effusion of serum being confined entirely to the spinal canal. Even the medulla spinalis may present no apparent in- * TL"ed fluid i. usually perfectly limpid excepting when menin- rritis has o curred, when it is generally thick turbid and flocculent E may be of a light yellow, greenish, or dark hue, and is often mixed with pus, or with more or less blood. 696 CONGENITAL AFFECTIONS, ETC. When an effusion of fluid exists, at the same time, in the cavity of the cranium, and in that of the spine, the fluid in the former has been found to be of a different colour from that in the latter, showing the two to be perfectly distinct. In other cases, the fluid was prevented from escaping from the fourth ventricle into the subarachnoid cavity, by a firm, reddish membrane, which formed a cul-de-sac below the in- ferior angle of the ventricle. The spinal cord may either present congenital deficiencies, or mal- formations, or more or less traces of disease. The substance of the cord has been found entirely Avanting, the membranes alone remain- ing; forming sometimes a closed sac, filled Avith a fluid. ^ It may be diminished in size, divided into two parts, or expanded into a mem- brane. It is often, according to Ollivier, preternaturally long. The spinal nerves have been seen floating in the fluid of the tumour. They have been found, also, distributed on the inside of the tumour, forming, occasionally, a kind of nervous netAvork. More commonly, however, the substance of the cord is softened, like the walls of the cerebral ventricles in hydrocephalus; and very generally, traces of meningitis of the spine exist, often extending even to the brain. Fisher, (London and Edinburgh Philosoph. Mag., vol. x.) in two cases, observed a union of two or more sacral ganglions, their respec- tive nerves passing through the sheath in one bundle, the termination of the spinal cord being united with the walls of the sac. Hewett (London Med. Gaz., 1844,) refers to cases on record, in which neither the cord nor the nerves had any connexion with the sac; these parts following their usual course doAvn the spinal canal. In far the greater number of cases that have been published, some kind of connexion betAveen the nerves and the sac was observed. Of tAventy preparations of spina bifida, occupying the lumbo-sacral region, ex- amined by Mr. Hewett in various collections, he found but one in which such connexion did not exist. If the tumour corresponds to the two or three upper lumbar vertebrae only, the cord itself rarely deviates from its course, and the posterior spinal nerves are generally the only branches which have any connexion Avith the sac. But when the tu- mour occupies partly the lumbar and partly the sacral regions, both the cord itself and its nerves will be found intimately connected with the sac. Cruveilhier believes from the dissections made by him, that this connexion is constant. When the cord and its nerves pass through the cavity of the sac, it is probable, Mr. Hewett thinks, that the fluid was originally effused into the subarachnoidal tissue, after extensive adhesions had united the cord and its nerves to the tAvo layers of arachnoid membrane covering its posterior surface; whereas, ay hen the liquid is effused into the cavity of the arachnoid, before adhesions take place betAveen the two layers of the membrane, he believes that no nerves will be con- nected with the sac. In regard to the pathology of hydro-rachis, numerous discordant opinions have been entertained. The disease is evidently a true con- genital dropsy, either of the spine, or of the spine and brain; the de- ficiency in the vertebras, as well as the external tumour, being the re- SPINA BIFIDA. 697 suit of the accumulation and pressure of the fluid within the cavities of the cranium and spine. When the tumour in the spine is not formed, the child usually perishes soon after birth, with symptoms of hydrocephalus; or tumours, in some instances, form upon the head, in all respects similar to those of spina bifida, the fluid protruding the dura mater and a layer of the arachnoid membrane, through an opening in one of the bones of the cranium. Dropsy of the spine, with the formation of an external tu- mour, has succeeded to hydrocephalus, produced by contusion of the head; or has resulted from the disease of the spinal cord. In regard to treatment; it would appear, from a careful examina- tion of all the facts upon record, and from the result of the few cases which have fallen under our OAvn notice, that, when the tumour is small, and more especially when it is covered with the common integuments in a sound state, and the infant, as is generally the case, suffers little or no inconvenience, the most prudent course is to let it alone, merely guarding the tumour from accidental pressure, and from every source of irritation. So long as the tumour remains unopened, there is, com- paratively, little danger, but soon after it becomes opened, meningeal inflammation, with all its train of fearful consequences, soon sets in, and quickly destroys the child. The opening of the tumour is always, therefore, to be considered a most unfortunate circumstance. Hence, if the infant be born with an ulcerated tumour, but incompletely perforated, it ought not to be opened for the purpose of allowing the discharge of its contents. It is true that the operation first practised by Ruysch, and revived by Aberne- thy, of puncturing the tumour with a fine needle, and aftenvards em- ploying gentle pressure, has been performed, and it is said, in several cases with success. The operation has however, been unsuccessful in the hands of Otto, Berndt, Hayer, Sherwood, Trompei, Churchill and others. When decided upon, the puncture should be made with a needle or slender trochar, and, according to Mr. Hewett, never along the median line of the tumour, especially in the sacral region, for it is generally at this part that the cord and its nerves are connected with the sac. The puncture he directs to be made on one side of the sac, and at its lowest part. Very recently, tAvo cases are related by Dubourg, in which a per- fect cure was effected by cutting off the tumour, and then bringing the edges of the divided skin together, and retaining them so by means of the twisted suture, until union took place; great care being taken to prevent the entrance of air into the spinal canal, and as much as pos- sible, the escape of the spinal fluid. The application of gradual and i^apted ... produced a radical cure in some instances. It has been very correct- ly remarked that when the tumour is very large, puncture should not be attempted while in cases where the fluid effused in the spine com- municates with the ventricles of the brain, pressure must always be of very doubtful propriety. 698 CONGENITAL AFFECTIONS, ETC. Beynard and Latil have practised the linear ligature by means of two quills or pierced wooden rods, retained on the two sides of the tu- mour by a proper contrivance, and containing in their interior a thread; by the gradual tightening of which, lateral constriction is applied; the tumour at the end of a few days is destroyed, and a permanent cure effected. M. Dubois combines the ligature with puncture, while M. Chassiagnac proposes puncture followed by injection of iodine; the success of Avhich plan has been but small, while seA-eral of the patients in whom it was practised were destroyed by it. (Bouchut, Diseases of Children.) In all cases, much benefit will unquestionably be derived from placing the patient under such a hygienic course of treatment as will be adapted to improve the health and nutrition of the body generally. Hence, the importance of changing the milk of the mother, if the quality of this be doubted, for that of a healthy nurse; of removing the in- fant from the confined and impure air of the city, to a dry, healthy situation in the country; of clothing it warmly, and carrying it abroad, every fine day, in the open air; of sponging its body daily with warm water, and using frictions over its entire surface, and of keeping its bowels regular by gentle aperients. It has been proposed to apply repeated small blisters above the tu- mour, in the course of the spine, each being kept on so long as to cause a rubefacient effect only, with a view, in this manner, to promote the absorption of the fluid. The preparations of iodine may also be ad- ministered with the same intent. When the disease is associated with hydrocephalus, or with menin- geal inflammation, either of the brain or cord, the treatment adapted to the latter affections will, of course, become necessary. 9.—Inflammation and Ulceration of the Navel. Within the first nine or ten days after birth, inflammation followed by ulceration of the navel is very liable to occur, if the utmost atten- tion is not paid to prevent it. Upon the separation of the cord, instead of a quick and perfect cicatrization succeeding, the navel in some cases remains raw, and soon becomes irritated and inflamed, presenting a deep, red, ulcerated surface, with an inflamed condition to a greater or less extent, of the surrounding skin. A thin, purulent, and often offen- sive discharge takes place from the surface of the ulcer, and the infant evidently suffers considerable pain, as is evinced by its general fretful- ness, and its cries when the ulcer is examined or accidentally touched. Not unfrequently the navel presents an elevated, ulcerated surface, with somewhat prominent edges; in these cases, the discharge is generally the most profuse. In other cases, a kind of fungous excrescence, of a dark-red colour, protrudes from the centre of the navel, without any appearance of ulceration, and with but little discharge, and scarcely any inflammation of the surrounding skin. We have often, indeed, seen the skin, up to the very edge of the umbilical depression, remain perfectly natural. The fungoid tumour, which generally bleeds upon the slightest irri- tation, may either present a narrow base with a round, expanded head, INFLAMMATION AND ULCERATION OF THE NAVEL. 699 like a cherry, or a broad base, tapering gradually towards the summit, being more or less conical in form. Ulceration of the navel, as we have already remarked, is very gene- rally the result of neglect or mismanagement on the part of those who Avash and tend the infant. In a few instances, it is true, it may result from a slow and imperfect separation of the cord, in consequence of which it remains long attached by a thin, firm filament, and causes a constant irritation, by which the healing of the navel is prevented, and ulceration induced. More commonly, however, it is produced by rude management in washing and dressing the child, previous to the coming off of the cord, or by rude dragging, or other injudicious attempts to facilitate its separation, or by the ridiculous practice of dressing the navel subsequently, with a burnt rag, grease, and even more improper applications. It may also, arise from inattention to cleanliness, in the first washing of the child, in consequence of which a quantity of the vernix caseosa is left upon the skin surrounding the umbilicus, which soon acquires an irritating character. From a peculiar irritability of the skin, some infants are more liable to ulceration, or rather tardy and imperfect healing of the navel than others. In all cases, the utmost attention should be paid to cleanliness. The navel and surrounding skin should be carefully washed, at least twice a day, with lukewarm water, and then wiped perfectly dry with a soft linen cloth. If the cord still remains attached by a thin filament, the division of this, and the removal of the cord, will often, as stated by Dewees, be sufficient to allay the irritation, and thus allow the navel to cicatrize. When the ulceration is superficial, without much inflammation, wash- ing it with a little rose water, twice a day, and dressing it as often with the ceratum zinci oxydi impur. spread upon a soft rag, will often cause it promptly to heal; or, if this should not succeed in causing cicatriza- tion, the ulcer may be washed daily with a solution of sulphate of cop- per (ten grains to an ounce of water,) and then dressed with the same salve. In slight cases, by sprinkling the ulcerated surface with finely powdered oak bark or galls, we have repeatedly found cicatrization to take place very promptly, without any other dressing. If the ulceration should still show no disposition to heal, it may be washed by a weak solution of the nitrate of silver, and then dressed with an ointment formed of one scruple of the acetate of lead inti- mately combined with an ounce of lard. In aggravated cases of ulce- ration of the navel, prompt and very decided benefit is said by Dr. Eberle to be derived from applying to the ulcerated surface, three or four times daily, by means of a soft hair pencil or feather, a liniment made by slowly simmering the coarsely powdered root of the wild indigo, (baptisia tinctoria,) in cream, and afterwards squeezing it through a thick piece of muslin or flannel. In all cases, however, in which the ulceration is attended with con- siderable inflammation extending to the surrounding skin, stimulating applications of every kind should be withheld until the inflammation is reduced by soft, emollient poultices, and frequent washing of the in- flamed skin with a solution of the acetate of lead. In some instances, 700 CONGENITAL AFFECTIONS, ETC. we have seen the inflammation, in cases of ulceration of the navel, so extensive as to demand the application of a few leeches. It is not unfrequent for the bowels of infants affected Avith ulcerated navel to be considerably disturbed, the passages being frequent, thin, and attended with griping:—whenever this is the case, the administra- tion of very minute doses of calomel and ipecacuanha, combined with a few grains of magnesia, with the daily use of the warm bath, will be demanded. When a fungoid tumour forms or protrudes from the navel after the separation of the cord, if it have a narrow base, we may readily re- move it by a ligature applied around its pedicle, sufficiently tight to arrest the circulation, without cutting into its substance. The tumour usually separates in the course of a few days, Avhen the ulcerated sur- face may be washed with a solution of sulphate of zinc, (fifteen grains to an ounce of water,) or dressed with the ointment of acetate of lead. It is seldom, however, that the separation of the tumour by means of the ligature is attended with any permanent benefit; very generally, the fungous growth will recur to as great an extent as at first. It is better, therefore, to treat it at once by astringent applications, as the decoction of galls or oak bark, or solutions of the sulphate of copper or zinc, in the proportion of one drachm to the ounce of water; or, we may sprinkle the surface of the tumour with finely powdered oak bark or galls, and Avash carefully, night and morning, with lukewarm water. It is said that the root of the sanguinaria Canadensis, in fine poAvder, is an admirable application for the removal of these fungoid growths. When the tumour is soft and spongy, and not invested by a mem- brane, applying to its surface daily, by means of a camel's hair pencil, a pretty strong solution of the nitrate of silver will generally destroy it in a few days, and allow the navel to cicatrize. 10.— Intumescence and Inflammation of the Breasts. Infants of both sexes are very liable to a tumid, hard, and painful condition of the breasts, which is occasionally present at birth, but more generally presents itself a day or two subsequently, and is, in some cases, attended with a degree of redness and inflammation of the external skin. Even when the swelling and hardness are very considerable, they will both, after continuing, perhaps, for a week or tAvo, Avithout any sensible abatement, very generally subside entirely. Unfortunately, however, a vulgar notion is prevalent among mothers and nurses, that the swelling, in the female at least, is the result of milk in the breasts, which it is necessary, by all means, to draw or squeeze out; an opinion that is confirmed, as they suppose, by the escape, sometimes, of a white-coloured fluid, resembling milk, at the nipple, and Avhich induces them, not un- frequently, to resort to very rude measures to get rid of the offending fluid. The consequence is, in not a few cases, severe inflammation, followed by suppuration, and the formation of an abscess: many in- stances of this are on record, and we have ourselves met with a num- ber. The entire substance of the female mammae has, in this manner, been occasionally destroyed. HERNIA. 701 The intumescence of the breasts in young infants would appear to be the result of a subacute inflammation, attended with serous infiltra- tion into the cellular tissue of the part. Occasionally, the inflammation extends to the substance of the mammae, and the skin by which the gland is covered, becomes very tense, shining, and of a dark-red colour. Even this aggravated form of the disease will very generally give way in a few days to the simplest treatment; and we do not recollect ever having seen a case which was attended with any degree of trouble, or any great or prolonged suffering, and certainly no one which showed any tendency to terminate in suppuration, excepting when the tumour had been subjected to the rude and unjustifiable processes adopted for the removal of the stagnant milk. All that would seem to be required, in the generality of cases, is to anoint the tumour daily with a little sweet-oil, or fresh lard, and to cover it with a piece of tolerably thick, soft muslin. When from any cause, considerable inflammation, pain, and swelling of the breasts take place, the case should be treated by a few leeches, and the appli- cation of soft emollient poultices. A weak solution of the hydrochlorate of ammonia in diluted vine- gar, has been proposed as a prompt and certain application in the ordinary form of this affection; we have never used it ourselves, but we have no doubt that it will prove beneficial. IJ.—Hydrochlorat. ammoniae, gss. Aquae. Acid. acet. impur. aa ^ij.—M. To be applied warm, by moistening pieces of soft linen rag with it, and laying them upon the affected parts. (Eberle.) It would be well for the practitioner himself to examine daily, for the first three or four days after birth, the breasts of the infant, in or- der to detect immediately any swelling that may occur, and when it does appear, to direct the proper measures to be pursued, forbidding, positively, at the same time, any attempt being made on the part ot the nurse or other attendants, to squeeze or draw out" the stagnant milk," which, in their opinion, is the cause of the swelling. 11.—Ruptures.— Herniae. Hernia is, by no means, unfrequent in early infancy. Children have even been born with an umbilical, inguinal, or scrotal hernia or with two or more hernial protrusions. More commonly, however the pro- trusion takes place within the first few days or weeks after birth, and it is important that it should receive early attention, as well to project the infant from suffering or danger, as from the circumstance that by proper treatment, a radical cure may then in many cases, be ef- fected and thus the patient saved, in after life, from all the serious consequent invariably attendant upon this infirmity, in whatever region of the abdomen it may be located. ....... . ., . , The most frequent form of hernia met with in the infant i that of the umbilicus, (exomphalus.) This results from the circumstance of he Use of the umbilical cord, in early foetal life, forming a portion of the anterior parietes of the abdomen, and containing the greater part of h ? intestinal tube. In proportion as the development of the foetus 702 CONGENITAL AFFECTIONS, ETC. is perfected, the base of the cord contracts, the convolutions of intes- tine, at the same time, retire within the cavity of the abdomen, and an aponeurotic sheath surrounds, and further contracts the base of the cord, allowing only a sufficient opening for the passage of the latter, with the urachus and umbilical vessels. In some instances, however, the commencement of the cord remains of a large size, and some of the convolutions of intestine continue within it, forming at birth a hernial sac of a round or rather conical form; the summit correspond- ing with the proper commencement of the cord, and the base to the circumference of the aponeurotic ring at the umbilicus, which is of larger size than natural. The hernial sac is composed in these cases of the peritoneum with the skin and cellular tissue more or less con- densed. This form of hernia, though strictly congenital, may not be percep- tible until some days after birth, when the intestines become distended by aliment, and crowded downwards towards the umbilicus by the con- tractions of the diaphragm during inspiration, and the act of crying. The bulk of the protrusion varies very much; ordinarily, it is about the size of a hickory nut, but may increase to that of a walnut, or even beyond. It generally contains a convolution of intestine, but may con- tain only omentum;—it is always larger and more tense when the in- fant cries or coughs. Upon relaxing the abdominal muscles, and using gentle pressure, the contents of the sac may be readily forced back into the cavity of the abdomen, when, through the parietes of the empty sac, an aperture into which the point of the finger can be in- serted is perceptible in the linea alba. Until the separation of the cord, and the cicatrization of the navel, it is unnecessary to do any thing more than to apply, in addition to the usual bandage, a compress formed of a few folds of soft linen imme- diately over the umbilicus. As soon, however, as cicatrization is com- pleted, a more effectual course of treatment must be commenced; and the earlier this can be done, the greater will be our chances of effect- ing a radical cure. Our object is to keep the protruding bowels com- pletely and permanently within the abdomen, so as to permit the na- tural closure of the opening through which they escape to take place. The best means for effecting this we have found to be a portion of gum elastic of a conical shape, and about an inch in thickness: this being neatly covered with a portion of soft muslin, is to be stitched to the centre of the ordinary belly-band. The apex, which should not be larger than the umbilical opening, is to be accurately applied over the latter, and the band fastened in the usual way. This compress should be kept on constantly, for it is only by long continuance, that we can expect any benefit to result from its employment. In proportion, how- ever, as the infant advances in age, the umbilical opening contracts, and at the same time the intestines acquire a greater volume, so that they cease to pass through it, and finally, the use of the compress and bandage may be discontinued. We have, in numerous instances, ef- fected a complete cure, by the means here described. Another mode of treating umbilical hernia in infants, and one that will no doubt be found admirably adapted to prevent the protrusion of HERNIA. 703 the intestines, is that described by Dr. Maunsell. It consists in the application of a graduated compress, formed of white leather, spread with adhesive plaster, over the opening, and above this, the common flannel roller. The apex of the compress, which is to be applied next the navel, should be, as nearly as possible, of the size of the opening. The compress should consist of three or four pieces, the largest being about three inches in diameter; and a double stitch should be passed through them, and knotted externally, so as to keep each piece in situ. We should ahvays adjust the compress with our own hands, as great care is necessary to insure the complete return of the hernia; and un- less the child exhibits marks of uneasiness, it should not be removed, until the plaster loses its adhesive quality, and then a new one should immediately be applied. In conducting the case, patience will be greatly exercised, as months will be required for the completion of the cure, and this should be explained to the friends at the beginning. It has been recommended by A. Cooper to apply a section of an ivory ball over the umbilicus, and retain it there by adhesive plaster and a bandage. To maintain an equal and constant compression, an elastic belt and pad might be found useful, in all cases. A plan, originally adopted by Mr. Woodroofe, of Cork, answers, we are informed by Dr. Maunsell, very well, when there is a small open- ing with a considerably elongated sac: it is, after reducing the con- tents, to hold the pouch firmly between the fingers, and then to wind around it a narrow strip of adhesive plaster, commencing as close as possible to the abdomen, and continuing to the apex. This plan may succeed, by causing adhesion of the walls of the sac, which will thus form a natural truss, and prevent protrusion through the opening in the linea alba: it cannot be employed, however, when the hernial tu- mour is broad and flat. It has been proposed by Desault and Dupuytren to apply a ligature around the base of the tumour, with the view of inducing inflammation and adhesion of the sides of the hernial sac. This plan, which is the one described by Celsus, though apparently well adapted to effect a permanent cure, has, nevertheless, been abandoned by most^modern surgeons, in consequence of its being found that the patients m whom it was tried, are liable subsequently to a return of the hernia. In the male, congenital inguinal hernia is, by no means, unfrequent. It may exist upon one or both sides. In passing out of the abdomen of the foetus, through the abdominal ring, the testicles always carry with them a portion of the peritoneum, by which they become enve- loped, and which also forms the vaginal sac in which they are con- tained. This sac may become perfectly closed at its upper part so as to cut off all communication between it and the cavity of the abdomen; often, however, it remains partially or entirely open so as to allow a convolution of intestine, or a portion of omentum to descend into it, the bowel being in contact with the testicle, and becoming sometimes adherent to it The communication between the vaginal cavity of the scrotum and tne abdomen, may, however, exist without giving rise to hernia- and it is possible for a portion of intestine or omentum to de- scend to the bottom of the sac, although the testicle may still remain 704 CONGENITAL AFFECTIONS, ETC. within the abdomen, or have descended no farther than the ring, while, again, ordinary, non-congenital, inguinal hernia, Avith strangulation, has been observed, according to Lawrence, in an infant of fourteen months. It is no uncommon occurrence for the testicle, at the period of birth, to be arrested at the ring, or to have just passed through it, forming a hard rounded tumour in the groin ; we must be cautious not to mistake this for hernia, and as the testicle may remain in this position even while a portion of intestine has descended into the sac, this fact must always be kept in mind, as no truss should be ever applied, until the testicle has passed fully into the scrotum. Scrotal hernia should not be confounded with hydrocele, which is of common occurrence in infants. The latter may be distinguished by its transparency, and by our being unable to feel the cylinder of the intestine rolling under our fingers, within the sac. The fluid dis- tending the vaginal sac of the scrotum, we are to recollect, may, in many instances, be returned into the cavity of the abdomen, and when this is the case, the size of the hydrocele Avill be increased when the infant cries or coughs; but with a very little care such SAvellings may very readily be distinguished from congenital or accidental hernia. As a general rule, there can be very little certainty as to the existence of the latter until the testicle has descended into the scrotum. A curious case is related by Billard, of congenital inguinal hernia in a female infant. There existed in this instance, in the left inguinal region, a rounded tumour about the size of a filbert, rather hard to the touch, and incapable of being returned into the abdomen or di- minished by pressure, neither was it enlarged by the crying of the child. The tumour was directed obliquely towards the labium of the same side, but did not quite reach to it. The child died from pneumonia, when it was found that the tumour was a real hernial sac, containing the left ovarium, with the fimbriated extremity of the Fallopian tube, a little reddened and swollen. These had descended and passed through the inguinal canal and ring—which latter was much larger than it usually is in the female infant—and were contained in a sac formed of a prolongation of the peritoneum, with the cavity of which it communicated. There were no convolutions of intestine adhering to the surrounding parts;—the right ovarium was in its usual situa- tion;—the round ligament of the uterus on the side at which the ovarium had descended, was much shorter than that on the opposite side, and terminated in the labium by an aponeurotic expansion, in- stead of losing itself in loose filaments, as usual. Hence, it Avould appear, that the shorter and more firmly attached ligament had first caused the uterus to incline towards the left side of the bladder, and then drew with it the ovarium through the inguinal ring. In the treatment of congenital inguinal hernia, the same objects precisely are to be had in view, as in the treatment of that of the um- bilicus, namely, to retain permanently the protruding bowel within the cavity of the abdomen, and to favour the natural closure of the ring. The child should be kept as tranquil as possible; it should be restrained by every means in our power from violent paroxysms of crying, and from all exertion likely to increase the protrusion. HERNIA. 705 A\ hen the hernia is present at the period of birth, or appears soon after, it should be at once reduced and a temporary bandage applied, with a small compress upon the abdominal ring. But little compres- sion, however, should be at first resorted to, and the bandage and com- press should be frequently changed, as well from a due attention to cleanliness, as to prevent the irritation of the skin, which would other- wise speedily result from their being constantly wet, and soiled by the natural discharges. From the smallness of the pelvis, before the end of the first year, and the difficulty of keeping the straps from being continually wet, and causing, in consequence, chafing of the parts with which they are in contact, it is scarcely possible to get any truss to fit, or to keep it on sufficiently constant, previous to that period. We have seldom seen much good result from a truss, or any other retentive apparatus, ex- cepting a simple bandage and compress, before the third or fourth year. Attention should be paid to preserve the boAvels of children affected with hernia freely and regularly open. If the hernia should become the seat of inflammation, indicated by increased tumefaction, pain, and tenderness upon pressure, leeches should be immediately applied, in numbers adapted to the age and strength of the child; the warm bath should be employed; the tumour covered with a light emollient poultice, and the bowels freely evacuated by castor oil or mild laxative enemata. Should the hernia become strangulated, which is a rare occurrence in young children, an operation will become necessary; provided we are unable to procure a reduction of the tumour by the ordinary means. We have cases on record in which the operation was performed by Mr. Curling, in a boy twenty-one months old, (London Med. Times, 1853,) and by Mr. Rayner, in an infant seven weeks old. In the latter case there was stercoraceous vomiting. In both instances the operation was successful, and the children revived. (London Lancet, 1857.) Fergusson has operated on an infant only seventeen days old. Besides the herniae resulting from the escape of a portion of the bowels at one or other of what are termed the natural openings in the walls of the abdomen, they may also be produced by a congenital deficiency in the parietes of this cavity. This usually occurs near the umbilicus, and on the median line. The integuments are sometimes wanting around the umbilicus, and the sac, enclosing a portion of in- testineris formed by the base of the cord alone; this covering is some- times so thin that the intestine may be seen through it. In a case of this kind, a permanent occlusion of the umbilical opening was pro- duced by reducing the intestines, the return of which was prevented by an assistant compressing the cord close to the abdomen; when a compress, formed of circular pieces of leather spread with adhesive plaster laid one upon another in a conical form, was placed upon the navel;'the skin upon each side of the aperture was brought into con- tact one lip slightly overlapping the other, and the whole was secured by a linen belt with a thick quilted pad, of a circular form applied over the navel. The bandage was renewed occasionally. By these 45 706 CONGENITAL AFFECTIONS, ETC. means, the intestine was securely retained within the abdomen, and at the expiration of a fortnight after the separation of the funis, the aperture at the navel was so far contracted, that not the least protru- sion was occasioned even by the crying of the child. This case will sufficiently indicate the general plan upon which the irregular herniae, occurring during infancy, are to be managed: of course, slight modifications will be required in particular cases, which the good sense of the practitioner will readily suggest. Early and judiciously treated, nearly all of these herniae may be permanently re- moved ; whereas, if neglected or improperly managed, they may entail a serious infirmity that will last as long as the individual lives. Arrest of the Testicle.—As closely connected with the subject of con- genital inguinal hernia, a feAV words will be proper, in this place, in relation to a not unfrequent occurrence, from which we have repeatedly seen a very considerable amount of suffering result; we allude to the arrest of the testicle at the abdominal ring, or in the groin, in its pas- sage from the abdomen. In this situation, it frequently becomes in- flamed, which, after causing severe pain, sometimes of several days' continuance, attended with considerable febrile reaction, and occasion- ally with tension and tenderness of the abdomen, nausea, or vomiting, obstinate constipation, and the other symptoms of peritoneal inflam- mation, produces, in the groin, or at the ring, a small, intensely red tumour, exquisitely painful to the touch, and upon every motion of the patient's body; in this, suppuration, sooner or later, occurs, forming an abscess of considerable size. This inflammation is often attended with complete disorganization of the testicle. The treatment consists in leeching, warm bathing, and emollient poultices to the groin, laxatives by the mouth, and gentle purgative enemata. The child should be kept as much as possible at rest, and as soon as an abscess forms it should be opened. 12.—Vaginal Hemorrhage. In many cases, a discharge of red fluid blood takes place from the vulva of the new-born female infant, and continues, without interrup- tion, for several days or even weeks after birth. This sanguineous discharge is unattended by redness, swelling, or any other indication of the existence of the least degree of irritation in the vagina, or ex- ternal parts of generation; nor do the functions and general health of the child appear to suffer any derangement. Billard has twice observed effusion of blood in the form of clots into the cavity of the uterus in female infants who have died soon after birth. M. Mallat mentions the case of a child who had some days after birth, vulvar hemorrhage, followed by the formation of a vaginal clot, which was drawn out by the mother at the end of two weeks. It was at- tended by intumescence of both mammary glands; all disappeared by the end of ten days. Dr. Camerer has observed a similar case, four days after the birth, at the full term, of a little girl; some drops of blood escaped from the vulva, and the flow did not reappear: five days afterAvards, the breasts became for a short period swollen; otherwise the child remained in good health. Barrier cites a precisely similar (EDEMA OF THE PREPUCE. 707 case. Lastly, Ollivier, of Angers, appears to have observed this he- morrhage in a number of infants at the breast. He states that the blood is red and fluid, escapes for one or two weeks or longer, and then ceases spontaneously Avithout the health of the child suffering.— (Bouchut.) It is very difficult to understand the cause of this discharge. The whole of the mucous surfaces are, it is true, during the early period of infancy, in a state of extreme vascularity, amounting often to perfect hyperaemia; but we can trace the excretion of blood by the vaginal membrane of the infant to no very evident exciting cause. The he- morrhage, in these cases, has been attributed by Ollivier, of Angers, to the same physiological cause which, in after life, produces the cata- menial discharge—nature appearing to anticipate, in some degree, the establishment of a function which is fully developed and regulated, * only, at a much later period of life. This suggestion would be more plausible were the discharge in the infant, instead of appearing only once for a few days, to recur repeatedly at regular or nearly regular periods. The hemorrhage always ceases of itself, and requires no particular treatment; the preservation of perfect cleanliness by repeated ablu- tions of the vulva will, of course, be necessary. The alarm and anxiety which it almost invariably excites in the mother, and those about the child, should be quieted by an assurance that it is unattended with danger. In no instance, so far as we are aware, certainly in none that has fallen under our notice, has any in- convenience resulted from it; nor has it ever continued beyond the first few weeks after birth. 13.—(Edema of the Prepuce. The cellular structure of the prepuce, in the male infant, is occa- sionally the seat of serous effusion, by which this part becomes some- times enormously distended, and very hard to the feel: in a feAV in- stances, we have found the whole of the integuments of the penis to be similarly affected. When the prepuce is at the same time retracted behind the glans penis, a species of paraphymosis is produced, and we have known considerable difficulty to be experienced in the passage of the urine, from the stricture upon the urethra which is thus occa- sioned. A similar difficulty may also result, when the tumefied parts envelop the glans, from the closure of the prepuce: ordinarily, how- ever, the intumescence gives little or no trouble, and is unattended with pain or suffering, and generally disappears spontaneously. We have known it, however, to continue for a long time, with little or no abatement. * , ,. Although we have arranged oedema of the prepuce among the dis- eases occurring within the month, it is by no means confined to this period; we have met with it frequently in children from one to six ^ThVcauses of this affection it is, in many cases, somewhat difficult to trace' It would appear to be occasionally produced by an irrita- tion seated within the urethra, as a stone sticking in the canal, or a 708 CONGENITAL AFFECTIONS, ETC. small splinter of wood or fragment of straw, introduced by the child. In one case, we saw it produced by a portion of thread that the child had wound round the end of the penis. It is occasionally connected Avith an erysipelatous affection of the integuments of the penis and scrotum, and not unfrequently we have found it accompanied with an herpetic eruption around the external skin of the prepuce at the point of duplicature. In some cases it is attended by a discharge from within the prepuce, resembling a strong lather of soap, or the froth of milk; this is evi- dently caused by the retention of the natural discharges of the part, rendered perhaps more copious from the irritation of the urine, which often fills the cavity of the prepuce before it is discharged externally: the discharge almost invariably disappears as soon as the tumefaction subsides. In the treatment of this affection, if the tumefaction be not very extensive, and it presents no difficulty or impediment to the discharge of the urine, little else is required than to wash the part frequently with camphorated spirits, and an equal quantity of water, or with two parts of the aqua camphorata and vinegar, or to envelop the prepuce in crumb of bread moistened with a weak solution of the acetate of lead. In all cases it will be proper to examine the urethra, and if a stone or other foreign substance be found in the passage, to extract it. If the oedema be very extensive, and the free discharge of the urine is interfered with, the best plan is to slightly scarify the skin at the most depending portion of the tumour, and foment it freely with tepid water. When connected with an erysipelatous inflammation of the penis and scrotum, this should be treated by its appropriate remedies; and in cases in which an herpetic eruption is present, the application to this, night and morning, of a little of the unguentum nitratis hydrar- gyri, diluted with an equal quantity of fresh hog's lard, we have found to be generally sufficient for its speedy removal. 