.V!:l;':'5ifii8 [rfrl.-xii*f;i.:.*J:*"-Ji; :^;-:*^* ■j-;,j!jiig®{5Sii*.i t*,-i:i;*; i'J,v--^*'*'i!5'r•■■•• .*•<.« ■S-SB82&) ci-T-c'^*^ -pWHSft E*ife-2.^i;:s!yff li::;,//^!;,!.!^^^^-''!,*:^.:,1,;;!!)!*]; ffifei:';**'. .v wmmwm UNITED STATES OF AMERICA *- • . FOUNDED 1836 WASHINGTON, D. C. GPO 16—67244-1 ESSAYS ON THE DISEASES OF CHILDREN, WITH CASES AND DISSECTIONS. VOLUME FIRST, CONTAINING ESSAY I.....OF CYNANCHE TRACHEALIS, OR CROUP ESSAY II.....OF THE BOWEL COMPLAINTS. BY JOHN CHEYJVE, M. D. Fellow of the Royal College of Surgeons of Edinburgh PHILADELPHIA ■ PUBLISHED BY ANTHONY FINLEY, AT HIS MEDICAL BOOKSTORE. Merritt, Printer. 1814. vtBrVl^> AN ESSAY on CYNANCHE TRACHEALIS, OR CROUP, BY JOHN CHEYNE, M. D. Fellow of the Royal College of Surgeons of Edinburgli. PHILADELPHIA: PUBLISHED BY ANTHONY FINLEY. Sold also by Bradford and Read, Boston; A. Miltenberger and J. Gushing, Baltimore; R. Cottom, Petersburg}], and J. and J. Boyce, Richmond, (Va ); Seymour and Williams, Savannah; W. Graydon, Harrisburgb; and A. Montgomery, Frankfort, (Kentucky). 1813. PREFACE. When Dr. Harris published his Essay on the Acute Diseases of Children, Sydenham said to him, " Without flatte- " ry> y°u are the first man I ever en- " vied ; and it is my firm belief that your " little book will be more useful to man- " kind than all I have written." The book did not in itself, perhaps, merit so high a commendation; but Sydenham foresaw that it would turn the attention of physicians to a part of their profession the most useful, and the most neglected. . Still this department is strangely over- looked. Children are not admitted into A 4 public hospitals, and their diseases are ill understood, and superficially treated, or slurred over, by those who profess to teach medicine. The best physicians do not scruple to acknowledge, that they find nothing at first so difficult as the treatment of these diseases; and it is only by careful observation, and after years of practice, that this most inte- resting branch of professional knowledge is to be attained. These things had made a deep impression on my mind when I entered on the charge of an ex- tensive range of practice, in a place where some of the most formidable of the diseases of children are peculiarly fre- quent and dangerous. I devoted my chief attention, therefore, to this subject, and resolved to seek, with unremitting diligence, all occasions of observation 5 and of study in a department so intimate- ly connected with the duties which I had undertaken. I soon found my cases and observations multiply. I have been careful to compare them with the obser- vations and cases of others; and I have arranged them systematically, with the intention of submitting them to the pub- lie, not without hopes of being useful to my profession^ My design is to discuss, in separate Essays, the most important of the Dis- eases of Children, beginning with those, as less intricate, to which children, after being weaned, are exposed, and proceed- ing afterwards to those which attack in- fants at the breast. My hopes of being- useful rest upon the fidelity of my obser- vations, and the minuteness and acdura- 6 cy of detail, where I may have been en- abled by dissection to elucidate any im- portant points in the nature and history of the diseases of which I treat. In this Essay, which I now venture to publish, I have attempted the dis- cussion of one of the most interesting diseases, the most alarming in appear- ance, and in reality one of the most dan- gerous to which a child can be exposed. These motives might alone have been sufficient to lead me first to the discus- sion of the subject I have chosen ; but in my situation I found an additional motive, of great influence. To this dis- ease children are peculiarly exposed in the town where I practise; and the op- portunities which this frequency has af- forded me of observing it in all its stages, 7 and also of tracing, after death, the ap- pearances and nature of the disease, have given me a confidence in what I have to lay before the public, which I could not otherwise have attained. a2 ESSAY I. ON CYNANCHE TRACHEALIS. ' ■•JV'!7.::;>1. THIS ESSAY IS INSCRIBED AS A TESTIMONY OF RESPECT, TO JOHN ROLLO, M. D. SURGEON GENERAL TO THE ROYAL ARTILLERY, &C. &C B YHIS MOST OBEDIENT SER VJMT, JOHN CHEYNE. ESSAY I. ON CYNANCHE TRACHEALIS. The disease which in this country is called Croup, may be defined an in- flammatory affection of the Trachea, which in the progress of the disease is accompanied with an effusion which be- comes a tubular membrane, lining the inflamed surface. It might seem strange that a disease so striking in the symptoms, and so spee- dy and fatal in the event, should not have been clearly described CO earlier than the (1) The following passage (transcribed from Ballonius into the Sepulchretum of Bonetus, Vol. I. p. 484.) may refer to this disease: " iEgri qua- " luor mihi noti, qui eodem fere tempore interi- 14 middle of the last century, were it not remembered, that formerly all the ailments of children were much neglected, and that even the most eminent physicians, when called to children, went with re- " ere pene morbo consimili: Omnibus medicis " negotium dedit: Imo ausim asserrere morbum " non intellexisse : Difficultas erat spirandi sum- " ma, spiritus frequens et parvus ad mortem us- ""■ que : In sicco vehit spirare videbantur: Nee " tussis nee sputum, spiritum ne ad momentum « cohibere poterant: Erecto paulum corpore ita " parvum et frequens spirabant: Febris non erat " magna, nee quae istam re-spirationem require- " ret," -See. " Chirurgus affirmavit se secuisse cadaver pue- •« ri ista difficili spiratione et morbo, ut dixi incog- " nito sublati: Inventa est pituita lenta contumax, -' quae instar membranae cujusdam arteriie asperse " erat obtenta, ut non esset liber exitus et introi- " tus spiritui externo, sic suffocatio repentina." " Ballonius, Epid. et Ephemer. Lib. II. p. 197. «•"• and 201. See also Hiidanus, Cent. III. Obs. « 10. Exemp. 1. 15 luctance, judging their diseases to form a labyrinth for which they had no clew(2). Yet the descriptions to be met with in every systematic writer of that danger- ous angina, in which no tumour is to be found in the fauces &\ however vague (2) " Quapropter medici non pauci, nominis u amplissimi, palam sunt nobis aliquando professi, " se pueris aegrotis, ac praesertim recens natis vi- " sendis advocatos, invita quidem Minerva, tan- " quam ad mysterium nescio quod evolvendum, " aut insanabilem affectum sanandum, plumbeis " pedibus accede're solitos." Harris de Morbis " Acutis Infantum, p. 2. (3) " Etenim angina alia vera, alia notha est: " Yerae et legitime quatuor sunt differentiae. " Una quam omnium periculosissimam censuit " Hippocrates, ubi neque in faucibus, neque in " cervice quicquam apparet." Fernelii, Universa Medicina de Partium Murbis et Symptomat. Lib. V. cap. 9. " Inter anginae species gravissima est et celer. " rima, quae nee in cervice, nee in faucibus con- " spicuum, aliquid efficit."—" Pbrro mortifera at- " que omnium horrendissima anginacitissimeocci- B lo they may be, afibrd sufficient evidence that the disease (4) was not altogether overlooked. " dit, quae neque in cervice, neque in faucibus quic- " quam conspicui vel tumoris vel ruboris exhibet, 11 simulque summi doloris tormentum, et vehe- " mentem febrem, atque tantum non prsesentem ■" suffocationem infert. Turn profecti oculi ver- ft tuntur et rubent et veluti his qui strangulantur '' prominent. Vox iinpedita nihil significat, et " qualis catulorum est," &.c. Mcol. Piso de Cog- noscend. et Curand, Morbis, Lib. II. cap. 3, " Si inflammatio interiores laryngis musculos u occupet synanche appellatur. In synanche ma- a ximaest respirationis laesio, itaut aegri strangu- '' lari videantur. Fauces vehementer dolent, nul- " lus tamen rubor aut tumor, neque in faucibus " intus neque extra in cervice apparet. Haec ■" species anginae omnium periculosissima est." Lazari, Rcverii Cp. Universa Prax. Med. Lib. VII. cap. 7. See also the -801. and 802. aphorism of Boer- baave, with Van Swieten's commentary. (4) Perhaps it may be added, that there is grcur.d for supposing the disease more frequent 17 Martin Ghisi (*), an Italian physician, published the first regular history of Croup; now than it was formerly. In an inaugural dis- sertation, defended at Edinburgh in 1780, by Dr. Ambrose Cookson, there is the following commu- nication from his friend Mr. Fell, of the county of Lancaster: « After diligent search, I have " found some remarks made on Croup at its first " appearance in this place in 1760. I say its first " appearance, because my father, who was an ac- " curate observer of diseases, and practised phy- " sic here for upwards of forty years, could not " recollect that the disease once occurred to him ; " and none of my medical acquaintances had at " that time the least knowledge of it." " In that spring, six children labouring under " the disease were committed to my care, to all of " whom it proved fatal. Catarrhal complaints " were then very frequent; indeed in most of " them the disease commenced with symptoms " of catarrh," &c. p. 8. (5) Martino Ghisi Lettere Mediche in Cremo- na, 1749. This performance I have not been able to procure; I therefore must rely on the accuracy of Michaelis. J.8 but the best and fullest is that of Chris. Frider. Michaelis, De Angina Polyposa she Membranacea, published at Gottingen in 1778. The frequency of Croup in Leith and the neighbourhood, furnished Dr. Home of Edinburgh with materials for an essay on the subject in 1765. From possessing the same, or perhaps better opportunities, I have been enabled to compose the following history, which I trust is a faithful picture of this striking disease-C6*). (6) I do not allow that the dissertations of Wilcke, De Angina Infantum, (Sandifort, The- saurus, Vol. II.) or those of Millar and of Rush; relate to this disease. The dissection by Dr. Martin in Wilcke's essay appears to have induced Michaelis to say, in p. 6., that it contains one or two examples of the disease ; but I think even that is far from being a clear case of Croup. The acute asthma of Dr. Millar is evidently a differ- ent disease, and in the Nosology ought to occu- py a place in a different class. 19 The Croup (O is less known in the temperate than in the northern regions of Europe. Peculiar to no season, it how- ever chiefly appears in the winter and spring, in low situations (8) exposed to air passing over large bodies of water j and it is most especially the disease of sea-port towns. It is very prevalent in cold changeable weather, often appearing after a cloudy and hazy day ; insomuch (7) Concerning the etymology of this word, Rosenstein says, « He has not been able to learn " any vulgar name for this disease, except that " the Scots call it Croup." I rather think roup is the word; it is called Roup in this town; and, like many of our words, it is I imagine, of French origin, roupie. <8) This disease, we are informed by Dr. Craw- ford, prevailed in the Carse of Gowrie, a plain in Perthshire, bounded by the river Tay; but he adds, « Haec planities vero nuper desiccata fuit, et " rarius occurritur morbus." Disquisitio Med,. InauguruU* de Cynanehe Stridula, p. 13. B2 20 that I have seen a mother, in whose fami- ly the disorder had been a frequent in- truder, kept in constant anxiety by this condition of the atmosphere. i The Croup chiefly prevails in chil- dren from a short time after birth (y) un- til puberty ; attaching itself to particular families; and generaly attacking the most robust and ruddy children. It does oc- cur, but more rarely, in children exhaus- ted by some other disease. The disease C1) generally comes on in (9) I have known this disease in a child three months old, but it does not frequently occur be- fore weaning. It has been observed (I believe by Dr. Home), very justly, that the younger chil- dren are when weaned, they are the more liable to the disease. (1) This description is in the main taken from a very perfect ease which I attended the winter before last, and which exhibited the disease as it will often be seen in violent attacks. 21 the evening, after the little patient has been much exposed to the weather during the day, and often after a slight catarrh of some days standing. At first his voice is observed to be hoarse and puling; he shuns his play-fellows, and sits apart from them, dull, and, as it were, foreseeing his danger. His illness, indeed, does not prevent him from going to sleep, but soon he awakes with a most unusual cough, rough and stridulous. And now his breathing is laborious, each inspira- tion being accompanied by a harsh shrill noise, most distressing to the attendants: His face is swelled and flushed, and his eye bloodshot; and he seems in constant dan- ger of suffocation : His skin burns, and he has much thirst; he labours more and more in breathing; still the ringing noise is heard, and the unusual cough: He tries to relieve himself by sitting erect; no change of posture, no effort gives him relief. Generally his sufferings are thus protracted until morning, when per- 22 hasps there is a slight remission; his breathing is a litde easier, but the anx- iety, the fever, and the cough remain; he is soon as ill again as ever ; and these symptoms continuing, weakened by the violence of his illness, with purpled lips and leaden countenance, he dies in two or three daysC2). In other cases, the disease, after continuing some time, ap- pears suddenly alleviated : The breathing is free, the child soon becomes cheerful, his appetite for food returns, he amuses himself, and seems perfectly recovered, and the hope of every one is raised, only to make the disappointment more keen; for the child suddenly gets worse, and (2) There are very distinct histories of the dis- ease ending fatally in 24 hours: Of this Mr. Alex- ander saw four instances. Generally, however, the child does not die before the third or fourth day. Sometimes the disease continues much longer, for several weeks. 23 dies, his livid and swoln face and con- vulsive struggles giving him the ap- pearance of one that is strangled. When Croup is favourable, it termi- nates in various ways. Most commonly, after the disease has arrived at its height, the sequel is as it were a retrogression of the attack; there is poured out a mois- ture on the skin, the fever declines, and the croupiness, and, lastly, the cough, gradually wear away. When bleeding is used upon the commencement of the violent symptoms, the relief is often immediate; and I have scarcely believed that I saw the same phild breathing softly, who ten minutes before lay gasping and convulsed. Sometimes, after the disease has con- tinued a few days, a viscid and white substance is expectorated, and the child 24 is relieved (3): Sometimes the Croup is chronic, and does not subside for weeks, when the resolution is very gradual, the child now and then coughing up portions of this white membrane. When, in the urgency of the attack, the fauces and neck are examined, with a view to investigate the cause of these symptoms, even when a sense of heat is complained of in the throat, the tonsils are not swelled, and but little inflamed. In some instances there is a fullness to be discerned in the swell of the neck ; but the disease is < generally unaccompanied f with this sign. It may be said of this complaint, in common with Cynanche Tonsillaris, that the first attack establishes a predisposi- (3) This does not always happen. See case !0, where the membrane was twice rejected, com- pletely formed, and yet the child died. 25 tion to the disease. I have observed, that after the first attack, a slighter cause will produce Croup a second time than is required originally; nay, I believe that external cold and wet, without any speci- fic state of the atmosphere, will bring on a recurrence of the disorder (0. It is a confirmation of this, that children who have had croup, when they are affected with catarrhal complaints, have more or less of the croupy cough until they arrive at their 14th or 15th year. Upon dissecting the body, the cause of these alarming symptoms becomes suf- ficiently obvious. When the child dies after an illness of three, four, or five (4) Subsequent attacks are supposed to be less violent than the first; but I should, from my own experience, be led to believe that there is some error in this. Perhaps the immediate steps taken in consequence of the alarm excited by a knowledge of this dangerous complaint, may pre- vent it from forming. I have seen the third at« tack more violent than any former one. 26 days, there is found lining the windpipe a white membrane, of considerable te- nacity. It arises a little under the larynx, and is sometimes prolonged into the di- vision of the trachea; and generally a quantity of white fluid, like matter with which the lungs are filled, is seen gurg- ling up. The attachment of the mem- brane is slight, but the inner coat of the windpipe is inflamed. The inflamation, which is still perceptible, and which of course must have been more violent be- fore this fluid exuded, I hold to be the immediate cause of the bad symptoms in the first stage of the disease; as the ad- ventitious membrane and puriform flu- id (5), the consequence of that inflam- mation, is in the conclusion of it. (5) I have added a case, where the membrane, observed on dissection, was not such as to im- pede the respiration ; it was not more than a few detached crusts : But it would seem that the in- flammation, the effusion in the lungs, and the general affection, had produced the same fatal effect. 27 The pathology of Croup is very sim- ple. When the child dies, the inflam- mation has terminated by effusion. This effusion is of a lymph, strongly resem- bling purulent matter; which exuding on the inflamed surface of the windpipe, thickens there, forming the membrane. That this is the natural explanation, is proved to my conviction by analo- gies from other diseases; for a similar membrane is thrown out on other secret- ing surfaces, as in diseases of the intes- tines ; and it is one of the most common appearances (6) we find in dissections, being the effect of pneumonia, and the cause of adhesions between the lungs and and pleura. As an argument, I may state, that I have discovered in a dissec- tion of Croup an effusion (~) surround- (6) Morgagni de Sed. et Caus. Epist. 21 (7) See case 7. In the Paedanehone of Sevcr- inus there is a similar appearance observed in the C 28 ing the outside of the trachea, resem- bling, in quantity and quality, the white of an egg, and which, if it had been ex- posed to the drying influence of the air in respiration, would probably have as- sumed the very appearance of the mem- brane. I have seen this exudation, in all its different degrees of consistence, gurgling up at the epiglottis, puriform, and quite fluid ; then at the larynx, pos- sessing more tenacity ; and, lastly, lining the lower part of the trachea, firm, and completely membranous. But in all these circumstances the colour was precisely the same. That this membrane is not merely inspissated mucus, I likewise conclude from the dissimilarity of ap- pearance from the fluid of which it is dissection of a boy who died of the epidemical angina, of which he treats: « Pervestigata larynx, « Crustacea quadam pituita, facie exteriore con- " tecta, citra ulceris speciem." Lie Abscess. .Yat. p. 528. 29 Composed wanting that resiliency which characterises mucus; from the mem- brane bearing maceration, without hav- ing its structure destroyed; and from their chemical properties being widely different ( ). But indeed it is not natural to explain the appearance in this manner ; and certainly it is not necessary to re- sort to this solution of the difficulty,. for similar concretions are found in situations where there are no mucous glands; and I do not think that mucus will in any circumstances assume this structure; if it did, we should see the membrane in those diseases of chil- dren where the secretion of mucus is pro- fuse, but where from weakness the pow- er of expectoration is lost. It is no hard matter to explain the difficulty of breathing in the latter part of this complaint, when the membrane (8) Vide Michaelis, p. 60. et seq. 30 is compleatly formed; but in the begin- ning, the tumor and inflammation (al- though I suspect they are then much more considerable than they are after- wards) will hardly be thought to afford a sufficient explanation of the orthopncea. I must suppose, therefore, that along with this fullness, and perhaps in some measure occasioned by its stimulus, there is a spasmodic constriction of the larynx. This I am the more inclined to believe, because, although in the first stage I have never seen an intermission in the disease, unless in consequence of bleed- ing (9), I have observed the breathing, which is always laborious, performed at particular times, and for several minutes together, with incomparably more dis- tress. The inflamatory affection of the larynx is doubtless sufficient to account for the alteration which takes place in the sound of the voice and cough. (9) Or some other antiphlogistic remedy. 31 There is a circumstance mentioned in the history of the disease, which I have not seen satisfactorily resolved: I allude to the sudden extinction of our hopes when they are at the highest, consisting first in a wonderful remission of the dis- order, and soon after in a fatal exacer- bation. Perhaps this ought to be at- tributed rather to a mechanical than to a spasmodic affection of the parts. It some- times takes place after the expectoration of part of the membrane; and I suppose that the connection of the remainder with the trachea may be loosened ; so that in taking a full inspiration, this detached portion acts as a valve, completely shut- ting up the tube, and thus suddenly suf- focating the child. Michaelis 0) supposes this disease to occur as frequently in adults as in chil- (1) *-T: '• t*~ l/n-n-'v '>•::({ sr.l 'i*l *•"■ I'M 7T17 MD ; *V.;. • J4. iiMiv; .■-.">;. ::.., - h>n orlt -- j •v on .:/ni;-bv ; *.-- ♦'_.!:/ :.-tu\ '■■:'. ■■ j,.r; vr, tniii •» --:^ *-*,»■ rf J ; r ;'{ ;t-' . ".■■'•// o-i :r :-v.;:;: i.;-..-'^ .,. ; ■ .. .. ! . • '.i...: <'.€.•;.-!»'• >rfj vri bov:J!/-: ! '» ;.J lit. :.fi 2l- .; j;*f■?»# . ,'--, •• • ■■ •*.,*' * * , ■ . i K 52 CASE II. May l&.....One o'clock, P.M. Mr. H----'s son, eight years old,— dark eyes and complexion. He has had several attacks of this dis- ease; one very severe, exactly three years ago, when he was relieved by bleeding in the neck. m Last night at bed-time he was taken ill. His mother gave him an emetic, and, as usual in slight attacks, he was a good deal relieved by the sickness and vomit- ing. He continued free from all the symp- toms of the disease, except the ringing cough, until about half an hour ago, when his breathing became so difficult as to excite great alarm. 53 His breathing is now laborious, and the sound resembles the hissing of confi- ned air through a narrow opening ; it is rather slower than natural; he has a vox rauca and the ringing cough in the greatest perfection; his skin is warmer than is na- tural ; his countenance is flushed; and his eyes are very heavy ; his pulse is 120; he has had no passage from his bowels for two days. He had been a good deal exposed to damp hazy weather ; and I remember to have remarked, the night before he was seized, that I was afraid the weather would produce some more instances of this disease, a child I then attended being ajbout to die of it. Four o'clock,. With this boy. Croup always occasi- ons much apprehension ; and at my last visit he readily allowed me to bleed him from the arm, whence I took four oun- ces of blood, and ordered him imme- 54 diately a dose of infusion of senna with tincture of jalap. _His breathing was not relieved ; and about half an hour after the bleeding it v>as 'much bppTessed, but he soon became* easier. The purge has just operated, after sickening him very much. ,: i;q Evening. His pulse, Which in the.morning was 120, is now only 100; his breathing is free; he has had a profuse perspiration ever since the purge operated ; and he is again cheerful. ■"■* ; '*'■*> ' He was ■ordered a spoonful of the fol- lowing solution every four hours : §,; Sol. Antim. Tart. ' jvi. Aq. Cass. gi. Aq; 5iii. "l. 1J Slf> ; May .18. He has been quite vcell, since last re- port: His cough is still a little rough: Yesterday, and. to day he has been run- ning about the room, and amusing him- self as usual. 