14.—Cohesion of the Labia and Nymphae. In female infants, there is, occasionally, an adhesion of either the labia or nymphae; but much more frequently of the latter. This co- hesion may be congenital, or occur some time after birth. The cohesion of the labia, when present, is easily detected. In some cases it is so slight as to give way upon the mere separation of the labia; in others, it is produced by a very firm but delicate and trans- parent membrane, extending across from the inner surface of one labium to that of the other, for the division of which, the aid of the knife will become necessary; in other cases, again, the adhesion of the labia is more intimate and extensive, and requires a cautious use of the knife for its removal: finally, there may occur a complete oc- clusion of the external orifice of the vagina, which is usually con- nected with a deficiency of some one or all of the internal sexual organs. In all these cases of cohesion of the labia, excepting the last, the sooner it is removed the better; but when a complete closure of the HARE-LIP. 709 vagina happens from a congenital and perfect fusion of the two labia, nothing should be attempted previously to puberty, unless Ave are able to determine with certainty that the vagina or uterus is not want- ing, inasmuch as the child might otherwise be subjected to a severe and fruitless operation. By waiting, however, until the period of pu- berty, we shall then be able to decide with tolerable accuracy, as to the existence or non-existence of the internal organs, and consequently, as to the propriety or non-necessity of an operation. Adhesion of the nymphae is much more common than cohesion of the labia, and requires for its detection a much closer inspection. When the nymphae cohere, upon the separation of the labia, they are extended in such a manner as to form a flat, continuous covering to the origin of the vagina, and by the blood being pressed out of their tissues when they are thus put upon the stretch, they become pale, and scarcely to be distinguished from the surrounding surface; hence, at first view, it appears as though the nymphae were wanting, and there existed no vagina; but by gradually approximating the labia, the nymphae assume their usual form and situation; a probe may also be passed behind them, and if the cohesion was not congenital, we may learn from the nurse, that the opening into the vagina was the same, at first, as it is in other infants. Cohesion of the nymphae, the same as of the labia, may often be destroyed by the mere separation of the labia; or a probe being passed behind the coherent nymphae, and made to bear upon the line of juncture; this may often be gently torn asunder, by merely draw- ing the instrument towards us; in some cases, however, the adhesion is so intimate and firm as to require the aid of the knife. Care must always be taken by the interposition of a portion of soft linen, moist- ened with sweet-oil, or fresh lard, to prevent the divided surfaces from again adhering. Simple cohesion of the nymphae should be remedied at an early period. The longer it is allowed to continue, the more difficult, in, general, does its removal become. 15.—Hare-Lip. It is not our province to enter into a description of the several" forms of hare-lip, nor of the surgical operations by which they are to be remedied. The only question in relation to them we propose to ■ notice, is, at what period should any operation be performed. This question will be often put to the physician, and it is important that' he should be able to answer it understandingly. As the deformity is always considerable, a natural feeling on the ■ part of the parents urges them to desire its early removal, and, in many cases, an immediate operation is absolutely necessary, in order ■ to preserve the life of the little patient—the abnormal division of the • lip complicated, perhaps, with a division or deficiency of the bony^ palate preventing the child from sucking. Here, whatever may be the risk attendant upon an early operation, it must be encountered, as the removal of the deformity is the only means we have of saving the infant from a lingering death from inanition. If the deformity, how- 710 CONGENITAL AFFECTIONS, ETC. ever, does not interfere with suckling, we believe it will be better, in all cases, to defer the operation until the child has attained an age when it will be attended with less danger of inducing convulsions, or other dangerous consequences, and when there is a greater chance of its proving successful. The question, nevertheless, still presents itself, how long it is proper to wait before performing the operation, or, in other words, Avhat is the earliest period at which it may be undertaken, without danger to the child, or of its failure in the removal of the deformity. The end of the first or second year is the time usually adopted for the ope- ration. A much earlier period, however, has been recommended by Dr. Houston, as the most suitable for its safe and efficient per- formance, and several cases are adduced by him to prove the resi- lience of a young infant, under the operation, and the strength of its reparative powers. The age which the gentleman just referred to considers the best for undertaking it is about the third month:—he has never seen convulsions follow its performance at this age, and he knows of no other evil consequences, that the young infant is liable to, to which it is not liable when a year or two older. Dr. Hullihen, of Wheeling, Virginia, is decidedly in favour of ope- rating early. He states that he has operated on thirteen cases before dentition had commenced; three of the infants were only four weeks old. He remarks, that he has yet to witness the first untoward event, or the slightest unfavourable indication resulting from the operation when thus early performed. Paul Dubois, in a paper read before the French Academy of Medicine, in May, 1845, adduces his experience in favour of an early operation for hare-lip. He details a number of cases operated on by himself or his friends, at intervals varying from a few minutes to several days or weeks after birth, all of which had proved completely successful. Dr. Dawson, in a paper in the Dublin Medical Press, for 1842, advocates the same practice, and relates two cases, one of a child four days old, and the other of a child seven hours old, in which he operated successfully. Dr. Mason Warren (Amer. Journ. Med. Sciences,) has frequently resorted to the operation twenty-four hours afterbirth, and with better success than in older children. Dr. Anselon (Union Medicate,) af- firms that a long experience has convinced him that the practice of early operating is the best. _ Guersent, the younger, agrees with Dubois in believing that the best time for the operation is immediately after birth; and that if this favourable opportunity be allowed to pass by, it is better to wait until the eighth, tenth, or twelfth year. ^ Malgaigne has operated nine hours after birth, on a child with simple hare-lip, complicated with a wide fissure of the palate, and of the alveolar process. The operation succeeded perfectly, but the child died on the sixteenth day, from diarrhoea and aphthae. The cicatrix was found to be admirable, and the separation of the bones was so much lessened, that, had death not occurred, the fissure would un- doubtedly have been quite obliterated. Baudon has operated, and with success, in a case of double hare-lip and fissure of the palate, in an in- CLUB-FOOT. 711 fant aged four days. He operated first on the right, and at the end of a fortnight on the left side. Andrew Nolan records (Dub. Med. Press, 1853,) a successful case of operation for single hare-lip on an infant six hours after birth; and Bateman (Med. Times, 1854,) on one only four hours after birth. Mestenhauser, of Raaste, in Silesia, during a practice of thirty-two years, operated for hare-lip eighty times, and prefers the children to be at least ten or twelve weeks old before it is undertaken. Dieffenbach has operated upon a thousand cases, and states that, while union has taken place at every age, from a few days after birth up to extreme old age, it is better to wait until dentition is accomplished, as when performed very early the cicatrix is apt to yield as growth advances. If it were not for the danger supposed to attend upon an early operation, there would be no question at all as to the importance of remedying the defect, at the earliest age possible; the effectual re- moval of the deformity, and the inconvenience attendant on it, being then more easily and certainly effected than when the operation is de- ferred to a later period. We are persuaded with Dr. Houston, that the dangers and difficulties attendant upon early operations are, how- ever, greatly overrated. Several instances of the successful removal of simple hare-lip, at ages varying from a few days up to as many months, have been recorded within the last few years, and we have so repeatedly seen the operation performed in children, from six weeks to four months old, with perfect success, and without the occurrence of the slightest untoward symptom, that we feel it our duty to recom- mend its adoption very generally at the termination of the third month, or, where the deformity is very great, at even an earlier period. The advantages of operating at a very early period, especially in cases complicated with a more or less extensive fissure of the palate, are very clearly pointed out by Henry Smith, Esq., in the number of the Medical Times for March, 1854. 16— Club-foot— Talipes. Children are frequently born with various deformities of the feet, to which the popular denomination, club-foot, has been applied. The foot may either be turned outwards, so as to allow its inner margin to rest upon the ground, (valgus, talipes valgus;) or inwards, its outer edge being directed to the ground, (varus, talipes varus;) or the heel may be drawn up, so as to direct the toes downwards, and extend the loot, causing it to approach a right line with the \eg (pes equinus, talipes equinus.) A fourth variety has been described by Little, in which the foot is flexed upon the leg, and the heel only is applied to the ground This distortion is caused by a contraction of the muscles in front of ^Thete deformities are, in general, apparent from birth, but increase in extent as the child grows older, particularly as it approaches the period when it should walk. If they are not remedied a an early period, the child is, in general, doomed to lameness and deformity for tbp residue of its life. , . Much attention has been directed of late years, to the investigation 712 CONGENITAL AFFECTIONS, ETC. of the pathology and mode of remedying the various congenital dis- tortions of the feet, by several distinguished surgeons and physicians of Europe and America. Their immediate cause would appear to be a shortening of the gastrocnemii and other extensor muscles, or of those Avhich rotate the foot outwards. The pes equinus, or extended foot, from shortening of the extensor muscles, is probably the most common form of distortion, the twisting of the foot inAvards being produced secondarily, in consequence of the natural inclination of the os calcis, and the normal action upon this of the gastrocnemii, causing the foot to turn someAvhat in that direction. As the turning inwards of the foot increases, the plantar muscles, liga- ments, and aponeuroses become more and more contracted, the de- formity increases, and first, the side of the foot, and finally, its dorsum, is applied to the ground; the bones of the tarsus are at the same time throAvn into an unnatural position, and after the child begins to walk, being subjected to continual pressure, become altered in shape, in con- sequence of which the deformity, which in the first instance might, Avith due care, have been removed, becomes permanent. The twisting of the foot outwards, which is of comparatively unfrequent occurrence, is produced by a shortening of the abductor muscles. The remote cause of club-foot is to be referred to a defect in the nerves distributed to the muscles of the leg, in consequence of which there is a want of balance in the development and action of the anta- gonist muscles. Distortions of the feet have been met with in foetuses of from three to five months, with co-existing deficiencies, and malformations in the brain and spinal cord; in anencephalous and hemicephalous em- bryos, the hands, as well as the feet, have exhibited similar distor- tions. Children born with a deficiency or disease of the spinal mar- row, are also very commonly affected with club-foot; the deformity is hence a common accompaniment of spina bifida. It may also take place subsequent to birth, when, from disease of the spine, temporary paralysis of the muscles of the extremities is produced, and on a par- tial recovery taking place, the flexor muscles acquire more power than the extensors. Distortions of the feet are said to be hereditary, in consequence of the transmission of a morbid irritability of the nervous system, pre- disposing to convulsive and spasmodic contractions of the muscles. We have no doubt that this may occasionally be the case, but of all the numerous instances of club-foot that have fallen under our notice, no one occurred in children born of parents, either of whom Avere simi- larly affected. In the treatment of club-foot, the grand object to be effected is to extend those muscles, the inordinate contraction or shortening of which has produced the distortion, and to increase the action and poAver of their antagonists. The first must be effected by mechanical contri- vances, adapted to preserve the feet in their natural position, and counteract the force by which they are draAvn out of it; and the se- cond, chiefly by friction of the limbs, and a well-conducted general hygienic treatment, calculated to reduce the excitability of the ner- vous system, and to give tone to the body generally. INDURATION OF THE CELLULAR TISSUE. 713 A variety of mechanical contrivances have been suggested, in the form of splints, stocks, and shoes, to retain the foot in its natural po- sition, and counteract the distorting force. It is not Avithin the province of the present work to present a de- scription of these several apparatus, or to enter into a discussion of the question, as to Avhich of them is the best adapted to effect the object for which they are employed: Ave would merely remark, that whatever contrivance we adopt, simplicity and lightness are of the first import- ance, as well as such a form as will prevent any undue pressure upon the part that is made the point d'appui. The form of the apparatus will vary somewhat, according to the species and degree of distortion, in order to enable it to act effectually upon the shortened muscles, which should be gradually and gently, but constantly extended. When the shortening of the muscles is very considerable, or the force they exert in drawing the foot in an unnatural position too powerful to be overcome by any mechanical means that it would be prudent to employ, it is probable that a division of the tendons may be advantageously resorted to; but we must recollect that such divi- sion will not be sufficient to effect a cure: in no case can this be ac- complished without a long-continued use of appropriate mechanical means—while the latter alone, will, in most cases, be fully adequate to produce a complete removal of the deformity, if commenced with sufficiently early, when the parts involved in the deformity are still sufficiently flexible, and the ligaments, aponeuroses, and bones of the foot have undergone no important changes, and when the confinement of the foot can be borne with greater ease than at a later period. 17.—Induration of the Cellular Tissue. INDTJRCISSEMENT DU TISSU CELLULAIRE-CEDEMA CELLULARIS—SKIN-BOUND—SCLEREMA. A peculiar hardness and tension of the skin of the lower extremities, often of the trunk, and occasionally of the face, with coldness and a yellowish or wax-like appearance, or a pale red or purple colour of the affected parts, are often observed in infancy, during the first few days or weeks after birth. The disease sometimes commences at the feet, but more generally about the pubic region, and inner surface of the thighs; from whence it gradually extends over a considerable portion, and in some cases, over the whole of the surface of the body. The affected parts become swollen, hard, and incompressible; the skin is tense, and adheres firmly o the parts beneath, so" as not to allow of its being pinched up or moved oyer them; it is at the same time dry, harsh, and decidedly cold to the touch, and, in some cases, presents a yellowish, or waxen abearance- whilst in others, it is of a pale red, purple or livid hue. P?rthe atter case, the swelling is the most considerable; whilst the firmness and tension of the parts are the greatest when the skin as- sumes a pale yellowish colour. The diminution of temperature is always remarkable; and Avhen the disease extends over the greater part of the surface, the body is acted upon by external heat in the same manner as so much dead matter. 711 CONGENITAL AFFECTIONS, ETC. M. Roger (Archives Gen. de Med.) states that in 19 cases he found the temperature to be less than 91°, in 7 it sank below 78°, while the mean of 52 observations was only 87*8°. In extreme cases the tem- perature may sink to 77°, 74°, 72°, and in one instance it was as low as 71*6°. According to M. Roger, a diminution of temperature pre- cedes the occurrence of induration, or at least exists in a very marked degree while the induration is still very slight. The reduction of the temperature is always in direct proportion to the degree of induration, and consequently forms an important element in the prognosis. Re- covery took place in only a single case after the temperature had sunk below 90-5°, though life was often prolonged for several days, not- Avithstanding a much greater reduction of temperature. The slowness of the pulse and respiration likewise bear a direct relation to the low- ness of the temperature and degree of induration, the former having sunk even as low as 60, the latter to 16 or 14. The infant labouring under this disease refuses to suck; its coun- tenance becomes pale and contracted; it is restless; appears unable to make a full inspiration, or cry out, but almost constantly makes a pe- culiar kind of moaning noise, which has been compared by Dorfmuller to the cry of young mice. Deglutition appears, in general, to be at- tended Avith difficulty, and is sometimes impossible. The pulse is usually small, rapid, and irregular; and there is always more or less disorder of the alimentary canal, with frequent discharges of a bright green, or whitish, or clay-coloured appearance. There is generally a deficient secretion of urine; though to a greater extent in some cases than in others. Respiration becomes gradually more and more difficult, until death ensues; usually before the fourth day, but sometimes not until a much later period. In some cases, tetanic spasms supervene towards the close of the disease; the head and trunk being occasionally bent rigidly backAvards, and the jaws firmly locked. The disease is unattended, throughout, with any degree of febrile reaction ; though in some cases a degree of febrile excitement may pre- cede its occurrence. Occasionally it is accompanied with a jaundiced condition of the entire surface. Induration of the skin in infants is an affection which is always of a dangerous character; generally terminating fatally, within one, two, or, at farthest, three weeks. In slight cases, in which the morbid con- dition of the integuments is of limited extent, sometimes, in a few days, the respiration of the infant improves, the parts affected increase in temperature, and become softer, and by slow degrees an entire recoA'ery takes place. On the examination of the bodies of infants who have died of indu- ration of the skin, the subcutaneous cellular tissue is usually found to be thickened, condensed, and loaded with serum. It is often of a red- dish or granular appearance, not unlike a portion of hepatized lung. In many cases the adipose substance is firm, hard, and indurated; con- sisting of solid fatty granules, easily detached. The tissue is of a deep yelloAv; usually from half a line to three lines thick, and sometimes below it there is a gelatinous deposit. The indurated tissue is traversed INDURATION OF TnE CELLULAR TISSUE. 715 by numerous veins gorged with black blood. (Elsaesser.) This state of the adipose tissue may occur with or Avithout infiltration of the cel- lular tissue. The whole of the tissues are engorged with venous blood, with which every organ is unusually loaded. The induration seldom extends below the chorion. The muscles are pale, as if infiltrated, and in those of the buttock small deposits of blood have been found. (Elsaesser.) The most frequent lesion of the viscera is inflammation of the ali- mentary canal, with more or less morbid change of the liver. In the forty-nine fatal cases observed by Elsaesser, (Archiv. GSn.,) the veins and sinuses of the brain were mostly filled with dark diffluent blood, and effusion was found in the ventricles or at the base. In one- tenth of the cases, lobular pneumonia was present, and in a third, por- tions of the lungs were permeable to air. Intestinal lesions and hy- peraemia of the abdominal viscera were common, and in eight cases, peritonitis was present. The lymphatic glands are frequently found indurated and enlarged; more especially those of the mesentery. In general, the serous infil- tration is not confined to the subcutaneous cellular tissue; it has been observed in the subperitoneal tissue, in the cavity of the mediastinum, and in the plexus choroides: we have met with it in the interlobular structure of the lungs, at the base of the brain, and along the whole of the spinal marrow. When free incisions are made through the skin, the serum gradually flows out, and the swelling and hardness of the diseased parts disappear, excepting in those cases in which there co- exists with the serous infiltration a hardening of the adipose tissue. (Andry, Auvity, Denis, Duges, Wolff, Billard.) Induration of the skin usually occurs soon after birth; occasionally it is congenital. It is more frequent in winter than in summer. It prevails to the greatest extent in hospitals appropriated to the recep- tion of children, and among the offspring of the impoverished classes of society, who inhabit unhealthy localities, and small, ill-ventilated, and filthy habitations. It has been observed by Caspar, Billard, Wolff, and others, that infants reared by the hand are more liable to the dis- ease under all circumstances, than those who are nourished at the brpRSt Although the disease may attack infants apparently in perfect health, yet, in the great majority of instances, those who become the subjects of it are observed to be feeble or languid from birth; or to labour under more or less disorder of the alimentary canal previously to the occurrence of the cutaneous affection. We should hence be in- clined to refer the disease to gastro-intestinal disease, and a generally languid and debilitated condition of the organism, the result of conta- cted air, and improper or unwholesome diet; and probably in some instances, an additional morbific cause, a cold and humid atmo- ____' „,,„ \n *♦<= production. The connexion of the disease initiated air, ana imprupei «» «....-------- \\ j I -j V some instances, an additional morbific cause, a cold and humid atmo- sphere may concur in its production. The connexion of the disease with ^/intestinal irritation had already been noticed by Denis, and it is further proved, by the fact of the frequency with which, in post- mortem examinations, inflammation of the mucous membrane of the digestive organs is detected. 716 CONGENITAL AFFECTIONS, ETC. The causes of the disease appear to differ but little from those which give rise to infantile erysipelas, to which it has a very close re- semblance. It is often attended with a condition of the skin not very dissimilar from that which occurs in erysipelas; while the latter is fre- quently associated with considerable induration of the surface, for some distance beyond the inflamed margin. The morbid condition of the surface is evidently dependent upon the simple infiltration of the cellular membrane with a serous fluid: this is proved by the appearance of the subcutaneous tissue after death, as well as by the fact, that when, during the lifetime of the patient, in- cisions are made into the indurated parts, and pressure is applied, the serum is discharged, and the swelling, tension, and hardness, entirely disappear. It would appear, therefore, that the disease is, in fact, a genuine oedema; the extreme hardness of the skin resulting from the less loose and yielding nature of its tissues in early infancy. The oedema has been referred, by Billard, to a languid circulation, the result of venous plethora, and the action of such external agents as have the effect of suspending the cutaneous transpiration, and thus favouring the accumulation of serosity in the subcutaneous cellular tissue. When the oedema is general, and the venous congestion exists to a very great degree, all the organs abundantly supplied with cellular tissue have their functions more or less disturbed, in consequence of the infiltration of serum. Thus, the glottis becoming ©edematous, while the lungs are overloaded with venous blood, the cry of the infant is rendered painful, acute, and smothered. The coldness of the sur- face is the result of the languid state of the capillary circulation, the deficient oxygenation of the blood in the lungs, and the general debi- lity of the patient. All this is no doubt true, so far as it regards a certain class of cases: in others, however, which have fallen under our notice, the venous con- gestion, and consequent serous infiltration of the subcutaneous cellular tissue, were evidently the result of an imperfect distention of the lungs at birth, and the consequent production of the condition denominated atelectasis by Jbrg. The probability of this as a frequent cause of the disease was suggested by Dr. Maunsell: its certain occurrence in se- veral cases, we have established by the result of our autopsies. M. Roger and Elsaesser notice the frequency with which partial consolida- tions of the lungs are met with in the induration of the cellular tissue of infants. This pulmonary affection differs no doubt essentially from true inflammation of the lungs. While in the latter the temperature rises even to 105°, in that peculiar condition of the lungs which ac- companies induration of the cellular tissue, it sinks as low as 71°, the pulse and respiration at the same time being slow, in place of accele- rated. We believe that there is still another class of cases, by no means unfrequent, in which the serous effusion into the subcutaneous cellular tissue is the result of a subacute inflammation of the latter, consecu- tive, most frequently, to irritation of the alimentary canal. There are, evidently, two distinct varieties of induration of the skin; INDURATION OF THE CELLULAR TISSUE. 717 that from serous infiltration of the cellular tissue, and another from induration or concretion of the adipose matter. The latter may exist with or without general infiltration of the subcutaneous cellular tissue. It is usually seated in the cheeks, nates, calves of the legs, or back, and occurs with or without the derangement of the circulation or re- spiration, and is seldom attended with symptoms of a nervous cha- racter. (Billard, Rostan, Wolff, Elsaesser.) When the adipose tissue is alone diseased, the affected parts are but little swollen, and have the firm feel, and yellowish-white appear- ance of wax, or concrete suet; in the latter stages of the disease they are said to be sonorous upon percussion, and are perfectly cold to the touch. In these cases, upon dissection, the subcutanous adipose sub- stance is found hardened and condensed like suet, with the skin con- tracted, and firmly adherent to it. In this country, induration of the skin is an extremely rare disease. Although connected, as physician, for eighteen years, with one of the largest medical charities, perhaps, in this country, Ave have met with but twelve cases of the disease during that period. In the hospitals for children, in Europe, it is, hoAvever, of more common occurrence. In the Foundling Hospital of Paris, 045 cases occurred between the years 1808 and 1811; of which number, 5G7 terminated fatally; and in 18*26, there occurred in the same institution 240 cases, of which fifty died. The disease is described by the generality of the writers on the sub- ject, as being but little under the control of medical treatment, and as terminating fatally in the majority of cases. The condition of the skin, however, appears to be of less importance than that of the sys- tem generally; and death more seldom results, according to Billaid, from the morbid state of the integuments, than from the serious dis- eases of the internal organs—the alimentary canal, the lungs and the brain—with Avhich it is commonly associated. When limited in extent, and occurring in infants possessed of some vigour of constitution, or even when general, but not of an aggravated character, and uncomplicated with severe visceral disease, it will often yield to very simple remedies. ...... •„ A The proper treatment of induration of the skin in infants will de- pend pretty much upon the particular character of each case. In some, there is no doubt that the general plethora or local accumulations of blood, will demand the employment of leeches, cups, or even general blood-letting, and gentle purgatives; and that a cautious use of these remedies will' be attended wkh the best effects. Friction o ^ he sur- face with the hand, or warm flannel, and the use of flannel garments next the skin, are all-important remedies in the generality of cases, and should noi be neglected. Blisters have been «™?J™™™^ ed by Richter, and according to the experience of Dr Eberle, when early applied to the affected parts, they would appear to remove the sanguineous engorgement of the subcutaneous tissues, promote the ab- !o Ption of the ffused serum, and prevent its undue accumulation We havPe in several instances, seen good effects result from a well-timed biter—it should be kept on about three hours; immediately upon its removal, the part being covered with a large emollient poultice. 718 CONGENITAL AFFECTIONS, ETC. The exhibition of an emetic of ipecacuanha, for the purpose of re- lieving the air-passages from accumulations of mucus, and unloading the vessels of the lungs, has been recommended; and we have no doubt that it will prove, in most cases, highly beneficial. The vapour-bath has been considered by some practitioners one of the most effectual remedies that can be employed in this disease; and when it is dependent upon subacute inflammation of the subcutaneous tissues, or gastro-intestinal irritation, will no doubt prove advan- tageous; but it is not a remedy adapted to the generality of cases: in many, dry heat, and friction of the surface, as directed by Baron, will have a far better effect. In some cases, the respiration, during the continuance of the patient in the bath, is painfully accelerated, and congestion and effusion in the lungs or brain have, it is asserted by Billard, occasionally followed its use. Incisions through the skin, at the seat of the disease, have been sug- gested by Andr}', Wolff, and others, as a means of relieving the over- loaded state of the subcutaneous vessels, and of giving exit to the se- rum distending the areola of the subcutaneous cellular tissue. We are not aware that this procedure has been practised to any great extent; nor are we acquainted with the results of the cases in which it has been tried: we can, however, see no valid objection to it. In cases attended Avith derangement of the alimentary canal, small doses of calomel in combination with ipecacuanha, three or four times a day, with the occasional interposition of a dose of castor oil and tur- pentine as recommended in infantile erysipelas, should be administered. If, however, the symptoms indicate that the gastro-intestinal mucous membrane is the seat of acute or subacute inflammation, a few leeches should be applied to the epigastrium, or wherever the tenderness is most decided, and followed by large emollient cataplasms. Where there exists very great debility, wine whey, or even ammo- nia in combination with the aqua camphorata, with friction of the sur- face with camphorated spirits, or the oil of amber, followed by the ap- plication of a flannel envelope, will be the most ^appropriate treat- ment. 18.—Naevus. Children are often born with permanent spots or marks upon the skin, varying in extent, and very materially in their nature and im- portance. The whole of these have been generally included under the vague denomination of naevi materni. A very common form of naevus is that of a mole or slightly elevated tumour, differing in size in different cases; generally of a dark colour, and often covered thickly with fine, short, silky hair, of the same colour as the mole. These naevi may occur upon any part of the body, and Avhen seated upon the face or neck, or upon the shoulder or breast in the female, produce very considerable deformity. They often increase slowly in size, and acquire a darker colour, until towards puberty; after which period they commonly remain stationary for the re- mainder of life, and are unattended with pain or inconvenience. They are generally attributed to some alteration in the structure of the retc N2EVUS. 719 mucosum: their true nature does not appear, however, to be as yet well understood. It is not customary to interfere with them; they could certainly be dissected out without much difficulty, but the defor- mity resulting from this procedure would probably be as great as that it was intended to remove. Another very common form of naevus is a dark-red circumscribed stain, which generally appears upon one side of the face, and is some- times of considerable extent. It is perfectly superficial, and has been supposed to result from a simple dilatation of the subcuticular capil- lary vessels at the part affected: it would appear to us, however, rather to depend upon a local abnormal condition of the rete mucosum. Like the former, it sometimes increases in extent until about the period of puberty, when it undergoes no further change throughout the re- mainder of life;—being attended with no other inconvenience than its unsightliness. We have known it, however, to disappear entirely during childhood. It has been proposed by Frankel to diminish the deformity by tattooing the part affected Avith a white pigment. The naevus appears frequently in the for..a of a slight dilatation of the capillaries; in some cases superficial, and in others extending deeply into the mucous membrane of the lips. In some instances the dilated capillaries appear as tortuous, wide-spread lines, proceeding from a small round spot, like the legs of the spider from its body; in others, they form small, defined, granular tumours, of a bright-red co- lour ; in other cases, again, the naevus is composed of a congeries of venous capillaries, and is of a deep-blue, or bluish-red colour. These sometimes disappear before puberty; at others, they continue sta- tionary, neither enlarging nor diminishing during life. They are never troublesome, constitute but a very inconsiderable deformity, and, as a general rule, should not be interfered with. The most important of the naevi is that which appears in the form of a deep red-coloured, slightly elevated spot, which often rapidly augments in size, with a well defined margin, and a granular surface; it !s obliterated by pressure, but rapidly rises again when this is removed. It is formed of an erectile, vascular tissue, and it acci- dentally wounded, often gives rise to copious, prolonged, and dan- gerous hemorrhage. When seated near to an arterial trunk of any size, it pulsates powerfully beneath the finger and is attended by a thrilling purr, synchronous with the action of the heart. (Aneurism ^Variourp'ans have been proposed for the removal of the vascular DTtS" The application of cold and pressure (Abernethy.) This will frequently succeed when the naevus is small, and not disposed to in- crease rapidly in size, and when it is seated over a bone; but in those of larger*,?£ of rapid growth, and seated over soft parts, it is al- t0%f VacctSn over the surface of the tumour. (Hodgson.) This will frequently succeed: it is always, however, productive of aeon- Tid rable scar, and if ulceration or sloughing occur, as is sometimes the case, the scar is often large, and forms a very decided deformity in parts exposed to view. 720 CONGENITAL AFFECTIONS, ETC. 3d. Pustulation with tartar emetic upon the surface of the naevus (J. B. Brown—Gumming.) The same objections are applicable to this as to the preceding plan. 4th. Caustic. (Wardrop.) This will also repeatedly succeed when the vascular tumour is of small size, and inactive. A portion of ad- hesive plaster, with an orifice in its centre, of less diameter than that of the naevus, should be applied closely around the tumour. The kali purum is then to be rubbed upon the surface of the naevus, until slight discoloration takes place; the whole is then to be covered with adhe- sive plaster, and suffered to remain some days. When the tumour is flat, one of its largest vessels may be punctured, and a stick of the caustic, finely pointed, passed into the orifice, vinegar being imme- diately applied to prevent the too extensive action of the caustic. The caustic will not succeed in the removal of large, diffused, or deeply seated naevi; it cannot be applied in those seated in the immediate vicinity of the eye, and however carefully performed, is productive of an unsightly scar. 5th. Painting the surface of the naevus with iodine. Dr. S. Ed- wards has used it with success in two cases. He applies the iodine by means of a camel's hair pencil every alternate day; occasionally omit- ting it for three or four days when the skin became very irritable and rough. 