55 CASE III April 19. Mr. W----?s daughter, set. 12. This girl is exceedingly robust and big of her age, of a florid complex- ion. She has been threatened with this, complaint two or three times, and was taken ill yesterday evening. She had the day before been much exposed to the weather, which was damp and chilly. Though her cough was very rough, she went out to day. I saw her at ten o'clock at night. Her respiration was performed with the utmost difficulty; she breathed so high, that I heard her immediately on E2 56 entering the house, although she lay above stairs. Her friends, tremblingly alive to the danger of her situation, were supporting her in bed, for she could not lie down. Her cough resembled the barking of a lap-dog, very hoarse and sharp ; she was much flushed, and com- plained of pain, or rather great heat in the windpipe; her tongue was white ; the tonsils and uvula were not inflamed nor swelled in the slightest degree; she swallowed easily; there was perhaps a fullness in the throat; her pulse was about 130, and pretty strong: She had an evacuation from her bowels this after^ noon. I took from five to six ounces of blood from the arm, and should have taken more, but she nearly fainted under the operation : She got very sick in con- sequence of it, and vomited; but she could l^reatl* in the recumbent posture 57 immediately after the bleeding, though her cough was still very frequent. Observing that while the sickness continued, she breathed, comparatively speaking, easily, I was willing to keep it up, and gave her an emetic, which emptied her stomach, about half an hour after the bleeding. When the sickness went off, I had her put into the warm bath, where she remained about a quar- ter of an hour. I then gave her, to be taken during the night, a nauseating so- lution, similar to that ordered in the last case. A large blister was applied to the sternum. Soon after I left her last night, she fell asleep, and slept softly for two hours. The medicine made her very sick during the early part of the morning. Since she was in the bath she has constantly had a moisture on her skin, which is cooler. The blister rose very well. She had 58 during the night considerable thirst, which still continues. Her breathing is easier, but often is interrupted by the cough. Her pulse is 100, and some- what irregular. The blood is rich an4 florid, but not sizy. She has had no passage from her bowels. I was somewhat surprised to be again sent for in the evening to visit this girl. Her complaint had returned about four o'clock, and in expectation that it would soon abate, I was not sent for until ele- ven. Her cough was worse than ever; it was ringing and incessant; the effort it occasioned resembled the convulsions of the whooping cough. Her breathing was quicker than last night, although not so difficult; her pulse was 110, and pretty full; her tongue foul. I found her sitting in the warm bath, and there I bled her to eight ounces. Before I could get the arm bound up she fainted. When she recovered, her breathing was 59 manifestly easier. I continued sitting by her for half an hour, during which time she was not two minutes free from a con- vulsive shudder, which sometimes made her even start up in bed. Her pulse was now, however, under 100, and not very weak. As she was still faint and sick, I gave her a small tea cupful of weak port wine negus. I ordered the volatile lini- ment, to rub her neck. April 21. When I left her last night, her cough became much less frequent, and she has not coughed since one o'clock in the morning. Her pulse is 70; and she breathes like a person in perfect health. She had a very severe fit of convulsive shuddering about two hours after the bloodletting. I called in the evening, when she had rather more feverishness, and some cough, but it had quite lost the croupy sound. She has started much much during the day. Her bowels are 7 60 open, in consequence of using the laxa- tive powder, which was not given before this morning. April 24. She is quite free from all her com- plaints. 61 CASE IV. " A girl 15 months old, living a mile " distant from the sea, appeared in the " evening to be somewhat indisposed, her " skin being a little more hot than usual. " Dr. Home, who went to see her in c< the morning, found her breathing la- " borious, the pulse hard, and beating " one hundred and thirty-five times in a " minute. He ordered five ounces of " blood to be drawn off immediately: her " voice then grew sharp, and resembled " that of a cock ; the breathing frequent " and deep; her forehead and inside of " her hands very hot; both hands and feet " swelled, but without any redness. The '" pulse now being hard, she was bled "again, which gave her much ease. She " was made to drink and breathe the va- " pours of warm water mixed with a little 62 " vinegar: this had a good effect, and pro- " moted expectoration. The body was " unbound with the magnesia alba ; in the " evening a blister was applied round the " neck : The third day she was somewhat " better; but the voice the same as before, " the pulse hard, and the breathing deep. " In the evening four leeches were applied " under the chin, just at the top of the " windpipe; and they having left off "sucking, the place was fomented with " warm water, so that the blood continu- " ed to ooze out for some hours. The " child was well the next morning." 63 CASE V. " Infantis unius et dimidii anni, qui " nutricis adhuc lacte spissiore jam aleba- " tur, lectulum cum mutato loco fenes- " trse apposuissent, aeri liberorem justo " transitum concedenti, die 29 Novem- " bris habitum alacrem cum tristi muta- " vit, accedente noctis prsecipue tempore, " graviori tussi: Nee insequente die etsi " obambularet melius valuit. Cum febris " observaretur nulla, nil nisi laxans accep- " it. Insequente media nocte cum aliqua " tussi, spiritus ducendi apparuit difficul- " tas, anxia erat et celer respiratio, quae " suffocationis metum induceret, praeter- " naturale clangori stridenti juncta. Forti- " ter movebatur pectus, fortiterque pul- " sabant arterise. Per bihorium haec con- " tinuavit aegrotse ratio ; tunc autem tur- <{ bas istas placida excepit quies. Primi " Decembris, tempore matutino, pulsus " plenus erat ac celer, facies rubra, in- u quietudo summa ; increverat interea et F 64 respirationis difficultas et raucedo. Cum de morbo nostro jam cogitaretur, vena in brachio secta quinque sanguinis uncial mitte bantur; quo facto et pul- sus minuebatur vehementia et respi- rationis difficultas ; vesicatorium nunc colli anterioris lateri applicabatur, nee enemata omittebantur. Attamen spei eventus minus respondit; exacerbaban- tur enim versus vesperam et pulsus ve- hementia et spiritus ducendi difficultas, facillimumque jam erat stridorem istum peculiarem distinguere atque agnoscere. Diversa nunc aceti vapores ratione, in usum trahebantur; nam non solum spongia aceto calido immersa, ori ae- grotat admovebatur, sed vas etiam ace- to ebulliente repletum, tenuique solum- modo linteamento tectum, Iecto appone- batur, et itaque aer quern aeger duce- bat aceto impregnebatur. Nee quid- quam hoc remedio, aegrotas majus afferre videbatur levamen ; respirationis enim inde minuebatur difficultas, et placidus plerumque mox insequebatur somnus. 65 " Infusum nunc florum sambuci theifor- " me, copiosumque oxymel simplex exhi- " bebatur. Vespertino tempore collecta " urina, a primo jam initio alba apparuit, " frustulisque mucosis quam plurimis " fundum neutiquam petentibus, sed ei " innatantibus, commixta. Prima inse- " quentis diei luce, aliquando melius va- " luit, et sponte muci aliquid rejecit. 14 Quae omnia cum ante meridiem bene " se haberent, imminutaque deprehende- ,c retur morbi vis, emeticum exhibere " muci spontanea ejectio jussit. Repeti- " tis itaque vicibus oxymel propinabatur " squilliticum, usque dum vomitus cie- " retur. Accedente vomitu insignis nee " muco remixta membranae albae, diver " sae magnitudinis, in frustula divisae, a " muco ordinario ob majorem tenacita- " tem facillime distinguendae copia excer- " nebatur. Felicissimus ille prions erne- " tici successus aliud exhibere suasit. " Nee illud quoque levamine caruit; li- " berabatur enim aeger a membranacea " materia aeque ac muco omnium tenacis- 66 " simo. Gratissima nunc in infante ap- " paruit mutatio; pulsus aeque ac respi- " ratio naturali similior evasit, et placido " sopitus somno per totam jacebat vespe- "ram, maximamque insequentis noctis " partem, sine ulla pene febre vel aliis " pathematibus transegit. Tertii Decem- " bris diei initio bene valuit, nee de alia " re nisi de vesicatorio questus est. Nunc " laxans propinabatur, cujus ope larga " educebatur muci copia. " Abundans nunc quoque ex naribus " stillare ccepit humor. Nee minus in- u sequente nocte bene se habuit, etsi tus- '4 sis, nee molesta tamen, per intervalla " rediret. Clangor specificus post pri- " mum jam evanuerat vomitum, et rau- " cedo in dies minuebatur. Quarto De- " cembris mane aliud exhibitum fuit erne- " ticum, quod vero paullulum modo muci •* ejiciebat. Quinto jam cibum appetere, et "pristinam recuperare alacritatem ccepit. •* Laxantia, quorum adhuc continuabatur 67 " usus, magnam semper muci quantita- " tern evacuarunt." I shall now proceed to detail five Cases which terminated fatally. The four first occurred in my own practice, the fifth is taken from Michaelis. In the first and fourth the membrane was most completely formed, but there was least inflammation. In the second, the membrane, of which perhaps part had been expectorated, was less complete, but the inflammation was greater. In the third the inflammation was very great, but the membrane was less perfect than in any of the other cases. In the fourth case a con- siderable quantity of calomel was given, without producing any good effect. The fifth case ended fatally after the expec- toration of the membrane, the boy dy- ing hectic. F2 68 CASE VI. On the 22d of February, in the same house where I saw the first case, I found a second in a child of a similar tempera- ment. The character of the disease, however, was quite different. The inspi- ration was very difficult, but not hoarse ; the cough was stridulous; the child was pale rather than flushed. When his mo- ther took him on her knee, he struggled for breath, and seemed to be easiest when lying on his back, with his head low. His eye was heavy ; he was afraid to cry; But was extremely fretful and irritated when I laid hold of his arm, insomuch that it was long before I got his pulse numbered. In the five seconds it beat 14 strokes, and was weak. His hands were chilly; he had great thirst, and swallowed easily : He had eaten nothing for two days : He had no fullness in the upper part of his neck, and it was not in 69 my power to examine the fauces: He had three stools this morning; and his urine, which has much sediment, he voids frequently. Ten days ago he took a diarrhoea, at- tended with griping, which his mother imagined proceeded from detention. This disorder continued till Wednesday the 17th, when it entirely left him, and the croupy cough came on that afternoon; but the mother was not at all alarmed before the 20th, when his breathing had become very high ; still she thought his illness proceeded from his teeth. This morning he was cheerful and easy; but the respite was granted only for a short time; his disease became much more threatening, and her fears were seriously awakened. Of her own accord she had applied a blister two days ago, and she gave the boy a vomit this morning, which brought away much viscid expectoration and bile. 70 I ordered an emetic and two leeches to be applied to the neck. February 23. I called early this morning, and found that the child had died an hour before. The leeches were not applied. DISSECTION. There did now appear a fullness in the neck; but this was not an occasional fullness, but rather a thickness and na- tural shortness of the neck. The face, and skin of the neck, were peculiarly pale, like marble; the cellular mem- brane and fat were white, and most deli- cately transparent, and free from a stain of blood ; the thyroid veins on the ante- rior part of the trachea were turgid, as were the external and internal jugulars* The incision was made from the chin to the sternum, and the tongue, trachea, and gullet, were cut out, and pulled from the cavity of the thorax. There 71 was no inflammation of the fauces, nor any apparent affection of the throat; but upon looking into the glottis, a fluid like pus was observed working up from the trachea. The oesophagus was cut away, and the trachea slit up upon the back part, where there is a deficiency of the cartila- ginous rings, and then the membrane presented itself fully formed. The trachea was cut away near its branching off; and here, upon careful examination, the membrane was found most complete, and very strong; but gradually, as it stretched upwards be- hind the thyroid cartilages, it degenera- ted into a puriform matter, which loose- ly adhered to the rima glottidis and sac- culus laryngeus. This matter was not like the natural secretion of the mucus of these parts ; it was not the mucus thicken- ed and become tough ; much of it was flu- id as the natural mucus is, but it had no other resemblance to it; it was like that matter which at first flowed out of the 72 larynx; it was of the consistence of ' cream, or rather the fluid part of it was thin xand watery like whey; and in this the firmer matter, curdy, and like the discharge from a scrophulous joint, floated. Upon taking up the membrane from the lower part of the trachea, where it was firm, the inner coat was seen inflamed, the vessels red, enlarged, and distinct. 73 CASE VII. March 20. G. D----'s daughter, two years and a half old. She is extremely stifled in her breath- ing, which is rather frequent; the" expi- ration is performed as if the tube were shut up by a valve, and this forced back with a flap when the air returns from the lungs. There is no tumor in the fauces, no redness ; her cough is very croupy and frequent; her neck is not swelled; her countenance is of a death-like pale- ness, and her extremities chilly; her pulse is very quick, but still firm and regular. She had a stool this evening. This child some days ago, her friends say four or five, took the croupy cough, 74 and for two days her breathing has been affected; but as she had some appetite for food, and drank easily, they appre- hended nothing. The child was visited some hours ago for the first time. She seemed suffocating, and five ounces of blood were taken from her neck. Before the compress could be applied to the ori- fice, she nearly fainted ; she then vomit- ed very freely, and derived temporary ease in her breath from the bleeding; but Soon after the dyspnoea returned. The warm bath was ordered, and a blis- ter, which was immediately applied to the neck. In addition to this, when I saw the child, I recommended an emetic, from a notion that the membrane of croup was formed. March 21. I saw the child at eight o'clock this morning ; she was writhing and twisting about, of an ashy paleness, and was just 76 dying. The vomit brought away a quan- tity of mucus, but notwithstanding my injunctions, it was not kept. The first mouthful, which seemed like the white of an egg, she rejected with great vio- lence. I think there is reason to suppose it might contain in it part of the mem- brane. The urine passed since last visit had a most copious sediment. The child died at nine o'clock. DISSECTION. Upon making the first incision in the neck, and fat and cellular substance re- sembled very much, in whiteness and transparency, that of the last patient. The thyroid veins were not peculiarly distended, but the internal jugulars were very turgid. The thyroid gland was large, and the lobes of the thymus gland extended upwards to the thyroid carti- lage, in two distinct slips. Although there appeared no active inflammation, yetthe effect of an increas- G 76 ed action was very manifest, from the quantity of a gelatinous effusion which surrounded the lobes of the thyroid gland, and passed behind them round the trachea. Upon lifting the sternum, the thy- mus, of a monstrous size, lay extended over the pericardium. The lobes of the lungs, which projected, were of a pale greyish colour (J). Upon raising them from the thorax, the posterior part was of as darker red, not, however, as if in- v flamed, but as if more gorged by the gravitation of the blood in the supine posture of the body after death (3). (3) 1 suspect this appearance had led to an er- ror in the first case described by Michaelis ; for he says, •" Fulmonum dextro aeque ac sinistro " in latere, facies inferior ac posterior colore in- u signis erat livido, unde ad inflammationem ha- " rum partium concludere Lt, est. Facies autem ** pulmonum anterior ac superior, naturali gau- " debat colore." P. 256.—And again in the 06- H servaiions par M. Mahon, " La portion des lo- 77 Having taken out trie trachea and part of the lungs, the trachea was opened upon the back part at the bifurcation; but here there was no membrane. The trachea was then slit upwards, and on approaching the back part of the great cartilages of the larynx, the membrane was found distinct, fully formed, but not so strong as in the last instance. It was of less extent, as well as possessing a less degree of firmness. A streak of the membrane passed down a considerab'e way, attached to the fore part of the tra- chea. In general, it has been observed, that the membrane extended farther down, and was firmer on the back and membranous part of the trachea. The membrane, which extended " bes du poumon qui, s'est presentee la premiere " a la vue, lorsqu'on a enleve le sternum, etoit "dans son etat naturel.—II n'en a pas ete de " meme du reste du poumon. II etoit rouge et " engorge," &c. 78 about an inch and a half downwards from the glottis, was in a manner float- ing in a milky-like fluid, white and opaque. Upon tracing the branches of the bronchiae, there was no membrane; but in cutting into the substance of the lungs, a frothy mucus was observed in the minute branches of the bronchia"!. 79 .* ..■■ i o :• :>■■ CASE VIII. May 14. ]VI. D-----'s daughter, 18 months old, was the day before yesterday seized with a croupy„cough. Yesterday, with the cough, she began to have much dif- ficulty of breathing, which towards noon increased to a great height; and this symtom has not once intermitted since.^ Yesterday and this morning she had her usual apetite for food. At present she labours inexpressibly in her breathing; her nostrils are inflated; and every inspi- ration raises her chest from the bed. If she is at all fretted, in crying her voice is very stridulous, and then she takes the ringing cough. Her face is of a leaden paleness, her eyes are languid, and she is very lethargic. When she is lifted up, G2 80 she struggles and tosses about till she again gets to lie down on her back, and then when her head is low, she appears easier, and is inclined to dose. She has vomited several times this afternoon. Her pulse is rather full and quick, and her skin warm ; her bowels have been loose; her fauces are without swelling or redness; and there is no swelling in the neck. The treatment in this case was simi- lar to that already mentioned, only that I used no internal medicines but an emetic and calomel. The child died in nine or ten hours after I first saw her. DISSECTION. During this dissection I was much an- noyed by the jealous watchfulness of the attendants, so that the operation was hurried. On the fore part of the neck there was nothing particular to be observed; 81 there was neither swelling nor any ap- pearance of inflammation; but upon ma- king an incision, separating the larynx from the pharynx and root of the tongue, and then folding down the trachea and oesophagus, a viscid tenscious froth was seen to fill the upper part of the pharynx and opening of the windpipe. Upon cutting out and carefully ex- amining the trachea in its whole length, the inner coat was observed to be consi- derably inflamed. The epiglottis was in- flamed, and somewhat tumid. The swelling of the epiglottis was not consi- derable, but it was red, and its vessels were distinct and turgid ; and upon its concave surface films of a membranous crust adhered : When these were remo- ved, slight ulcerations were observed on each side of the little ligament which runs down the middle of it. The membrane covering the cornua of the os hyoides and the thyroid cartilage was swelled and red, 82 and had that purplish or bluish cast, with lake-coloured turged vessels, which would incline me to say that the inflam- mation was of an erythematous kind. Within the cartilages of the larynx the membrane was distinctly formed, but irregular, perhaps displaced in some measure in the hurry of dissection. There was little inflammation lower in the trachea; and there was none of the membranous pellicles or crusts to be ob- served lower down than the crecoid car- tilage ; but the internal membrane had the vessels distinct, and slightly turgid. I was not allowed to open the breast. S3 CASE IX. Sunday, June 7. A. R----'s daughter. She has had catarrhal complaints since Sunday last, with a rough cough. On Thursday her breathing became affec- ted in the manner it is at present, namely, frequent and laborious. During the night there is an aggravation of the dyspnoea. Her cough and her voice are croupy; her eye is heavy; her pulse is moderate in strength, and not much quicker than usual; she has no thirst; her appetite for food is natural; she is generally re- served, but sometimes amuses herself as if nothing was the matter; and is at no time fretful. The tonsils and velum are slightly inflamed; the submaxillary glands are full, but not painful. He ex- 84 pectoration is copious ; her urine is high coloured, depositing much sediment. The disease is well marked, but it has been less active in the attack than usual. Evening. In the morning I ordered a vomit, which brought away a great deal of mu- cus; and she had afterwards leeches, and then a blister applied to her throat. After the vomit had operated, she had a grain of calomel, which has been repeated every two hours since. This medicine has pro- cured her several stools. I think her breathing is more difficult now than it was in the morning, and indeed she has more pyrexia. I ordered the warm bath,. and a continuation of the calomel every hour and a half during the night. Monday Evening. She has had 10 grains of calomel, but without any abatement of the disease. This morning she got another vomit. 85 which caused the expectoration of much mucus, mixed with puriform flakes, re- sembling portions of the membrane. I ordered another vomit for this evening, and a continuation of the calomel. Tuesday. The emetic had a powerful effect, bringing up a considerable quantity of pulmonary secretion. The child, howe- ver, died this morning. She had taken 12 grains of calomel. DISSECTION. Instead of examining the trachea by dissecting it from the neck and cutting it up upon the back part, it was determin- ed to open it on the forepart, and to trace the diseased appearance through its whole length, and to follow its branches in the lungs. When the integuments of the neck Were dissected back, though there did 86 not any where appear marks of inflamma- tion, there was a turgidity of the great veins. This, however, was evidently oc- casioned by the difficult respiration af- fecting the circulation of the heart, the impeded action of the heart causing a remora in the cavas and right sinus. Accordingly, upon opening the tho- rax, we found the right auricle and the superior cava turgid with blood, as if the irritability of the heart and general sys- tem had been gradually exhausted by the laborious forcing respiration through the tube of the windpipe, which was pro* gressively diminishing in capacity. When the trachea was slit up on the fore part, from the thyroid cartilage to the division in the lungs, the membrane appeared completely formed in all this length, and of a firmer body than in any of the cases which have been given. It was more delicate behind the great car- tilages of the throat, was firmest about 87 the middle of the neck, and again be- came more soft and liquid after the di. vision of the trachea in the lungs ; and gradually as I traced the bronchiae, it lpst its consistency. Although I obser- ved a slight affection of the membrane of the bronchiae, the adventitious mem- brane could, be traced but a very little way into the lungs. The lungs were distended with air in such a manner as if the air had escaped from the cells into the cellular membrane of the lungs. This I conceive to be the effect of the violent play of the lungs, and which musH have obstructed the natural functions. H 88 CASE X. " Puer novem annorum, habitus cor- " poris tenuis delicatuli, adfectionibus ca- " tarrhalibus saepe obnoxius, ceteroquin " sanus, tempore vernali anni 1775 febri- " cula cum levi tussi et tonsillarum tu- " more correptus est. Hunc morbum ab " acre frigido vespertino, in quo obam- " bulaverat puer, ortum duxisse ratus, " potum theiformem calidum, pulveres- " que camphoratos et linctum pectoralem "" praescripsi. Satis bene inde se habuit *' aegrotus, febris disparuit, tussis metuit, " tumor faucium fere evanuit. Cum vero " nulla adesset expectoratio, hanc ut pro- " moverem, oxymel squilliticum addidi- " linctui pectorali. Verum in eodem sta- " tu per benas septimanas remansit tussis, *e ita tamen ut aegrotus genio puerili late 89 " indulgeret, cibos appeteret, nocturnu " quieta frueretur. " Neque febris sub eo tempore re- " cruduit, neque respirationis difficultas, " aliudve incommodum supervenit. Quin- " decimo autem die accersitus res inveni " quam maxime mutatas. Quippe puer " moribundi instar facie pallida, oculis " labiisque diductis immobilibus, cute " frigido sudore perfusa, anhelitu difficil- " limo, stridulo, lento, respirabat. Pul- " sus parvus erat et cellerrimus. Ver- " bo quovis momento misellum animam " efflaturam esse putabant adstantes. Un- " de vix obtinui a parentibus ut venam " secari sinerent. Quatuor sanguinis un- " ciis absque levamine eductis, periculo " magis magisque increscente, emeticum " praescripsi; tartari nempe stibiati ali- " quot grana in aqua simplice soluta, re- " fracta dosi porrigenda, donee invertere- u tur stomachus. Secundus remedii haus- " tus, vomitum excitavit tussimque. Quo- 90 " rum unita vi, non sine summo suffoca- " tionis periculo ex faucibus protrusum " forasque demum rejectum est concre- " mentum membranaceum, firmum, ra- " mosum, totoque tractu cavum, arte- " riae asperae bronchiorumque conforma- " tionem satis apte referens. Post sin- " gularem banc excretionem, pauculas " sanguinis guttas secum vehentem, ces- " sarunt omnia, quae infanti mortem *ni- " nata crant symptomata, spiritum liber- " rime traxit puer, calorem naturalem " ciborum adpetitum, mentis hilaritatem " recuperavit, laetusque cum parentibus " laetis, ceu a morte ad vitam revocatus " prandium cepit. Neque tamen restitu- " turn sivi relinquere linctus camphorace- " orumque usum ; suasi etiam vaporis le- " mentis inhalationem. At breves atque •' deceptrices fuerunt illae induciae. Quip- u pe tertio a dicta mutatione die respiratio " denuo fit anhelosa, stridula, gallinae gra- " cillantis sono similis; pulsu tamen non " adeo depresso et languido, quam in pri- 91 " ori mali accessu. Hinc venam iterum " secui, sed absque sensibili levamine. " Circa vesperam, aucto suffocationis pe- " riculo, tincturam ipecacuanhae aceto " scillitico mistam ad excitandum vomi- " turn propinavi, et quidem cum succes- " su. Alterum enim concrementum pri- " ori plane simile ejecit asger moxque " sublata est spirandi difficultas. " Remanebat autem febris lenta, ver- :t sus vesperam exacerbans, sputum hac- " tenus mucosum mutatum est in puru- " lentum, accesset dysphagia, nee obsti- 11 tit corticis Peruviani et aquarum selte- " ranarum lacti additarum usus, quo mi- u nus sudores et diarrhoea supervenirent, " viresque aegroti penitus exhaurirent. " Sic decimo tertio post alteram rejectio- " nem die animam efflavit. Valde desi- " deranti non concessum est cadaver seca- "re, tracheae que cavum inspicere." H2 92 Extract from the note of the dissection of a singular case, as occurring in an adult (0. The Thoracic and Abdominal Vis- cera, in situ, appeared natural; there was rather more fluid in the Cavity of the Chest than usual, and of a brownish co- lour ; the posterior and inferior portions of both Lobes of the Lungs had evident marks of inflammation, but more particu- larly the latter; the fluid found in the Cavity of the Thorax coagulated when exposed to heat; the Tonsils were enlarg- ed, more particularly the left; and both Tonsils were covered with a thick mem- brane of coagulable lymph. About three inches of the Trachea from the Larynx (1) He was a gunner, and had, previous to the attack of Croup, of which he died, suffered se- verely from a catarrh. 