6th. Ligature. (Bell, White, Lawrence.) There are seAreral modes of applying the ligature. When the base of the tumour is very nar- row, the simple ligature may succeed; but when the base was large, a needle armed with a double ligature may be passed beneath the tu- mour and one portion tied around each hemisphere, and tightened, as it becomes loosened by ulceration; or, two double ligatures may be passed beneath the tumour, one in the direction of each of the di- ameters, and the tumour strangulated at four different points by tying together the single ends of the ligatures nearest to each other; or a hare-lip pin may be passed under the naevus, and then a double liga- ture under that at right angles; the separate ligatures are then to be tied tightly, and twisted around the pin tAvice or thrice. In both of the latter methods, it is as well to divide freely the substance of the naevus above the ligatures. A new plan for applying the ligature has been proposed by Mr. Christopher, and practised by him in six cases with perfect success. (Lond. Med. Gaz., Dec, 1848.) A strong silk, half a yard long, one half of which has been dyed black by dipping it in ink, after being well waxed, is to be passed through the eye of a needle so as to leave the ends equal. The needle is then to be passed beneath the centre of the part to be removed. The liga- ture being divided in the middle, so as to leave the needle on the black portion, the latter is to be passed through the skin immediately below the part to be strangulated. The superior, or white half of the liga- ture being now armed with the needle, this is to be passed through the skin in an opposite direction to the black ligature, immediately above the part to be strangulated. The needle being removed, the two ends of the black loop that includes the inferior half of the naevus, are to be tightly tied, and then the two ends of the white loop, including the NJ3VUS. 721 •superior half of the naevus. The four ends remaining, two black and two white, are now to be tied alternately and tightly the one to the other. The whole mass to be removed is thus completely and entirely enclosed in a double circle, both from within and without, and is most effectually and permanently strangulated. We have seen the ligature often perfectly successful: it is generally, however, attended with con- siderable pain, and cases are recorded in which it was productive of convulsions. It is always tedious, and leaves, generally, a large irre- gular scar. According to Mr. Christopher, the plan proposed by him is productive of little pain, and in the cases in which he has put it in practice, it has been unattended by any untoward accident. A plan of applying a ligature subcutaneously to the naevus, and sub- jecting it to elastic tension, by means of a vulcanized India-rubber ring or band, has been described by Dr. Martin, (Med. Times, 1852,) and its beneficial results shown by the history of several cases in Avhich it was resorted to. M. Regal (Memoires de la Soc. de Chirurg. 1853,) has also pro- posed a modification in the application of the ligature for the destruc- tion of naevi. 7th. Setons. (Adams.) Twelve or fourteen threads passed through the tumour at different points without tying. This is said to succeed perfectly in the removal of the naevus. 8th. Ligature of the principal arterial trunk which supplies the naevus. (Travers.) This will unquestionably succeed in some cases, and in the more extensive and distinctly marked aneurism by anasto- mosis, is, in fact, the only operation that can be depended on: it is, however, a very serious one, and has been found repeatedly unsuc- cessful. In the ordinary forms of vascular naevi, it is unnecessary to resort to it. . 9th. A plan of treatment has been suggested by M. Hall, which is said effectually to remove these tumours, to be applicable in all cases, without reference to size or locality, to be without danger of hemor- rhage, and to be unattended with the inconvenience of ulceration or slou-rhincr, and consequent deformity. It consists m passing a mode- ratefy sfzed needle, with cutting edges, through the naevus so fre- quently as to induce adhesive inflammation with the deposit of lymph, and thus to obliterate and consolidate the vessels of which it is com- posed, yet so seldom as not to incur the risk of inducing sloughing. The needle must be passed in several directions from one point in the circumference of the naevus, to several points more or less opposite; near the surface, in the superficial arterial naevus, but more deeply in the d eper-seated capillar/naBvus. The operation is to be repeated at intervals of two, three, or four months, according to the state of ?he case and the progress of the cure. We know nothing, personally, ortle merits of this operation, never having seen it performed. 10th Excision. (Bell) This is the plan which we have invariably adopted in aU t^e krteriil n.vi that have fallen under our notice, an7 have repeatedly seen it performed by others It is said by W«droo to be frequently dangerous, from hemorrhage, and to have even proved fatal. We have never found any injury to result from it. 46 722 CONGENITAL AFFECTIONS, ETC. The incision through the skin should be made at some distance from the margin of the tumour, which should be dissected out beneath its base: but little hemorrhage has resulted in the majority of cases, and this Avas readily commanded by pressure: occasionally, however, one or two small arterial branches had to be secured by ligature. By approximating and securing the edges of the wound, a very small cicatrix is produced. 11th. Lafargue recommends five or six punctures to be made on and around the naevus, with a lancet dipped in croton oil, as in vaccina- tion. By each puncture a pimple is immediately produced, which be- comes, in thirty-six hours, a little boil. The several boils unite and form a painful, burning tumour, covered with white crusts, and re- sembling a small carbuncle. Two days afterwards the scabs separate, and in place of the naevus is seen an ulcer, which is to be treated on general principle's. M. Lafargue considers that it would be danger- ous to make more than six punctures on a very young infant, as the irritation and fever that result are considerable. Whatever operation is adopted, it is important that the child should have attained its third year previous to its performance, and at the same time be in tolerable health, and free from fever, or other posi- tive disease. If considerable pain, restlessness, or fever result from the operation, these should be treated by their appropriate remedies. 19.—Cysts of the Neck. Tumours of a cystoid character are occasionally met with on the front or sides of the neck, in new-born infants, or those of only a few months old. In numerous instances, they are unquestionably of con- genital origin, though occasionally, there is every reason to suppose, that they are developed subsequently to birth. They are met with alike in both sexes; and in well formed and perfectly developed chil- dren, as in those affected with various imperfections and deformities. They often increase in size with great rapidity, and by their pres- sure impede, to a greater or less extent, deglutition and respiration, and the circulation of the blood to and from the brain, while, by their bulk, they often interfere with the movements of the head. In one of the cases recorded by Professor Mutter, of .Philadelphia, (Med. Ex- aminer, vol. vii.,) the child died from oedema of the glottis, brought on, probably, by the pressure of the distended cysts, which were both large and numerous. The size to which these cystoid, or, as they are A-ery properly named by Von Ammon, (Die Angeborenen Chirurg. Krankheiten,) the hygromatous cysts, sometimes attain is enormous. Von Ammon describes and figures one in an infant fourteen days old, which extended from ear to ear, covering the whole front part of the neck, and reposing upon the chest. When situated, as in this case, on the centre of the anterior part of the neck, they are, in general, larger than when at the sides of the neck. Occasionally, the projection of the tumour outwardly is compara- tively slight, while it dips deeply beneath the fascia and superficial muscles of the neck. The boundaries of the cyst are mostly well defined externally. Its CYSTS OF THE NECK. 723 shape varies in different cases—being sometimes globular, at others pyriform, and at others again, extending irregularly in different di- rections. Its surface may be smooth and uniform, or lobulated. It may be firmly or loosely attached to the surrounding tissues, being in the one case almost immoveable, whilst in the other it may be readily moved from side to side, or raised upwards with more or less ease. Occasionally the walls and integuments of the cyst become so thin as to render it throughout, or at parts, translucent when it is vieAved against a strong light. The skin covering the tumour is usually unchanged in colour; occa- sionally, however, it is red, or of a bluish tint. In some instances, especially when the tumour was congenital, it is covered with numerous ramifications of small blood-vessels, which become distended when the child cries, but without any proper pulsation of the tumour, or any distinct vascular trunk running into it. Neither is it diminished in size by pressure. Although the tumour is sometimes very tense, still fluctuation can almost always be detected by proper manipulations, save in those cases where it has existed for some time, and its walls have become thickened or its contents are of a semi-solid consistence. The tumour is unattended with pain, nor does it evince any tender- ness upon pressure. There may be but a single tumour, or several may be present in the same case. Each of the hygromatous cysts may present but a single cavity, or it may be multilocular; or, the cysts may be compound- that is, consist of cysts developed within cysts. Instead of a common involucrum, the individual cysts composing the mass may be ^inc} from each other, and united or not, to each other externally. Of this latter arrangement a striking example is presented by Mr. Hawkins, who found many hundred of such cysts in the case of a child. (Med. Chirurq. Trans., vol. xxii.) The fluid contained in these cysts is commonly a pure limpid serum; sometimes it is gelatinous, thick, or viscid, or flaky. It may be co- lourless, or, as is often the case, reddened by the colouring matter of 1 The° parietes of the cysts vary in thickness and density in different cases, Bruch, (Zeitscrift fur Rationalle Medizm, vol vm.,) found them to be formed of the common integuments entirely unaltered. The inner lamina is more or less vascular, and its free surface presents often a reticulated appearance, the striae of which are perceptible to the touch, as well as to the sight. Sometimes, according to \\ ehrner who has given the best exposition of the facts known in respect to these cysts, as they occur in the new-born infant their inner surface has a flocculent or shaggy appearance. (Die Angeborenen, kysten-hy- "Te'hrtlTaie^at in children in whom these cysts are present, dea h may occur, at racing periods, from a few days to several months after birth, in consequence of their preventing, by their size and pre* sure the deglutition of food, impeding respiration, or interfering with he circulation of the blood to and from the brain, or from the occur- 721 CONGENITAL AFFECTIONS, ETC. rence, spontaneously, or from violence accidentally inflicted on it, of inflammation in the cyst. In many cases, however, the cyst, after attaining a greater or less development, remains stationary, causing no little deformity, but less inconA'enience than would be anticipated. Occasionally a spontaneous opening takes place in the cyst, at one or more points, through which its fluid contents slowly escape, allowing it to contract and become finally obliterated, and every vestige of it to disappear. Even after becoming entirely emptied, the cyst may, however, be again filled with fluid, and this occur again and agam. Occasionally, according to Fleury and Marchessaux, (Archives Gin. de Med. Vol. v.,) the cyst may open spontaneously into the cavity of the chest, or into the trachea or oesophagus. The researches of MM. Fleury and Marchessaux, show that two distinct species qf these cysts occur. The one being developed in the actual tissue or substan.ce of the thyroid gland, and is in some in- stances superficial, in others deep-seated. This form of cystoid tu- mour corresponds with the cellular and thyroidean serous goitre of Beck and Heidenreich; the hydrocele of the neck, of Manoir; the hy- dro-bronchoeele of Percy, and the encysted goitre of other writers. The second species of cervical cyst is developed in the common cellular tissue of the neck, at a greater or less distance from the thyroid gland. It is the hydrocele of the neck, of O'Beirne; the cystic tumour of Boyer and Dupuytren; the fibro-serous cyst of Delpech, and the hy- groma cellularis of Von Ammon, and other of the German writers. It is the latter species which appears to be most frequently met with in young children. The cysts of the neck in children are always to be vieAved as a de- formity, and serious inconvenience; in many cases they may, as we have seen, give rise to a fatal result. In their treatment, we may either proceed by puncture, followed by iodine frictions to the tumour, and compression, whenever this latter can be put in practice, or, we may pass through the cyst a slender seton composed of several threads of silk. The seton, however, is liable to cause extensive suppuration and severe general symptoms, which renders its use in young and delicate infants of doubtful pro- priety. Professor Mutter remarks that the operation of excision should be restricted to cases in which the cyst is small, circumscribed, and super- ficial, and where a small scar is not considered of importance. Under such circumstances, he considers excision to be the preferable operation. Repeated tapping with a small trochar, care being observed to com- pletely empty the sac of its contents, to prevent these from infiltrating into the cellular tissue, may be practised as a palliative treatment in congenital cases, when severe measures would be unadvisable. By keeping the sac constantly empty, it may result sometimes in a radical cure, the chance for the occurrence of which will be increased by scratching the interior of the sac with the trochar, before withdraAA*- ing it, and then employing moderate pressure over the seat of the cyst, Avhenever practicable. The shortest, and most certain plan for the eradication of the cer- rJAUNDICE. 725 vical cyst, when superficial, is free incision into its cavity, followed by moderate pressure; but the long and unsightly scar to which it gives rise, is, in most cases, an insuperable objection to it. The seton, according to Mutter, is the best means for those cases in Avhich extirpation, repeated tapping, or incision is inappropriate, or has failed. No means is so promising, when the cyst is unilocular or of long standing. It occupies, often, several weeks, but it is safe, easy, little painful, and certain, while it is followed by scarcely any scar. 20. —Jaundice—Icterus Infantilis. In infants, two or three days after birth, it is not unusual for the whole surface of the body, as well as the tunica conjunctiva, to acquire a yellow hue, more or less intense, which, in the coutse of a few days, in general, gradually disappears. (Icterus neonatorum.) Generally speaking, this is an affection of very little importance, appearing to de- pend upon a temporary excess of the colouring matter of the bile in the serum of the blood, and to be unattended with disease of the liver, or any of the other organs. In some cases, it has appeared to us to be con- nected with the want of a free evacuation of the meconium. Occasion- ally, this discoloration of the skin we have known to be accompanied with a good deal of drowsiness, and an evident sense of uneasiness of the surface. Nothing more is required in any case, than a dose of castor oil, or a grain or two of calomel, and the same quantity of rhubarb, with the daily use of the warm bath. In some instances, the skin of the infant will be marked by dull- yellow, irregular blotches, (maculae hepaticce,) more or less extensive, and sometimes occupying the greater part of the surface. The colour of these blotches varies very much in intensity; and in cases where there exists considerable derangement of the alimentary canal, they occasionally assume a very dark hue (melasma)—in some instances they are accompanied with a prickling or tingling sensation. The disease appears to be most generally connected with derange- ment of the digestive organs,—the colour of the skin being dependent upon a morbid secretion from the cutaneous vessels:—it has little or no affinity with jaundice. Considerable debility and languor, and in- dications of a disordered state of the alimentary canal, generally pre- cede its occurrence. Its removal is to be effected by such means as are calculated to re- store the regular and healthy functions of the digestive organs, and to improve the health of the infant generally: in all cases, the breast-milk of a healthy nurse, a pure fresh air, and the daily use of the warm bath, with gentle friction of the surface, are important parts of the treatment. . . Genuine jaundice, with intense yellowness of the skin and tunica mation of the biliary ducts. Under such circumstances, the disease is incurable, and sooner or later will prove fatal. 726 CONGENITAL AFFECTIONS, ETC. In the Northern Journal of Medicine, Dr. A. B. Campbell relates three cases of icterus in new-born infants, all of which terminated fa- tally. In two, the disease was found to depend on congenital absence of the hepatic and cystic ducts, and in the other upon obstruction of the common biliary ducts by inspissated bile. In the first case the jaundiced hue of the skin appeared the day after birth: the infant, however, continued well until the ninth day—though the evacuations from the bowels were white: a hemorrhage from the umbilicus then occurred, and returned on the following day, when the child died. The gall-bladder was found to be a shut sac, the hepatic and cystic ducts being both wanting—the blood was tinged with bile. In the second case, the symptoms occurred early—no hemorrhage took place. The infant wasted away, while its abdomen enlarged in both hypochon- driac regions. The patient lived until the sixth month, being attacked immediately preceding its death with violent diarrhoea, and vomiting of a fluid like coffee grounds. The liver was large—the gall bladder, as well as the ducts, were absent,—the blood and various tissues were tinged with bile. The third case closely resembled the first; hemor- rhage from the umbilicus occurred on the seventh day, and returned at intervals until the eleventh, when the child sunk into a comatose state and died. The whole amount of blood discharged did not ex- ceed an ounce and a half. The gall-bladder was full of bile, the escape of which was prevented, however, by a plug of inspissated bile, which filled the common duct. The brother of this infant died at the same age and with similar symptoms. The same morbid phenomena, with the addition of pain and tender- ness of the epigastrium, vomiting of the food soon after it is swallowed, or, if retained, violent paroxysms of pain, occurring an hour or two after it is taken, may be produced in infants by inflammation, acute or subacute, of the mucous membrane of the duodenum. Here the treatment must be directed entirely to the removal of the latter dis- ease: mild mucilaginous fluids in small quantities, a few leeches to the epigastrium, followed by warm fomentations, or an emollient cataplasm; and, after the inflammation has been, in this manner, reduced, a blis- ter to the epigastrium, for a couple or three hours, succeeded.by a soft bread and milk poultice, and internally, very minute doses of calomel and ipecacuanha, three or four times a day. In many cases, however,—Ave have certainly met with a great num- ber—the jaundice of infants is dependent upon a state of hyperaemia, or of subacute inflammation of the liver. In these cases, the colour of the skin and eye is of a dirty yellow—the surface is harsh and dry; the urine is charged with bilious matter; the stools are dry and clay- coloured; the countenance has an anxious, distressed expression, and the infant is apt to fall into a languid, drowsy state; there is consi- derable thirst, acidity of stomach, flatulence, and frequent griping or colicky pains; and with these symptoms, there is always more or less fulness of the right hypochondriac region, with great tenderness upon pressure. The disease, in general, assumes a chronic character, and is at- tended with considerable and progressive emaciation, and with tume- JAUNDICE. 727 faction and hardness of the abdomen; frequently with oedema of the lower extremities, and sometimes with effusion within the peritoneal cavity. The tongue, which was at first coated with a thin layer of yellowish mucus, becomes, in the progress of the disease, dry, and of a dark-brown colour. It is occasionally accompanied by induration of the subcutaneous cellular texture, and more frequently with purpura, either simple or hemorrhagic. The disease is, in general, produced by the same causes which give rise, in infancy, to derangement of the digestive organs. When de- pending upon hyperaemia of the liver, it is usually connected with the indications of a general plethoric condition of the system, and a very languid circulation. It has been supposed by Eberle, that this condi- tion is most apt to occur in infants who, when born, present a turgid and livid appearance of the face and body, and an oppressed state of the brain, and which have not been sufficiently relieved by a flow of blood from the divided vessels of the cord. The treatment must be governed by the character of the symptoms in each case. When simple hyperaemia of the liver exists, an emetic of ipecacuanha should be given, and repeated in a day or two, if cir- cumstances require it. The emetic should be succeeded by the warm bath, and gentle friction over the whole surface of the abdomen, and a grain or two of calomel, followed by castor oil, or magnesia and rhu- barb. The bowels should be kept regularly open by divided doses ot calomel, magnesia, and ipecacuanha, given three times a day, with an occasional dose of castor oil, the activity of which may be increased by a few drops of turpentine. The warm bath should be repeated daily, and the infant allowed the benefit of a free, pure atmosphere. When the case is marked by symptoms indicative of hepatic in- flammation, a few leeches should be applied to the right hypochon- drium, and followed by an emollient cataplasm. The leeches may be repeated, after a short interval, if the fulness and tenderness of the right hypochondrium continue with little abatement Calomel should be administered in the same manner as directed above. After the hepatic inflammation has been somewhat reduced the warm bath, followed by a blister over the liver, will, in general be found of de- cided advantage; the blister should be removed in three hours and ?he part to which it has been applied covered with a soft emollient noultice When the calomel produces irritation of the intestines we Say ombine it with small do.5s of the extract of hyoscyamus/ which in no decree interferes with its action upon the bowels. The use ot L calomel, with an occasional purgative of castor oil and turpentine, hould bTcontinued, until natural, bilious stools are procured, when t should be suspended, and the freedom of the bowels maintained by fhe use of the citrate of magnesia and rhubarb, or castor oil. 1 ^.—Calomel, gr. iij. Ipecac, pulv. gr. ij. Magnes. calc. gr. xxxvj. Ext. hyoscyami, gr. iv.—M. f. ch. No. xij. Tn the chronic form of infantile jaundice, the warm bath, followed by frictions, blisters to the right hypochondrium, and a cautious use 728 CONGENITAL AFFECTIONS, ETC. of calomel and ipecacuanha, in alterative doses, are the remedies from which the most benefit is to be anticipated. The carbonate of soda, may, in many cases, be administered with advantage; a grain or two should be given every two or three hours, dissolved in a teaspoonful of carbonated water, or in the same quantity of a weak infusion of hops; or, it may be given in combination with taraxacum.1 We have seen very striking advantage result, in many of the chronic cases of jaun- dice occurring in infants, from the taraxacum, in combination with the vegetable alkalies; whilst in other cases, again, we have given it in tolerably large doses, and continued its use for some time, without any benefit whatever. When, in the chronic form of infantile jaundice, there is considerable flatulence of the intestines, with frequent griping or colicky pains, the turpentine has, in our hands, succeeded the best, in removing the ten- dency to the formation of gas, and relieving the suffering of the pa- tient. We have, generally, at the same time that we administered the turpentine—in the dose of from five to ten drops, according to the age of the patient, every three hours—directed a dose of extract of hyos- cyamus, in combination with ipecacuanha and carbonate of soda, three times a day,2 and a camphorated mercurial plaster over the whole of the right hypochondrium. i R.—Taraxaci, ^ij. 2 R.—Extr. hyoscyami, gr. iv.—vj. Bicarb, sodae, gr. xxiv.—xxx. Pulv. ipecac, gr. ij.—iij. Aquce, gij. Bicarb, sodae, gr. xxiv.—xxxvj. Syrup, limon. 3'j.—M. —M. f. pil. No. xij. Dose, a teaspoonful every four hours. When we have succeeded in procuring natural, bilious, discharges from the bowels, and the skin begins to assume its natural hue, the restoration of the patient's strength may be promoted by some light tonic; either the cold infusion of bark, or the sulphate of quinia, or the proto-carbonate or tincture of the sesquichloride of iron, with a light vegetable diet, the Avarm bath daily, gentle exercise in the open air, and occasional doses of some mild purgative, to keep the bowels regular if they are inclined to costiveness. 21.—Purulent Ophthalmia.—Ophthalmia neonatorum— Infantile Conjunctivitis, The purulent ophthalmia of infants commences, usually, within a few days after birth—generally between the third and seventh. We have seen it, however, upon the second day, and occasionally, not until the third Aveek. The first indication of the disease is, generally, the eyelids becoming glued together during the night, with swelling and redness externally. When the lid is raised there occurs a gush of tears, and its conjunc- tiva is found to be uniformly red, and slightly thickened, and covered often with a somewhat tenacious, transparent coating. As the disease proceeds, the lids become more constantly aggluti- nated, and an increased secretion from the surface of the inflamed con- junctiva takes place, of a thick, purulent matter, a portion of Avhich exudes from between the lids, but the greater part is retained, causing a considerable bulging of the palpebrae—the integuments of Avhich as- PUPvULENT OPHTHALMIA. 729 sume a dark-red hue. The child becomes fretful and uneasy, and manifests the utmost intolerance of light—keeping the eyes firmly and constantly closed, and averted from the light. The tumefaction and redness of the conjunctiva rapidly increase, and extend over the globe of the eye. Every separation of the eyelids is attended with a gush of purulent matter, which sometimes is so copiously effused as to burst open the firmly closed lids, and run down the cheek in large drops. The thickening of the conjunctiva often becomes so considerable, in the course of three or four days, as to rise up around the cornea, nearly concealing it, or causing it to appear as if sunk deep into the eye. The intumescence of the conjunctiva causes it to become everted upon every attempt to examine the affected organ, or every time the child cries; not unfrequently, the constant pressure of the orbicularis muscle renders the eversion permanent. The discharge from the eye is generally of a pale straw-colour; but sometimes of a deeper yellow; and, not unfrequently, it assumes a greenish hue; it is said, in some cases, to be ichorous, or mixed with blood. An ichorous state of the discharge we have never seen; but, occasionally, have known a small amount of blood to be mixed Avith it. A slight hazy condition of the cornea very generally occurs, and this may continue for a week or longer, without any permanent de- struction of its transparency. About the tenth or twelfth day, some- times later, purulent infiltration of the cornea, however, takes place; or an interstitial deposit in the conjunctival layer or substance of the cornea. . - When purulent infiltration occurs, ulceration may ensue, either ot the entire cornea, or of a small, circumscribed portion of it, giving place to prolapsus of the humours, or of the iris only. When an in- terstitial deposit takes place, complete opacity of a part, or of the whole of the cornea may result, or a thin, bluish-gray film may term over its surface. When a considerable portion of the cornea is de- stroyed by ulceration, the humours of the eye ordinarily escape, and the globe collapses. ,,,,'• -a. There appear to be two forms of purulent ophthalmia, as it occurs in children: one in which the inflammation is confined exclusively to the conjunctiva of the lids; another in which the conjunctiva of the eyeball becomes equally involved in the disease. In the first, the dis- ease is of a much milder character, and is seldom attended with any very serious injury to the eye: occasional y, however, it is equally Lvere in its symptoms, and protracted in its course, as when the in- flammation affects the whole of the conjunctiva, A\ e have repeatedly seen^t confined, for a number of days, to the palpebral conjunctiva, and thenSuddenly to extend over the ball of the eye, and be quickly followed by infiltration and ulceration of the cornea # In cases7 unattended with complete opacity or extensive ulceration of the cornea, adhesion of the iris to the latter may take place; or an ot tne corned, a gmaU be formed inPXVent ^Seri" heni-pb^. of the capsule of the lens Both eyes are generally attacked, either simultaneously, or within a very short interval of each other. 730 CONGENITAL AFFECTIONS, ETC. The result, favourable or unfavourable, of infantile purulent oph- thalmia, will depend pretty much upon the greater or less violence of the attack, and the period at which the treatment is commenced. In its early stages, the disease is by no means difficult to cure; but in its advanced stages, it is seldom arrested, until more or less injury to the eye has taken place. So long as the cornea retains its transparency, there is a possibility of saving the eye; but Avhen ulceration or purulent infiltration of the cornea has occurred, although the inflammation may still be removed, the sight will be permanently destroyed. Opacity of the cornea, resulting from a thickening of its conjunctival covering, may disappear completely in the course of time, but that from superficial ulceration is generally permanent, and may interfere, to a greater or less extent, with vision. Protrusion and adhesions of the iris may impede or totally destroy vision according to the part at which these occur; while the loss of vision resulting, at first, from central opacity of the capsule of the lens, may in time, with the enlargement of the pupil, which takes place with the growth of the child, disappear in part; but permanent short-sight- edness may remain. Not a little discrepancy of opinion has existed, and still exists, as to the true character and cause of purulent ophthalmia. By some, the disease has been supposed to be of a specific character—an erysipela- tous affection of the conjunctiva; others believe it to be simple catar- rhal inflammation, occurring in children of unhealthy constitutions; those who, according to Dr. Mildner, labour under "an albuminous crasis of the blood." (Annates d' Oculistique, torn, iv.) By the ma- jority of authors, it is referred to some acrid or morbid matter secreted in the vagina of the mother, and applied to the infant's eyes during birth. It is unquestionably true, that children born of mothers labouring under leucorrhcea, are far more liable to be affected with purulent ophthalmia after birth, than those born of healthy women; yet so many cases of the disease occur in the latter, that those physicians cer- tainly err, who refer it invariably to morbid vaginal discharges in the mother. During twelve months, Cerderschjold informs us, three hundred and sixty women were delivered in the General Lying-in Hospital of Stock- holm, and subtracting those of whom the children were dead-born, or died within a day or two after birth, of the remaining three hundred and twenty-eight, one hundred and forty-seven laboured under leucor- rhcea, and the remaining one hundred and eighty-one were free from disease. Thirty of the children were affected with purulent ophthalmia, namely, twenty of those whose mothers had the discharge, and ten of those whose mothers had none. From these facts it would appear, that discharges from the genitals are extremely common among pregnant women; that women may labour under them without causing purulent ophthalmia in their chil- dren ; and that infants may be affected with this disease, notwithstand. PUKULENT OPHTHALMIA. 731 ing their mothers have no discharge: it is evident, therefore, that the ophthalmia is not necessarily produced by infection received from the mother. Nevertheless, when we consider that twenty out of the one hundred and forty-seven children born of mothers in whom a vaginal discharge existed, or about one in seven, suffered from ophthalmia, while only ten in one hundred and eighty-one, or one in eighteen, of those whose mothers were unaffected, had the disease—the proportion of the former being nearly three times greater than the latter—we must conclude, that a discharge from the genitals of the mother, though not the sole cause of purulent ophthalmia in new-born infants, is, at least, a very frequent one. The disease is attributed by some to the too early and unguarded admission of light and heat to the eyes of the new-born infant. We cannot say that we have been able to trace purulent ophthalmia to this cause, though we admit that the practice of placing an infant, as soon as it is born, and day after day subsequently, on the nurse's lap, before a bright fire, with its face turned towards the latter, and with perhaps a candle or lamp at no great distance, and keeping it there, not only during the time necessary for dressing or changing it, but frequently, long after this is completed, is certainly one very liable to produce injury to the eyes. Impurities of the atmosphere, particularly smoke and other irritating vapours diffused in the air, are, no doubt, common causes of purulent ophthalmia; cold and dampness may also produce it; and perhaps, slight mechanical injuries of the conjunctiva. < ... Purulent ophthalmia is a common affection of infants in lying-m hos- pitals, almshouses, and children's asylums where the inmates are crowded together, without sufficient attention being paid to cleanli- ness, and to the securing at all times, a due supply of fresh air; speak- ing of the catarrhal form of the disease, Dr. Mildner says, that the influence of atmospherical causes was obvious, and often when the wards of the Prague Hospital were crowded with puerperal women, especially if the air was moist and cold, from six to ten infants would be seized on the same day, and usually in both eyes. It is among the children of the miserably poor, by whom little care is taken ot the hygienic management of their offspring, that, in private practice we most frequently meet with the disease. Contaminated air, with its often associated morbific causes, neglect of clean mess, defective nourishment, and want of sufficient exercise, is liable to produce a general tendency to disease, in the mucous tissues of chi dren; the mouth, anus, and vulva, under such circumstances, being alike liable to affections terminating rapidly in gangrenous ulceration In cases of purulent ophthalmia, it is said by Morrell, that the vagina of the little patient is liable to be affected with a purulent discharge, -oreciselv similar to that from the conjunctiva. P By some physicians, purulent ophthalmia is supposed to he conta- «ous- and numerous instances are referred to in which the disease is Sid to have been communicated to the nurse, by the accidental appli- atn of the matter from the eye of the infant to hers Our "oppor- tunities for observation on this subject have been tolerably extensive, 732 CONGENITAL AFFECTIONS, ETC. but we have never met with such an occurrence. The disease occa- sionally occurs epidemically, generally at periods when catarrhal affections prevail; being produced, probably, by the same causes as the latter. After the first three or four days, there is always a very great diffi- culty in obtaining a view of the ball of the affected eye, particularly of the cornea, in consequence of the thickening and disposition to ever- sion of the conjunctiva; and the irritation produced by every attempt to force open the lids, sufficiently to enable the practitioner to ascer- tain distinctly the actual condition of the affected organ, has induced us to forego it entirely, and trust to " what information can be obtained from the external condition of the lids, and the nature of the dis- charge which issues from beneath them." (Taylor.) At the same time, however, we consider it absolutely necessary to open the lids once or twice a day, first sopping them well with a little warm water, or milk and water, so as to soften the matter which glues them together, in order to give discharge to the morbid secretion which accumulates behind them; an object Avhich may be further promoted by the cau- tious injection of tepid water, or an infusion of pith of sassafras be- tween the lids. The agglutination of the lids may be prevented, by covering the eyes, as the patient lies upon his back, with a small por- tion of soft linen rag, and dropping upon the inner canthus, occasion- ally, a little warm milk and water. In the commencement of mild cases, we have often seen the disease very quickly arrested by warm fomentations, assiduously applied to the eye externally, and the occasional use of a wash formed of a strong infusion of common green tea, great attention being paid at the same time to the condition of the bowels, which are very generally deranged. They are occasionally constipated, when a grain or two of calomel, fol- lowed by castor oil, should be administered: much more frequently, however, there is diarrhoea, with green, watery discharges: in such cases, small doses of calomel, ipecacuanha, and magnesia,1 and the daily use of the warm bath will be required. When, however, there is general and decided redness and swelling of the conjunctiva, or if the eyelids are much swollen, and red exter- nally, local depletion by leeches will be absolutely necessary; and if not resorted to sufficiently early, and carried at once to a proper ex- tent, the only opportunity of saving the sight of the child may be lost. The number of leeches—which should be applied as near as possible to the eye—-will depend altogether upon the strength and vigour of the child, and their size; the best rule, perhaps, is to draw as much blood in this manner as will be sufficient to produce a slight paleness of the patient's skin. If the first application has not been sufficient to arrest the inflammation, the leeches should be repeated after a short interval. The leeches should be followed by purgatives, of which the best is calomel, succeeded by castor oil; or, the combination of calomel and ipecacuanha, as directed above. By some practitioners, a combina- tion of calomel and the pulvis antimonialis is considered peculiarly beneficial in this disease.2 PURULENT OPHTHALMIA. 733 1 R-—Calomel, gr. ij. a R.—Calomel, gr. iij. Pulv. ipecac, gr. ij. Pulv. antimonial. gr. xij.—M. f, "Miijrnes. calc. gr. xxxvj.