93 was taken off; it was covered with the same kind of membrane, and had the same appearance as in cases of Croup. Upon a farther examination oft the re- maining portion of the Trachea, we found a continuation of this membrane, but of a firmer texture than that in the superior part, accompanied with an appearance of inflammation of the natural membrane of the Trachea and its divisions; and this membrane, as well as the inflammation, prevaded the smallest ramifications of the Bronchiae, which upon pressure were found plugged up with a bloody frothy kind of matter. Upon opening the Heart, polypi and coagulable lymph were found in the right Auricle and Ventricle. APPENDIX. In Newhaven, on the 30th of May last, I saw a boy of twelve years of age, whose breathing was very difficult; it was attended with a sense of constriction at the larynx ; the inspiration was frequent and croaking, and his voice was rough and harsh : His breathing was so alarm- ingly difficult, that, according to the cus- tom of the common people, all the wo- men living in the neighbourhood were assembled to witness his death, which was hourly expected. His pulse was quick, but not strong; and he was much flushed. Since the attack commenced, he once or twice, unexpectedly, became easy, and continued so for a quarter or half an hour, and then the symptoms again returned in all their violence. In 96 these paroxysms he had many belching*, but I could not learn whether they reliev- ed him. His illness came on early this morn- ing; and it was imagined to have arisen from his having gone off in an open boat yesterday, which was a very cold day, to fish. I ordered him an emetic immediately, which sensibly relieved him. He was blistered, and he continued getting bet- ter under the use of a strong solution of assafoetida. This I conceived to be a case of the acute asthma of Millar, and under this impression I treated it successfully as a spasmodic disease. I have never seen another instance of the disorder; but from its supposed indentity with croup, I shall shortly point out the distinctive symptoms. 97 In croup, the cough, which I have so often noticed, is constantly ringing in our ears; in acute asthma there is little or no cough. In croup there is very sel- dom any remission; the remission m acute asthma is one of the most striking phenomena of the disease ; and it is at- tended with some evacuation, as bel- ching, vomiting, or purging. In croup the pulse is strong, the urine is high co- loured, the fever is much greater, the voice is sharp and small; in acute asth- ma, the pulse, though perhaps equally quick, is less full, the urine is limpid, and the voice is croaking and deep. By attending to these symtoms, we shall be able to determine the question of bleeding, which is safety in the one in- stance, and supposed to be improper in- the other. When there is sufficient time deliberately to consider the progress of croup, it is hardly possible that it should be mistaken for any other disease. 98 It may not be amiss to state the error in the genera morborum, which gave rise to this diagnostic. As synonymous to Cynanche Tra- chealis, Dr. Cullen (Synop.. JYos. Meth. g. x.) mentions, Suffocatio Stridula, Scotis The Croup, CI. Home on the Croup. Asthma Infantum, Millar on the Asthma and Chincough. Asthma Infantum Spasmodicum, Rush, Dissertation, London, 1770. Cynanche Stridula, Crawford, Dissert. Inaug. Edinb. 1771. The first and last of these desserta- tions treat of Croup, the intermediate two of the Asthma Infantum, the disease which occurred to the fisherman's bov. 99 Dr. Cullen, by departing from his usual accuracy and discrimination, has obliged me, in the first paragraph of the Essay, to state precisely the nature of the disease of which I was about to treat, a thing in the present instance of the last importance in a practical point of view, and to define it from the morbid organic condition, rather than from the symptoms, which, in a regular book of nosology, is unquestionably the preferable mode. My definition, therefore, is to be consi- dered rather as an enunciation of the sub- ject; for had I not been compelled by this mistake, I should not have thought it necessary to give any definition of a disease, which is particularly described in the next page. The advocates for the operation of bronchotomy, which, I find, is still recommended, will do well to at- tend to the distinction between the two diseases. I imagine I need hardly say, that in the asthma infantum there is no inflammatory membrane. I 100 In the present state of surgery, I scarcely thought it necessary to add much in support of my opinion as to the unfitness of the operation of bronchoto- my : But as I have been blamed for re- jecting this operation in the cure of croup, I shall consider it in another point of view. At the same time I should hope, that what I have already said will have influence with most physicians. Although in some instances, where the membrane has been formed and ex- pectorated, and the child in consequence has recovered, the affection appears not to have extended much beyond the larynx (4), yet I am convinced, that in nine cases out of ten, the immediate cause of death is not so much the narrowing and obstruction of the stream of air occasion- (4) This too must in a great measure be the ■vase in the peculiarity explained in p. 30. 101 ed by the membrane (5), as the puriform fluid with which the bronchiae are filled; for in most of my dissections, the puri- form fluid has been found so completely to gorge the lungs, that the air would have been met by this fluid, and prevented from finding its way into the air cells, even had it passed the larynx easily, or had the membranous effusion which lines the larynx been removed. This pu- riform fluid I conceive to be a mixture of the lymphatic effusion of the minute branches of the trachea, of the natural exhaltation of the lungs, and of mucus. He who imagines that the disease is al- ways confined to the larynx, takes a li- mited view of croup ; for by continuous sympathy, or from the exciting cause acting as violently there as at the larynx, (5) In Case VIII. there was no mechanical ob- struction in the trachea. It was indeed inflamed; but the immediate cause of death might be sought in the effusion of the lungs, and the general af- fection. 102 the inflammation often, perhaps always in some degree, extends to the more minute branches of the windpipe; and I have actually seen the membrane regu- larly formed in branches, not a line in diameter, which proves that inflamma- tion had subsisted as violently in these branches, as it usually does in the larynx. Suppose, then, in performing this operation, that the thyroid veins, and all the neighbouring blood-vessels, could be so commanded, that not one drop of blood should be poured out to embarrass the operator; that the membrane, as it lines the larynx, were extracted; and, to avoid any difficulty from the spasm of the larynx, that a tube were introduced into the trachea, and that the child were breathing through his tube, By what means could we promote the expectora- tion of the puriform matter which so ge- nerly fills the lungs? 103 Is it a consideration entirely to be overlooked, that the operation is to be performed upon an organ in a state per- haps of high inflammation? It is alleged, that one child did es- cape from this operation (6). When the (6) Burserius, Vol. V. § ccccxxxvii. Inst. Med. Pract. Burserius, like every other system- maker, must depend upon the observations of other men for the greater part of the intelligence which he is to communicate ; and accordingly he follows Michaelis (sequar CI. Christ. Frider. Mi- chaelium, qui hujusce morbi historiam prae aliis accuratissime conscripsit, § ccccxxiv.), who has in some measure made up for his want of experi- ence in this disease by his industry. The imper- fect case which Burserius gives froirt his corres- pondent Locatellius, cannot be admitted in evi- dence, until the history of the disease previously to the operation be known. That the impression made by this operation upon the mind of Burse- rius himself was very faint, may be inferred from the manner in which he proposes bronchotomy. " In extremo suffocationis periculo, sola tracheo- 12 104 surgeons of former times were perform- ing operations for the iliac passion, there may perhaps be an instance on record, where the patient has survived. But surely this would not be reason enough, why such an attempt should again be " tomia, reliquis irritis spem aliquam facit quan- " quam non ab omnibus probetur." L. c. Were it judged right to perform this operation, a more hopeless way of doing it (so far as I re- collect, for I have not the book by me), could not have been thought on. There was a transverse incision made between the second and third ring, and another between the fourth and fifth. Then there were two longitudinal incisions made, one on each side of the trachea, which joining the transverse ones at right angles, freed a quadran- gular piece of cartilage two rings in length, and in all probability at least a third of the circumfer- ence of the trachea in breadth, which was removed. I have known this operation performed in two instances, both of which were fatal, one of them under the most favourable circumstances, for the patient was an adult. 105 made. I must still maintain, that it be- comes the surgeon, for the credit of his profession, to decline an operation so im- probable, and which proceeds from a mechanical and contracted view of the disease. Dr. Rollo's case, although in an a- adult, does not invalidate my opinion, that debility of the trachea predisposes to croup ; for in his patient, the upper part of the trachea was previously reduced to a state of debility, by a severe attack of catarrh, a precursor to croup, which is daily observable in children. Before concluding, I may observe, that, in the second stage of croup, I have had no success in administering ca- calomel, which I have done in many in- stances since the foregoing Kssay was written ; that my opinion of its virtues is diminished by an extended experience 106 of its effects (7). During the first stage, in violent attacks, I should think myself (7) The praise given by some physicians to ca- lomel I was at a loss to explain, when I found it accounted for in a paper on Croup, by Dr. Ferriar of Manchester (Medical Histories and Reflections, Vol. III.), which I lately read with more satisfac- tion than any thing that I have seen upon the sub- ject. He observes, that " children who are liable " to attacks of the croup, are sometimes seized " with the deep barking cough, which will in- " creased to such a degree, as to excite much " alarm, about the usual time of the dangerous " exacerbation; yet it will decrease again, and at li lengh go entirely off, without any remedies but " common demulcents. Cases of this kind, I sus- " pect, have been described as genuine paroxysms " of croup, and very trifling methods of cure have " been recommended, in consequence of their ap- " parent efficacy in the spurious croup, which al- " ways cures itself." The spurious croup is that croupy cough which I have mentioned, p. 25. The only expectation from calomel which oc- curs to me, is, that it will occasion a new action in the trachea, and thus prevent the disease from 107 criminal, were I to neglect blood-letting and the antiphlogistic regimen, in favour running its fatal course to effusion. In this view, calomel can be of no use in the second stage, where the inflammatory action is completed, and where our sole hope is from expectorants. In the first stage, I have given it as my opinion, that the way to succeed, is to endeavour to obtain a resolution of the inflamation; and indeed where there is nothing peculiar in an inflammation, this is a preferable design to that of inducing a new action in a part. The physician whom I have al- ready quoted in this note, says, that the disease will generally be fatal, if the alarming symptoms be not mitigated within the first six hours. To this I do not accede ; for I have more than once relieved children, where croup had come on alarmingly, by bleeding, on the morning after. But I may venture to affirm, that the disease, if not within the twelve or sixteen hours from the invasion of the alarming symptoms, will not be cured at all; and this, doubtless, allows too limit- ed a period for the influence of colomel, which, it is a common observasion, is even more tardy in affecting the system of children, than that of grown people. However, should calomel be pro- posed on any other principle, I shall willingly 108 af any other measure; for I am more and more convinced, that previously to the formation of the membrane, the disease is certainly to be cured by the means (8) give it every farther consideration. For the pre- sent, I must decline using it, unless in such a va- riety as is mentioned./?. 