—M. f. chart. No. xij. cli. No. xij. One to be given every three hours. One to be given every three or four hours. There can be no doubt that in all cases, minute doses of calomel, repeated daily, will be productive of the best effects, and that their efficacy will be increased by the addition of either the ipecacuanha or antimonial powder. If by this means the bowels are not kept suf- ficiently open, an occasional dose of castor oil, or of magnesia and rhubarb may be given. If there be continued derangement of the alimentary canal, the spirits of turpentine, in small doses, by the mouth, or in the form of enema, will often be particularly serviceable. The patient should be kept in a dark, well-ventilated room; the eyes should be repeatedly fomented with warm water, or with a warm infu- sion of pith of sassafras, or of poppy-heads, and the directions already given to keep the eyes free from the purulent discharge constantly at- tended to. After the violence of the inflammation is reduced, it has been di- rected to apply blisters to the temples or over the closed eyelids; the latter mode of applying them is certainly to be preferred, and we have occasionally seen the best effects derived from their use. In young children, particularly when of a weakly and debilitated constitution, blisters must, however, be employed with the utmost caution, other- wise very dangerous consequences are apt to result from them. At that particular period of the disease when alone blisters, if they are resorted to, should be applied—that is, after the intensity of the inflammation has been considerably mitigated by leeches, purgatives, emollient applications, and a general antiphlogistic regimen—lightly scarifying the thickened conjunctiva, the eyelids being first carefully everted, and by this means procuring a free discharge of blood from its enlarged vessels, is considered by some as among the most effectual means for the complete removal of the disease: by Saunders and others, however, it is condemned as in all cases injurious. In chronic cases, attended with very great vascularity of the conjunctiva, we have known scarification to prove of the utmost service; we have never employed it, however, in the acute stage of the disease. We shall be obliged, in most cases, to judge of the effects of our re- medies upon the disease, by the diminution of the general symptoms, and the quietness of the infant, and by the reduced redness and tume- faction of the palpebral, the diminished amount of the discharge, and by the child being able to open to a certain extent, and for a longer or shorter period, his eyes. To determine properly this latter, it is necessary to watch the motions of the patient before light is admitted into the apartment; because the moment this takes place, the eyes will be very generally closed, and he will forcibly resist their being opened. Whenever it can be done without inducing considerable pain, or an in- crease of irritation, it is always important, however, that the state of the eye should be ascertained by actual inspection. By an early resort to the treatment just recommended, and by its judicious employment, we shall generally find that about the third, 734 CONGENITAL AFFECTIONS, ETC. fourth, or fifth day of the attack, the pain, swelling and irritation of the eye will begin very rapidly to subside; the discharge at the same time becoming much less in quantity, and of a thin, gleety nature, and the conjunctiva of a paler and more flabby appearance, but with its vessels still gorged with a considerable amount of blood. Mild astringent applications will now be proper. Various formulae for these have been recommended by different practitioners; each one recom- mending his own as the best. Solutions of the acetate of zinc, (one scruple to four ounces of rose water,) or of the acetate of lead, (five grains to an ounce of water,) of the In-chloride of mercury,1 of alum, (five grains to an ounce of water,) or of the nitrate of silver, (four grains to an ounce of water,) may be employed. With either of the first three, the eyes should be bathed three or four times in the twenty- four hours, and a portion carefully injected into the eye. Previously, however, to their use, the lids should be gently everted and the dis- charge carefully and cautiously wiped from their inner surface, by means of a soft sponge, wrung out of warm water. The solution of nitrate of silver may be applied once daily, with a large hair pencil, over the whole of the inflamed conjunctiva; it may be used in conjunc- tion with either of the other collyria. 1 R-—Bi-chlorid. hydrarg. gr. j. Hydrochloride ammoniae, gr. vj. Aquae, 3viij.—M. (Mackenzie.) The use of the nitrate of silver is recommended by many practi- tioners from the very onset of the disease, and in many cases may no doubt be advantageously resorted to at a much earlier period than is above directed. When the disease is unconnected with any constitu- tional affection, and confined to the conjunctiva, especially when pro- duced by any diseased discharge from the vagina of the mother, Dr. Mildner found it to yield readily to a wash of nitrate of silver, from one to four grains in four ounces of water. The chloride of lime, (one scruple to two ounces of water,) has been strongly recommended in the treatment of the purulent ophthalmia of infants, and deserves a trial. Von Ammon's favourite collyrium in the purulent ophthalmia of chil- dren, is composed of three to four grains of extract of belladonna, six to eight drops of oxy-muriatic acid, and three to four ounces of water. The proportion of water to be subsequently gradually dimi- nished. The conjunctiva continues often, after the inflammation has been subdued, in a relaxed puffy condition; when a wash of a strong solu- tion of zinc, or alum, may be used, or the conjunctiva may be touched daily with the vinous tincture of opium. When the membrane be- comes soft, spongy and granular, the solid nitrate of silver, or the ointment, (composed of ten grains to one ounce of lard,) may be ap- plied. When ulceration or disorganization of the cornea is threatened, it is all-important to support the patient's strength by the use of tonics, which will also be proper after ulceration or disorganization has taken place. The most convenient tonic will be the sulphate of quinia, HYDROCELE. 735 which may be given in divided portions, to the amount of two, three, or five grains daily, according to the extent of the exhaustion under Avhich the patient labours. It is all-important, in every case of purulent ophthalmia, and during the entire continuance of the disease, that the patient should enjoy a free, pure atmosphere; and be defended from cold or damp, and from the influence of domestic and personal filth. He should be nourished at the breast of a healthy nurse. Although not convinced of the infectious character of the discharge from the eye in this disease, we think it proper, however, not to run any risks; and hence, the attendants should be cautioned against in- curring the danger of communicating the infection to themselves or others, by the accidental contact of the matter with their eyes, which may be easily prevented by the most scrupulous cleanliness. 22.—Hydrocele. Hydrocele in infants may result from the distention of the vaginal sac of the scrotum with serum; the communication between this sac and the cavity of the abdomen being obliterated, or still continuing open;—or, the accumulation of serum may be confined to the vaginal tunic of the cord, without any communication with the scrotum or ab- domen, or with a free communication with the latter. The diagnosis is somewhat different in these different cases. In hydrocele of the vaginal sac of the scrotum, the tumour is semi- diaphanous, and the testicle, if it has descended, may be felt near its inferior posterior part. If no communication exists between the sac and abdomen, the swelling undergoes no change in its dimensions during crying or coughing; it usually gradually augments in size, pre- senting a kind of pyramidal form, with the apex towards the ring; and when the integuments of the scrotum are put upon the stretch, their natural rugosity is obliterated, and they become smooth, pale- coloured, and shining. If, however, a communication still exists between the scrotal and abdominal cavities, the tumour will increase in size Avhen the child coughs or cries, and pressure upon it will cause the serum by which it is distended, in great part or entirely, to pass upwards into the abdomen; but it immediately returns upon the pressure being re- moved. In this case, our diagnosis is to be founded upon the semi- diaphanous character of the swelling, the presence of fluctuation, and the inability to feel within it any fold of intestine, or portion of omen- tum. .. In hydrocele of the cord, the tumour most generally occupies a situa- tion midway between the testicle and groin; it is of an oblong figure, perfectly circumscribed, and generally very tense;—it undergoes no alteration from change of posture, or during coughing or sneezing. It may be accompanied by an inguinal hernia, and by hydrocele of the scrotal sac, in which case the true character of the disease is rendered very obscure, and its existence is with difficulty detected. When the hydrocele is situated higher up upon the cord, it often extends up- wards within the ring, or by gentle, continued pressure, it may be 736 CONGENITAL AFFECTIONS, ETC. made to recede within it, but the swelling immediately returns upon the pressure being removed. With the exception of a slight dragging sensation, which is the greatest when the hydrocele is low down upon the cord or in the scrotal sac, these tumours are unaccompanied by either pain or uneasiness. Hydrocele is very generally confined to one side; occasionally, how- ever, it occurs on both. In some cases, children are born affected with hydrocele either of the scrotum or cord; but most generally, it is not noticed until four or five days, and sometimes even longer, after birth. Children are also liable to the occurrence of hydrocele at a later period, from the same causes Avhich produce it in the adult. Notwithstanding the alarm to which these swellings, when they occur in infants and young children, give rise in the minds of the parents and those connected with the patients, they are seldom of much importance, and often disappear, after a time, spontaneously. The female, according to Sacchi, (Annali Univers. de Medicina, 1831,) is liable to the occurrence of a congenital hydrocele closely re- sembling that of the male. The swelling is caused by a collection of fluid in the peritoneal sheath of the round ligament which passes through the inguinal canal into the lower part of the labium pudendi; it is at first returnable, but not so after a time. In young infants, frequently sponging the tumour with a weak solu- tion of the acetate of lead, or with a mixture of two parts of aqua camphorata and one of vinegar, or with a solution of the hydrochlorate of ammonia in camphor water is, perhaps, the only treatment that it is proper to pursue. If, under this treatment, the swelling does not disappear, when the child has arrived at twelve or eighteen months of age, as well as in those cases in which the swelling appears late in in- fancy or during childhood, the affusion of cold water—the water being poured upon the hydrocele out of a tea-pot, and from a height—four or five times a day, will very generally cause its dispersion. The affu- sion must be unremittingly persevered in for a considerable time. In this manner we have, in repeated instances, effected a complete cure. The effects of the cold water may be increased, in children over two years of age, by brisk purging, and a simple farinaceous diet. R.—Bitart. potassae, gij. Pulv. jalap. 3J.—M. f. ch. No. xij. One of which may be given every day, or every other day, according to the effects pro- duced upon the bowels. Where the hydrocele is of considerable size, and, in place of dimi- nishing, continues steadily to increase in bulk, we have found that puncturing the tumour, and allowing the water gradually to drain off, has, after one or two repetitions, produced a radical cure. We have also seen the introduction, through the tumour, of a seton composed of a few threads of floss silk, effect a perfect cure, as well in cases of scrotal hydrocele, as of hydrocele of the cord, without the occurrence of much pain, or any disagreeable symptoms. The ends of the seton should be loosely tied together, and a thread drawn out every second or third day, until the whole is removed. PARONYCHIA. 737 Dr. Linharfc, in an instructive communication on the subject of hydrocele in young children, (Froriep's Notizen, 18-56,) remarks that when the swelling is met with immediately after birth, a wide commu- nication with the abdominal cavity usually exists, and as there is often a fold of intestine at the upper portion of the swelling, it may happen that hernia and hydrocele alternate—so that two practitioners seeing the case at different times may give a very different diagnosis. Such cases require scarcely any treatment. The serum returns during the horizontal position of the patient, into the cavity of the abdomen, Avhere it is readily absorbed. A compress so applied as to keep the neck of the processus vaginalis closed will generally be proper. When the hydrocele occurs later after birth the swelling is usually more tense, and the communication with the abdomen is either very small or en- tirely closed. When a very small communication still continues, the fluid will often return slowly into the abdomen, requiring, however, it may be, six or eight days for it to do so. These cases are apt to de- ceive by leading the attendants upon the child to believe that the means employed by them have produced an absorption of the fluid. This deception is the more liable to occur, from the fact, that in con- sequence of a very great narrowing of the upper mouth of the processus vaginalis, which is often over an inch in length, the return of the fluid cannot be effected by taxis. When entire closure has taken place, the case does not differ from one of ordinary hydrocele. Absorption, according to Dr. Linhart, may still take place sponta- neously, but it can rarely be promoted by the practitioner. The va- rious stimulant washes that have been recommended, are all inopera- tive, and may act injuriously upon the integuments of the scrotum. In the cases in which they appear to promote absorption, the communica- tion with the abdomen has, in fact, still existed. He believes, however, a cure may be very materially facilitated by a subcutaneous incision of the processus vaginalis, by which the fluid is allowed to escape into the cellular tissue of the scrotum, where it is rapidly absorbed. Dr. Linhart prefers this to any attempt at effecting an obliteration of the vao-inal process by means of pressure applied at its neck, which is sel- dom effectual, even could it be tolerated, or by the employment of injections, which in young children are not without danger. The discussion as to the particular circumstances under which it may become necessary and proper to resort to the usual surgical means for effecting a cure of hydrocele in the child, by causing the obliteration of the cavity of the tunica vaginalis, does not come within the scope of the present treatise. 23.—Paronychia. ONYCHIA—PANARITIUM—WHITLOW—FELON. Children are very liable to an inflammation, occurring usually near the end of one of the fingers or toes, or about the edge or root of the nail It may be seated in the cutis, in the subcutaneous cellular tissue, or in the thecre or synovial sheaths of the tendons, particularly on the inside of the fingers. . When the inflammation occurs in the cutis, we have usually the 17 738 CONGENITAL AFFECTIONS, ETC. symptoms of a slight phlegmon,—heat, pain, tension, and redness of the part, with some degree of febrile excitement. The inflammation terminates quickly in suppuration, marked by a semi-transparent ele- vation of the cuticle. The pus frequently travels around the finger, separating the cuticle to a considerable extent. When the inflammation is seated in the subcutaneous cellular mem- brane, the local symptoms are more severe, and there is often a decided febrile reaction, attended with distinct rigors. The suppuration oc- curs early, but the matter is sIoav in reaching the surface, and often extends laterally, burrowing beneath the nail. This form of paronychia is generally attended with very severe pain throughout its course. The affection is of a still more severe character when seated in the thecae or synovial sheaths. The pain is deep-seated, and generally intense. There are often severe rigors, followed by very decided symptoms of febrile reaction from the very commencement. The swelling is more extensive than in the other forms, often spreading over the whole hand or foot, and even to the forearm or leg; distinct red lines or streaks of inflammation—probably inflamed absorbents— extending to the axilla or groin. At this period, in very excitable children, convulsive action often ensues, and very generally extreme restlessness, or delirium. From the unyielding nature of the tissues, the matter formed, in place of reaching the surface, passes along the synovial sheaths, or tendinous thecae, to the palm of the hand or wrist, or to the sole of the foot; producing intense suffering for weeks, causing the death of the tendons, and destroying the motion of the joints, or even, in some cases, affecting the periosteum, and producing caries of the subjacent bone. In children of a lymphatic temperament, or of a plethoric, but un- healthy condition of body, the inflammation is often seated in the matrix and soft parts at the root of the nail. (Onychia maligna.) The disease commences with redness, swelling, heat, and tension at the root of the nail; attended with a dull, throbbing pain, great tenderness upon the slightest pressure, and shivering, succeeded by febrile ex- citement. From the sulcus at the lower part of the nail there soon takes place an oozing of a thin, ichorous fluid, succeeded by ulceration, which spreads round the semicircular edge of the soft parts covering the root of the nail: the ulcer is of an unhealthy appearance, with thin, flabby edges, and covered with a dirty yelloAv lymph; the skin is separated from the nail, which becomes exposed to its very root, and discoloured. The ulceration extending beneath the nail, this becomes gradually detached from the parts below. The surrounding soft parts are swollen, of a dusky red or purplish hue, and intensely sore; bleed- ing profusely upon the slightest touch. When allowed to proceed, the toe or finger becomes a deformed, bulbous, ulcerated mass, and may continue so for months; exhibiting not the slightest disposition to heal, so long as any portion of the nail remains attached. Paronychia often occurs in perfectly healthy children, without any very apparent cause: in many cases it would appear to be intimately connected with derangement of the digestive and assimilative organs; but its most common cause is either external injury, puncture, contu- PARONYCHIA. 739 sions or slight wounds, cold, or the retention of some acrid or extra- neous substance about the nail. During the inflammatory stage of paronychia, if any extraneous substance is present, it should be extracted or removed by repeated ablutions with warm water and a sponge, according to its nature. In the superficial variety, the best application is, probably, the common bread-and-milk poultice, frequently repeated, with a brisk purgatiA'e internally, and a mild restricted diet. In the cases in which the in- flammation is more deeply seated, leeches, saline purgatives, low diet, and perfect rest are required. If the local inflammation is very considerable, and attended with much febrile reaction, in robust, plethoric children, a few ounces of blood should be taken from the arm, and some saline diaphoretic with antimony administered.1 The free application of leeches to the seat of the disease is the most effectual means of abating the inflammation, and in this manner relieving the extreme pain. The early application of a blister around the affected finger or toe, has often arrested the progress of the disease. 1 R-—Sulph. magnes. giv. Pulv. nitri, gj. Tart. ant. gr. j. Spir. aeth. nitr. giv. Aqua1, giv.—M. Of which a teaspoonful may be given> every three hour* Various rubefacients have been recommended, as hot water, hot ley, hot turpentine, &c.: these will, when applied sufficiently early, often do good: we believe, however, that the blister should ahvays be pre- ferred. It is hardly necessary to say, that any derangement of the digestive organs that may be present, will require the appropriate remedies for its removal. In subcuticular paronychia, when suppuration has commenced, it is to be promoted by frequent poultices, and when the cuticle is raised by the formation of matter, it should be freely divided, and then cau- tiously removed as far as it has become separated from the skin be- neath. This is an important precaution, as suppuration is very apt to continue, if any portion of the detached cuticle is allowed to re- main ; and the disease thus travels around and over a considerable portion of the finger or toe. After the separation of the cuticle, the parts may be dressed with simple cerate, or the cerate of the oxide of zinc, and they, in general, heal very promptly. In the more deeply seated forms of paronychia, when we find that we are unable to arrest the course of the disease, an early and free incision is all-important. If we Avait until suppuration has taken place, we not only prolong, unnecessarily, the patient's suffering, but endan- ger the loss of motion in the affected finger or toe, if not more serious injury. The incision should be made freely, and through the cellular texture of the part, down to the periosteum, and Avhen the tendinous theca is affected, this should be freely divided with the knife. If the matter has burrowed beneath the nail, this should be scraped very thin, and then divided with a pointed bistoury. The incision gives almost immediate relief, allows the escape of whatever matter may 740 CONGENITAL AFFECTIONS, ETC. have already formed, or if suppuration has not commenced, prevents it by arresting the inflammation. After the incision, the parts should be dressed with soft bread-and-milk poultices until they heal. If we have not been called to the case until deep-seated suppura- tion has taken place, and one, or perhaps several openings have been formed externally, through which fungous granulations extend and spread out in the form of mushrooms, free incisions are essential to the cure. If the tendons or thecae are found to be dead or sloughing, the diseased portion should be clipped off with a scissors, with a small portion of that which is yet sound; if the bone is found to be in a state of caries, it should be extracted as soon as it becomes suffi- ciently loose. The best local application in these cases is a common bread-and-milk or carrot poultice. When the dead bone and tendons are removed, we have never seen much delay in the healing of the parts. Onychia maligna requires a somewhat different treatment. It is, according to our experience, one of the most frequent forms under which the disease presents itself in children, and unless properly ma- naged, is apt to produce a troublesome, painful ulceration, which may continue, Avithout the slightest appearance of amendment, for many months, and when finally healed, leave a very disagreeable deformity of the finger or toe, upon which a perfect nail is seldom reproduced. The child is to be placed upon a well regulated diet, composed chiefly of farinaceous articles and milk. It should be exposed to a pure fresh atmosphere, and take such exercise daily in the open air, as is adapted to its age and strength. Mild purgatives should be ad- ministered according to circumstances; and if the alimentary canal exhibit very considerable derangement, a mild alterative course, with occasional light tonics, and the warm or tepid bath every morning. The local treatment consists in the application of leeches, followed by emollient poultices. After ulceration has occurred, in some cases, benefit will be derived from an ointment composed of the ungt. hy- drarg. peroxyd. and sulphate of zinc;1 or of the sulphate of zinc and cdrrosive sublimate;2 but wheneA'er the ulceration has extended be- neath the nail and exposed its root, we have never seen any treatment in the least degree beneficial, until the whole of the nail is removed. This is certainly a very severe operation; but when skilfully and quickly performed, the suffering produced by it is infinitely less than that resulting from the long-continued painful ulceration kept up by the dead and partly detached nail. Upon the removal of the nail the ointment just mentioned, or the black Avash, or a weak solution of nitrate of silver, with a continuance of poultices, will quickly effect a cure. 1 R.—Ungt. hyd. peroxyd. £j. * R.—Sulph. zinci, Sulph. zinci, gr. xv. Chlorid. hydrarg. aa ^j.— M. Cerat. simpl. ^j.—M. To be sprinkled thickly upon the diseased surface and then covered with a pledget of lint, wet with tincture of opium. (Per- kins. Physick.) The removal of the diseased matrix of the nail, by making a deep incision down to the bone, about three or four lines below the lower BURNS AND SCALDS. 741 edge of the ulcer, and then carrying it around so as to dissect out en- tirely the diseased surface, has been recommended by Dupuytren and Rynd: we prefer, however, the removal of the whole nail, as a more effectual, and even less painful operation. 24.—Burns and Scalds. Burns and scalds are among the most frequent accidents that occur during the latter period of infancy, and throughout childhood. The carelessness of parents and servants, the natural temerity and incau- tiousness of children, and the necessity, in the ordinary mode of warm- ing apartments, of their being brought in close proximity to the open fire, or heated stoves, render these accidents of such frequent occur- rence, that no winter passes without our seeing a number of children who have suffered from them. They occasionally happen under cir- cumstances where they were the least to be anticipated:—infants be- ing left for a few moments alone, have crawled or climbed to parts of the room where vessels of heated water were standing, which they have overturned upon themselves:—some of the most serious scalds in child- ren that we have been called upon to treat, have been produced in this manner. There is a great variety in the character and extent of these acci- dents, Avhich require some modification in their treatment. The burn or scald may produce a simple and very circumscribed inflammation of the skin; or an inflammation accompanied Avith vesication; or the cuticle may be completely removed to some extent; or the Avhole of the integuments of a part may be entirely destroyed. The pain and suffering are always greater in superficial burns than in those attended with an entire destruction of the cuticle. Burns which involve a very large portion of the surface, would appear to be attended with no pain whatever;—the patient, if old enough, com- plains of a feeling of chilliness or cold, and is strongly inclined to sleep. There is in all extensive burns, immediately upon their occurrence, a very great depression of the vital powers, which continues for some time before the occurrence of reaction; while, in some cases, no reac- tion whatever takes place; the patient falling into a deep comatose sleep, from Avhich he never aAvakes. The danger in burns is always in proportion to their extent, taken in connexion with their depth;—but even superficial burns, seated on certain portions of the body, are attended with very great, and some- times immediate danger. Thus a burn, of even small extent, upon the head or stomach, has been known to produce very speedy death. In fatal cases, besides the external local injury, congestion of the brain and serous effusion, on its surface and in the ventricles, will be met with in many cases, while the air-cells of the lungs are loaded with a thin, muco-serous fluid. In young persons, severe burns have been. found, according to Mr. Curling, (Med. Chirurg. Trans, vol. v.) to be occasionally followed by an acute ulceration of the duodenum, which may cause death by perforation of the intestine, and consequent perito- neal inflammation, or by opening a large artery, and occasioning aa 742 CONGENITAL AFFECTIONS, ETC. effusion of blood, part of which is sometimes discharged by vomiting and purging. In superficial burns, of limited extent, and in which there is produced only a simple redness of the skin, the best immediate application is, cold water, vinegar, or any alcoholic liquor. The application of these fluids must be unremittingly persevered in: they always relieve the intense smarting with which the burn is attended, and often very speedily al- lay the inflammation. When nothing else is at hand, the common potato, scraped or mashed into a pulp, in its raw state, will often be found beneficial. After the cold application has been continued for some time, the injured part may be lightly covered or wrapped with loose cotton. This has always a soothing effect. If any considerable degree of inflammation still continue, we have found the best applica- , tion to be a liniment composed of fresh lard, and acetate of lead (tAventy grains to one ounce of lard.) Even in the most superficial burns, however, our own experience would lead us to recommend the immediate application, in all cases," of the spirits of turpentine. This removes, at once, the smarting pain, prevents vesication, and we have often been surprised at the rapidity Avith which, under its use, the inflammation entirely subsides. To de- rive, however, these advantages from the turpentine, it must be ap- plied without the least delay. In extensive burns, it ought invariably to be preferred to every other local application. Powdering the burnt or scalded part thickly with dry flour, is a soothing application, and may be adopted in cases unattended with vesications. When the latter are present, they are liable to be ruptured, and as Dr. Tanner has pointed out, the serum which escapes from them becoming mixed with the flour, forms a hard, irritating crust, which is with difficulty removed. A liniment composed of equal parts of lin- seed oil and lime water, will be found, in many cases, an excellent ap- plication, in conjunction with a covering of loosely-carded cotton. When vesication is produced by the burn or scald, the same treat- ment should be pursued. If the vesicles are large, it is best to punc- ture them, to allow of the escape of the serum, but without removing any portion of the cuticle. In burns attended with extensive vesication, suppuration, with a co- pious discharge of matter, in general, ensues. If the suppurating surface continues red and inflamed, the common bread and milk poul- tice, with a proper attention to the state of the bowels, and, if the child is weaned, a light farinaceous diet will be proper, until the inflamma- tion subsides, when, as well as in cases in which the ulceration of the skin is unattended with any considerable degree of inflammation, the parts may be dressed with the ceratum oxyd. zinci, or the simple cerate, intimately combined with a portion of prepared chalk. In deep burns, attended with a destruction of the integuments, warm emollient poultices should be applied until the inflammation of the surrounding skin is entirely removed, when the burnt part should be covered with a pledget of lint, thickly spread with the common resi- nous ointment, mixed with an equal portion of spirits of turpentine; which dressing should be continued until the dead portions of integu- BURNS AND SCALDS. 743 ment slough out. We have found, in deep burns, attended with con- siderable inflammation of the surrounding parts, the usual domestic application, of common lamp oil and molasses, spread on cotton, to be often a very useful one. When the dead parts are entirely separated, a simple bread-and-milk poultice should be applied, until granulations begin to form, when the ulcer may be dressed with the ointment of the oxide of zinc; and if cicatrization is long in taking place, adhesive strips should be applied, and the part subjected to the pressure of an appropriate bandage. In all burns situated" near joints, or in the neighbourhood of parts possessing a good deal of motion, care should be taken during the pro- cess of healing, to prevent, as much as possible, by the use of splints and bandages, any deformity, from the contraction of the first, or the drawing of the latter out of their proper place; for one of the peculiari- ties of the cicatrices of burns is, the formation of firm, elevated ridges, by the gradual contraction of which, the utmost deformity, or even the entire loss of the use of a limb may be occasioned. Even by the best devised means, it will often be impossible, in extensive burns, to prevent this occurring to a certain degree; nevertheless, the extent of the deformity may be greatly diminished by proper care and atten- tion. When the burn is seated upon the hand or foot, or in the vi- cinity of the ear, caution must also be observed to prevent the unna- tural adhesion of the fingers or toes to each other, or of the ear to the side of the head. During the healing of extensive burns, a rapid formation of fungous granulations very commonly takes place; nor is it possible entirely to restrain them by the application of pressure, caustic, or other escha- rotics. The first, however, we have found, in general, the most suc- cessful ; it may be applied, by covering the ulcer with a pledget of dry lint, and then enveloping it with a bandage; in some cases, the adhe- sive strips and bandage will answer very well. If an escharotic is used, the best will be, perhaps, the nitrate of silver: we must confess, however, that we have seldom seen much good result from its applica- As we have already remarked, in all extensive burns or scalds, there is a very great depression of the vital energies; the patient, if old enough, complains of a feeling of chilliness, and is usually inclined to sleep we have seen a child, immediately after being scalded, shiver as though he were exposed to a very considerable degree of cold. In such cases, a dose of the camphorated tincture of opium, adapted to the a^e of the patient, will be proper; or if the depression is very great, a few°drops of Hoffman's anodyne and spirits of camphor, combined, may be given, and the child should be placed in a room of a moaerately warm temperature. The moment that reaction takes place, every thing, whether in the form of food, drinks, or medicine, of a stimulating cha- racter, should be withheld. In some cases, a restricted diet, purgatives, and even bleeding, will be required, in consequence of the extent of the local inflammation, and the degree of febrile reaction with which it is attended. A most dangerous case of scalding is that of the mouth, pharynx, 744 CONGENITAL AFFECTIONS, ETC. and glottis, which occasionally occurs in children from an attempt to swallow very hot or boiling fluids. Considerable inflammation and swelling of the parts to which the hot liquid has been applied speedily ensue, and, in some cases, death is quickly induced by suffocation, from oedema of the glottis. The inflammation is seldom, if ever, found to extend, in these cases, into the interior of the larynx. The occurrence of the accident is rendered very evident by the whitish and scalded appearance of the interior of the mouth, the situ- ation of the pain of which the child complains, and the difficulty of re- spiration which soon sets in, and goes on increasing; often producing, if not promptly relieved, early suffocation. In the treatment of the injury, the main object should he to keep down the inflammation, by leeches to the neck, and the internal admi- nistration of calomel and antimony, and thus prevent it from involving the glottis to a fatal extent. The amount of local depletion, as well as the doses and repetition of the calomel and antimony, is to be governed by the age of the patient and the urgency of the symptoms in each case. When the dyspnoea is very great, and the danger of suffocation im- minent, tracheotomy should be performed without delay. This opera- tion affords the only chance of recovery we can give to our patient, al- though, judging from the results of the cases in which it has been per- formed, it must be confessed that the chance it furnishes is but a slen- der one. Erichsen states that in the majority of cases Avhich have fallen under his notice where the operation has been performed, the issue has been a fatal one, in consequence of the speedy supervention of broncho-pneumonia, LIST OF AUTHORS AND WORKS REFERRED TO. Abercrombie. On the Nature and Origin of Tubercular Disease. Edinburgh Medico- Chirurgical Transactions, vol. i. Aberle. De Tussi Convulsive. Vindobonce, 1843. Albers. De Tracheitide Infantum. Berlin, 1816. Alderson. On the Pathology of Hooping-Cough. London Medico-Chirurgical Trans- actions, 1830. Alibf.rt. Description des Maladies de la Peau. Paris, 1814. Alibert. Precis Theorique et Pratique sur les Maladies de la Peau. Paris, 1810. Alison. On the Pathology of Scrofulous Diseases. Edinburgh Medico-Chirurgical Transactions, vol. i. Ames. Epidemic Meningitis. New Orleans Medical and Surgical Journal, 1848. Ancell. Treatise on Tuberculosis. London, 1852. Andry. M6moire sur les Maladies du Foetus et ses Annexes. Journal des Progres, 1830. Archer. A Treatise on Croup. Philadelphia, 1798. Armstrong, G. On the Diseases most fatal to Infants. London, 1767. Armstrong. Practical Illustrations on the Scarlet Fever, Measles, and Pulmonary Consumption. London, 1818. Ashburner, J. On Dentition and some Coincident Disorders. London, 1834. Atlee, E. P. Observations on the use of Hydrocyanic Acid in Hooping-Cough. American Journal of the Medical Sciences. 1832. Autenrieth. Versuche fur die Praktische Heilkunde. Gottingen, 1768. Babington, B. G. On Chorea. Guy's Hospital Reports, 1841. Badham. Essay on Bronchitis. London, 1814. Bailly and Legendre. Nouvelles Recherches sur quelques Maladies du Poumon. Ar- chives Generates de Medecine, 1844. Bampfield. Essay on Curvatures and Diseases of the Spine. London, li*24. Bard. Inquiries into the Nature and Treatment of Angina Suffocans. New York, 1771. Barnard. Cases of Chronic Hydrocephalus. London, 1839. Baron. Memoire sur une Affection de la Bouche. Bulletin de la Faculte de Medecine, Baron'Ch. De la Pleurisie dans L'Enfance. Paris, 1841. Barrier, F. Traite Pratique des Maladies de l'Enfance. Paris, 1845 Bateman. A Practical Synopsis of Cutaneous Diseases. London 1814 BattersbY. On Hare Lip. Dublin Quarterly Journal of Med. bne>,c,s, 1846. Baumes. Memoire sur le Traitement de la Maladies Scrofuleuse Pans, 1805. Baumes. Traite de l'Ictere, ou Jaunisse des Enfans. Pans, 1805. B utmks. Traite des Convulsions dans l'Enfance. Pans, 1805. Beck, J. B. Essays on Infantile Therapeupcs. New York, 1849 Becquerel. Recherches Cliniqne. sur la Meningite des Enfans Pans 1845. Bednar. Die Krankheiten der Neugebornen und Saugl.nge. Wem lSoO Behrend. On the Periodic Nocturnal Cough of Children. Journal far Kmderhranh- -R»r'TuthIr V. An attempt to investigate some obscure and undecided Doctrines in Bell, Luther v. a j Vaccination. Boston, 1836. iJ^E P O^ Amer- J°Urnal °ftke Med' S0"™" 1S43> frN" ' " On Hydrocephalus. Tweedie's Library, ' OnTrLheotomyinCroup. Dublin Medial Press, 1841. Berth* Traite des Maladies des Enfans. Pans, 1837. Billard Traite des Maladies des Enlans nouveau-nes. Pans, 1828 bLaud Nouvelles Recherches sur la Laryngo-TracheUe. Pans, 1S24. Blaud. On Hooping-Cough. Revue Medicate, 1S31. 746 LIST OF AUTHORS AND WORKS REFERRED TO. Bouchardat. On Aphthae. Annnaire Thera.pentique, 1811. Bouchut. Manuel Pratique des Maladies des Nouveau-nes. Paris, 1845. Boudet. On Epidemic Croup. Archives Generates, 1P42. Boidin. Recherches sur les Complications que Accompagnent la Rougeole chez l'Enfant. Paris, 1835. Bouillaud. Traite Clinique et Physiologique de l'Encephalite. Paris, 1855. Brachet. Memoire sur les Causes des Convulsions. Paris, 1824. Branson. On Chorea and its Consequences. Provincial Medical and Surgical Journal, 1845. Bremser, Traite Zoologiqne et Physiologique, sur les Vers Intestinaux de l'Homme. Translated into French by Grandler, with notes by Blainville. Paris, 1824. Brendt. (Jeber Keichhusten. Griesswold, 1834. Brera. Treatise on Verminous Diseases. Translated into French, with notes by Bar- toli and Calvet, and into English, with Additions by John G. Coffin. Boston, 1817. Bretonneau, P. Des Inflammations Speciales du Tissu Muqueux. Paris, 1826. Brunet. Sur la Pneumonie Lobulaire. Journal Hebdomadaire, 1833. Bryce. Practical Observations on the Natural and Modified Small-pox. Edinburgh, 1802. Bull, Thos. Maternal Management of Children. Philadelphia Ed., 1840. Burgesson. Laryngismus Stridulus. Provincial Medical and Surgical Journal, 1842. See also London Lancet, 1838. Burrows. On Measles and Scarlatina. Tweedie's Library. Butter. A Treatise on the Infantile Remittent Fever. London, 1782. Butter. Treatise on Kink Cough. London, 1773. Butter. Treatise on the Hooping-Cough. London, 1782. Camerer. Versuche iiber die Natur der Krankhaften Magenerweichung. Stuttgard, 1828. Capuron. Traite des Maladies des Enfans. Paris Edition of 1830. Carrault. Guide des Meres. Paris, 1828. Cartwright. Pathology and Treatment of Cholera Infantum. American Medical Re- cord, 1826. Cazeaux. Infantile Syphilis. Bulletin de VAcademic, xvi. Cazenave and Schedel. A Practical Synopsis of Cutaneous Diseases. Philadelphia Ed., 1829. Cazenave and Schedf.l. Abr6ge Pratique des Maladies de la Peau. Paris, 1828. Chambon. Maladies des Enfans. Paris, 1799. Chapman, N. On Croup. Phila. Journal of the Med. and Phys. Sciences, vol. i. Chevers. On the Causes of Cyanosis. London Medical Gazette, 1817. Cheyne. On Croup. Cyclopcedia of Practical Medicine. Chey.ne. Essays on Hydrocephalus Acutus, or Water in the Brain. London, 1819. Cheyne, J. Essay on Cynanche Trachealis, or Croup. Edinburgh, 1801. Cheyne, J. Essays on the Diseases of Children. Edinburgh, 18U2. Cheyne, J. Pathology of the Membrane of the Larynx and Bronchia. London, 1809. Churchill. On the Diseases of Infants and Children. London, 1858. Clark, Jas. Treatise on Pulmonary Consumption and Scrofula. London, 1836. Clarke, Jno. Commentaries on the Diseases of Children. London, 1798. Cloquet. Anatomie des Vers Intestinaux. Paris, 1824. Coates. Description of the Gangrenous Ulcer of the Mouths of Children. N. A. Me- dical and Surgical Journ., 1826. Coindet. Memoire sur l'Hydrencephale. Geneva, 1818. Coley. A Practical Treatise on the Diseases of Children. London, 1P46. Combe, A. On the Management of Infancy and Childhood. Philadelphia Ed. Edited by J. Bell, M. D., 1840. Cook. Apoplexia Hydrocephalica, or Hydrocephalus Internus. Treatise on Nervous Diseases. Coxe, Jno. R. On Croup. Amer. Journ. of the Med. Sciences, vol. iii. Coxe, Jno. R. On Chorea. Philadelphia Med. and Phys. Journ. vols. xiii.