41. note 6. (8) It was stated to me as a serious objection to the foregoing Essay, that, in the cure of Croup, I had brought forward nothing new. This it was not my intention to do. I found the practice un- fixed, when I first entered on the consideration of this disease ; and my object, in the first place, was to determine, for my »wn satisfaction, what course I should follow, under circumstances which occured so frequently. My opinion is esta- blished, that this is an inflammatory disease, which, in the first stage, is to be treated by a strict antiphlogistic regimen, by emetics, and the warm bath : when violent, by blisters, large bleed- ings, and other evacuations, p. 24. et seg. In the se- cond stage, by emetics, expectorants, and blis- ters ; and that, while we have agents so powerful, we should neither trust to calomel, asafcetida, nor 109 which I have recommended. But when, by the paleness of the visage, the lividity of the lips, and the ghastliness of the eyes ; by the cough evidently becoming more stridulous, although less sonorous C9); and by the changes which I have pointed out, we discover that the inflammatory Stage is over ; I have no objection to of- fer against calomel; so that it does not preclude the use of expectorants, among any other drug which has been hitherto offered as a specific for croup. Should I have been success- ful in bringing other physicians to think that these are fair conclusions, my object is granted in its fnllest extent, and my time has been as usefully employed, as if I had been experimenting in or- der to produce a new remedy, which, as is shown by daily experience, however excellent in the sense of the innovator, is generally found only to involve the physician in fresh doubts. (9) A hoarse, deep, barking cough is not so alarming as a shrilly crowing and stridulous one. The latter always characterises the second stage. 110 which I may rank medicated vapours; but I particularly allude to emetics, which I prefer to all other remedies in the com- plete stage of croup. T. TOWN, PRIMER. • AN ESSAY ON THE BOWEL COMPLAINTS OP CHILDREN, MORE IMMEDIATELY CONNECTED WITH THE BILIARY SECRETION, AND PARTICULARLY OF ATROPHIA ABLACTATORUM, OR WEANING BRASH. BY JOHN CHEYNE, M. D. Fellow of the Royal College of Surgeons of Edinburgh • PHILADELPHIA: PUBLISHED BY ANTHONY FINLEY. Sold also by Bradford and Read, Boston; A. Miltenberger and J. dishing, Baltimore; R. Cotton), Petersburgh, and J. and J. Boyce, Richmond, (Va.); Se) mour and Willia-us, Savannah; W. Graydon, Harrisburgh; and A. Montgomery, Prankfort, (Kentucky). William Fry, Printer. 1813. INTRODUCTION. TO understand the economy of the vis- cera of the abdomen, and, consequent- ly, to comprehend the pathology or dis- eased state of those parts, it is of the first importance to attend to the con- nections of the hepatic system. The liver and stomach and intestines form the extremities of one system of ves- sels, the vena portse. The vena portae is aptly enough described as a tree, which shoots its roots widely amongst the membranous viscera of the belly, and extends its branches into the sub- stance of the liver. The bile, which is the peculiar secretion of the liver, being collected from the extreme branches of the hepatic system, by the branches A 6 of the ductus hepaticus, flows into the intestines; and as it is their peculiar stimulus, it holds a sway over their actions, according to the quantity and quality discharged into them. The ex- citement of the intestines, again, has a reciprocal influence upon the glandu- lar viscera, and particularly upon the liver; because, on the excitement of the intestines, depends the velocity of the circulation through them; and the returning blood of the intestines is sent back, not into the heart, but through the vena porta, into the liver. And thus, in an obvious manner, are the intestines and liver connected; namely, the intestines with the liver, by the biliary secretion, and the liver with the intestines and stomach, through the medium of the circulation of the blood in the vena portae. 7 As I introduce the proper subject of this paper with some notices of those diseases of infancy which depend on the liver, it may be necessary to preface these remarks with a short statement of the change which takes place in the system of the liver after birth. During the dormant state of the foe- tus, if I may so express myself, whilst it remains in the womb, the functions of the several organs are unexercised, and the mass of blood adapted to the growth of parts is supplied by the mo- ther. The organs, therefore, which in the adult are subservient to the supply- ing of the blood with nutritious matter, are unemployed in the foetus. The sto- mach, intestines, and glandular viscera of the belly, have as little connection with the economy as the undistended 8 lungs; and thus imperfections in these viscera are attended with no obstruc- tion to the system, until the child is born; as organic defects in the lungs, and in that part of the structure of the heart which is subservient to the cir- culation through the lungs, show them- selves only when the lungs have assu- med in part the function of the pla- centa. After birth, a complete revolution takes place in the circulation of the blood through the organs seated in the abdomen. By the action of the muscles of inspiration, and the consequent dis- tension of the lungs, a new route is opened to the blood flowing from the right side of the heart; and the united and forcible exertion of both ventricles, which was required for the extensive 9 circulation of blood through the body of the foetus and through the foetal part of the placenta, is now divided; and the pulsation of the chord, therefore, be- comes weak, and the function of the placenta is lost. The system of the child now depends on its own powers, and the secondary effect of the change of the circulating system falls on the abdo- minal viscera. The chief effect produced on this part of the system is the interruption of the supply of arterial blood to the liver by the umbilical vein; for now all the large venous vessels of the liver come to be entirely supplied by the returning blood of the intestines, by venous blood, and by blood which moves languidly through the viscus, owing to the limited source, namely, the veins of the stomach, spleen, A2 10 and intestines, and the great compara- tive size of the veins in the liver. Now only is the circulation, which is peculiarly adapted to the liver, esta- blished; now it is that it performs its function, and that stimulating bile is secreted. The effect of this is the ap- plication of a new stimulus to the in- testinal canal, and a consequent evacu- ation of the meconium by this natural purgation. That, during the foetal state, nature seems careful of maturing and giving importance to the liver, is evident from its great size, which is unnecessary, except as a provision for early child- hood. From this view of the system in in- fancy, the importance of the healthy 11 action Of the liver must be acknow- ledged, and the following Essay will illustrate the baneful effect of its dis- orders. ESSAY II. ON THE BOWEL COMPLAINTS MORE IMMEDI- ATELY CONNECTED WITH THE BILIARY SE- CRETION, AND PARTICULARLY OF ATROPHIA ABLACTATORUM. WHETHER the introductory state- ment and physical connection will fully explain the sympathy between the liver and the intestinal canal, is a curious question; but it is sufficient for my pur- pose, that this sympathy does exist, and is so great, that the one organ cannot be disordered without a corresponding de- rangement being produced in the other. It is, therefore, a material object, in con- sidering the intestinal diseases of chil- dren, to point out how far the liver is 13 concerned in producing these diseases, in aggravating them, or in assisting in their cure. The liver shows its healthy or dis- eased state by the nature and effects of the bile which it secretes. To adopt the arrangement of Bianchi, this secretion, in a morbid state, may be redundant, diminished or altogether obstructed, or depraved. In the diseases, of which I am about to treat, it will be found in all these states. In the disease, which I have termed the Atrophia Ablactatorum, in the first place, it will be found supera- bundant, and eventually it will appear to be possessed of unusual acrimony. In the Icterus Infantum, there is often a complete obstruction to the passage of the bile. 14 Taking these diseases in the order of time in which they occur, I shall first mention that species of jaundice which attacks infants a few days after birth. This is always an alarming disease; for when infants do recover, it is with great difficulty. It generally comes on about the third day after birth; for it is neces- sary that this time should elapse before the complete absorption, and subse- quent deposition of the bile into the blood, can take place. It is attended with languor, flatulence, and bilious urine, and continues many days, or even weeks: sometimes it goes gradu- ally away, but generally ends in a fatal marasmus. When this disease is fatal, it, in all probability, is so from an original mal- conformation in the liver; for we do not find, upon dissection, that it is a disease 15 of the hepatic or of the common ducts, which, though somewhat contracted, from the thickening of their coats, are always pervious. The malconformation is probably an impermeable thickening of the beginnings of the hepatic duct, or, as they are called, the Pori Biliarii. This disease has been supposed to arise from an obstruction of the biliary ducts forcing the bile back upon the liver; the obstruction being occasioned either by meconium, by mucus, or by viscid matter clogging the ductus com- munis; or by the milk coagulated in the stomach or duodenum, (0 distending (1) Dr. Heberden, whose opinion is always en- tided to the utmost deference, says, " That it " has been supposed that an infarction of the du- odenum may be great enough to hinder the " efflux of the bile; but this may be questioned, n if we reflect, that the duodenum has seldom 16 them so as to make them press upon the duct. On such slight causes may perhaps depend that species of jaundice described by authors, (2) which disap- " any solid contents in it, and that if it should be u so plugged up by them, or compressed by the " other intestines, as to hinder the passing of the " bile, it would, for the same reason, be incapa- " ble of admitting any thing into it from the sto- " mach, which is a supposition hardly counte- 4* nanced by experience." Medical Transactions by the College of Physicians of London, Vol. II, p. 129. (2) " L'observation demontre qu'il existe une " difference tres-remarquable chez les divers en- " fans attaques de la jaunisse apres la naissance. " Quand elle est legere, elle se dissipe d'elle- "meme," &c. Chambon, Tom. I. p. 272. No doubt there is a slight species of jaundice which goes off in a few days; but then the skin is of a reddish and not very deep yellow; but when it ia of a deep saffron colour, we should be prepared for a very obstinate disease. 17 pears in a few days, without hurting the child. But the fatal jaundice, such as is described below, (3); is not to be remo- (3) CASE I. Mat 10. G—— H ■ 's daughter, five days old, Was remarkably stout and healthy, when born; but, on the third day after birth, her skin became jaundiced. She took the breast very well before last night, when, from uneasiness, she ceased to suck; but she has returned to the breast again. She appears to be very well in every respect, but that her colour is jaundiced, and she has oc- casional (its of pain. May 18. The skin continues fully as deep as it was, and the child is becoming soft and emaciated; her stools are white, and like putty, with some streaks of bile in them; her bowels have been kept open by a weak effusion of senna; her urine stains the linen very deeply. She sucks freely. B 18 ved by emetics, gentle purgatives, and the warm bath, the natural remedies for May 21. There is no change in the jaundice; her stools and urine are much like what they were. Last night she had a slight bleeding from the umbili- cus, and she is plainly getting weaker. May 22. Although the ligature fell off on the sixth day from birth, there was a great haemorrhage from the umbilicus, and the child died this morning in consequence of it. DISSECTION. Upon opening the body, the first thing done was to examine the state of the vessels of the umbilical chord, as I thought in this case that it was not improbable, that the liver being affect- ed, the bleeding might have proceeded from the vein; but I found it empty of blood; and although there seemed to be no obstruction to the probe from the navel into the vein, it did not appear t"hat the bleeding had come from this source. I 19 an obstruction in the ducts. I believe it to be an original and incurable malcon- traced the grumous blood from the centre of the navel along the arteries, which were also open. The intestines had no degree of transparency, but were of a milky colour, tinged with a delicate yellow, from the bile in their coats, not in their cavity. The stomach was very much distended. The glands of the mesentery were larger than they should be, and white, compared with those of adults. The liver was full and firm, and of a dark green earthy colour. The gall-bladder was quite empty and contracted, so that it had sunk into the fissure of the liver, and only a small part of its fundus appeared. Within it there was a small soft mass, of a dark colour, and of the size of a grain of barley. The ducts also were contracted, rm, white, and like an artery, and, although pervious, contained no bile. The opening into the gut was perfectly free to the probe. When 20 formation in the liver. It is a disease pe- culiar to some families. I have known in one family two children successively die of this disease; and there is a striking confirmation of this remark in a history related by Mr. Pearson, where ten of eleven children died of this species of jaundice, the eleventh having died of jaundice at six years of age. (**) , When the substance of the liver was cut into, this appearance of firmness of the ducts was still discernible. The bleeding proceeded from the unhealthy change produced in the blood by the reception of the bile into the mass of fluids. (4) " Mrs. J. had been the mother of eleven " children, on nine of which the jaundice appear- " ed a few days after they were born, and they " all died within the period of a month after their " birth. The tenth child lived six years, was then " afflicted with the jaundice, and died. In May 21 As an infant cannot express his pe- culiar feelings of uneasiness, it is only « 1796, Mrs. J. was delivered of her eleventh « child; on the third day after its birth, the skin «« became yellow, and the child was at the same «time remarkably torpid and sleepy, and seem- « ed to be slightly convulsed. On the following »* days, the colour of the skin often varied, being » sometimes of a deeper yellow, and at others re- « gaining its natural colour. The child continued, " however, in the same languid and almost in- « sensible state, but received nourishment, and « sucked the breast of its mother, till within a "few days of death, which took place on the « ninth day I opened the body of this child the " day after death, and shall now describe the ap- " pearances on dissection. « The skin had nearly lost its yellow colour, « and the child did not appear at all reduced by " the disease. " The liver was almost twice its natural size; " the whole concave surface of the right lobe had B2 22 by the deep colour of the skin and of the urine, the continuance of the illness, and the appearance of decay, that we can judge of the violence of this dis- ease. I doubt much whether any thing "alivid appearance; but this dark colour did not " penetrate above a line or two, and the internal " surface was sound and healthy The convex "part of the liver was of the natural colour and " firmness, except on the margin of both the "lobes; there the thin edge exhibited a highly " injected appearance; the redness was, however, " less vivid and remarkable on the left lobe than " on the right. There was a slight adhesion of " the lower part of the right lobe to the perito- " neum. The gall-bladder was nearly filled with " bile of a deep yellow colour, and its ducts were " permeable. The heart seemed to be larger than " common, and the blood-vessels on its surface « were remarkably turgid. The right auricle was « distended with blood, and the pericardium con- '* fained about a table-spoonful «f water," fcc. 25 beyond assisting the breast-milk by a gently laxative medicine ought to be attempted; or perhaps frictions of the belly might be useful. At all events, these things, together with an emetic, are suited to the milder kind of jaun- dice, and are never to be neglected, when there is reason to suspect an in- terruption to the free passage of the bile. The liver appears also in the early months of childhood to be exposed to another derangement of function, which shows itself in a discharge chiefly bi- lious. When this discharge is merely a purging, it is called by the nurses The Green Scour; but it is still the same dis- ease when accompanied with vomiting. When the cause of it is violent, or the child of a very irritable constitution, it 24 is often ushefed in by convulsions, (*) and, during the fit, the child generally (5) In March and April last, many young chil- dren were attacked with pulmonary inflamma- tion. It was so prevalent, that I attended above fifty cases. In many, convulsions were the first symptom. This would not happen once in a thou- sand instances of the same disease in the adult system. In a fever which was epidemical among the children at Hampstead in August and Sep- tember 1776, Dr. Armstrong observes, that most of the children who took the fever were threat- ened with fits, and some had slight convulsions. The convulsions, which often arise from slight derangements in the intestines, and at the be- ginning of acute diseases, mark a greater de- gree of irritability, which is the chief difference between the infantile and adult constitution* and show the former to be what M. Baumes calls Un melange singulier de spasme et de debilite. Before the various animal functions are established in their regular series by habit, the constitution is susceptible of every impression, and hence arises the irritability so peculiar to infancy. 25 passes a quantity of green excrement. There is always a great deal of fever, with convulsive startings; a twisting of the limbs from gripes, and screaming. In the interval between the convulsions, there are partial spasms of the face, about the eyes and mouth; and I have not a doubt that children are often car- ried off in these paroxysms. But this disease, sometimes so violent, begins at other times more mildly; and it is the milder attack which in general is the more tedious. It becomes a chronic di- arrhoea, with the same kind of dejec- tions, green, and frequently sour and curdy, and accompanied with a retch- ing, irregular fever and wasting of the body. This disease is occasioned either by the child's diet being offensive to the stomach, or by cold. Panado, with too 26 much sugar, the milk of a bad and neg- ligent nurse, who indulges in heating liquors or high seasoned dishes, or of a nurse who has had a sudden fright, or who has menstruated, are very frequent sources of this disease. It appears so immediately after the application of the cause, that it bears considerable resem- blance to the cholera crapulosa in adults; for in both diseases the correspondence between the stomach and liver gives rise to the first step in the cure, assisting to expel the noxious matter, by adding to its stimulus that of an increased quan- tity of bile, which, as it has been ob- served, is probably better fitted to be a stimulus to the intestines, from its hur- ried and imperfect secretion. A disease similar to this I have seen in England, occasioned by improper food given to children brought up by 27 the hand. It is very destructive; but it is not to be met with in Scotland, where fortunately this unnatural practice does not prevail. This disease is, in the violent attacksj to be cured by the warm bath, by vo- mits and cathartics, especially cathartic glysters; and should the disease, or any symptom of it denoting great irritation, continue after the full operation of these medicines, we must have recourse to opiates and testaceous powders; but we must be cautious in giving opiates, (^ (6) CASE II. June 12. Mr. S----'s child, nine months old, the night before last took a violent purging, was restless and very fretful, and would not sleep. Last night, the mother, to alleviate these symptoms, and lull the child, gave her a large dose of syrup of 28 until the purgative medicines have ope- rated. This observation may be support- ed by the authority of Harris, whose opinions are generally founded on ex- perience. " Diarrhoea infantum ab or- poppies, which not only set her asleep, but stop- ped the purging. The child slept till mid-day. Upon awaking, she vomited a great quantity of bile, and soon went to sleep again; but she awoke now and then sick, and the vomiting continued quite bilious. She is easily disturbed, and has fre- quent startings, and a great deal of fever. The mother, intending to wean this child, had fed her the day before yesterday with a quantity of strong beef-tea, and then had allowed her to suck the nurse in the evening, which she did very greedily. Moreover, the nurse had menstru- ated a day or two before. The child was in a fair way of recovering from this mismanagement, had the purging been allowed to continue for a little while longer; but, instead of this, the purg- ing was stopped, and the bile poured into the in- 29 " gasmo humorum in intestina delaben- " tium, vel a turgescentia illic bilis cum "acido praedominium habente semper "profluens, neque astringentibus pro- " prie dictis, neque narcoticis est cohi- 11 benda." Harris de Morbis Acutis In- fantum, p. 30. The disease which I am now to con- sider, and which is the chief object of the present paper, is somewhat allied to the last in its nature, and is vulgarly de- nominated in this part of Scotland The tinal canal, until the accumulation of it brought on the sickness and fever. June 14. This child was relieved by an emetic of ipeca- cuan wine and a purgative glyster, and to-day, by continuing to take a weak infusion of senna, she is nearly recovered. c 30 Weaning Brash. (7) It is one of the most fatal of the diseases of children, and, as far as I know, it is overlooked by those physicians who have made these diseases their study. It is an atrophy, the consequence of weaning children too suddenly at an un- favourable season of the year. (7) It is hoped that the nosological name which I have given to weaning brash (viz. Atro- phia Ablactatorum,) as a literal translation of the vulgar one, and as placing this disease under the genus Atrophia, which, I presume, is its natural situation, will be deemed unexceptionable. Atro- phia is the second genus of the third class of Cullen, who defines it," Marcor et Asthenia, sine « pyrexia hectica." By Sauvages, in whose very useful and comprehensive system of nosology it will be found as the third genus of the tenth class, it had been defined, " Macies sine febre.'* 31 This disease sometimes comes on two or three days after weaning; frequently not for three or four weeks; sometimes not before five or six weeks have elaps- ed. v The first symptom is a purging, with griping pain, in which the dejections are usually of a green colour. When this purging is neglected, and, after contin- uing for some time, there is added a retelling, with or without vomiting; when accompanied by vomiting, the matter brought up is frequently colour- ed with bile. These increased and painful actions of the alimentary canal, produce a loath- ing of every kind of food, and naturally are attended with emaciation and soft- ness of the flesh, with restlessness, thirst, and fever. 32 After some weeks, I have often ob- served a hectic blush on the cheek; but the most characteristic symptom of this disease, is a constant peevishness, the effect of unceasing griping pain, ex- pressed by the whine of the child, but especially by the settled discontent of his features; and this expression of dis- content is strengthened towards the con- clusion of the disease, when the coun- tenance has shared in the emaciation of the body. In the progress of the disease, the evacuations frorn the belly show very different actions of the intestines, and great changes in the biliary secretion; for they are sometimes of a natural co- lour, at other times slimy and ash colour- ed, and sometimes lienteric. 