—xviii. Coxe, Jno. R. Observations on Vaccination. N. A. Med. and Surg. Journ., 1828. CrMgie. On Cyanosis. Ed. Med. and Surg. Journal, 1843. Crampton. On Cyanosis. Cyclopaedia of Practical Medicine. Crampton. On Hydrocephalus. Trans. oftheKingand Queen's College in Ireland, 1817. Crisp. On Infantile Pleurisy. London Medical Gazette, 1816. Cumin. On Rickets and Scrofula. Cyelopcedia of Practical Medicine. Cuming, Thos. Observations on the Peripneumonia of Children. Tra?is. of King and Queen's College, Ireland, vol. v. LIST OF AUTHORS AND WORKS REFERRED TO. 747 Cijrrie, Wm. Hydrocephalus. Croup. Cholera of Infants. Diseases of the United States. Philadelphia, 1811. Dance. Observations pour Servir a l'Histoire de l'Hypertrophie du Cerveau. Paris. Danz, F. G. Versuche Einer Algemeine Geschichte des Keickhustens. Marbourg, 1791. Davis, D. D. Acute Hydrocephalus, or Water in the Head, an Inflammatory Disease. American Ed., 1810. Dendy. Practical Remarks on the Diseases of the Skin. London, 1837. Denis, R. S. Recherches Anatomiques et Physiologiques sur Quelques Maladies des En- fans. Comercy, 1816. Paris, 1824. De Salle. Traits des Maladies des Enfans. Paris, 1826. Desruelles. Traite Theorique et Pratique du Croup. Paris, 1822. Desruelles. Traite de la Coqueluche. Paris, 1827. Detmold. Essay on Club Foot. New York, 1810. Dewees. A Treatise on the Physical and Medical Treatment of Children. Philadel- phia, 1844. 9th Ed. Dieffenbacii. Abscessus Capitis Sang, neonatorum, 1839. Dismelles. Traite Therapeutique et Pratique du Croup. 1830. Do3pp. On Cephalaematoma, Annates de la Chirurg. Franc, et Etrang., 1814. Donne. On Certain Pathological Conditions of the Milk as a cause of disease in Infants. Cours de Microscopic Paris, 1844. Donne. Conseils aux meres sur l'allaitement et sur la maniere d'elever des Enfants nouveau-ne"s. Paris, 1846. Droste. On Gelatinous Softening of the Stomach in Children. Zeitschrift far die Ge- sammte Medicin, vol. i. Duges. Recherches sur les Maladies les plus Tmportantes et les moins Connuesdes En- fans Nouveau-nes. Paris, 1821. Duncan, Jas. On the Epidemic Ulceration of the Gums in Children. Dublin Journal of Medical Sciences, 1845. Dunglison, R. Commentaries on the Diseases of the Stomach and Bowels in Children. London, 1823. Duplay. On Inflammation of the Umbilical Vein in Infants. Medico-Chirurgical Re- view, 1838. Ebelung. Dissertatio de Tussi Infantum Convulsiva. Gottingen, 17(i8. Eberle. A Treatise on the Diseases and Physical Education of Children. Philadel- phia, 1839. Cincinnati, 1843. Edwards, W. F. G. On the Influence of Physical Agents upon Life. Phila. Edition. 1838. Eichstedt. Ueber den Durchfall der Kinder. Wein, 1853. Eisenmann. On the Exanthemata. Hufeland''s Journal, 1840. Elam. On Chorea. Provincial Medical and Surgical Journal, 1849. Elsaesser. Die Magenerweichung der Sauglinge. Stuttgard, 1846. Emangard. Memoire sur l'Angine Epidemique ou Diphtherite. Paris, 1829. Englehard. Ueber der Croup. Berlin, 1829. Englemann. On the Treatment of Hydrocephalus by Compression. Chehus und Nagele's Medicinische Annalen, vol. viii. Evanson and Maunsell. A Practical Treatise on the Management and Diseases of Children, 5th Ed. Dublin, 1847. Fabre. Maladies des Enfans, 1850. Farre. On Worms in the Intestines. Tweedie's Library. _ Faubel. Recherches sur la Bronchite Capillaire, 1840. And, Memoires de la Societe Medicale d'Observation. Tome 2d, 1844. jir-.ii u v Feiler. P-xdiatrik oder Anleitung zur Erkenntniss und Heilung der Kinderkrankheiten, 1814. „ > , ... Francis. On Croup. New York Med. and Phys. Journ. vol. in. Friedleben and Fle.sch. On the Pathology of the Intestinal Mucous Membrane in Young Infants. Z.itschrift fur Rationelle Medicui. Heidelberg S16 Fuchs. Historische Untersuchung uber Angina Maligna. Wurtzbourg, 1828. Fuller. Report on the Treatment of Cholera Infantum. 18o0. Gairdner. On Pulmonary Collapse. Edinburgh, 1S53. Gakdien. Des Maladies des Enfans. Edition of 1^8. G^s Recherches sur I'Acams ou >carpote de la Gale. Pans, 1S34. Ged'dings. On Pseudo-membranous Inflammation of the Throat. Amer. Journ. Med. Sciences, 1839. 748 LIST OF AUTHORS AND WORKS REFERRED TO. Gerhard, W. W. On Pneumonia in Children. Tweedie's Library. American Journ. Med. Sciences, 1834. Gerhard, W. W. On the Cerebral Affections of Children. American Journal of the Medical Sciences, 1834. Gibb. Treatise on Hooping-Cough. London, 1854. Gintrac, E. Observations et Recherches sur la Cyanose. Paris, 1821. Girard. On the Influence of the Quality of the Nurse's Milk on the Health of the In- fant. Journal de Pharmacie, 1845. Girtanner. Ueber de Krankheiten der Kindern. Berlin, 1794. Glover. On the Pathology and Treatment of Scrofula. London, 184G. Goelis. Treatise on Acute Hydrocephalus. Translated by Robt. Gooch, M.D. Lon- don, 1821. Goelis. De rite Cognoscenda et Sananda Angina Membranacea. Vienna, 1813. Goelis. Praktische Abhandlungen. Vienna, 1820. Gooch. On some Symptoms in Children erroneously attributed to Congestion of the Brain. London, 1831. Graves. Clinical Lectures. American Edition, 1842. Graves. On Infantile Convulsions. London Med. and Surg. Journ., 1833. Green. Observations on the Pathology of Croup, etc. New York, 1849. Green. A Practical Compend of the Diseases of the Skin. London, 1835. Green. Contributions on the Pathology of Children. London Lancet, vol. ii. et seq. Green. On Nervous Tremors in Children. Provincial Med. and Surg. Joum., 1814. Green, Hennis. On Hypertrophy of the Brain. Provincial Med. and Surg. Journ.,\8i0. Green, Hennis. On Tubercle of the Brain in Children. Medico-Chirurg.Ti aus., vol. xxv. Gregory. On Small-pox, Chicken-pox, and Vaccination. Cyclopcedia Prac. Med. See also Tweedie's Library. Gregory. On Vaccination. London Med. Gaz., 1827-28. Gregory. On Vaccination and Small-pox. Medico-Chirurg. Trans, vol. vi. See also London Lancet, 1841. Gregory. Lectures on Eruptive Fevers. New York Ed. 1851. Grissolle. Traite Pratique de la Pneumonia aux differens Ages. Paris, 1841. Guersent. On Muguet; on Gangrenous Angina; on Croup. Dictionnaire de Medecine. Guersent. On Tonic Convulsions of Children. Gazette Mhlicale, 1832. Guersent et Blache. Small-pox. Dictionnaire de Medecine. Guibert. Recherches Nouvelles et Observations Pratiques sur le Croup et la Coqueluche. Paris, 1824. Guibert. Observations sur 1'Hydropericarde chez les Enfans. Journal des Progrls, 1830. Hache. Maladies des Enfans. Paris, 1820. Hahn. De la Moningite Tuberculeuse, etudiee au point de vue clinique. Paris, 1853. Hall, Marshall. On Scarification of the Gums during Dentition. London Lancet, 1844. Hall, Marshall. On the Nature and Treatment of Stridulous Convulsions in Infants. London Lancet, 1842. Hall, Marshall. On the Diseases and Derangements of the Nervous System. Lon- don, 1841. Hallowell, Ed. On the Endemic Follicular Gastro-enteritis, or Summer Complaint of Children. American Journal of the Medical Sciences, 1847. Hamernjk. On Tubercular Meningitis. Schmidt's Jahrbucher, 1S45. Hamilton, Robt. Observations on Scrofulous Diseases. London, 1791. Hamilton, Jas. Hints for the Treatment of the Principal Diseases of Infancy and Child- hood. London, lb09. Hamilton. On the Treatment of Scarlatina Anginosa. Edinburgh Med. and Surg. Journal, 1839. Harris. De Morbis Acutis Infantum. London, 1689. Harrison. On Hydrocephalus. Transylvattia Journal of Medicine, 1831. Heilborn. Zur der Charakteristik der Kuhpocken Narben. Rust's Magazin, 1829. Heine. On Revaccination. London Medical Gazette, 1834. Henke. Handbuch der Kinderkrankheiten. Berlin, 1813. Herard. On Tartar Emetic in the Pneumonia of Children. British and Foreign Med.- Chirurg. Review, 1848. Herrick. Boebachtungen und Bemerkungen uber den Rasch Verlaufenden Wasserkopf. 1847. Hesse. Ueber die erweichung der Gewebe und Organe der Menschliken Korpera. Leip- sic, 1827. Hewitt, P. Remarks on Cases of Spina Bifida. London, 1845. LIST OF AUTHORS AND "WORKS REFERRED TO. Hkyfelder. Beobachtungen iiber der Krankheiten der Neugebornen, 1822. Hildreth, C. C. Practical Observations on Chorea. American Journal of the Medical Science*, 1848. Home. Medical Facts and Experiments. London, 1759. Hood. A Practical Treatise on the Diseases most fatal to Children. London,1745. Horner, W. A. An Inquiry into the Anatomical Characters of Infantile Follicular In- flammation of the Gastro-intestinal Mucous Membrane. American Journal of Medical Sciences, 1829. Horner, W. A. Contribution to the Pathology of Infantile Convulsions. Amer. Journ. of the Med. Sciences, 1831. IIosack, D. Observations on Croup, or Hives. American Medical and Physical Register. New York, 1812. Hueter. Beobachtungen und Bemerken iiber den Wasserkrebs. Berlin, 1829. Hufeland. Ueber Verschiedene Kinderkrankheiten, 1798. Hufeland. Neues System der Kinderkrankheiten, 1803. Hufeland. A Treatise on Scrofulous Diseases. Translated by C. D. Meigs, M. D. Philadelphia, 1829. Hulliiien. On Hare Lip. ArMrican Journal of Dental Science, 1844. Hunter. On Rotatio or Chorea. Ed. Med. and Surg. Journ., 1823. Hurteloup. Sur 1'Inflammation de la Membrane Muc. Gastro-pulmonaire chez les Nouveau-nes. Paris, 1823. Iselin. On the Softening of the Stomach in Infants. Edin. Med. and Surg. Journ., 1840. Isnard. Dissertation sur une Affection Gangreneuse Particuiiere aux Enfans. Itard. Sur l'HydrocSphale Aigue. Diet, des Sciences Med. Jackson. On Gangraenopsis. Amer. Med. Recorder, 1827. Jackson. On Cholera Infantum. N. E. Journ. of Med., vol. i. Jaeger. On the Softening of the Stomach in Infants. Hufeland's Journal, J-811- Jansecowicii. Einige Bemerkungen iiber den Croup. 0 ester eichische Jahrbuch, 18o7. Joerg. Handbuch zum Erkennen und Heilen der Kinderkrankheiten, 1836. Joerg. Die Fcetus Lunge in Gebornenkinde. Grimma, 1836. Johnson. On Carpo-pedal Spasms. Medico-Chirurg. Review, vol. in. Johnson. On Hooping-Cough. Ibid. Joy. Tabes Mesenterica—Disorders of Dentition—Worms—Hydrocephalus—Infantile Remittent Fever. Cyclopcedia of Prac. Med. Judd W. H. On the Structure of the Small-pox pustule. London Lancet, 1841. Katona, M. Von. On the Inoculation of Measles. Oesterreiche Medicinische Wochen- schrift, 1842. 1or 'Kenedy On the Management of Children. Glasgow, lS-o. Kennedy, E. On the Apoplexy, Paralysis, and Convulsion, of New-born Infants. Guy , Hospital Reports, 1836; and Dublin Journal of Medical Sciences, 1836 Kennedy. Account of the Epidemics of Scarlatina in Dublin from 1834 to 1842. Dub. Trio?4' On T trvnrismus Stridulus. Ed. Med. and Surg. Journ., vol. lviii. LrSriSe. 7nTTmploymentof Cimicifugain.the Treatment of Chorea. Amencan Journ. of the Med. Sciences, 1840. K^A ^^^fs^^r*^, 1830 Lop, 1»»**^ Krukenberg ^^^ f^Ambulaterischen Klinik zu Halle, 2 vols., 1824. La™J' OblerTationf pour Servir 1'Histoire de 1'Hypertrophic du Cerveau. Revue LASiAtn.^Recherches Anatomico-Pathologiques sur 1'Hypertrophic du Dependances. Paris, 18-25. hez kg Enfans NouveaUx-n^s. Paris, 1839. Landouzy. Sur 1 »«™X;f ofhthalmia. Kcuve Chirurg. BibUothe. £tLGKB«.CKbn ApSSinX^tus and New-born Child. Journal de Medecine de Toulouse, 1845. . Morbid affections and the Diseases which Lee, Chas. A. On the W*™ t American Journ. of the Med. Sciences, 1842. arise from its Abnorma *^eJ^ ADMin Journ. 0/the M..d. Sciences, 1842. Lees, C. On Hypertrophy of the tfram• " ^ J ^^ de rEnfance. Legendre. Rp<^""^ fa ^ Paris, 1846. 750 LIST OF AUTHORS AND WORKS REFERRED TO. Leger. Sur la Pneumonie des Enfans. Paris, 1823. Lelut. De la Fausse Membrane dans le Muguet. Archives de Medicine, 1827. Lenhosseck. Einige Bemerkungen iiber die Erweichung des Magens. Vienna, 1823. Leroy. On Pertussis. Medecine Miternelle. Paris, 18U3. Ley. Essay on the Laryngismus Stridulus or Croup-like Inspiration of Infants. Lon- don, 1836. Lindsley. On Cholera Infantum. Amer. Journ. of Med. Sciences, 1839. Little. Lectures on the Nature and Treatment of Deformities. London, 1853. Lloyd. Treatise on the Nature and Treatment of Scrofula. London, 1821. Locock. On Infantile Convulsions. Cyclopaedia of Prac. Med. Lombard. On Hooping-Cough. Dublin Journal of Medical Sciences, 1838. Louis, P. C. A. Recherches Anatomique et Pathologique sur le Croup. Paris, 1826. Louis. Recherches sur la Gastro-enterite. Paris, 1829. Louis. Memoires, ou Recherches Anatomico-Pathologiques. Paris, 1826. Luders. Yersuch einer Kritischen Geschichte der bei Vaccinirten Beobachtungen Men- schenblattern. Altona, 1824. Macilwain. Clinical Observations on the Constitutional Origin of the Various Forms of Porrigo. London, 1834. Mackenzie. A Practical Treatise on Diseases of the Eye. London, 1832. Magill. On Scarlet Fever. American Journ. of Med. Sciences, 1839. Malins. De Cynanche Tracheali. Edinburgh, 1830. Marcus. Der Keichhusten; iiber Seine Erkenntniss, Natur, und Behandlung. Bamberg, 1816. Marcus, A. F. Traite" de la Coqueluche. French Translation by Jacques. Paris, 181G. Marley, M. On the Nature and Treatment of the most frequent Diseases of Children. London. 1830. Martin, J. C. On the Identity of Cow-pox and Variola. Boston Medical and Surgical Journal, 1841. Mathey. Memoire sur l'Hydroce'phale. Paris, 1818. Maiwoir. Sur les Amputations, l'Hydrocele du cou, etc., Geneve, 182"). Mauthner. Die Krauken des Gehirns und Riichenmarks bei Kindern. Vienna, 1844. Mayne. Epidemic Meningitis. Dublin Quarterly Journ. of Med. Sciences, August, 1846. Mende. Analekten iiber Kinderkrankheiten. iStuttgard, 1834. Meigs, J. Forsyth. A Practical Treatise on the Diseases of Children. Phila., 1858. Meigs, C. D. On certain of the Diseases of Young Children. Philadelphia, 1850. Meissner. Grundlage der Literatur der Paidiatrik, 18-30. Michaelis, F. De Angina Polyposa. Gottingen, 1779. Michaelis. Ueber eine eigene Art von Blutgeschwiilsten. Loder's Journal, 1804. Miguel. On the means of Preventing Scarlatina. Transactions of the Royal Academy of Medicine, 1834. Millar. Observations on the Asthma, and on the Hooping-Cough. London, 1769. Miller, Ed. Cholera or Bilious Diarrhoea of Infants. Medical Works, N. York, 1814. Mills. On Hydrocephalus. Trans, of the King and Queen's College in Ireland, vol. v. Mitchell and Bell. History of the Natural and Modified Small-pox as it prevailed in Philadelphia in the years 1823, 1824. N. A. Med. and Surg. Journ., 1826. Mitchell, J. K. Observations on the Treatment of Curvature of the Spine. N. A.Med. and Surg. Journ., 1827. Mo'hl. De Varioloidibus et Varicellis. Copenhagen, 1827. Monro. Morbid Anatomy of the Brain, vol. i. Hydrocephalus. Edinb. and Lon., 1827. Monro, A. L. On 8mall-pox. Edinburgh, 1818. Montgomery*. On Rubeola. Cyclopccdia of Prac. Med. Montgomery. On the Sudden Death of Children from Enlargement of the Thymus Gland. Dublin Journal of the Medical Sciences, 1836. Morton, Richard. Opera Medica. Loudon, 1697. Moss. On the Management and Nursing of Children. London, 1782. Musgrove. Essay on the Nature and Treatment of the so called Worm Fever. Lon- don, 1776. Mutter. A Lecture on Loxarthus, or Club Foot. Philadelphia, 1839. Naumann. On Pseudo-membranous Inflammation. Handbuch der Med. Klinik, vol. iv. Neumann. Krankheiten des Menschen, 1836. North. Practical Observations on the Convulsions of Infants. London, 1826. Odier. Manuel de Medecine Pratique. Geneva, 1821. LIST OF AUTHORS AND WORKS REFERRED TO. 751 Oesterlf.n. JEtiologie und Pathologe der Krankheiten Neugebornen Kindern. Heidel- berger Klinische Annalen, 1831. Olliffe. On the Treatment of Variola by the Ectrotic Method. London Lancet, 1841. Oppenheim. Ueber die Function der Chronischen Innerren Wasserkopf. Rust's Ma- gazin, 1827. Otto. On Pertussis. Nyehygaea, 1824. Ozanam. Histoire Medicale, Genenile et Particuliere, des Maladies Epidemiques, &c. Paris, 1817. Page. Essay on Diseases of Children. Amer. Med. Recorder, 1829. Paldam, V. H. L. Ueber die Stickhusten. Halle, 1805. Papavoine. Sur les Tubercles Considered Specialement chez les Enfans. Journ. des Progres, 1830. Papavoine. Observations des Convulsions chez les Enfans. Journal des Progres, 1830. Parent-Duchatelet et Martinet. Recherches sur l'lnflammation de l'Arachnoide CVrebrale et Spinale. Paris, 1819. Parrish, J. Observations on a particular Complaint in Children. N. A. Medical and Surg. Journ., 1826. Parrish, J. On Infantile Convulsions, arising from Spasms of the Intestines. N. A. Medical and Surgical Journ., 1827. Pearson. Medical Dissertations on Chin-cough. Edition of 1832. Pemberton. A Practical Treatise on the Various Diseases of the Abdominal Viscera, London, 1806. Penada, G. Memoria sulla Tusse Convulsiva. Verona, 1815. Phillips. Scrofula, its Causes, its Prevention, and the Principles of Treatment. Lon- don, 1846. Phillips (of Missouri.) Epidemic Meningitis. Medical Examiner, vol. x. Piorry, P. A. De l'lrritation Encephalique des Enfans. Paris, 1823. Plumbe. A Practical Treatise on the Diseases of the Skin. London, 1824. Pohl. Analogia inter Morbillos et Tussim Convulsivam. Leipsic, 1809. Porter, W. H. Observations on the. Surgical Pathology of the Larynx and Trachea. London and Edinburgh, 1826. Porter. On Spasm of the Glottis. Dublin Medical Press, 1840. Qutn. De Apoplexia Hydrocephalica. Dublin, 1799. Raciborski. On the Influence of Menstruation on the Milk of Nurses. Dublin Medical Press, 1843. Ramisch. De Gastromalacia et Gastropathia Infantum. Prague, 1824. Raspail. Sur l'Histoire de l'lnsect de la Gale de l'Homme. Paris, 1834. Rail Handbuch der Kinderkrankheiten. 1846. Rayer. Traite" Theorique et Pratique de la Maladies de la Peau. Paris, 1835. Rayer. Traite des Maladies des Reins. Paris, 1839. Rees. Treatise on Diseases of Children. London, 1817. Rees, G. A. On Laryngismus Stridulus. London Lancet, 1841. Reid.' On Infantile Laryngismus. London, 1849. Renucci. On the Itch Insect. London Lancet, 1834. Richard. Traite des Maladies des Enfans. Paris, 1805. Richardson. Epidemic Meningitis. Western Journal of Medicine and Surgery. 1842. Richter. Der Wasserkrebs der Kinder. Berlin, 1828. Ricord. Traite de la Maladie vdnerienne, chez les Nouveaux-ne*s, etc. Paris, 1810. Rilliet and Barthez. Traite Clinique et Pratique des Maladies des Enfans. Paris, 1853. Ritscher. Pneumonia Infantilis. Rust's Magazin, 18o0. Roberton. On the Physical Management of Children. London. 1827. Roberts, W. C. On Thymic Enlargement. New York Medical Gazette, 1842. Roberts'. Epidemic Meningitis. Western Journal of Medicine and Surgery, vol. xi. Robertson. On Aphthae. Cyclopaedia of Practical Medicine. Roe G. H. Treatise on the Nature and Treatment of Hooping-Cough. London, 1838. Roesch. On Scrofula. Haeser's Archives, 1811. Roger. De la Temperature chez les Enfants. Paris, 1844 Roger. On the (Edema of New-born Infants. Archives Genirales, 1845. Rokitansky. Pathologist Anatomie, 1848. Romberg. Einige F'alle von Magenerweichung, Wasserkrebs, und Rose bei Kindern. Rust's Mjgaziii, 1830. 752 LIST OF AUTHORS AND WORKS REFERRED TO. Rosen Vox Rosenstein. Anweisung zur Kenntniss und Kur der Kinderkrankheiten. Gottingen. 1798. Rosen Von Rosenstein. Treatise on Diseases of Children. Translated from the Swe- dish. London, 1776. Rousseau. Hydrops Capitis Infantum. American Medical Recorder, 1819. Royard Collard. On Croup. Dictionnaire des Sciences Medicates. Rudolphi. Entozoon, sive Verminum Intestinum Historia Naturalia. Amsterdam, 1811, Rufz. Researches on some Points of the History of Chorea in Children. Archives Gi- nSrales, 1834. Rush. On Dropsy of the Brain, and Croup. Med. Inq. and Observations, vol. ii. Ryland. On Laryngismus Stridulus. Provincial Medical and Surg. Journ., 1842. Salle. French Translation of Underwood, with Notes. Paris, 1823. Schaeffer. On Vaccination. Medicinische Zeitung, 1844. Schedel. On the Diseases of the Skin. Tweedie's Library. Schmid. De Angina. Vienna, 1790. Schmidt. Convulsiones Infantum. Berlin, 1826. Schreber. Die Eigenthumlickeiten des Kindlichen. 1852. Scoutteten. Hypertrophy of the Brain. Archives Generales, vol. vii. Seaton. On the Protective and Modifying Power of Vaccination. Journal of Public Health. London, 1857. Senn. Recherches Anatomico-pathologiques sur la Meningitis. Paris, 1825. Shapter. On Scrofula. Tweedie's Library. Sidey, Chas. On Epidemic Scarlet Fever. Edinburgh Med. and Surg. Journal, 1839. Sims. On Hypertrophy of the Brain. Medico-Chirurgical Trans., 1835. Smith, Thos. On the Nature, Causes, Prevention, and Cure of Acute Hydrocephalus, or Water-brain Fever. London, 1845. Smyth. On Rickets and Hydrocephalus. Miscellaneous Contributions to Pathology and Therapeutics. London, 1844. Steinbrenner. Traite" sur la Vaccine. 1846. Stewart, James. A Practical Treatise on the Diseases of Children. New York, 1846. Stewart, James. On Cholera Infantum. New York, 1857. Stiebel. On St. Vitus's Dance. Wochenschrift fur die Gesammte Heilkunde, 1837. Stille, Moreton. On Cyanosis. American Journ. of Medical Sciences, 1844. Streeter. On the Nature and Seat of Hooping-Cough. London Med. Gazette, 1844. Stuart, Jno. On the Use of Hydrocyanic Acid in Chorea. Edinburgh Med. and Surg. Journal, 1827. Symonds. On Diseases of the Mouth. Tweedie's Library. Tait. On the Treatment of Scarlatina. London Medical Gazette, 1837. Tanner, T. H. Practical Treatise on the Diseases of Infancy and Childhood. London, 1858. Taupin. On Vaccination. Dictionnaire de Medecine. Taupin. Clinical Researches on Typhoid Fever in Children. Journal des Connaissances Medico-Chirurg kales, 1839-40. Taupin. On Gangrenous Inflammation of the Mouth. Ibid., 1838. Taylor. On Infantile Remittent Fever. London, 1856. Thilenius. Medicinische Chirurgische Bemerkungen. Edition of 1800. Thompson. On the Varioloid Epidemic. Edinburgh, 1820. Thompson. On Chorea and Tabes Mesenterica. Tweedie's Library. Thore. De la Peritonite chez les Nouveau-nes. Archives Gen. de Med., 1846. Tonnelle. On Tonic Convulsions of Children. Gazette Medicale, 1832. Tourtual. Praktische Beitrage zur Therapie der Kinderkrankheiten. Minister, 1852. Troccon. Sur la Maladie Connue sur le nom d'Endurcissement du Tissue Cellulaire. 1814. Trousseau. On Infantile Syphilis. Archives Generates de Med., 1846. Trousseau. On Pneumonia in Infants. Medical Times, 1846. Trousseau. On Diphtheritis. Dictionnaire de Med. Trousseau. On Thymic Asthma. Journal de Medecine, 1845. Trousseau. Croup. Tracheotomy. Dictionnaire de Medecine. Trousseau. On Epidemic Measles. Journal de Medecine, 1843. Trousseau. Memoire sur la Coqueluche. Journal de Medecine. Paris, 1843. Tweedie. On Scarlatina. Cyclopaedia of Practical Medicine. Uldall. De Dentitione Infantile. Copenhagen, 1833. LIST OF AUTHORS AND WORKS REFERRED TO. 753 Underwood. Treatise on the Diseases of Children, with Notes by S. Merriman, M. D., and Marshall Hall, M. D., and John Bell, M. D. Philadelphia, 1841. Ure. Materia Medica adapted to the Diseases of Infancy. London, 1839. Vaidy. Hydroc6phale Aigue Essentielle et Symptomatique. Diet, des Sciences Med. Valentin, L. Sur le Croup. Paris, 1812. Valleix. Clinique des Maladies des Enfans Nouveau-ne"s. Paris, 1839. Valleix. On Croup. Bulletin Generate de Therapeutique. Paris, 1843. Veron. Observations sur les Maladies des Enfans. Paris, 1821. Vieusseux. Me"moire sur le Croup. Paris, 1812. Volz. On Hooping-Cough. linker's Archives, vol. iv. Vondem Buscii. German Translation of Desruelles on Croup, with Notes. Bremen, 1828. Vrolik. Traite" sur l'Hydrocephalus Interne. Amsterdam, 1839. Watt, R. Treatise on the History and Treatment of Chincough. Glasgow, 1813. Weber. Betrage zur Pathologischen Anatomie der Neugebornen. 1853. Wendt. Die Kinderkrankheiten Systematische Dargestellt. Vienna, 1827. Wernher. Die Angeborenen Kysten-Hygrome und die ihnen verwandten Geschwulste. Giessen, 1843. West. On Pneumonia in Children. British and Foreign Medical Review, 1843. West, J. W. On the Salaam Convulsion. London Lancet, 1841. West, Chas. Lectures on the Diseases of Infancy and Childhood. Phila. Edit,, 1850. Whatton. On the Pathology and Treatment of Pertussis. London Lancet, 1831. White (of Tennessee.) Epidemic Meningitis. New Orleans Medical and Surg. Journ. 1848. Whitlock, N. Practical Remarks on Disordered States of the Cerebral Structures oc- curring in Infants. London, 1821. Wicke. Analeckten der Kinderkrankheiten. 1833. Willan, Robt. On Vaccine Inoculation. London, 1806. Williams. On Croup, Laryngismus, and Hooping-Cough. Tweedie's Library. Willis. Urinary Diseases and their Treatment. London, 1838. Wilson. A Practical and Theoretical Treatise on the Diagnosis, Pathology, and Treat- ment of the Diseases of the Skin. London, 1842. Winter. On Softening of the Stomach. Rust's Magazin, 1830. Wolff. Beitrag zu der Lehre von den Kinderkrankheiten. Hufeland and Osann's Jour- nal, 1831. Wolff. Ueber Kinderkrankheiten. Berlin, 1837. Wood. On Scarlet Fever. Edinburgh Med. and Surg. Journ., 1839. Worcester, N. A Synopsis of the Symptoms, Diagnosis, and Treatment of the more common and important Diseases of the Skin. Philadelphia, 1845. Worthington. On Gangroenopsis. American Medical Recorder, 1828. Wyatt. Observations on the Dropsy in the Brain. Edinburgh, 1768. Yeats. A Statement of the Early Symptoms which lead to the Disease termed Water in the Brain. London, 1817-1819. Zangert. Ueber die Convulsionem in Kinderlichen Alter. Vienna, 1834. Zeller. Dissertatio de Natura Morbi Ventriculo Infantum Perforantis. Tubingen, 1818. Zeller. Commentaria de Cephaloemate. 1822. Zeroni. Practical Remarks on Croup. Henle and Pfeuffer's Zeitschrift fur Rationallt Medizin, 1847, Zichner. De Angina Membranacea. Berlin, 1S25, 48 INDEX. A. Ablutions, daily, importance of, 20. Acirus scabiei, 597. ActiJents occurring within the month, 668. Adipous tissue, induration of the, 94, 713. Affective faculties, state of, in infancy, 76. Air, importance of pure, 17, 111, 606. cold and damp, injurious effects of, 20, 607. overheated, injurious effects of, 21, 112. impure and stagnant, productive of disease, 18, 111, 606. Albuminous nephritis in children, 101. Alimentary canal, state of, in infancy, 67, 70, 77, 78. Amusements for children, 52. Anaemia in infancy, 106. Aneurism by anastomosis, 719. Anger, bad effects of, in children, 58. Angina externa, 183. pseudo-membranous, 172. malignant, 175. polyposa or membranacea, 819. Anginose scarlatina, 487. Ani, prolapsus, 235. Anuria, 654. Anus, imperforate, 669. Aphtha lactumina, 138. Aphtha), 143. deaths from, 88. infantiles, 138. Apneumatosis in infancy, 87. Apnoea neonatorum, 276. Apoplexy, 394. deaths from, 91, 394. Arachnoid cavity, hemorrhage of the, 396. Ascaris, 242. lumbricoides, 242. Asphyxia, 276. Asthma, Kopp's, 347. Millar's, 342. thymic, 347. Atelectasis pulmonum, 87, 303, 312. Atmosphere, impure, injurious effects of, 18, 606. cold and damp, injurious effects of, 18, 20, 607. overheated, injurious effects of, 21,112. Atonic ulcer, 587. Atrophia ablactatorum, 210. B. Bathing, importance of, 22, 24, Beds, proper for infants and children, 24. Belladonna as a prophylactic of scarlatina, 509. Bilious diarrhoea, 212, 218. Black pock, 519. Bladder, urinary, state of, in infancy, 67. Blood, in infancy and childhood, 68. Blood-vessels, in infancy, 67, 70. diseases of, in children, 106. Bloody tumour of the scalp, 678. Blue disease, 684. Boils, 569. Bones, state of, in infancy and childhood, 65, 77. indications of disease from state of, 133. scrofulous disease of the, 616, 643. Bothriocephalus latus, 242. Bowels, indications of disease from the dis- charges from the, 130. Brain, organization of, in infancy and child- hood, 68, 70, 78. liability of, to disease, in infants, 91. deaths from diseases of the, 91. hydrencephaloid disease of, 457. hypertrophy of the, 388. hyperaemia of the, 394. hemorrhage of the, 394. inflammation of the, 420. dropsy of the, 442, 457. tubercles of the, 98, 627. Breasts, intumescence of the, 700. Breath, indications of disease from the, 130. Bronchi, dilatation of, 290. inflammation of the, 285. Bronchial croup, 287. glands, tuberculization of, 625. phthisis, 62-5. Bronchitis, 283. capillary, 287, 289. diffused, 289. vesicular, 290. deaths from, in children, 87. Broncho-pneumonia, 87, 2(j7. 756 INDEX. Bullae febrilis, 590. Burns and scalds, 741. Butter, use of, by children, Cachexia aphthosa, 147. Calorification, state of, in infancy, 73. Cancer in children, 108. Cancrum oris, 152. Canker of the mouth, 152. Capillary system, state of, in infancy, 68. bronchitis, 287, 289. Caps, injurious, 26. Caries of the vertebrae, 620, 646. Carnified lung, 86, 307. Carriages for infants, 48. Carrot pap, 31. Carrying infants, caution to be observed in, 48, 59, 643. Catamenia, influence of, on milk, 110. Catarrh, simple, 281. Catarrhal croup, 342. Catarrhal fever, 287. Causes of disease in infancy, 108. Cellular tissue, induration of the, 94, 713. Cephalaematomia, 678. Cerebral hyperaemia and hemorrhage, 394. tubercles, 98, 627. Cerebro-spinal meningitis, 431. Chicken-pox, 548. Childhood, organization of, 77. diet of, 37. functions of, 78. Cholera infantum, 224. deaths from, 88, 225. Chorea, 460. Chylous diarrhoea, 213. Circulation, state of, in infancy, 71. Circulatory organs, state of, in infancy, 67. Cleanliness, domestic, importance of, 18. personal, importance of, 21. Clothing of infants and children, 25. Club-foot, 711. Cold, injurious to infants, 20, 23. and dampness a cause of disease, 20, 111, 607. diarrhoea from, 210. Cold-bath, improper during infancy, 23. Colic, 201. deaths from, 88. Colitis, 258. Colon, inflammation of the, 258. Condensation of pulmonary tissue, 86, 303. Confined air, a cause of disease, 18, 111, 606. Confinement of children, injurious effects of, 18, 50. Congenital affections, 108, 668. Congestion of the brain, deaths from, 91. Congestive measles, 478. scarlatina, 501. small-pox. 517, 519. Conjunctivitis, infantile, 728. Consumption in children, 94, 627. deaths from, 94. Contagion, susceptibility of infants to, 115. Contraction, muscular, tonic, 419. Convulsions, 91, 404. deaths from, 91, 404. epidemic, 410. nine-day, 410. salaam, 418. tonic, 419. Convulsive enteralgia, 202. Cornea, ulceration of, 611, 640. Coryza, 281. Couch, sleeping, proper for infants, 42. management of, 44. Cough, nocturnal, of infants, 332. Countenance, indications of disease from, 118. Cow-pock, 534. Cradles, the use and abuse of, 43. Croup, 319. bronchial, 287. catarrhal, 342. false, 342. spasmodic, 342. deaths from, 87, 319. Crusta lactea, 554. Crusted tetter, 556. Cry, indications of disease from the, 124. Crying in infants, causes and morbid ef- fects, 56, 59. Cucurbitani, 242. Curd-like exudation, stomatitis with, 138. Cutaneous disease, frequency of, in chil- dren, 84, 107. eruptions, 552. Cyanosis, 684. Cynanche trachealis, 319. Cysts of the neck, 722. D. Damp and cold, injurious effects of, in in- fancy, 20, 111, 607. Dandriff, 584. Debility, deaths of children from, 81. Dental paralysis, 164. Dentition, 77. as a cause of disease, 114. difficult, 162. diarrhoea from, 210. convulsions from, 411. cutaneous eruptions during, 552. Diabetes, in children, 102, 664. mellitus, 664. Diagnosis of disease in infancy, 115. Diarrhoea, 206. deaths from, in children, 88. bilious, 212, 218. chylous, 213. chronic, 207, 221. mucous, 210, 215. from cold, 210. dentition, 210, 217. errors in diet, 208, 213. excessive heat, 211. worms, 211. Diet of infants and children, 27, 37. INDEX. 757 Diet of a wet nurse, 34. after weaning, 37. diarrhoea from errors in, 208, 213. Digestive organs, in infancy, and childhood, 67, 70, 72, 78. diseases of the, 137. deaths from affections of the, 88. Digestive mucous membrane, liability to disease in infancy, 82. Diphtheritic inflammation of throat, 172. Discharges from stomach and bowels, indi- cations of disease from, 130. Disease, causes of, in infancy and child- hood, 108. seldom simple in children, 82. Diseased persons, impropriety of children sleeping with, 45. Diuresis, 102. Drink of infants and children, 32, 38. Dropsy in children, 93. deaths from, 94. of the brain, 442, 457. deaths from, 91. after scarlatina, 489. Dry scall, 576. Dry-nursing, danger of, 28. Dysentery, 258. deaths from, 88. Dysuria, 102, 649. E. Ear, inflammation of the, 612, 640. Ecchymoses, 592. Ecthyma, 587. Eczema, 559. lactea, 554. Education, too early attempts at mental, improper, 51, 60. moral, 54. Effusion of serum or lymph in children, 83, 93. Emotions of the mind, influence of, on nurse's milk, 110. Encephalic inflammation, deaths Endocarditis in children, 97. Enlargement of the tonsils, 170. brain, 388. Enteralgia, 201. Enteritis, 253. deaths from, 88. Enuresis, 658. Epidemic meningitis, 431. Eruptions, cutaneous, 552. syphilitic,.599. from gastro-enteric disease, 558. during lactation and dentition, 552. with languid cutaneous action, 584. from infection, 596. frequency of, in infancy, 84. Eruptive fevers, 473. Erysipelas, 562. Erythema, 558. Erythematic stomatitis, 137. Evacuations, indications of disease from state of the, 130. ! Example, its powerful influence, 62. Exanthemata, 473. deaths from, 84. Exanthematous ophthalmia, 612. Exercise, its importance during childhood, 47, 50. precautions in regard to, 48, 53. defective, a cause of disease, 606. Exomphalus, 701. External senses, state of, during infancy and childhood, 69, 79. Eye, inflammation of the, 610, 637, 728. F. Fauces, diphtheritic inflammation of, 172. Favus, 579. Fear, injurious effects of, in children, 57. Feeding of infants; artificial, 29. Feet, defence of, in infants, 26. Felon, 737. Fever in children, 103. deaths from, 104. the remittent or gastric, of infancy, 266. catarrhal, 287. eruptive, 473. gastric, 266. mesenteric, 266. rubeolous, 476. scarlet, 485. pemphigoid, 590. typhoid, 271. variolous, 520. verminous, 244. worm, 266. Fish-4skin disease, 585. Flannel, importance of, for children, 23. Follicular gastro-enteritis, 227. stomatitis, 143. warts, 578. Food of infancy and childhood, 27. as a cause of disease, 109, 605. of the nurse, influence of, on her milk, 34. Foreign bodies in the larynx and trachea, 386. Fractures, 668. Fruits, the use of, by children, 41. Functions, state of the. during infancy and childhood, 64, 71. G. Gall-bladder, during infancy, 66. Ganglionic system, during infancy, 69. Gangraenopsis, 152. Gangrene of the mouth, 152. throat, 175. Gastric fever of infancy, 266. Gastritis, 195. deaths from, 88. Gastro-intestinal mucous membrane, lia- bility to disease in infants, 88. Gastro-enteric disease, eruptions with, 558. liability of infants to, 88. 758 INDEX. Gastro-enteritis, follicular, 227. Gastro-malacia, 88, 190, 197. Gelatinous softening of the stomach, 190, 197. Gengivitis, 150. Genital organs, in infancy, etc., 69, 78. Gestures, indications of disease from, 120. Girls, exercise of, 51. Glands, bronchial, tuberculization of, 625. lymphatic, disease of, 93, 608, 635. mesenteric, disease of, 88, 254, 615, 641. Glottis, spasm of the, 347. Granulations, meningeal, 99. Gravedo, 281. Gravel, 103. Gray granulations, 623. Growth of the body, 71. Gum, the red, 552. white, 552. Gums, inflammation of the, 150. H. Haemoptysis, rare in infants, 95. Hair, management of, in infancy and child- hood, 24. Hare-lip, 709. Harsh treatment of children, morbid effects of, 56. Head, covering proper for, in infants, 26. Head, bloody tumour of, 678. Healthy child, its appearance, 116. Heart, condition of, in infancy, 67, 70. disease of, in children, 97. malformations of, in infant^, 685. deaths from diseases of, 98. Heat, importance of, to infants, 20. excessive, morbid effects of, 21, 112. diarrhoea from, 211. Hemorrhage, cerebral, 394. intestinal, 691. vaginal, 706. from the navel, 672. of the brain, 394. Hemorrhagic purpura, 593. Hernia?, 701. Herpes, 574. Hip-disease, 619, 645. Honeycomb scall, 579. Hooping-cough, 87, 363. deaths from, 87. Hordeolum, 572. Humid tetter, 556. Hydrencephaloid disease, 457. Hydrocele, 734. Hydrocephalus, acute, 442. chronic, 457. false, 457. Hydro-rachis, 691. Hygienic management of children, 17. Hyperaemia, frequency of, in infancy, 82. of the brain, 394. Hypertrophy of the brain, 388. of the tonsils, 170. of the heart, 98. Hyperuresis-, 664. Ichthyosis, 585. Icterus infantilis, 725. Ileitis, 253. Impetigo, 556. larvalis vel mucosa, 554. Impure air, morbid effects of, in infancy, 18, 111, 606. Indigestion, 187. Induration of the cellular tissue, 94, 713. Infancy, period of, 64. Infant, picture of a healthy, 116. Infants, cautions in handling, 47, 643. cautions in carrying, 19, 48, 59, 643, Inflammation of the brain, 420. deaths from, 91. breasts of infants, 700. bronchi, 285. colon, 258. digestive organs, deaths from, 88. fauces, 172. ear, 612, 640. eye, 610, 612, 637, 728. gums, 150. intestines, 253, 258. kidney, 101. lungs, 295. lymphatic glands, 93. mammae, in infants, 700. mouth, 137. nares, 281. navel, 698. neck, 183. oesophagus, 185. pleura, 313. parotids, 181. peritoneum, 88, 262. stomach, 195. tonsils, 168. throat, 168, 172, 183. trachea, 319. Integuments, signs of disease from state of, 127. Intellectual faculties, during infancy and childhood, 76, 79. injury from too early exercise of, 51, 6;). Intestinal mucous membrane, pathology of, in infants, 89. hemorrhage, 691. worms, 241. Intestines, state of, in infancy, 66. diseases of the, 201. congenital malformations of, 669. deaths from disease of, 88. inflammation of the, 253, 258. invagination of the, 88, 239. worms in the, 241. Intumescence of the breasts in infants, 700. Intus-susception, SH, 239. Invagination of the intestines, 88, 239. Iritis, scrofulous, 612, 640. Ischuria, 656. INDEX. 759 Itch, 596u J. Jaundice, 30, 725. Joints, scrofulous disease of the, 617. K. Ranker of the mouth, 152. Kidneys, state of, in infancy, 67. inflammation of, in infancy, 101. deaths from disease of, 102. Kopp's asthma, 347. L. Labia, adhesion of the, 708. Lactation, cutaneous eruptions during, 552. injury from protracted, 110. Laryngeo-tracheitis, 319. Laryngismus stridulus, 87, 347. Laryngitis, spasmodic, 342. Larynx, during childhood, 78. foreign bodies in the, 386. Laudanum, danger of its use during in- fancy, 42. 60. Lepra alphoides, 576. Leucorrhoea, infantile, 614. Light, influence of, on health of infants, 111, 606. Lippitudo, 573. Liver, state of. in infancy, 66. Lobar pneumonia, 84, 307. Lobular pneumonia, 84, 300. Lumbricoid worm, 242. Lung, partial collapse of, 304. Lung, carnified, 86, 307. Lung, condensation of, 303. Lungs in infancy and childhood, 67, 78. inflammation of the, 29-3. imperfect dilatation of the, 312. tuberculization of the, 94, 627. Lymph, effusion of, in diseases of infancy, 83. Lymphatic glands, disease of, 93, 608, 635. system, liability of, to disease in in- fants, 93. M. Maculae hepaticae, 725. Malformations of the intestines, 669. Mammce, intumescence of the, 700. Management of children, 17. Marasmus, deaths from, 88. Mawworm, 242. Meals of children/ regulation of, 38. Measles, 474. false, 476. deaths from. 84. inoculation of, 480. Medulla spinalis, during infancy, 69, 70. Melasma, 725. Mellituria, 664. Meningeal granulations, 99. Meningitis, acute, 420. cerebro-spinal, 431. Meningitis, subacute, 442. tubercular, 442. encephalica, 430. epidemic, 431. Menstruation, its influence on the milk, 110. Mental emotions, influence on milk, 110, Mesenteric glands, disease of the, 88, 254, 615, 641. fever, 266. Micturition, difficult, 649. Miliary tubercles, 622. Milk of the nurse, a cause of disease, 109^ 605. influence of menstruation on the, 110. pregnancy, on the, 110. mental emotions, on the, 110. food on, 109. Millar's asthma, 342. Mitigated small pox, 545. Modified small-pox, 545. Months, mortality of children during the different, 113. Moral treatment of children, 54. causes of disease, 109. faculties, state of, in children, 75, 79- Morbilli, 474. Morbus cceruleanus, 684. coxarius, 619, 645. Mortality of children in Philadelphia, 112. Mouth, condition of, in infancy, 65. indications of disease from state of, 126. diseases of the, 137. inflammation of the, 137. sore, of children, 138. gangrene of the, 152. canker of the, 152. Mucous membrane, in infancy, 65. Mucous membrane, digestive, liability to disease in infant-, 82, 88. Mucous membrane, respiratory, liability to disease in infants, 84. diarrhoea, 210, 215. Muguet, 138. Mumps, 181. Muscles, in infancy and childhood, 65, 74, 77. tonic contraction of the, 419. Myogenic paralysis, 92. N. Naevus, 718. Narcotics, dangerous -during infancy, 42, 60. Nares, inflammation of the, 281. Nausea, 187. Navel, inflammation of the, 698. hemorrhage from the, 672. Neck, cysts of the, 722. Nephritis in children, 101. Nerves, state of in infancy, 69, 75, 78. Nervous affections in infancy, 91. Nervous excitement a cause of disease, 109. functions, in infants, 69, 75, 78. ; system, diseases of the, 91, 388.' 760 INDEX. Nettle rash, 560. New-born infants, washing of, 22. Night dress of infants, 27. Nine-day convulsions, 410. Nocturnal cough of infants, 332. Nurse, choice of a wet, 33. diet of a " 34. drink of a " 35. residence of a " 35. Nursery, proper location of the, 18. management of, 45. Nursing, protracted, a cause of disease, 110. rules for, 31. Nutritive functions in infants and children, 70, 72, 78. diseases of the, 603. Nymphae, cohesion of, 708. O. Obstinacy in children, its management, 5". CEdema cellulaiis, 718. of the prepuce, 707. Edematous swellings, frequent in infancy, 93. OEsophagitis, 185. QEsophagus, inflammation of the, 185. Old persons, danger of children sleeping with, 45. Omphalitis exsudativa, 564. Onychia, 737. maligna, 738. Ophthalmia, exanthematous, 612. neonatorum, 728. scrofulous, 610, 637. purulent, 728. pustular, 612. Opiates, dangerous during infancy, 42, 60. Organization, during infancy and childhood, 64, 77. Organic disease, blue skin from, 685. nerves, state of, during infancy, 69, 75, 78. Organs, their development during infancy, 70. Otitis, 612, 640. Out-door exposure, importance of, 19, 47, 52. Over-fatigue a cause of disease, 607. Oxyures, 242. P. Palsy, 91,394. Panaritium, 737. Paralysis in infancy and childhood, 91, 394. Paralysis, myogenic, 92. from teething, 164. Paronychia, 737. Parotids, inflammation of the, 93, 181. Parotitis, 93, 181. Passions in infancy, 54. depressive, a cause of disease, 109, 607. Pathology of infancy and childhood, 81. Peevishness, its causes and treatment, 55. Pemphigoid fever, 590. Pemphigus, 590. Perceptive faculties of children, 61. Pericarditis in children, 97. Peritoneum, inflammation of the, 88, 262. Peritonitis, 88, 262. chronic, 263. Pertussis, 87, 363. Petechiae, 592. Petechial small-pox, 519. Phlegmone parotidea, 183. Phlegmonous tumours, 569. Phthisis in children, 94, 627. Pityriasis, 584. Pleura, inflammation of the, 313. Pleuritis, 313. Pneumonia, 84, 295. form of, in children, 84. broncho, 297. lobular, 84, 300. mammelonated, 301. lobar, 84, 307. partial, 101, 302, 314. deaths from, in children, 87. Polypus of the rectum, 236. Pompholyx, 590. Porriginous ophthalmia, 612. Porrigo, 554, 579. Pregnancy, influence of, on milk, 110. Prepuce, oedema of the, 707. Prickly heat, 559. Primary and secondary diseases of children, 82. Prolapsus ani, 235. Prurigo, 553. Pseudo-membranous inflammation of the throat, 172. Pseudo-membranous croup, 319. Psora, 596. Psoriasis, 576. Pulmonary cells, obliteration of the, 86, 304. collapse, 86, 304. consumption in children, 94, 627. Pulse, state of, in infancy, 71. Purpura, 591. simplex, 591. hemorrhagica, 593. febrilis, 593. Purulent ophthalmia, 728. Pustular ophthalmia, 612. Putrid angina, 175. R. Rachitis, 616, 643. Rash, the scarlet, 512. Rectum, polypus of the, 236. Red gum, 552. Relation, functions of, during infancy, 73. Remittent fever of infants, 266. Repose of infants, 42. Respiratory organs, during infaney, 67. diseases of the, 276. function, during infancy and child- hood,. 71, 78. IND EX. 761 Respiration, indication of disease from, state of, 125. Respiratory mucous membrane, liability to disease in infants, 84. deaths from disease of, 87. Revaccination, 536. Rheumatism in children, 107. Rickets, 616, 643. Ringworm, 575. Roseola, 512. Rubeola, 474. Rubeola nigra, 484. Rubeolous fever, 476. Rupia, 587. Ruptures, 701. S. Saint Vitus' dance, 460. Salaam convulsions, 418. Sarcopes scabiei, 597. Scabies, 579, 596. Scabies vermicularis, 597. Scald head, 579. Scalds, burns and, 741. Scall, 556, 576, 579. Scalp, bloody tumour of the, 678. Scarlatina, 485. inflammatory, 485. angino-a, 487. congestive, 501. maligna, 501. deaths from, 84. Scarlet fever, 485. rash, 512. Sclerema, 713. Scrofula, 603, 630. Scrofulous ophthalmia, 610, 637. disease of lymphatic glands, 93, 606, 635. spine, 646. otitis, 612, 640. discharge from the vagina, 641. ulcer, 609. disease of the mesenteric glands, 88, 254, 615, 641. bones, 616, 643. Seasons, influence of, on health of infants, 112. Semeiology of disease in infancy, 115. Senses, external, in infancy and childhood, 69, 79. Serous effusion, common in children, 83, 93. Serous diarrhoea, 210, 215. Sickly persons, danger of children sleeping with, 45. Skin, state of, during infancy, 04, 73. liability of, to disease in children, 82, 107. Skin, diseases of the, 473. induration of the, 94, 713. bound, 713. Skin, indications of disease from state of, 127. Skull, state of, during infancy, 68. Sleep of infants and children, 42, 76, 79,116. 49 Sleep, indications of disease from, phenomena of, 122. Sleeping apartments of infants, 45. Small-pox, 514. distinct, 517. confluent, 517. congestive, 517, 519. malignant, 519. black, 519. modified, 545. mitigated, 545. deaths from, 84. Snuffles, 281. • Softening of the stomach, 88, 190, 197. Sore mouth of children, 138. Spasmodic colic, 203. croup, 342. laryngitis, 342. Spasm of the glottis, 87, 347. Speech in infancy, 76. Spina bifida, 691. Spinal apoplexy, 395. marrow, state of, in infancy, 69, 70. Spine, disease of the, 620, 646. Spleen, state of, in infancy, 66. Spread of morbid action in infancy, 83. Still-born infants, treatment of, 276. number of, in Philadelphia, 276. Stomach, state of, during infancy, 66, 70. deaths from diseases of, 88. discharges from, as indications of disease, 130. diseases of the, 187. softening of the, 88, 190, 197. inflammation of the, 195. Stomatitis, follicular, 143. simple erythematic, 137. with curd-like exudation, 138. ulcerative, 148. Stools, indications of disease from the, 130. Stridulous laryngismus, 347. Strophulus, 552. Strumous diathesis, 100. Study, injury from too early, 52. Stye, 572. Suckling, protracted, a cause of disease, 110. Suckling of infants, importance of, 28. Sugar, the use of, by children, 40. Summer complaint of infants, 224. Surface, indications of disease from state of, 127. Swine-pox, 549. Syphilitic eruptions, 599. T. Tabes mesenterica, 88, 254, 615, 641. Tache meningitique, 445. Taenia lata, 242. " solium, 212. Talipes, 711. Tape worm, 242. Teething, 77. as a cause of disease, 114, 162, 210. deaths from, 88. Temperaments, 80. 762 INDEX. Temperature proper for infants, 20. Testicle, arrest of the, 706. Tetter, crusted, 556. humid, 556. scally, 576. Thirst in infants, 32. Thorax, its form in infants, 78. Thread worm, 242. Throat, diseases of the, 168. gangrene of the, 175. inflammation of the, 172. diphtheritic inflammation of, 172. Thrvfth, 138. Thymic asthma, 347. Tinea muciflua, 554. capitis, 579. ciliaris, 573. favosa, 579. Tongue, indications of disease from state of, 126. Tongue-tie, 671. Tonsillitis, 168. hypertrophy of the, 170. Tonsils, inflammation of the, 168. Trachea, foreign bodies in the, 386. inflammation of the, 319. Tracheitis, 319. Tracheotomy in croup, 339. Trichuris, 242. Tricocephalus dispar, 242. Trismus nascentium, 407, 411. Tubercles, liability of children to, 94. diffusion of, in children, 96. of the brain, 98, 441, 627. Tubercular meningitis, 441. phthisis, in children, 94, 627. depositions, 94, 622, 648. Tuberculous infiltration, 623. dust, 623. Tumours, phlegmonous, 569. Typhoid fever in children, 104, 271. deaths from, 104. U. Ulcer, atonic, 587. scrofulous, 609. Ulceration of the navel, 698. cornea, 611, 640. Ulcerative stomatitis, 148. Umbilical hemorrhage, 672. herniae, 701. Uncleanliness, personal, a cause of disease, 607. Urinary organs, diseases of the, 101. discharge, indications of disease, from state of, 133. Urinary bladder, state of, in infancy, 67. secretion in infants, 72. Urine, suppression of, 654. retention of, 656. Urine, incontinence of, 103, 658. Urodialysis neonatorum, 649. Urticaria, 560. Vaccination, 534, 540. phenomena of, 540. period for, 541. mode of, 543. Vagina, discharges from, 614, 641. hemorrhage from, 706. Varicella, 548. Variola, 514. confluent, 517. congestive, 517. distinct, 517. malignant, 519. nigra, 519. vaccina, 536. Varioloid, 545. Variolous fever, 520. Vegetables, use of by children, 38. Ventilation, importance of, 606. Ventilation, imperfect, a cause of disease, 111. Verminous fever, 244. Vertebrae, state of, in infancy, 69. disease of the, 620, 646. 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With eighty illustrations on wood. In one handsome octavo volume, of a jout 400 pages, extra cloth. $2 00. (Just Issued.) The death of Dr. Bird has rendered it necessary to entrust the revision of the present edition to other hands and in his performance of the duty thus devolving on him, Dr. Birkett has sedulously endeavored'to carry out the authors plan by introducing such new matter and modifications ol the text as the progress of science has ca'led for. Notwithstanding the utmost care to keep the work within a reasonable compass, these additions have resulted in a considerable enlargement. It 1- therefore hoped that it will be found fully up to the present condition of the subject, and that the reputation of the volume as a clear, complete, and compendious manual, will be fully maintained. BENNETT (J. HUGHES), M. D., F. R. S. E., Professorof Clinical Medicine in the University of Edinburgh, &c. THE PATHOLOGY AND TREATMENT OF PULMONARY TUBERCU- I OSIS and on the Local Medication ol Pharyngeal and Laryngeal Diseases frequently misiake:: lor or associated with, Phiui^- One vol. S\ o.,extra cloth, with wood-cuts. pp. 130. $1 25 4 BLANCHARD & LEA'S MEDICAL BUDD (GEORGE) M.D., F. R. S., Professor of Medicine in King's College, London. ON DISEASES OF THE LIVER. Third American, from the third and enlarged London edition. In one very handsome octavo volume, extra cloth, with four beauti- fully colored plates, and numerous wood-cuts. pp. 500. $3 00 Has fairly established for itself a place among the classical medical literature of England.—British and Foreign Medico-Chir. Review. Dr. Budd's Treatise on Diseases of the Liver is now a standard work in Medical literature, and dur ing the intervals which have elapsed between the successive edilions, the author has incorporated iritn riie text the most striking novelties which have cha- racterized the recent progress of hepatic physiology and pathology; so thatalthough the size of the book is not perceptibly changed, the history of liver dis- eases is made more complete, and is kept upon a level with the progress of modern science. Ft is the best work on Diseases of the Liver in any language.— London Med. Times and Gazette. This work, now the standard book of reference on the diseases of which it treats, has been carefully revised, and many new illustrations of the views of the learned author added in the present edition.— Dublin Quarterly Journal. BY THE SAME AUTHOR. ON THE ORGANIC DISEASES AND FUNCTIONAL DISORDERS OF THE STOMACH. In one neat octavo volume, extra cloth. $1 50. BUCKNILL (J. C), M. D., and DANIEL H. TUKE, M. D., Medical Superintendent of the Devon Lunatic Asylum. 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 ore handsome octavo volume, of 536 pages. $3 00. The increase of mental disease in its various forms, 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. At the same time there has been for some years no work accessible in this country, present- ing the results of recent investigations in the Diagnosis and Prognosis 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 To fill this vacancy the publishers present this volume, assured that the distinguir-hed reputation and experience of the authors will entitle it at once to the confidence of both ftudent and practitioner. Its scope may be gathered from the declaration of the authors that "their aim has been to supply a text book which may serve as a guide in the acquisition ol such knowledge, sufficiently elementary to be adapied to the wants of the student, and sufficiently modern in its views and explicit in its teaching to suffice for the demands of the practitioner." BENNETT (HENRY), M.D. A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. To which is added, a Review of the present state of Uterine Pathology. Fifth American, from the third English edition. In one octavo volume, of about 500 pages, extra clo'.h. $2 00. BROWN (ISAAC BAKER), Surgeon-Accoucheur to St. Mary's Hospital, &c. ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT- MENT. With handsome illustrations. One vol. 8vo., extra cloth, pp 276. $i 60. Mr. Brown has earned for himself a high reputa- | and merit the careful attention of every surgeon* tion in the operative treatment of sundry diseases and injuries to which females are peculiarly subject. \Ve 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, accoucheur.—Association Journal We have no hesitation in recommending this bo< k to tii** careful attention of all surgeons who make female compiaints a part of their studv an<" practice. —Dublin Quarterly Journal. BOWMAN (JOHN EJ, M.D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Second Ame- rican, from the third and revised English Edition. In one neat volume, royal l2mo., extra cloth, with numerous illustrations, pp. 288. $1 25. BY THE SAME AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- LYSIS Second American, from the second and revised London edition. With numerous illus- trations. In one neat vol., royal 12mo., extra cloth, pp.350 $125. 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 12mo., extra cloth, pp. 296. 60 cents. BUSHNAN'S PHYSIOLOGY OF ANIMAL AND VEGETABLE LIFE; a Popular Treatise on the Functions and Phenomena of Organic Life. In one handsome royal 12mo. volume, extra cloth, with over 100 illustrations, pp. 234. 80 cents. BUCKLERONTHE ETIOLOGY, PATHOLOGY) AND TREATMENT OF FIBRO-BRONCH1- T1S AND RHEUMATIC PNEUMONIA. In one 8vo. volume, extra cloth, pp.150. $125. BLOOD AND URINE (MANUALS ON). BY JOHN WILLIAM GRIFFITH, G. OWEN REESE, AND ALFRED MARKWICK. One thick volume, royal 12mo., extra cloth, with plates, pp.460. SI 25. BRODIE'S CLINICAL LECTURES ON SUR- GERY. 1 vol. 8vo. cloth. 350 pp. 8125. AND SCIENTIFIC PUBLICATIONS. & BUMSTEAD (FREEMAN J.) M. D., Lecturer on Venereal Diseases at the College of Pnysicians and Surgeons, New York, &c. THE PATHOLOGY AND TREATMENT OF VENEREAL DISEASES, including the results of recent investigations upon the subject. With illustrations on wood. In one very handsome octavo volume, of nearly 700 pages, extra cloth; $3 75. (Now Ready.) The object of the author has been to prepare a complete wort, which should present the results of the most recent researches and modern experience on all branches of the subject, with special reference to the wants of the practitioner, theoretical disquisitions being rendered subordinate to practical utility. To show the thoroughness of the outline which is thus filled up, a condensed synop-is ol the contents is subjoined. . CONTENTS. INTRODUCTION. PART 1.—Gonorrhoea and its Complications.—Chapter I. Urethral Gonorrhoea in the Male. II. Gleet III. Balanitis. JV Phymosis. V. Paraphymosis. VI. Swelled Testicle. VII. Inflammation of the Prostate. VIII. Inflammation of the Bladder. IX. Gonorrhoea in Women. X. Gonorrheal Ophthalmia. XI. Gonorrhoea! Rheumatism. XII. Vegetations. XIII. Stric- ture of the Urethra. PART II.—The Chancroid and its Complications : Syphilis.—Chap. I. Introductory remark*. II. Chancres. III. A flections of the Lymphatic Vessels and Ganglia attendant upon Primary Sores. IV. General Syphilis—Introductory remarks. V. Treatment of Syphilis. VI. Syphi- litic Fever—State of the Blood—Affections of Lymphatic Ganglia. VII. Syphilitic Affections of the Skin. VIII. Syphilitic Alopecia, Onychia, and Paronychia. IX. Mucous Patches. X. Gummy Tumors. XI Syphilitic Affections of Mucous Membranes. XII. Syphilitic Affections of the Eye. XIII. Syphilitic Aflections of the Ear. XIV.'Syphilitic Orchitis. XV. Syphilitic Affections of ihe Mu.-cles and Tendons. XVI. Syphilitic Aflections of the Nervous System. XVII. Syphilitic Affections of the Periosteum and Bones. XVIII. Congenital Syphilis. BARCLAY (A. W.i, M. D., Assistant Physician to St. George's Hospital, &c. A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the Signs and Symptoms of Disease. In one neat octavo volume, extra cloth, of 424 pages. $2 00. (Lately issued.) The task of composing such a work is neither an easy nor a light one ; but Dr. Barclay has performed k in a manner which meets our most unqualified approbation. He is no mere theorist; he knows his work thoroughly, and in attempting to perform it, has not exceeded his powers.—British Med. Journal. We venture to predict that the work will be de- servedly popular, and soon become, like VVatson'e • Practice, an indispensable necessity to the practi- tioner.—N. A. Med. Journal. An inestimable work of reference for the young practitioner and student.—Nashville Med. Journal. We hope the volume will have an extensive cir- culation, not among students of medicine only, bu^ practitioners also. They will never regret a faith- ful study of its pages.—Cincinnati Lancet. An important acquisition to medical litenture. It is a work of high merit, both from the vast im- portance of the subject upon which it treats, and also from the real ability displayed in its elabora- tion. In conclusion, let us bespeak for this volume that attention of every student of our art which it so richly deserves - that place in every meuical library which it can so well adorn.—Peninsular Medical Journal. BARLOW (GEORGE H.), M.D. Physician to Guy's Hospital, London, &c. A MANUAL OF THE PRACTICE OF MEDICINE. With Additions by D. F. Condie, M. D., author of "A Practical Treatise on Diseases of Children," &c. In one hand- some octavo volume, leather, of over 600 pages, f 2 75. will be found hardly less useful to the experienced physician. The American editor has added to the work three chapters—on Cholera Infantum, Yellow Fever, and Cerebro-spinal Meningitis. These addi- tions, the two first of which are indispensable to a We reeommendDr. Barlow's Manual in the warm- est manner us a most valuable vade-mecum. We have had frequent occasion to consult it, and have found it clear, eoncise, practical, and sound. It is eminently a practical work, containing all that is essential, and avoiding useless theoretical discus- sion. The work supplies what has been for some time wanting, a manual of practice based upon mo- dern discoveries in pathology and rational views of treatment of disease. It is especially intended for the use of students and junior practitioners, but it work on practice destined for the profession in this country, are executed with great judgment and fi- delity, by Dr. Condie, who has also succeeded hap- pily in imitating the conciseness and clearness of style which are such agreeable characteristics of the original book.—Boston Med. and Surg. Journal. BARTLETT (ELISHA), M. D. THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS OF THE UNITED STATES. A new and revised edition. By Alonzo Clark, M. D., Prof. of Pathology and Practical Medicine in the N. Y. College of Physicians and Surgeons, &c. In one octavoSvoluine, of six hundred pages, extra cloth. Price $3 00. It is a work of great practical value and interest, containing much that is new relative to the several diseases of which it treats, and, with the add turns of the editor, is fully up to the times The distinct- ivefeatures of the different forms of fever are plainly and forcibly portrayed,and the lines.of demarcation carefully and accurately drawn, and to the Ameri- can practitioner is a more valuable and safe guide than any work on fever extant—OAio Med. and Surg Journal. This excellent monograph on febrile disease., has stood deservedly high since its first publication. It will be seen that it has now reached its fourth edi- tion under the supervision of Prof. A. Clark, a gen- tleman who, from the nature of his studies and pur- suits, is well calculated to appreciate and discuss the many intricate and difficult questions in patho- logy. His annotations add much to the interest of the work, and have brought it well up to the condi- tion of the science as it exists at the present day in regard to this class of diseases.—Southern Med. and Surg. Journal. 6 BLANCHARD & LEA'S MEDICAL BARWELL (RICHARD,) F-R. C. S., Assistant Surgeon Charing Cross Hospital, ice. A TREATISE ON DISEASES OF THE JOINTS. Illustrated with engrav- ings on wood. In one very handsome octavo volume, of about 500 pages, extra cloth; $5 00. (Now Ready.) "A treatise on Diseases of the Joints equal to, or rather beyond the current knowledge of the day, has long been required—my professional brethren must judge whether the ensuing pages may supply the deficiency No author is fit to estimate his own work at the moment of its completion, but it may be permitted me to say that the study of joint diseases has very much occupied my atten- tion, even from my studentship, and that for the last six or eight years my devotion to that subject has been almost unremitting.....The real weight of my work has been at the bedside, and the greatest labor devoted to interpreting symptoms and remedying their cause."—Author's Preface. At the outset we may state that the work is | to be of much use to the practising surgeon who worthy of much praise, and bears evidence of much I may be in want of a treatise on diseases of the joints, thoughtful and careful inquiry, and here and there : and at the same time one which contains the latest of no slight originality. VVe have already carried information on artiaular affections and the opera- nds notice further thon we intended to do, but not tions for their cure.—Dublin Med. Press, Feb. 27, to the extent the work deserves. We can only add, ! l&GI. that the perusal of it has afforded us great pleasure. This volume will be welcomed, both by the pa- Tlie author has evidently worked very hard at his . thologist and the surgeon, as being the record of ation into 'lie author has evidently worked very hard at his thologist and the surgeon, as being the ibject, and his investigations into the Physiology i mucft honest research and careful investis and Pathology of Joints have been carried on in a mnnner which entitles him to be listened to with attention and respect. We must not omit to men- tion the very admirable plates with which the vo- lume isenriched. 'We seldom meet with such strik the nature and treatment of a most important class of disorders. We cannot conclude this notice of a valuable and useful book without calling attention to the amount of bon&fi'le work it contains. In the present day of universal book-making, it is no slight ing and faithful delineations of disease.—London j maUer for a volume to show laborious investiga- Me surgery up to the present hour. It is de- servedly a popular manual, both with the student and practitioner.—London Lancet, Nov. 19,1859. In closing this brief notice, we reeommend as cor- dially as ever this moBt useful and comprehensive hand-book. It must prove a vast assistance, no* only to the student of surgery, but also to the busy practitioner who may not have the leisure to devote himself to the study of more lengthy volumes.— 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 Quarterly 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. Second edition, revised and enlarged, with two hundred and seventy-one illustrations on wood. In one very beautiful octavo volume, of 700 pages, extra cloth, $4 00; leather, raised bands, $4 50. (Just Issued, 1861.) The general favor which has so soon exhausted an edition of this work has afforded the author an opportunity in its revision of supplying the deficiencies which existed in the former volume. This has caused the insertion of two new chapters—one on the Special Senses, the other on Im- bibition, Exhalation, and the Functions of the Lymphatic System—besides numerous additions of smaller amount scattered through the work, and a general revision designed to bring it thoroughly up to the present condition of the science with regard to all points which may be considered as definitely settled. A number of new illustrations has been introduced, and ihe work, it is hoped, in its improved form, may continue to command the confidence of those for whose use it is in- tended 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 b> the same fea- ' cies in the first edition, have already made the pre- tures which characterize the remainder of the vol- | tent one a necessity, and it will no doubt be even ume, and render it by far the most desirtble text- j 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 j statement of the following principal additions and the English language, or perhaps in any other. We therefore have no hesitation in recommending Dr. Dalton's book for the classes for which it is intend- ed, satisfied as we are that it is better acapted to their use than any other work of the kind to which they'have access.—American Journal of the Med. Sciences, April, 1861. It is, therefore, no disparagement to the many books upon physiology, most excellent in their day, to say that Dalton's is the only one that gives us the science as it was known to the best philosophers throughout the world, at the beginning of the cur- rent year. It states in comprehensive but concise diction, the facts established by experiment, or other method of demonstration, and details, in an understandable manner, how it is done, but abstains from the discussion of unsettled or theoretical points. Herein it'is unique; and these characteristics ren aer it a text-book without a rival, for those who desire to study physiological science as it is known to its most successful cultivators. And it is physi- ology thus presented that lies at the foundation of correct pathological knowledge j and this in turn is the basis of rational therapeutics; so that patholo- gy, in fact, becomes of prime importance in the proper discharge of our every-day practical duties. —Cincinnati Lancet, May, 1861. Dr. Dalton needs no word of praise from us. He is universally recognized as among the first, if not the very first, of American physiologies now living. The first edition of his admirable work appeared but two years since, and the advance of science, his alterations which he has made. The present, like the first edition, is printed in the highest style of the printer's art, and the illustrations are truly admira- ble tor their clearness in expressing exactly what their author intended.—Bnston Medical and Surgi- cal Journal, March 28, 1661. It is unnecessary to give a detail of the additions; suffice it to say, that they are numerous and import- ant, and such as will render the work still more valuable and acceptable to the profession as a learn- ed and original treatise on this all-important branch of medicine. All that was said in commendation of the getting up of the first edition, and the superior Btyle of the illustrations, apply with equal force to this. No better work on physiology can be placed in the hand of the student.—St. Louis Medical and Surgical Journal, May, 1861. These additions, while testifying to the learning and industry of the author, render the book exceed- ingly useful, as the most complete expose of a sci- ence, of which Dr. Dalton is doubtless the ablest representative on this side of the Atlantic.—New Orleans Med. Times, May, 1861. A second edition of this deservedly popular work having been called for in the short space of two years, the author has supplied deficiencies, which existed in the former volume, and has thus more completely fulfilled his design of presenting to the profession a reliable and precise text-book, and one which we consider the best outline on the subject of which it treats, in any language.—N. American Medico-Chirurg. Review, May, 1861. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICLNE: 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. $12 00. **.* This work contains no less than four hundred and eighteen distinct treatises, contributed by Bixty-eight distinguished physicians, rendering it a complete library of reference for the country practitioner The most complete work on Practical Medicine extant; or, at least, 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. 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 ol 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 opportunities for an extensive practi- cal acquaintance with them and whose reputation It has been to us, both as learner and teacher, a , carries the assurance of their competency justly to work for ready and frequent reference, one in which ; appreciate the opinions o1 others, while it stamps modern English medicine is exhibited in the most j their own doctrines witl high and just authority.— advantageous light.—Medical Examiner. I American Medical Journal. DEWEES'S COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occasional cases and many engravings. Twelfth edition, with the author's last improvements and corrections In oneoctavo volume, extra cloth,ofGOO pages. 8320. DEWEES'S TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILD- REN. The last edition. In one volume, octavo, extra cloth, 548 pages. $2 -0 DEWEES S TREATISE ON THE DISEASES OF FEMALES. Tenth edition. In one volume, octavo extra cloth, 532 pages, with plates. S3 00 12 BLANCHARD & LEA'S MEDICAL DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. NEW AND ENLARGED EDITION. 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, Dentistry, tec. Notices of Climate ana of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic Preparations, &c. With French and other Synonymes. Revised and very greatly enlarged. In one very large and handsome octavo volume, of 992 double-columned pages, in small type; strongly bound in leather, with raised bands. Price $4 00. E'pecial care has been devoted in the preparation of this edition to render it in every respect worthy a continuance of the very remarkable favor which it has hitherto enjoyed. The rapid sale of Fifteen large editions, and the constantly increasing demand, show that it is regarded by the profession as the standard authority. Stimulated by this fact, the author has endeavored in the present revision to introduce whatever might be necessary " to make it a satisfactory and desira- ble—if rot indispensable—lexicon, in which the student may search without disappointment for every term that has been legitimated in the nomenclature of the science." To accomplish this, large additions have been found requisite, and the extent of the author's labors may be estimated from the fact that about Six Thousand subjects and terms have been introduced throughout, ren- dering the whole number of definitions about Sixty Thousand, to accommodate which, the num- ber of pages has been increased by nearly a hundred, notwithstanding an enlargement in the size of the pase. The medical press, both in this country and in England, has pronounced the work in- dispensable to all medical students and practitioners, and the present improved edition Will not lose that enviable reputation. The publishers have endeavored to render the mechanical execution worthy of a volume of sucli universal use in daily reference. The greatest care hns been exercised to obtain the typographical accuracy so necessary in a work of the kind. By Ihe small but exceedingly clear type employed, an immense amount of matter is condensed in its thousand ample pages, while the binding will be lound strong and durable. With all these improvements and enlargements, the price has been kept at (he former very moderate rate, placing it within the reach of all. 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 medical literature. One wmld hardly suppose after constant use of the pre- ceding editions, where we have never failed to find u sufficiently full explanation of ever} medical terra, 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 withootdoubt thebest and most comprehensive work of the kind wh ich 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 he said to constitute a new work, by itself. We have examined the Dictionary attentively, and are most happy to pronounce it unrivalled of its kind. The erudition displayed, and the extraordinary industry which must have been demanded, in its preparation and perfection, redound to the lasting credit of its author, and have furnished us with a volume indis- pensable at the present day, to all who would find themselves as niveau with the highest standards of medical information.—Boston Medical and Surgical Journal, Dee. 31, 1857. Good lexicons and encyclopedic works generally, are 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 is something appalling to contemplate. The author tells us in his prefaee that be has added about six thousand terms and subjects to this edition, which, before, was considered universal!} as the best work of the kind ia any language.—Silliman's Journal, March, 1858. He has raaed his gigantic structure to the founda- tions, and remodelled and reconstructed the entire pile. No less than six thousand additional subjects und terms are illustrated and analyzed in this new edition, swelling the grand aggregate to beyond sixty thousand ! Thus is placed before the profes- sion a complete and thorough exponent of medicaj terminology, without rival or possibility of rivalry. —Nashville Journ. of Med. and Surg., Jan. 1858. It is universally acknowledged, we believe, thaA this work is incomparably the best and most com- plete Medical Lexicon in the English language. The amount of labor which the distinguished author has bestowed upon it is truly wonderful, and the learning and research displayed in its preparation are equally remarkable. Comment and commenda- tion are unnecessary, as no one at the present day thinks of purchasing any other Medical Dictionary than this.—St. Louts Med. and Surg. Journ., Jaa. 1856. It is the foundation stone of a good medical libra- ry, and should always be included ia the first list oi books purchased by the medical student.—Am. Med. Monthly, Jan. 1858. A very perfect work of the kind, undoubtedly tbt most perfect in the English language.—Med. and Surg. Reporter, Jan. 1858. It is now emphatically the Medical Dictionary oi the English language, and for it there is no substi- tute.—A'. H. Med. Journ., Jan. 185&. It is scarcely necessary to remark that any medi- cal library wanting a copy of Duogtison's Lexicon must be imperfect.—Cin. Lancet, Jan. 1858. We have ever considered it the best authority pub- lished, and the present edition we may safely say liaj no equal in the world.—Peninsular Med. Journal, Jan. 1858. The most complete authority on the subject to 1m found in any language.— Ya. Med. Journal, Feb. '£8. BY THE SAME AUTHOR. THE PRACTICE OF MEDICINE. A Treatise on Special Pathology and Th* rapeutics. Third Edition. In two large octavo volumes, leather, of 1,500 pages. $6 35. 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, leather, 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 incorp»rated, 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 fhe author bestowed more labor to secure this result. We believe that it can trulv be said, no more com- i The best work of the kind in the English lan- plete repertory of tacts upon the subject treated, guage.—Silliman's Journal. 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 studious 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 present edition the author has made a pcnc^ i 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 wil I 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., leather, of about 1100 pages. $6 00. 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 juBtly extolled. It must not be supposed, however, that the present is a mere reprint of the previous edition: tne character of the author for laborious research, judicious analysis, and clearness of ex- pression, is tullv sustained by the num-rous 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. The work will, we have little doubt, be bought and read by the majority of medical students; iis size, arrangement, and reliability recomaiend it to all; no one, we venture to predict, will study it without profit, and there are few to whom it w.ll not be in some measure useful as a work of ref r- ence. The young practitioner, more especially, will find the copious indexes append, d to this edi;ion of great assistance in the sel-ction and preparation of suitable formulas.—Charleston Med. Journ. and Re- view, 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, leather, of 770 pages. $3 75. Another edition of the." New Remedies" having been called for, the author has endeavored to add everything of moment that has appeared since the publication of the last edition. ThP articles treated of in the former editions will be found to have undergone considerable «- nansion in thfs, in order that the author might be enabled to introduce as far as practicable .he ?esuts of the subsequent experience of others, as well as of his own observation and reflection , Sd to make the work still more deserving of the extended circulation with which the preceding editions have been favored by the profession. By an enlargement of the page, the numerous addi- tions have been incorporated without greatly mcreasmg the bulk of the vo\ume.-Preface. 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 tn examine the original papers.—The American Journal of Pharmacy. One of the most useful of the author's works.- Southern Medical and Surgtcal Journal. This elaborate and useful volume should be found in every medical library, for as a book.of re- ference for physiHans, it is unsurpassed by an> other work in existence, and the double index for a sc\s2s and for remedies ^WcaLue™ * enhance its value.—New York Med. Gazette. ELLIS (BENJAMIN), M.D. TTTF MEDICAL FORMULARY: being a Collection of Prescriptions, derived fVnm the writings and practice of many of the most eminent physicians of America and Europe & .hfr with tke u«ual Dietetic Preparations and Antidotes for Poisons. To which is added Together with the "^ ^mic use of Medicines, and on the use of Ether and Chloroform The an Appendix, on ue fewbrief Pharmaceutic and Medical Observations. Eleventh edition, ^SaXCn emended by Robert P. Thomas, M. D., Professor ot Materia Medica in the Philadelphia College of Pharmacy. (Preparing.) 14 BLANCHARD & LEA'S MEDICAL ERICHSEN (JOHN), Professor of Surgery in University College, London, Ice. THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical Fnjtiries, 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, leather, raised bands. $4 50. (Just Issued.) The verv distinguished favor with which thiswork 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 pipfession. The additions ol 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 ■ step of the operation, and not desertinc him until the book of the kind in the English language. Strange | final issue of the case is decided— Sethoscope. that just such books are notoftener produced by pub lie teachers of surgery in this country and Greai Britain Indeed, it is a matter of great astonishment. but no less true than astonishing, that of ihe many works on surgery republished in this country within the last fifteen or twenty yeaTS 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 of thisbraneli of the profession.— Western Jour .of Med. awl Surgery. Its value is greatly enhanced by a very copious well-arranged index. We regard this as one of the most valuable contributions to modern surgery. To one entering his novitiate of practice, we regard il the most serviceable guide which he can consult. He will find a fulness of detailleadinghim through every Embracing, as will be perceived, the whole surgi- cal domain, and each division of itself almost com- plete and perfect, each chapter full and explicit, each subject faithfully exhibited, we can only express oui 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. Erichsen's work, for its size, has not been surpassed; his nine hundred and eight pages, pro- fusely illustrated, are rich in physiological, patholo- gical, and operative suggestions, doctrines, details, and processes; and will prove a reliable resource for information, both to physician and surgeon, in the hour of peril.— N. 0. Med. and Surg. Journal. FLINT (AUSTIN), M. D., Professor of the Theory and Practice of Medicine in the University of Louisville, ke. PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECT- ING THE RESPIRATORY ORGANS. In one large and handsome octavo volume, extra cloth, 636 pages. $3 00. We regard it, in point both of arrangement and of the marked abilitv of its treatment of the subjects, as destined to take the first rank in works of this class. So far as our information extends, it has at present no equal. To the practitioner, as well as the student, it will be invaluable in clearing up the diagnosis of doubtful cases, and in shedding light upon difficult phenomena.—Buffalo Med. Journal. A work of original observation of the highest merit. We recommend the treatise to every one who wishes to become a correct auscultator. Based to a very large extent upon eases numerically examined, it carries theevidtnee of careful study and discrimina- tion upon every page. It does credit to the author, and, through him, to the profession in this country. It is, what we cannot call every book upon auscul- tation, a readable book.—Am. Jour. Med. Sciences. 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. $2 75. We do no* know that Dr. Flint has written any- thing which is not first rate; butthis, 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, atd 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 hi ve 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. We have thus endeavored to present our readers with a fair analysis of this remarkable work. Pre- ferring to employ the very words of thedistinguished author, wherever it was possible, we have essayed to condense into the briefest spacea general view of his observations and suggestions, and to direct the intention of our brethren to the abounding stores of valuable matteT here collected and arranged for their use and instruction. No medica' library will here after be considered complete without this volume; and we trus'. it will promptly find iis way into the hands of every Ame'iean student and physician.— Ar Am. Med. Chir. Review. This last work of Prof. Flint will add much to his previous well-earned celebrity, as a writer of great force and beauty, and,'with his previous work, nlacea him at the head of American writers upi.n diseases of the chest. We nave adopted his work upon the heart as a text-book, believing it to be more valuable for that purpose than any work of the kind that has yet appeared.—Nashville Med. Journ. With more than pleasure do we hail the advent of this work, for it fills a wide gap on the list cf text- hooks for our schools, and is, tor the practitioner, the n.ost valuable practical work of its kind.—N. O. Med. Newt. In rogard to the merits of the work, we have no hesitation in pronouncing it full, accurate, and ju- dicious. Considering the present stale of science, such a work was much needed. It should be in the hands of every practitioner.—Chicago Med. Journal. But these are very trivial spots, and in no wise prevent us from declaring our most hearty approval of the author's ability, industry, and conscientious- ness.—Dublin Quarterly Journal of Med. Sciences. He has laborer1 on wi'h the same industry and care, and his place among theirs* authors of our country isbecoming fully established. Tothisend, the work whose title is given above, coniributes in no small degree. Our space will not admit of tn extended analysis, and we will close this orief nonce hy commending it without reserve to every class of readers in the profession.—Peninsular Med. Journ. AND SCIENTIFIC PUBLICATIONS. FOWNES (GEORGE), PH. D., «tc. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. From the seventh revised and corrected London edition. With one hundred and ninety-seven illustrations Edited by Robert Bridges, M. D. In one large royal 12mo volume, of 600 pages. In leather, $1 65; extra cloth, SI 50. (Just Issued.) The death of the author having placed the editorial care of this work in the practised hands of Drs. Benee Jones and A. W. Hoffman, everything has been done in its revision which experience could surest to keep it on a level with the rapid advance of chemical science. The additions requisite to this purpose have neces-itated 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 vet equal attention has been bestowed on the other branches of the subject—Chemical Physics and Inorganic Chemistry—to present all investigations and discoveries of imporiance, and to keep up the reputation of the volume as a complete manual of the whole science, admirably adapted for the learner. By the use of a small but exceedinglv clear lype tbe 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 work has been universally recognized everywhere in his own and this country, as the best elementary treatise on chemistry in the English tongue, and is very generally adopted, we believe, ae the standard text-book in all < ur colleges, both literary and scientific.—Charleston Med Journ. and Review. A standard manual, which has long enjoyed the reputation of embodying much knowledge in a small space. The author hasachieved the difficult task of condensation with masterly tact. His book is con- cise without being dry, and brief without being too dogmatical or general.— Virginia Med. and Surgical Journal. The work of Dr. Fownes has long been before the public, and its merits have been fully appreci- ated as the best text-book on chemistry now in existence. We do not, of course, place it in a rank superior to the works of Brande, Graham, Turner. Gregory, or Gmelin, but we say that, as a work for students, it is preferable to any of them.—Lon- don Journal of Medicine. A work well adapted to the wants of the student It is an excellent exposition of the chief doctrinet and" facts of modern chemistry. The size of the work and still more the condensed yet perspicuous styit in which it is written, absolve it from the charges very properly urged against most manuals termed popular.—Edinburgh Journal of Medical Science FISKE FUND PRIZE ESSAYS —THE EF- FECTS OF CLIMATE ON TUBERCULOUS DISKASK. By EnwiN Lee, M.R.C.S .London, and THE INFLUENCE OF PREGNANCY ON THE DEVELOPMENT OF TUBERCLES By Edward Warren, M.D , of Edenton, N. C. To. petlier in one neat 8vo volume, extracloth. SI IK). FRICK ON RENAL AFFECTIONS; their Ding- nosis and Pathology. With illustrations. One volume, royal 12mo., extra cloth TO cents FERGUSSON (WILLIAM), F. R. S., Professor of Surgery in King's College, London, &c. 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 00. GRAHAM (THOMAS), F. R. S. THE ELEMENTS OF INORGANIC CHEMISTRY, including the Applica- tions of the 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 pa^es, with two hundred and thirty-two wood-cuts, extra cloth. $4 00. *lt Part II., completing the work from p. 431 to end, with Index, Title Matter, &c, may be ha? separate, cloth backs and paper sides. Price $2 50. From Prof. E. N. Horsford, Harvard College. It has, in its earlier and less perfect editions, been familiar to me, and the excellence of its plan and the clearness and completeness of its discussions, have long been my admiration afford to be without this edition of Prof. Graham's Elements.—Silliman's Journal, March, 1858. From Prof. Wolcott Gibbs, N. Y. Free Academy. The work is an admirable one in all respects, and its 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., 8lc. A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad- ministering Officinal and other Medicines The whole adapted to Physicians and Pharmaceii. ™sts. Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas. M n Pmfrssor of Materia Medica in the Philadelphia College of Pharmacy. In one large and handsomeoctavo volume, extra cloth, of 650 pages, double columns. $3 00; or in sheep, $3 25. It was a work requiring much perseverance, and when published was looked upon as by far the bes work if its kind that had issued from the Amer can press. Prof Thomas has certainly -improved" as well as added to this Formulary, and has rendered H rddilionalb deserving of the confidence of pharma- ceutists and physicians.-jlm. Journal of Pharmacy We are happy to unnounce a new and improved edition ot"This one of the most valuable and useful . works that have emanated trom an American.pen. i now, we believe, one of the most complete work It would do credit to any country, and will be found ! 0r its Kjnj -m any language. The additions amount of daily usefulness to practitioners of medicine; it is . l0 abouiseventy pages, and nc effort has been spared better adapted to their purposes than the dispensato < t0 include in them all the recent improvements \ ries —Southern Med. and Surg Journal. I WOrli of this kind appears to us indispensable to ihe ..".___-fth. most ,iSeful books a countrv practi i physician, and there is none -.ve can more cordially tiilercanpolsib?)-^ye.-Medical Chronicle. 'recommend. AT Y Journalof Medicine. This is a work of six hundred and fifty one pair; _ embracing all on the subject of preparing and admi- nistering medicines that can be desired by the physi- cian and pharmaceutist.— Western Lancet. The amountof useful, every-day matter.for a prac licing 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 - BLANCHARD & LEA'S MEDICAL GROSS (SAMUEL DJ, M. D., Professor of Surgery in the Jefferson Medical College of Philadelphia, Ac. Enlarged Edition—Now Ready, January, 1862. A SYSTEM OF SURGERY : Pathological, Diagnostic, Therapeutic, and Opera- live. Illustrated by Twelve Hundred and Twenty-seven Engravings. Second edilion, much en'fg-d and car •fully re'i-ed. In two large and beautifully printed octavo volumes, of about tweniy-two hundred pages; strongly bound in leather, with raised bands. Price §12. The exhaustion in little more than two years of a large edition of so elaborate and comprehen- sive a wo k as this is the best evidence that the author was not mistaken in his estimate of I ht- wutu which existed of a complete American System of Surgery, presenting the science in all n- necessary de'ails and in all its branches. Thai he has succeeded in the attempt to supply this want is shown not only by the rapid sale of the work, but aUo by the very favorable manner in which it has been received by the organs of the profession in this country and in Europe, and by the fact that a. translation 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 new 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 of surgery have been everywhere introduced; while the series of illustrations has been enlarged by the addition of nearly three hundred wood-cuts, rendering it one of the most thoroughly illustrated works ever laid before the profession. To accommodate these very extensive additions, the work has been printed upon a smaller type, so that notwithstanding the very large increase in the matter and value of the book, its size is more convenient and less cumbrous than before. Every care has been taken in the printing to render the typographical execution unexceptionab'e, and it is confi- dently presented as a work in every way worthy of a place in even the most limited library of the p actitioner or student. A few testimonials of the value of the former edition are appended. Has Dr. Gross satisfactorily fulfilled this object? I Of Dr. Gross's treatise on Surgery we can say A caieful perusal of his volumes enables us to give no more than that it is the most elaborate and cotn- an answer in the affirmative. Not only has he given | plete work on this branch of tlu I eating art which to the reader an elaborate and well-written account has ever been published in any country. A 8V* of his o.vn van experience, but he has not failed to embody in his pages the opinions and practice of surgeons 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 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 of the c'assical style of the author, and the exhaust- ing way in which each subject is treated.—Dublin Quarterly Journal of Med. Science. nental authors. It has been justly objected that The work is s0 superior to its predecessors in these have been far from complete in many essential matter anij extent, as well as in illustrations and particulars, many of them having been deficieni in j gtyle of publication, that we can honestly recom- some of the most, important points whnh should | men(1 jt as lhe begt work ()f the kind (nbet8ken characterize such works Some ot them have been , nome D theyo practitioner—Am. Med. Journ. elaborate—too elaborate—with respect to certain i ,,r. diseases, while they have merely glanced at, or With pleasure we record the comp'etion of this given an unsatisfactory account of, others equally long-anticiptted work. The reputation which the important 10 the surgeon. Dr. Gross has avoided author has for manv years sustained, both as a »ur- thiserror, and has produced the most complete work | seon and as a writer, had prepared us to expect a that has yet issued from the press on the se'ence and treatise of great excellence and originality; but we practice of surgery It is not, strictly speaking, a I confess we were by no means prepared lor the work Dictimarv of Surgery, but it gives to the reader all ' which is before us—the most complete treatise upon the information that he may requir, for his treat nent I surgery ever published, either in (his or any ntui of suigical diseases. Having said so much, it might I country, and we might, perhaps, safelv say, the apnear superfluous to add another w .rd ; but it is most original. Ther« is no suhject belonging pro- only due to Dr. Gross to state that he has embraced ' Perly to surgery which has not received from the the opportunity of transferring to his pages a vast j author a due share of attention. Dr. Grois has sup- number oi engravings from English and other au- vlled a want ,n surgical literature winch has long Mors, illustrative of the pathology and treatment of I been felt by practitioners; he hasfurnisheo us with Biirirical diseases. To these are added several hun a complete practical treatise upon surgery in all its dred original wood-cuts The work altogether coin- | departments As Anrieric ins, we are proud rf the mends itself to the attention of BritUn surgeons, I achievement; as surgeons, we are most sincerely from whom it cannot fail to meet with extensive ' thankful to him for his extraord nary labors in our patronage— London Lancet, Sept. 1, I860. behalf — N. Y. Monthly Remew and Buffalo Med. i Journal. BY THE SAME AUTHOR. 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. Price in extra cloth, $4 75; leather, raised bands, $■> 25. (Lately Published.) The very rapid advances in the Science of Pathological Anatomy during the last few year? have rendered essential a thorough modification of this work, with a view of making it a correct expo- nent of the present state of the 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 lhe 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. We most sincerely congratulate the author on the , We hnve been favorably impressed with the gene- successful manner in which he has accomplished his ' ral manner in which Dr Gross hasexecuted his task proposed object. His book is most admirably eal- of affording a comprehensive digest of the present culated to fill up a blank which has long been felt to exist in this department of medical literature, and a* such must become very widely circulated amongst all classes of the profession. — Dublin Quarterly state of the literature of Pathological Anatomy, and have much pleasure in recommending his work to our readers, as we believe one well deserving of diligent perusal and careful study.—Montreal Med. Tourn of Med. Science, Nov. 1857. | Chron., Sept. 1857 BY THE SAME AUTHOE. A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PAS SAGES. In one handsome octavo volume, extra cloth, with illustrations, pp. 468. $2 75. AND SCIENTIFIC PUBLICATIONS. 17 GROSS (SAMUEL D.), M. D.. Professor of Surgery in the Jefferson Medical College of Philadelphia, &c. A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE URINAR.V BLADDER, THE PROSTATE GLAND, AND THE URETHRA. Second Edition, revised and much enlarged, with one hundred and eighty- four illustration* In one large and very handsome octavo volume, of over nine hundred page*. In leather, raised bands, $.r> 25; extra cloth, $4 75. Philosophical in ts design, methodical in its ar- ; agree with us, that there is no work in the English rangement, ample and sound in its practical details, it may in truth be said to leave scarcely anything to be desired on so important a subject.—Boston Med. and Surg Journal Whoever will peruse the vast amount of valuable practical information it contains, will, we think, language which can make any just pretensions to be its equal.— N. Y. Journal of Medicine A volume replete with truths and principles of the itmost value in the investigation of these diseases.— American Medical Journal. GRAY (HENRY), F. R. S., Lecturer on Anatomy at St. George's Hospital, London, See. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. V. Carter, M D., 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 edilion. In one magnificent imperial octavo volume, of over 800 pages, with 3S8 large and elaborate engravings on wood. Price in extra cloth, $6 25; leather, raised bands, $7 00. (Now Ready, 1802.) The speedy exhaustion of a large edition of this work is sufficient evidence that its plan and exe- cution have been found to present superior practical advantages in facilitating the study of Anato- my- In presenting it to lhe profession a second time, the author has availed himself of the oppor- lunity to supply any deficiencies which experience in its use had shown to exist, and to correct any errors of detail, to which the first edition of a scientific work on so extensive and complicated a science is liable. These improvements have resulted in some increase in the size of the 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 re-pects accurate, and it is now presented, without any increase of price, as fitted to maintain and extend the popularity which it has everywhere acquired With little trouble, the busy practitioner whose to exist in this country. Mr. Gray wTites through knowledge of anatomy may have become obscured by want of practice, mav 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 of the medical man will soon be considered incomplete in which a copy of this work does not exiBt.- Madras Quarterly Journal of Med. Science, July, 1861. This edition is much improved and eularged, and contains several new illustrations by Dr. Westma- cott. The volume is a complete companion to the dissectins-room, and saves tne necessity of the. stu dent possessing a variety of" Manuals."—The Lon don Lancet, Feb. 9, lfeof. The work before us is one entitled to the highest praise, nnd we accordingly welcome it. as a valu- able addition to medical literature. Intermediate in fulnesR of detail between the treatises of S tar 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 ordinary size, and admirab y executed. The various parts are also lettered after the plan adopted in Holden's Osteology. It would be aim- cult to over-estimate the advantages offend by this mode of pictorial illus ration Bones, ligaments, muscles, bloodvessels, and nerves are each in turn figured, and marked with their appropriate names; thusenabiingthestudenttocrk on anatomy hitherto published in the English lan- guage, affording a complete view of the structure of the human boav, with especial reference to practical surgery. Thus the volume constitutes a perfect book of reference for the practitioner, demanding a place in even the most limited library of the physician or surgeon, and a work of necf ssity for the student to fix in his mind what he has learned by the dissecting knife from the book of nature.—The Dublin Quar- terly Journal of Med. Sciences, Nov. 1858. In our judgment, the mode of illustration adopted in the present volume cannot but present many ad- vantages to the student of anatomy. To the zealous disciple of Vesalius, earnestly desirous of real im- provement, the book will certainly be of immense value; but, at the same time, we must also confess that to those simplv desirous of "cramming" it will bean 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 iu those portions which treat of the bones of the head and of thsir development. The study of these parts is thus made one of comparative e-.se, if not of positive pleasure; and those bugbears of the student, the temporal and sphenoid bones, are shorn of half their terrors. It is, in our estimation, an admirable and complete text-book for the student, and a useful work of reference for the practitioner; its pictorial character forming a novel element, to which we have already sufficiently alluded.—Am. Journ. Med. Sci., July, 1859. IS BLANCHARD & LEA'S MEDICAL GI1SSOVS INSTITUTES AND PRACT1CK OF SURGERY. Eighth edition, improved ai.d al- tered. \V ith thirty-four plates. In two handsome octavo volumes, contain ng about 1,000 pagea, leather, raised band i. S6 50 GARDNER'S MEDICAL CHEMISTRY, for the use of Students and the Profession. In one royal ll!mo. vol., cloth, pp. 396, with woodcuts. SI. GLUGE'S ATLAS OF PATHOLOGICAL HIS- TOLOGY. Translated, with Notes and Addi- tions, by Joseph Lkidy, M. D. In one volume, very large imperia1 quarto, extra cloth, wi'i 3i20 copper- plate figures, plain and colored, $5 00. HUGHES' INTRODUCTION TO THE PRAC- TICE OK AUSCULTATION ANIj OTHER MODES OF PHYSICAL DIAGNOSIS IN DIS- EASES OF THE LUNGS AND HEART. Se- cond edition 1 vol. royal limo., sx. cloth, pp. 304. $1 00. HAMILTON (FRANK H.), M. D., Professor of Surgery in the Long Island College Hospital. A PRACTICAL TREATISE ON FRACTURES AND DISLOCATIONS. In one large and handsome octavo volume, of over 750 pages, with 289 illustrations. $4 25. (Now Ready, January, 1860.) Among the many good workers at surgery of whom i opinion may be gathered as to its value.— Boston Medical and Surgical Jourral, March 1, I860. The work is concise, judicious, and accurate, and adapted to the wants of the student, practitioner, and investigator, honorable to the author and to the profession.—Chicago Med. Journal, March, 1860. We reeard this work as an honor not only to its author, but to the profession of our country. Were we to review it choroughly, we could not convey to the mind of lhe reader more forcibly our hontst America may now hoast rot the least is Frank II ist ir.gs Hamilton ; and the volume before us 's (we say it wi'h a pang of wounded patriotism) the best and handiest book on trie subject in the Ei glish lan- guage. It is in vain to attempt a review ot it; nearly as vain to seek for any sins, either of com- mission or omission. We have seen no work on practical surgery which we would sooner recom- mend to our brother surgeons, especially those of '* the services," ir those whose practice lies in dis- tricts wnere a man has necessarily to rely on his | opinion expressed in the few words—we think it the nest book ol its kind extant. Every man interested in surgery will soon have this work on his desk. He who does not, will be the loser.—New Orleans Medical News, March, I860. own unaided resources. The practitioner will find in tt directions for nearly every possible ac-ioent, easily found and comprehended ; and much pleasant leading for him to muse over in theafter contidera- tion ofhiscases.—Edinburgh Med. Journ Feb lfcOl. I Now that it is before us, we feel bound to say that This is a valuable eonlribution to the surgery 6f much a,s was expected from it, and onerous as wag most important affections,and is the more welcome, I *h.f,:!|.^rl*kin&:u1.Lh.a,?.„B^Pa!!f,diexpectatl<^* and 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 our American brother to produce a complete trtatise upon the suhject, and bring together in a convenient form those alterations and improvements that have been made from time to lime in the tieaiment of these affections. One great and valuable featuie in the work before us is the fact that it comprises all the improvements introduced into the practice of both achieved more than was pledged in its behalf; for its title does not express in full the richness of its contents. On the whole, we are prouder of this work than of any which has for years emanated from the American medical press; its sale will cer- tainly be very large in this country, and we antici- pate its eliciting much attention in Europe.—Nash- ville Medical Record, Mar. 1860. Every surgeon, young and old, should possess himself of it, and give it a careful perusal, in doing English and American surgery, and though far from which he will be richly repaid.—St. Louis Med omitting mention of our continental neighbors, the I and Surg. Journal, March, 1860. author by no means encourages the notion—but too prevalent in some quarters—that nothing is good unless imported from France or Germany. Tne 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, 1S60. Dr. Hamilton is fortunate in having succeeded in filling the void, so long felt, with what cannot fail to be at once accepted as a model monograph in some respects, and a work of classical authority. We sincerely congratulate the profession of the United States on the appearance of such a publication from one of their number. We have reason to be proud of it as an original work, both in a literary and s^i- It is emphatically the book upon the subjects of entitle point of view, and to esteem it as a valuable which it treats, and we cannot doubt that it will guide in a most difficult and important branch of continue so to be for an indefinite period of time, j study and practice. On every account, therefore, When we say, however, that we believe it will at, we hope that it may soon be widely known abroad once take its place as the best book for consultation i as an evidence of genuine progress on this side of by the practitioner; and that it will form the most J the Atlantic, und further, that it may be still more complete, available, and reliable guide in emergen- widely known at home as an authoritative teacher ciesof every nature connected with itssubjects; and j from which every one may profitably learn, and as also that thestudentof surgery may make it his text- l affording an example of honest, well-directed, and book with entire confidence, and with pleasure also, | untiring industry in authorship which every surgeon from its agreeable and eaty style—we Ihink our own may emulate.- Am. Med. Journal, April, 1860. 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 of the Medical Sciences." In one large royal 12mo. volume, leather, 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 in definition, and sufficiently full and complete for ordinary consultation —Charleston Med. Journ. We know of no dictionary better arranged and adapted. It isnot encumbered with theobsoleteterms of a bygone age, but it contains all that are now in down to the very latest date.—Western Lancet. Hoblyn's Dictionary has long been a favorite with us. It is the best book of definitions we have, and ought always to be upon the student's table.— Southern Med. and Hurg. Journal. HOLLAND'S MEDICAL NOTES AND RE- FLECTIONS. From the thiid London edition. In oEe handsome octavo volume, extra cio;h. S3. HORNER'S SPECIAL ANATOMV AND HIS- TOLOGY. Eighth edition. Extensively revised and modified. In two large octavo volumes, ex- tra cloth, of more than 1000 pages, with over 300 illustrations. $6 00. AND SCIENTIFIC PUBLICATIONS. 19 HODGE fHUGH 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. S3 25. (Now Ready.) We will say at once that the 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 ot 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 rankns such immediately.—Maryland and Virginia Medical Journal, Feb. 1661. This contribution towards the elucidation of the pathology and treatment of some of the diseases peeul iar 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 obscuiity; 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 tteir disposition again and again to leeur—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 is not emi- nently deserving of perusal and study, we think that the nine chapte rs devoted to this subject, are espe- ciallv 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 br one of the most original and m >st practical works of the day ; one which every 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. Of the many excellences of the work we will not speak at length. We advise all who would acquire a knowledge of the proper management of the mala- dies of which it treats, to study it with care. The second part is of itself a most valuable conrribution to the practice of our art.—Am. Med. Monthly and New York Review. Feb. 1861. The illustrations, which are all original, are drawn to a uniform scale of one-half the natural size. 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 $1 75. (Now Ready.) JONES (T. WHARTON), F. R. S., Professor of Ophthalmic Medicine and Surgery in University College, London, &c. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY. With one hundred and ten illustrations. Second American from the second and revised London edition, with additions by Edward Hartshorne, M. D., Surgeon to Wills' Hospital, &c. In one large, handsome royal 12mo. volume, extra cloth, of 500 pages. $1 50. JONES (C. HANDFIELD), 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, leather. $3 75. obliged to glean from a great number of monographs, and the field was so extensive that but few cultivated it with any degree of success. As a simple work As a concise text-book, containing, in a condensed form, a complete outline of what is known in the domain of Pathological Anatomy, it is perhaps the best work in the English language. Its great merit consists in its completeness and brevity, and in this respect it supplies a great desideratum in our lite- rature. Heretofore the student of pathology was of reference, therefore, it is of great value to the student of pathological anatomy, and should be in every physician's library.—Western Lancet. KIRKES (WILLIAM SENHOUSE), M.D., Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c. A MANUAL OF PHYSIOLOGY. A new American, from the third and improved London edition. With two hundred illustration*. In one large and handsome royal 12mo volume, leather. pp.586. $2 00. (Lately■ Published.)........ 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 b> the busy praeritioner.-2>~6/Vn Quarterly Journal: One of the very best handbooks of Physiology we nossess-presenting just such an outline of the sci- possess ___»...»*,' „i,„« Hiirinp his attendance and its carefully cited authorities. It is the most convenient of text-books. These gentlemen, Messrs. Kirkes and Paget, have the gift of telling us what we want to know, without thinking it neces3ary to tell us all they know.—Boston Med and Surg. Journal. possess— presenting just such an outline of the sci- J por the student beginning this study, and th ence as the student require* during his attendance practitioner who has but leisure to refresh hi nnon a course of lectures, oi for reference whilst memory, this book is invaluable, a U| • _ c______-,.•__H™ Am Medical Journal . .h„t it io imn„rtiiit tn Irnmir __/ unon a course oi lectures, ui •"• '*"y:—,- ......, preparing for examination — Am. Medical Journal Its excellence is in its compactness, its clearness, practitioner wno nas out leisure to refresh his memory, this book is invaluable, as it oontains all that it is important to know.—Charleston Med. Journal. 20 BLANCHARD & LEA'S MEDICAL KNAPP'S TECHNOLOGY; or, Chemistry applied to the Arts and to Manufactures. Edited by Dr. Ronalds, Dr. Richardson, and Prof. W. R. Johnson. In two handsom« 8vo. vols., with about 500 wood engravings. $6 00. LAVCOCK'S LECTURES ON THE PRINCI- PLES AND MKTHOL.S OF MEDICAL OB- SERVATION AND RESEARCH. For th-Use of Advanced Students and Junior Practitioners. In one royal l'imo. volume, extra cloth. Price81. LALLEMAND AND WILSON. A PRACTICAL TREATISE ON THE CAUSES, SYMPTOMS, AND TREATMENT OF SPERMATORRHOEA. By M. Lallemand. Translated and edited by Henry J McDougall. Third American edition. To which is added-----ON DISEASES OF THE VESICUL^E SEMINALES; and their associatkd organs With special refer- ence to the Morbid Secretion;- of the Prosiatic and Urethral Mucous Membrane. By Marris Wilson, M.D. In one neat octavo volume, of about 400 pp., extra cloth. $2 00. (Just Issued.) LA ROCHE f no better companion for the student I crammed into his head by the various professors to during the hours spent in the lecture room, or to re- whom he is compelled *o listen.— Western Lancet, fresh, at a glance, his memory of the various topics | May, 1857. LEHMANN (C. G.) PHYSIOLOGICAL CHEMISTRY. Translated from the second edition by George E. Day, M. D., F. R. S., &c, edited by R. E. Rogers, M. D., Professor of Chemistry in the Medical Department of the University of Pennsylvania, with illustrations selected from Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Complete in two large and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus- trations. $6 00. The work of Lehmann stands unrivalled as the most comprehensive book of reference and informa- tion extant on every branch of the subject on which it treats.—Edinburgh Journal of Medical Science. The most important contribution as yet made to Physiological Chemistry__Am. Journal Med. Sci- tnces, Jan. 1856. by the same author. (Lately Published.) MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital Force, by Protestor Samuel Jackson, M. D., of the University ol Pein^ylvania. With illus- trations on wood. In one very handsome octavo volume, extra cloth, of 336 pages. $2 25. From Prof. Jackson's Introductory Essay. In adopting the handbook of Dr Lehmann as a manual of Organic Chemistry for the use of the students of the University, and in recommending his original work of Physiological Chemistry for their more mature studies, the high value of his researches, and the great weigntof his autho- rity in that important department of medical science are fully recognized. AND SCIENTIFIC PUBLICATIONS 21 LYONS (ROBERT D.l, K. C. C, Late Pathologist in-chief to the British Army in the Crimea, Sec. A TREATISE OX FEVER; or. selections from a course of Lectures on Fevor. Being part of a course of Theory and Practice of Medicine. In one neat octavo volume, of 362 pages, extra cloth; $2 00. (Now Ready.) From the Author's Preface. "I am induced to publish this work on Fever with a view to bring within the reach of the student and junior practitioner, in a convenient form, the more recent results of inquiries into the Pathology and Therapeutics of this formidable class of diseases. " 1 he works of the great writers on Fever are so numerous, and in the present day are scattered in so many languages, lhat they are difficult of access, not only to students but also to practitioners. I shall deem myself fortunate if I can in any measure supply the want which is felt in this respect. We have great pleasure in recommending Dr. Lyons' work on Fever to the attention of the pro- fusion. It is n work which cannot fail to enhance the author's previous well-earned reputation, as a diligent, careful, and accurate observer.—British M'd. Journal, March 2, 1861. Token an a whole we can recommend it in the, .. highest terms as well worchy the careful perusal May, 1861 and study of every student and practitioner of medi- ' cine. We consider the work a most valuable addi- tion to medical literature, and one destined to wield no little influence over the mind of the profession — Med and Surg. Reports, May 4, 1861. This is an admirable work upon the most remark- able and most important, class of diseases to which mankind are liable.—Mid. Journ. of N. Carolina, MEIGS (CHARLES D.), M.D., Professor of Obstetrics, Sec. in the JefTerson Medical College, Philadelphia. OBSTETRICS: THE SCIENCE AND THE ART. Third edition, revised and improved. With one hundred and twenty-nine illustrations. In one beautifully printed octavo volume, leather, of seven hundred and fifty-two large pages. $3 75. Though the work has received only five pages of The best American work on Midwifery that is enlargement, its chapters throughout wear the im- accessible to the student and practitioner—N. W. press of careful revision. Expunging and rewriting, Med. and Surg. Journal, Jan. 1857. remodelling its sentences, with occasional new ma- This is a standard work by a great American Ob- tenal, all evince a lively desire that it shall deserve stetrici,.m. ]t is tne lnird and *jnst edition, and, in to be regarded as improved in manner as well as tne ial!f,ua„e 0ftne preface, the author has "brought matter. In the matter, every stroke of the pen has the BUbject up to the latest dates of real improve- mcreased the value of the book, both in expungings ment in „ur art and Science."—Nashville Journ. of and additions — Western Lancet, Jan. 1857. | Med. and Surg., May, 1857. by the same author. (Just Issued.) WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Leo^ tures to his Class. Fourth and Improved edition. In one large and beautifully printed octavo volume, leather, of over 700 pages. $3 60. which cannot fail to recommend the volume to the attention of the reader.—Ranking's Abstract. In other respects, in our estimation, too much can- not be said in praise of this work. It abounds with beautiful passages, and for conciseness, for origin- ality, and for all that is commendable in a work on the diseases of females, it is not excelled, and pro- fa ibly 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 t>nd practitioneras 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 Britishand Foreign Medico-Chi- rurgical Review. Everv chapter is replete with practical instruc- tion, aiid 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 ol symptoms, and in the rules for diagnosis, It contains a vast amount of practical Knowledge, By one who has accurately observed and retained the experience of many years.—Dub'.in Quarterly Journal. Full of important matter, conveyed in a ready and agreeaole manner.—St.Louis Med. and Surg. Jour. There is an ofT-hand fervor, a glow, and a warm- neartedness infecting the effirt 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 3f lucidly explaining it. The most elementary, as well as the obscurest subjects, undeT the pencil of Prof. Meigs, are isolated and made to stand out in sucn bold relief, as to produce distinct impressions upon the mind and memory of the reader. — The Charleston Med. Journal. BY THE SAMB AUTHOR. 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, ol 365 pages. $2 50. 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- BY THE SAMB AUTHOR : A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK OF THE UTErUJS. With numerous plates, drawn and colored from nature in the highest style ol art. In one handsome octavo volume, extra cloth. $4 50. 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. 22 BLANCHARD « LEA'S MEDICAL 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. $11 00. %* 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 $9 00. One of the greatest artistic triumphs of the age i A work which has no parallel in point of accu- in Surgical Anatomy.—British American Medical racy and cheapness in the English language.—AT. Y. Journal. I Journal of Medicine. No practitioner whose means will admit should fail to possess it.—Ranking's Abstract. Too. much cannot be said in its praise; indeed, we have not language to do it 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 elegantty printed, so well illustrated, and so useful a work, is offered at so moderate a price.—Charleston Medical Journal. Its plates can boast a superiority which places them almost beyond the reach of competition.—Medi- cal Examiner. Country practitioners will find these plates of im- mense value.—N. Y. Medical Gazette. We are extremely gratified to announce to the profession the 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 the subject in hand.—Tht New Orleans Medical and Surgical Journal. This is by far the ablest work on Surgical Ana- tomy that has come under our observation. We 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 the instantaneous command of minute anatomical knowledge, a work of this kind keeps the details of the dissecting-room perpetually fresh in the memory.—The Western Journal of 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.j 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. (Lately Published.) $3 75. We congratulate the author that the task is done. I tion to which its merits justly entitle it. The sty* We congratulate him that he has given to the medi- is such that the descriptions are clear, and each sub- cal public a work which will secure for him a high j ject is discussed and elucidated with due regard to and permanent position among the standard autho- j its practical bearings, which cannot fail to make it ntieson the principles and practice of obstetrics, acceptable and valuable to both students and prac- Congratulations are not less due to the medical pro- titioners. We cannot, however, close this brief fession of this country, on the acquisition of a trea- | notice without congratulating the author and ^the tise embodying the results of the studies, reflections, and experience of Prof. Miller. Few men, if any, in this country, are more competent than he to write on this department of medicine. Engaged for thirty- five years in an extended practice of obstetrics, for many years a teacher of this branch of instruction in one of the largest of our institutions, a diligent student as well as a careful observer, an original and independent thinker, wedded to no hobbies, ever ready to consider without prejudice new views, and to adopt innovations if they are really improvements, and withal a clear, agreeable writer, a practical treatise from his pen could not fail to possess great value.—Buffalo Med Journal. In fact, this volume must take its place among the standard systematic treatises on obstetrics ; a posi- profession on the production of such an excellent treatise. The author is a western man of whom we feel proud, and we cannot but think that his book will find many readers and warm admirers wherever obstetrics is taught and studied as a science and an art.—The Cincinnati 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 witl 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 modern literature of the science; and we hope to see this American produc- tion generally consulted by the profession.—Va. Med. Journal. MACKENZIE (W.), M.D., Surgeon Oculist in Scotland in ordinary to Her Majesty, See. Sec. 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, leather, raised bands, with plates and numerous wood-cuts. $5 25. 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, ei ther English or foreign. —Dixon on Diseases of the Eye. Few modern books on any department of medicine or surgery have met with such extended circulation, or have procured for their authors a like amount of European celebrity. The immense research which it displayed, the thorough acquaintance with the subject, practically as well as theoretically,and the MAINE'S DISPENSATORY AND THERA- PEUTICAL REMEMBRANCER. With every Practical Formula contained in the three British Pharmacopoeias. Edited, with the addition of the Formulae of the U. S. Pharmacopoeia, by R. E. Griffith,M.D 1 12mo. vol. ex.cl.,300pp. 75 c. able manner in which the author's stores of learning and experience were rendered available for general use, at once procured for the first edition, as well on the continent as in this country, that high position as a standard work which each successive edition has more firmly established. 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 him- self familiar with this the most complete work in the English language upon the diseases of the eye. —Med. Times and Gazette. MALGAIGNE'S OPERATIVE SURGERY, based on Normal and Pathological Anatomy. Trans- lated from the French by Frkdbkick Bhutan, A.B.,M.D. Withnumerous illustrations on wood. In one handsome octavo volume, extra cloth, of nearly six hundred pages. 82 25. AND SCIENTIFIC PUBLICATIONS 2J MILLER (JAMES), F. R. S. E., Professor of Surgery in the University of Edinburgh, Sec. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and verv beautiful volume, leather, of 700 pages, with two hundred and forty illustrations on wood. S3 75. The work takes rank with Watson's Practice of Physic; it certainly does not fall behind that great work in soundness of principle or depth of reason- ng and research. No physician who values his re- Hie work of Mr. Miller is too well and too favor ably known among us, as one of our best text-books, to render any further notice of it necessary than the announcement of a new edition, the fourth in our country, a proof of its extensive circulation among us. As a concise and reliable exposition of the sci- ence of modern surgery, it stands deservedly high— we know not its superior__Boston Med. and Surg. Journal. putation, or seeks the interests of his clients, can acquit himself before his Uod and the world without ma king himself familiar with the sound and philo- sophical views developed in the foregoing book.— New Orleans Med. and Surg. Journal. BY THE SAME AUTHOR. (Just Issued.) THE PRACTICE OF SURGERY. Fourth American from the last Edin- burgh edition. Revised by the American editor. Illustrated by three hundred and sixty-fouT engravings on wood. In one large octavo volume, leather, of nearly 700 pages. $3 75. his works, both on the principles and practice of surgery have been assigned thehisrhest rank. If we No encomium of ours could add to the popularity of Mrller'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, were limited to but one work on sursery. 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, Palhology, and Treatment. With illustrations. In one large and handsome octavo volume, of about 600 pages, extra cloth. (Just Issued.) $3 50. 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 work one of great interest, and one which will prove in the highest degree useful to the general practitioner.—N. Y. Journ. of Medicine, 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 BY THE SAME AUTHOR.—(Now Ready.) THE MORBID EFFECTS OF THE RETENTION IN THE BLOOD OF THE ELEMENTS OF THE URINARY SECRETION. Being the Dissertation to which the Fir-ke Fund Prize was awarded, July 11, 1S61. In one small octavo volume, S3 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 m Ireland, &c. 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-cut.. In one very handsome octavo volume, extra cloth, of nearly 600 pages. (Lately Published.) $3 7o. A book unusually rich in practical suggestions.— fresh, and vigorous, and classical is our author's A dook unusuaiiy "y"'» v. .„„ &° sty e; and one forgets, in the renewed charm of Am. Journal Med. Sciences, Jan. 1B57. Wery page, that it, and'every line, and every word These several subjects so interesting in ™e"»- hag been welg|,ed ana reweighed through years of selves, and so important, every one of them, to tne aratjon . that thig ig of an ot)iers the book of most delicate and precious of social relations, con- , obgtetrie LaWi 0n each of its several topics; on all trolling often the honor and domestic peace oi a intg connecteti -vtricli pregnancy, to be everywhere MOHR (FRANCIS), PH. D., AND REDWOOD (TH EOPH I LUS). PR ACTIC \L PHARMACY. Comprising the Arrangements, Apparatus, and 'Sr'^.rr.MiptiAn* of the Pharmaceutical Shop and Laboratory. Edited, with extensive Additions, ^ Pm William Procter, of the Philadelphia College of Pharmacy. In one handsomely printed octavo volume, extra cloth, oi 570 pages, with over 500 engravings on wood. $2 75, 24 BLANCHARD & LEA'S MEDICAL NEILL (JOHN), M. D., Surgeon to the Pennsylvania Hospital, &c; 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. Strongly bound in leather, with raised bands. $3 00. The very flattering reception which has been accorded to this work, and the high estimate placed upon it by the profession, as evinced by the constant and increasing demand which has rapidly ex- hausted two large editions, have stimulated the authors to render the volume in its present revision more worthy of the success which has attended it. It has accordingly been thoroughly examined, and such errors as had on former occasions escaped observation have been corrected, and whatever additions were necessary to maintain it on a level with the advance of science have been introduced. The extended series of illustrations has been still further increased and much improved, while, by a slight enlargement of the page, these various additions have been incorporated without increasing the bulk of the volume. The work is, therefore, 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 dale may easily and cheaply acquire a knowledge of the 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 nands of every one who takes pupils into his office with a view of examining them ; and this is unquestionably the best of 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. The 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 Stetho- scope NELIGAN fj. MOORE), M. D., M. R. I.A., See (A splendid work. Just Issued.) ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, extra cloth, with splendid colored plates, presenting nearly one hundred elaborate representations of disease. $4 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 of the 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. Nehsran's Atlas of Cutaneous Diseases supplies a long existent desitleratum much felt by the largest class of our profession. It presents, in quarto size, 16 plates, each containing from 3 to 6 figures, and forming in all a total of 90 distinct representations of the different species of skin affections, grouped together in genera or families. The illustrations give, at a coup d'ctil, the remarkable peculiarities of each individual variety. And while thus the dis ease is rendered more definable, there is yet no loss of proportion incurred by the necessary concentra- tion. Each figure is highly colored, and so truthful has the artist been that the most fastid ous observer could not justly take exception to the correctness of have been taken from nature, and have l.een copied the execution of the pictures under his scrutiny.— with such fidelity that they present a striking picture Montreal Med. Chronicle. of life; in which the reduced scale aptly serves to I BY THE SAME AUTHOR. A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Third American edition. In one neat royal 12mo. volume, extra cloth, of 334 pages. $ 1 00. The two volumes will be sent by mail on receipt of Five Dollars. OWEN ON THE DIFFERENT FORMS OF I One vol. royal 12mo., extra cloth with numerous THE SKELETON. AND OF THE TEETH. | illustrations. 8125 PIRRIE (WILLIAM), F. R. 8. 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, sician or student desiring information on the subjectof which it treats. With Griffith's " Medicil Formulary" and this, the practising physician would be supplied with nearly or quite all the most useful infor nation on the sub- ject.—Charleston Med. Jour.and Review, Jan. Ib60 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, of over 600 pages. (Lately Published.) $3 75. We would recommend it to the medical student and practitioner, as containing a summary of all that is known of the important subjects which it treatij; of all that is contained in the great works of Simon and Lehmann, and the organic chemists in general. Master this one volume, we would say to the medical student and practitioner—master this book and you know all that is known of the great fundamental principles of medicine, and we have do hesitation in saying that it is aa honor to the American medi- cal profession that one of its members should have produced it.—St. Louis Mid. and Surg. Journal. It embraces a library upon the topics discussed within itself, and is just what the teacher and learner need. Another advantage, by no means to be over- looked, everything of real value in the wide range which it embraces, is with great skill compressed into an octavo volume of but little more than six hundred pages. We. have not only the whole sub- ject of Histology, interesting in itself,ably and fully discussed, but what is ot infinitely greater interest to the student, because of greater practical value, are its relations to Anatomy, Physiology, and Pa- thology, which are here fully and satisfactorily set U>nh-Nashville Journ. of Med. and Surgery. PEREIRA (JONATHAN), M. D., F. R. 3., AND L. S. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. Third American edition, enlarged and improved by the author; including Notices of mostof the ii.!Ii.!n» Substances in use in the civilized world, and forming an Encyclopaedia of Materia MS EdSTSSh Additions, by Joseph Carson, M. D Professor of Materia Medica and Pharmacy i the University of Pennsylvania. In two very large octavo volumes o 2100 pages on snuUI type, with about 500 illustrations on stone and wood, strongly bound in leather, with raised bands. $y 00. ^♦^ Vol. II. will no longer be sold separate. PARKER (LANGSTON), Surgeon to the queen s Hospital, Birmingham. TRF MODERN TREATMENT OF SYPHILITIC DISEASES, BOTH PRI- mTuvanD SECONDARY; comprising the Treatment ol Constitutional and Confirmed Syphi- MAltx fiT tld «ucces-l'ul method. With numerous Cases, Formulae, and Clinical Observa- lib, by a_ sate - entirely rewritten London eanion. In one neat octavo volume, Uons. rrom tne nuru «■ j extra cloth, of 31b pages. $175._________________ ROYTF'S MATERIA MEDICA AND THERAPEUTICS; including the ■"X Pharmacopoeias of London, Edinburgh, Dublin, and of the United States. wTtK^new TJfoZ Euited by Joseph C.kso*, M. D With ninety-eight tllustraUon, In oneSe octavo volume, extra cloth, ol about 700 pages. S3 00. 26 BLANCHARD & LEA'S MEDICAL RAMSBOTHAM (FRANCIS H.), M.D. THE PEINCIPLES 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 beauliful Plaies, and numerous Wood-cuts in the text, containing in all nearly 200 large and beautiful figures. $5 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 | truly elegant style in which they have brought it Utility of this work. It is already appreciated in our j out, excelling themselves in its production, espe- country for the value of the matter, the clearness of cially in its plates. It is dedicated to Prof. Meigs, its style, and the fulness of its illustrations. To the and has the emphatic endorsement of Prof. Hodge, physician's library it is indispensable, while to the as the best exponent of British Midwifery. We student as a text-book, from which to extract the know 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.—Med. Gazette. 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 RICORD (P.), M. D. A TREATISE ON THE VENEREAL DISE AS HI By John Hunter, F. R. S. With copious Additions, by Ph. Ricord, M. D. Translated and Edited, with Notes, by Freeman J. Bumstead M.D , Lecturer on Venereal at the College of Physicians and Surgeons,New York. Second editicn, revised, containing a resume of Ricord's Recent Lectures on Chancre. In one handsome octavo volume, extra cloth, of 550 pages, with eight plates. $3 25. (Just Issued.) In revising this work, the editor has endeavored to introduce whatever matter of interest the re- cent investigation? of syphilographers have added to our knowledge of the subject. The principal source from which this'hasbeen derived is the volume of "Lectures on Chancre," published a lew months since by M. Ricord, which affords a large amount of new and instructive malerial on many controverted points. In the previous edition, M. Ricord's additions amounted to nearly one-lhird of the whole, and with the matter now introduced, the work may be considered to present his views and experience more thoroughly and completely than any other. secretaries, sometimes accredited and sometimes not. In the notes to Hunter, the master substitutes him- self for his interpreters, and gives hisonginal thoughts to the world in a lucid and perfectly intelligible man- ner. In conclusion we can say that this is incon- lestably the besttreati-e on syphilis with which we are acquainted, and, as we do not often employ the phrase, we may he excused for expressing the hope that it may find a place in the library of every phy- heretofore'onlybeen interpretedhy moreorlessskilful ] sician.— Virginia Med. and Surg. Journal. 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. SLADE (D. D.), M. D. DIPHTHERIA; its Nature and Treatment, with an Account of tbe History of its Prevalence in various countries. Being the Dissertation to which the Fiske Fund Prize was awarded, July 11, I860. In one small oclavo volume, extra cloth; 75 cents. (Now Ready, lb'31.) Every one will recognize the attractiveness and value which ihiswork derives from thus presenting the opinions of these two masters side by side. But, it must be admitted, what has made the fortune of the book, is lhe fact that it contains the " most com- plete embodiment of the veritable doctrines of the HOpital du Midi," which has ever been made public. The doctrinal ideas of M. Ricord, ideas which, if not universally adopted,are inconleslably dominant, have ROKITANSKY Curator of the Imperial Pathological Museum, A MANUAL OF PATHOLOGICAL bound in two, extra cloth, of about 1200 pages, king, C H. Moore, and G. E. Day. $5 50. 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 most profound, 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 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. The effort of the distinguished author to concentrate in a small space his great fund of knowledge, has (CARL), M.D., and Professor at the University of Vienna, Sec. ANATOMY. Four volumes, octavo, Translated by W. E. Swainje, Edward Sieve- so charged his text with valuable truths, that any attempt of a reviewer to epitomize is at once para- lyzed, and must end in a failure.—Western Lancet. As this is the highest source of knowledge upon the important subject of which it treats, no real student can afford to be without it. The American publishers have entitled themselves to the thanks of the profession of their country, for this timeous and beautiful edition.—Nashville Journal of Medicine. As a book of reference, therefore, this work must prove of inestimable value, and we cannot too highly recommend it to the profession.—Charleston Med. Journal and Review. This book is a necessity to every practitioner.— Am. Med. Monthly. RIGBY (EDWARD), M. D., Senior Physician to the General Lying-in Hospital, &c. A SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. Second American Edition. One volume octavo, extra cloth, 422 pages. $2 50. by the same author. (Lately Published.) ON THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES. In one neat royal 12mo. volume, extra cloth, of about 250 pages. $ 1 00. AND SCIENTIFIC PUBLICATIONS. 27 STILLE (ALFRED), M.D. THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. In two large and handsome octavo volumes, of 1789 pages. (Just Issued.) SS 00. This work is designed especially for the student and practitioner of medicine, and treats the various articles of the Materia Medica from the point of view of the bedside, and not of the shop or of the leeiure-room. While thus endeavoring to pive 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 ca?es with all that the experience of the profession has suggested. Rarely, indeed, have we had submitted to ni 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 accorting to its relations to a just logic and experience—manifests itself everywhere, and gives to the guidance of the author all the 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'B volumes, the great value and interest of the stores of knowledge they present. We have pleasure in referring rather 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, ub 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. Our expectations of the value of this work were based on the well-known reputation and character of the author as a man of scholarly attainments, an elegant writer, a candid inquirer after truth, and a philosophical thinker; we knew that the task would be conscientiously performed, and that few, if any, among the distinguished medical teachers in this country are better qualified than he to prepare a systematic treatise on therapeutics in accordance with the present requirements of medical science. Our preliminary examination of the work has salis- fied us that we were not mistaken in our anticipa- tions.—New Orleans Medical News, March, 1S60. The most recent authority is the one last men- tioned, 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 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 work. There is first.an " Irdex 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, 1661. We think this work will do much to obviate the reluctance to a thorough investigation of th is 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 is a fas- cination in itB 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. The author has much enhanced the practical utility of his book by passing briefly over the physical, botanical, and commercial history of medicines, and directing attention chiefly to their physiological action, and their application for the amelioration or cure of disease. He ignores hypothe- sis and theory which are so alluring to many medical writers, and so liable to lead them astray, and con- fines himself to such facts as have been tried in the crucible of experience.—Chicago Medical Journal. SMITH (HENRY H.), M. D. AND HORNER (WILLIAM 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. $3 00. These figures are well selected, and present a complete and accurate representation of that won- derful fabric, the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its superb artistical execution, have been already pointed out. We must congratu- late the student upon the completion of this Atlasi as it is the most convenient work of the kind that has yet appeared ; and we must add, the very beau- tiful manner in which it is "got up" is so creditable to the country as to be flattering to our national pride.__American Medical Journal. SHARPEY (WILLIAM), M. D., JONES QUAIN, M. D., AND RICHARD QUAIN, F. R. S., &c. HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidy, M D , Professor of Anatomy in the University of Pennsylvania Complete m two large octavo volumes, leather, of about thirteen hundred pages. Beautifully illustrated with over five hundred engravings on wood. $6 00.____________ SIMPSON (J. Y.', M. D., Professor of Midwifery, &c, in the Univeisity of Edinburgh, See. CLINICAL LECTURES ON THE DISEASES OF FEMALES. With nume- rous illustrations. This valuable series of practical Lectures now appearing in the "Medical News and LiBRARY^'ToTTswl'TsblTand"!^," and can thus be had without cost by subscribers to the » American Journal of the Medical Sciences." See p. 2. hoi r.Y ON THE HUMAN BRAIN; its Structure, Phvsiol<-v! and Diseases. From the Second and mnT-h enb'ieed London edition. In one octavo volume extfa cloth, of 500 pages, with 1*0 wood- cuts. »2 00. SKEY'S OPERATIVE SURGERY. In one very handsome octavo volume, extra cloth, of over 650 pages, with about one hundred wood-cuts. $3 25. SIMON'!1 GENERAL, PATHOLOGY, as conduc- ive to the Establishment of Rational Principles for the prevention ano Cure of Disease. In one octavo volume, extra cloth, of 212 pages. SI 25. 28 BLANCHARD aician who shall fail to pei use it, wil. have failed to read one of the most instruc- tive books of the nineteenth century.—N. O. Med and Surg. Journal. It is more concise than Carpenter's Principles, and more modern than the accessible edition of Mailer's Elements; its details are brief, but sufficiei.t; its deseripi ions vivid ; its illustrations exact and copi- ous; and its language terse and perspicuous.— Charleston Med. Journal. We know of nt work on the subject of physiology tion.—St. Louis Med. and Surg. Journal. Our notice, though it conveys but a very feeble and imperfect idea of the magnitude and importance of the work now under consideration, already tran- scends our limits ; and, with the indulg' nee of our readers, and the hope that they will peruse the book for themselves, as we feel we can with confidence recommend it, we feave it in their hands. — The Northwestern Med and 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. $150. BY THE SAME author. (Now Rea, 186U. WILLIAMS (C. J. B.), M.D., F. R. S., Professor of Clinical Medicine in University College, London, See. PRINCIPLES OF MEDICINE. An Elementaiy View of the Causes, Nature, Treatment, Diagnosis, and Prognosis of Disease; with brief remark* on Hygienics, or the pre- servation of health. A new American, from the third and revised London edition, lii one octavo volume, leather, of about 500 pages. $2 50. (Just Issued.) We find that the deeply-interesting matter and style of this book have so far fascinated us, that we have unconsciously, hung upon its pages, not too long, indeed, for our own profit, but longer than re- viewers can be permitted to indulge. We leave the further analysis to the student and practitioner. Our judgment of the work has already been sufficiently expressed. It is a judgment of almost unqualified praise.—London Lancet. A text-book to which no other in our language is comparable.—Charleston Medical Journal. No work has ever achieved or maintained a more deserved reputation.— Va. Med. and Surg. Journal. WHAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. Published under the authority of the London Society for Medical Observation. A new American, from the second and revised London edition. In one very handsome volume, royal l2mo., extra cloth. SI 00. To the observer who prefers accuracy to blunders I One of the finest^aids to a young practitioner we and precision to carelessness, this little book is in- valuable.—A". H. Journal of Medicine. have ever seen.—Peninsular Journal of Medicine. 30 BLANCHARD & LEA'S MEDICAL New and much enlarged edition—(Just Issued.) WATSON (THOMAS), M.D., &c, Late Physician to the Middlesex Hospital, &c. 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; the whole strongly bound in leather, with raised bands. Price $4 25. 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 of 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 aprice 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 reuders it an exceedingly attractive volume. The fourth edition now appears, so carefully re- I The lecturer's skill, his wisdom, his learning, are vised, as to add considerably to the value of a book equalled by the ease of his graceful diction, Ins elo- already acknowledged, wherever the English Ian- quence, and the far higher qualities or candor, of guage is read, to be beyond all comparison the best courtesy, of modesty, and of generous appreciation systematic work on the Principles and Practice of | of merit in others. May he long remain to instruct Physic in the whole range of medical literature. | us, and to enjoy, in the glorious sunset of his de- livery lecture contains proof of the extreme anxiety j clining years, the honors, the confidence and love of the author to keep pace with 'he advancing know- ' gained during his useful life.—AT. A. Med.-Chir. ledge of the day, and to bring the results of the Review. labors, not only of physicians, but of chemists and I „. ,. , ,, . , , ,. histologists, before his readers, wherever they can Watson's unrivalled, perhaps unapproachable be turned to useful account. And this is done with j w"rkuon, Practice—the copious additions made to such a cordial appreciation of the merit due to the ' wl*ich (the fourth edition) have given it all the no- industrious observer, such a generous desire to en- ' Y,eltV and much of the interest of a new book- courage younger and rising men, and such a candid ! Charleston Mtd. Journal. acknowledgment of his own obligations to them, that 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 shining through his work. —London Med. Times and Gazette. 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 tlian 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. Lecturers, practitioners, and students of medicine will equally hail the reappearance of the work of Dr. Watson in the form of a new—a fourth—edition. We merely do justice to our own feelings, and, we are sure, of the whole profession, if we thank hiin for having, in the trouble und turmoil of a larg« practice, made leisure to supply the hiatus caused by the exhaustion of the publisher's stock of the third edition, which has been, severely felt for lhe last three years. For Dr. Watson has not merely caused the lectures to be reprinted, but scattered through the whole work we find additions or altera- tions which prove that the author has in every way sought to bring up his teaching to the level of .he most recent acquisitions in science.—Brit, and For. Medico-Chir. Review. WALSHE (W. H.), M. D., Professor of the Principles and Practice of Medicine in University College, London, &c. A PRACTICAL TREATISE ON DISEASES OF THE LUNGS; includiog the Principles of Physical Diagnosis. A new American, from the third revised and much en- larged London edition. In one vol. octavo, of 468 pages. (Just Issued, June, 1860.) $2 25. 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; the causes and mode of production of the more important affections, so far as they possess direct prac- tical significance, are succinctly inquired into; an effort has been made to bring the description ol 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 seciions on Treatment and the Appendix (concerning the influence of climate on pulmonary disorders), have, especially, been largely extended.—Author's Preface. **£ In press, by the same aulhor, a volume on Diseases of the Heart and Aorta, to match the above. WILSON (ERASMUS), F. R. S., Lecturer on Anatomy, London. THE DISSECTOR'S MANUAL; or, Practical and Surgical Anatomy. Third American, from the last revised and enlarged English edition. Modified and rearranged, by William Hunt, M. D., Demonstrator of Anatomy in the University ol Pennsylvania. In one large and handsome royal 12mo. volume, leather, of 582 pages, with 154 illustrations. $2 00. AND SCIENTIFIC PUBLICATIONS. 31 New and much enlarged edition—(Just Issued.) WILSON (ERASMUS), F. R. S. A SYSTEM OF HUMAN ANATOMY, General and Special. A new and re- vised American, from the last and enlarged Engli-h 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; leather. $3 25. 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 (or 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 author has not only thus added largely to the work, but he has also made alterations throughout, wherever there appeared the opportunity of improving the arrangement or style, so as to present every fact in its most appro- priate manner, and to render the whole as clear and intelligible as possible. The editor has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the number of illustrations, of which there are about one hundred and fifty more in this edilion than in the last, thus bringing distinctly before the eye of the student everything of interest or importance. ft may be recommended to the student as no less i beauty of its mechanical execution, and the clear- 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 up this volume without being struck with the great 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 our highest commendation.— Southern Med. and Surg. Journal. BY THE SAME AUTHOR. (Jllst Issued.) ON DISEASES OF THE SKIN. Fourth and enlarged American, from the last and improved London edition. In one large octavo volume, of 650 pages, extra cloth, $2 75. The writings of Wilson, upon diseases of the skin, are by far the most scientific and practical that have ever been presented to the medical world on this subject. The presentedition 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, howtver, look at some of the more salient points with which it iliounds,and which make iiincoinpiuaoiy superior in excellence to all other treatises on the subject of der- matology. 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 an enlightened and rational therapeia are introduced on every appropriate occasion.—Am. Jour. Med. Science, Oct. 1657. ALSO, NOW READY, A SERIES OF PLATES ILLUSTRATING- WILSON ON DISEASES OF THE SKIN ; consisting of nineteen beautifully executed plates, of which twelve 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 $4 25. 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. We have already expressed our high appreciation of Mr. Wilson's treatise on Diseases of the S'kin. 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 of the size.—Boston Med. and Surg. Journal, April 8, 1859. The plates 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. Ot these plates it is impossible 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 in point of delicacy and finish.— British and Foreign Medical Review. BY THE SAME AUTHOR. ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON SYPHILITIC ERUPTIONS. In one small octavo volume, extra cloth, beautifully printed, with fourexquiMie colored plates, presenting more than thirty varieties ol syphilitic eruptions. $2 25. BY THE SAME AUTHOR. HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preserva- tion and Management. Second American, from the fourth London edition. One neat volume, royal 12mo., extra cloth, of about 300 pages, with numerous illustrations. 61 00; paper cover, 75 cents. ivhitphpaI) ON THE CAUSES AND TREAT- I Second American Edition. In one volume, oeta- UENT OF ABORTION AND STERILITY. I vo extra cloth, pp. 308. SI 75. 32 BLANCHARD & LEA'S MEDICAL PUBLICATIONS WINSLOW (FORBES), M.D., D. C. L., fitc. ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Prophylaxis. In one handsome octavo volume, of nearly 600 page*. (Just Issued.) $3 00. We close this brief and neeessarily very imperfect notice of Dr. Winslow'g 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 pre^s —Dublin Med. Jress, July 25, 1860. We honestly believe this to be the best book of the seasot.—Ranking's Abstract, July, 1860. It cairiedusback to our old days of novel reading, it kept us from cur dirner, from our but-iness, and from our slumbers; in short, we laid it down only when we had got to the end of the last paragraph, and even then turned back to the repei usal of several passages which we had marked as requiring further study We have failed entirely in the above notice to give an adequate acknowledgment of the profit and pleasure wiln which tve have perused the above worK. We can only say to our readers, study it yourselves; and we extend the invitation to unpro- fessional as well as professional men, believing that it contains matter deeply interesting not to physi- cians alone, but toall who appreciate the truth that: " The proper study of mankind is man."—Nashville Medical Record, July, I860. The latter portion of Dr. Winslow's work is ex- clusively devoted to the consideration of Cerebral 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 valuajle and deeply in- teresting work —London Lancet, June 23, 1860. It contains an immense mass of information.—, Brit, and For. Med.-Chir. RevUw, Oct. lfcCO. WEST (CHARLES), M. D., Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital foi Sick Children, dee. LECTURES ON THE DISEASES OF WOMEN. Second American, from the second London edition. In one handsome octavo volume, extra cloth, ot about 500 pages; price $2 50. (Now Ready, July, 1861.) *^.*Gentlemen who received the first portion, as issued in the "Medical News and Libraiy," can now complete iheir copies by procuring Part II, being page 309 to end, with Index, Title matier. &c., 8vo., cloth, price $1. We mustnow 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.—iV. Y. Journal of Medicine, March, 1858. We know of no treatise of the kind so complete an 1 yet so compact.—Chicago Med. Journal, Janu- ary, 1858. 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, January 1858. We gladly recommend his Lectures as in the high- est degree instructive to all who are interested in obstetric practice.—London Lancet. We have to say of it, briefly and decidedly, thai it is the best work on the subject in any language; and that it stamps Dr. West as the facile princept of British obstetric authors.—Edinb. Mtd. Journ. As a writer, Dr. We6t stands, in our opinion, sec- ond only to Watson, the •' Macaulay of Medicine;" he possesses that happy faculty of clothing instruc tinn in easy garmeuts; cjmbining pleasure with proverb, along a royal road to learning. His work is one whicn will not satisfy the extreme on eilher Bide, 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 can- did, sale, and valuable guide. We anticipate with pleasure the appearance of the second part of the work, which, if it equals this part, will complete one of our very bent volumes upon diseases of fe- males —N. A. Med -Chirurg. Review, July, 1858. Happy in his simplicity of manner, »nd moderate in his expression of opinion, the author is a sound reasoner and a good piactitioner, and his book is worthy ot the handsome ga-b in which it has ap- peared from tne press of the Philadelphia publishers. — Virginia Med lournal We must take leave of Di West's veiy useful work, Willi our commendation ot tne clearness of its style, and lhe mi ustr\ and sobr.ety of judgment of which u gives evidence.—London Mtd Tn/us and Gazette Sounu judgment and good sense riervade every chapter ot the uo«k. From its perusal we have de- profit, he leads his pupils, in spue of the ancient I rived unmixed lalisfaction —Dublin Quart. Juurn. BY THE SAME AUTHOR. (Just Issued.) LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. Third American, from the fourth enlarged and improved London edition. In one handsome octavo volume, extra clotn, of about six hundred anil fifty pages. $ i 75. The three former editions of the work now before diseases it omits to notice altogether. But those us have placed the author in tne foremost rank of ■- those physicians who havetevoted special attention to tne diseases of early life We attempt no ana- ly sis of thisedition, but may refer the reader to some ot the cuapters to which the largest additions have been made—those on Diphtheria, Disorders of the Mind, and Idiocy, for instance—as a prooi that the work is really a new edition; not a mere reprint. In its pretent shape it will be lound of the greatest possible service in the every-day practice of nine- tenths of the profession.—Med. Times and Gazette, London, Die. 10, 1809. All things consid red this book of Dr. West is by fur the best treatise in our language upon such modifications of morbid action and diseise as are Winn bsed when we have to deal with infancy and childhood. It U true that it confines itself to such disorders a.s come wnhin the province of the phy- ncian, aud evtu with respect to these it is unequal aa regards uimulemss ot consideration, and some who know anything of the pietent condition of paediatrics will readily- admit that it would he next to impossible to effect more, or effect it better, tnun the accoucheur of S:. Bartholomew's has done in a single voiume. The lecture (XVI.) upon Disomu of the Mind in children is an admirable specimen of the value oi the later information conveyed in me Lectures of Dr. Charles West.—London Lancet, Uct. 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 and eiguiy dissections made among neaiiy four- teen thousand children, they now embody the results of nine hundred observations, and two hundred and eigh I > -eight post-mortem examinations iuikIc among nearly thirty thousand children, who, during tne past tweity years, have been undei his care___ British Med. Journal, Oct. I, 1859. BY THE SAME AUTHOK. AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCER- ATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 00. NATIONAL LIBRARY OF NLM 0-3332^37 fl ';v&( m**' &•■ v-,; 1-SrS'Fv ' ■» >'.Vl*>i*tit«"i #* NLM023326378