33 Towards the end of the disease, the extremities swell, and the child becomes exceedingly drowsy; but these I rather conceive to arise from debility, than to be pathognomic symptoms. It is re- markable, in the advanced stages of the disease, that the purging sometimes ceases for a day or two, but without any amelioration of the bad symptoms; nay, I think that children decay even faster than when the purging is most violent. The disease seldom proves fatal be- fore the sixth or seventh week; and in this short time I have seen the finest chil- dren miserably wasted. I have seen, though rarely, a child recovered after the disease had continued three or four months; and again, I have seen the dis- ease cut short by death, in the second, third, or fourth week, before it had C2 34 reached the acme; the sudden termina- tion having been occasioned by an in- cessant vomiting and purging, or by con- vulsions, from the immense irritation in the bowels. The disease is more frequent in chil- dren who have been weaned before the eighth or ninth month, and in particular, in those who, in consequence of some accident happening to the nurse, have been weaned abruptly. I have not been able to determine what temperament is most peculiarly liable to this disease; but, without mean- ing to insinuate any necessary relation, I think it appears most frequently in those children of a lax fibre, whose con- stitutions, at a more advanced stage of life, might be supposed liable to the at- tack of strumous disorders. 35 This is a disease of the autumnal months. I seldom, comparatively speak- ing, have seen it commence before the solstice, nor after the end of the year; and I suspect that it is most general in sultry seasons. As it will presently be shown, this dis- ease gives origin to a great change in the glandular system of the mesentery, and this explains how it should happen, that after it has been removed, either by me- dicine, or by a proper regimen, and the healthful exertions of a good constitu- tion, it is very apt, after slight errors in diet, or from cold, to return, even after the lapse of months. A person who knows this disease, will often be able to recognise it in the very obstinate and baffling complaints of the bowels, which children have from the beginning of the second to the end of the third year. 36 At the time when weaning brash comes on, the teeth are usually appear- ing; and, from a common notion, that a flux is wholesome during teething, the disease is sometimes allowed to make an irremediable impression on the consti- tution, before the physician is called. My attention was very early directed to this disease, W from finding that it had (8) It may be asked, How happens it that a disease which occurs so frequently should not have been frequently described? It is because we have not been favoured by writers on the dis- eases of children, with individual histories, or cases, as they are called. In my opinion, these constitute the most important part of illustration, in explaining the nature of a disease; for I have always found it more satisfactory to read a case, well and clinically taken, than the most elaborate general history of the symptoms of a disease; a detail which, however accurate, does not fix the 37 an appropriate name among the vulgar, and yet that it was not known to those physicians whom I consulted respecting attention, and is useful only after the disease in question is understood, from having seen or read of examples of it. The obscurity and difficulty attending the diagnostics and treatment of the diseases of children, proceed from this more than from any thing, that the writers on these diseases have hardly one case from the beginning of their books to the end. Surely the infancy of the pa- tient does not prevent an accurate and full case from being taken? Should the student wish to attain an early knowledge of this branch of his profession, he will find nothing so useful as the keeping of case books for the insertion of every important variety of disease. There are indeed some notices of weaning brash; but they do not identify it as a particular disease; at least, I should not have discovered them as such, had I not been reading expressly for the subject. 38 its nature. Some of them had observed a purging as a very common conse- quence of weaning; but they supposed that it arose from teething: Others told me, that it arose from a mesenteric en- largement in scrophulous children: And until I could satisfy myself by dissec- tion, I rested on this latter supposition. I was the more inclined to this opin- ion, in consequence of having observed a scrophulous enlargement of the lym- phatic glands in the neck, and a scro- phulous suppuration in the back, in two children who at the same time had wean- ing brash. The safest foundation for reasoning on the nature of diseases, is laid by ana- tomical investigation, C9*) and, with little (9) Had it been more fully adopted, Cowper, the anatomist, would have had less occasion to 39 exception, it is the only one upon which I shall rest in these dissertations. It was adopted first of all by Glisson, in his ex- cellent history of rickets; and it is much to be wished that succeeding physicians had followed him more closely, not only in treating of the diseases of children, but in treating of all diseases which have exclaim, with so much indignation and justice, " That the advancement of true knowledge is " sadly retarded, by the general opinion, that the t( senses are mean and ignoble, and that abstract- " ed contemplations are the perfections of human "nature; and so it comes to pass, that men's " minds are fed with shadows and chimeras, in- " stead of substantial knowledge, which is only "from the physical examination of things by " sense and experiment." " Rien n'interesse que ce qui est vrai, et rien " en medecine, n'est vrai que ce qui a l'experi- " ence et 1'observation pour base." 40 in their beginning increased actions of the circulatory system. With this con- viction, I resolved not to indulge in any speculation upon the proximate cause, until I could procure a dissection, where- in might be displayed the morbid effects of this disease; and, in the mean time, I was satisfied with observing and making out a history of the symptoms, as they appeared in a variety of cases which I attended in the years 1799 and 1800. The first dissection which I had an opportunity of making of a child who had died of weaning brash, did not in- struct me in the true nature of the dis- ease; for the mesenteric glands were con- siderably enlarged and inflamed, and I still imagined that their affection might have occasioned the purging and maras- mus. But in prosecuting my research, 41 I was convinced, that the disease was an undescribed one; and that although there might, in some instances, be mesenteric obstruction, it was not necessary to the disease; that it was the effect, and not the cause of it. I observed, in every instance, that the intestinal canal, from the stomach down- ward, abounded with singular contrac- tions, and had in its course one or more intus-susceptions; that the liver was ex- ceedingly firm, larger than natural, and of a bright red colour, and that the en- larged gall-bladder contained a dark green bile. In some dissections, the me- senteric glands were swelled and in- flamed; in others, however, they were scarcely enlarged, and had no appearance of inflammation. D 42 These contractions and intus-suscep- tions C1) were entirely of a spasmodic (1) Strangulated intus-susception is a very fa- tal disease to infants on the breast, which is proved by the many preparations of this nature found in every extensive anatomical museum. It is often found, in the dissection of infants who die convulsed, or in great pain, that there are those temporary intus-susceptions, the effect of spasm, which I have described as constantly occurring in weaning brash; and it may be in- ferred, that they are by no means rare in many disordered states of the bowels. Should the irri- tation in the bowels be so great, as to occasion any inflammation at the time when this tempo- rary intus-susception exists, it is highly proba- ble that the continued stimulus of improper ali- ment acting upon the inflamed intestine, may, by increasing the irritation, assist in converting this occasional intus-susception into a permanent and fatal volvulus. It has always appeared to me, upon this view, that the cathartic medicines usu- ally given by the mouth in iliac passion, as sti- 43 nature, as in the latter the contained part of the gut was easily disengaged from that which formed its sac; and in no part of the entanglement was there adhesion, or even the mark of inflammation; and the contracted portions of the intestine were again permanently dilated, by push- ing the finger into them. These appearances lead me to im- agine, that the weaning brash, in its con- firmed state, is imputable to an increas- ed secretion of acrid bile, or rather to the morbid state of the liver, which oc- mulating the upper or contained part of the gut, must be attended with the worst effects, by in- creasing this inflammation, and confirming, in- stead of removing, the strangulation; yet I have known it to be the first thing done, to give brisk, or, as they are called, drastic purgatives, which were continued during the whole progress of the disease. 44 casions this; of which, however, I am afraid to attempt the explanation. It is proved, that there is an increased quan- tity of bile in the intestines, by the green dejections which are frequent in the be- ginning of the disease, and by the bilious vomiting. Perhaps the affection of the liver may be explained in this way. The breast milk is a mild food, adapted to the pow- ers of the child; I shall not say to the weak powers of digestion in the child, but rather to the peculiar powers and properties of the secretions. When the child is weaned abruptly, and put upon common food, this becomes too violent a stimulus to the intestines. Between the liver and intestines there is the most intimate relation. This excited state of the intestines causes a discharge of bile into them, which increases the stimulus. 45 and assists in maintaining a purging. Had the original cause been accidental and transitory, the bile, like the opera- tion of a smart purge, would have thrown out the offensive matter, and cured the complaint; but crude unfit food being still poured into the stomach, the dis- ease must proceed. It is probable, there- fore, that, in the first instance, a redun- dant secretion of the bile, which may also be an acrid and imperfect one, (2) (2) In treating of cholera morbus, Dr. Saun- ders says, " It seems probable, from the quantity " secreted, and the rapid manner in which it is " poured into the duodenum, that there is not " time sufficient for a perfect secretion. The va- " ried and increased action of a gland has much 14 influence in determining the nature of a fluid " secreted. In some cases, bile is discharged of " a green colour, and extremely acrid, not pos- « sessing the qualities of healthy bile." A Trea- tise on the Liver, p. 147. D2 46 originating from an irritation of the stomach, is a salutary exertion of the constitution, to remove the cause of the irritation from the intestinal canal. But I think it likewise probable, that the fre- quent repetition of this effort brings the liver into such a state, that it cannot re- turn to the performance of its ordinary or natural function, when the demand for its unusual action ceases; and it is in this manner that the disease may con- tinue, after the original stimuli have been removed, by again putting the child upon a proper diet. It may arise pardy from the remissness of the nurse, and from a relaxation in that care which per- haps prevented the weaning brash from coming on sooner, that this disease is produced even many weeks after wean- ing. ~ 47 The dejections are sometimes okery, or even clay coloured, which does not seem to favour the idea of a redundant secretion of bile. However, they con- tinue pale only for a short time, and soon resume the thin consistence, with their dark colour. The explanation of this I presume to be, that, during this interval, the spastic contraction may have seized the duodenum, at that part where the common duct emulges the bile into the intestines. And farther, I presume that the intestines have now become so irri- table, that they are stimulated to inordi- nate action by the aliment, even at the time when, from the supposed stricture of the duct, the bile may be deficient; and hence the griping pain still con- tinues. But it may be, and most probably is, in the ducts, that the explanation of this 48 irregularity, in a great measure, is to be looked for. I have, on dissection, found the bile collected in such quantity in the Common duct gall-bladder, that this accumulation be- came the cause of the confinement of the bile; for then the natural curve which the cystic duct takes becomes so acute, and the distended bladder presses 49 so much upon it, that the bile is pre- vented from flowing, or flows in very small quantity. By this retention, the bile becomes more concentrated, and thence perhaps more acrid. And finally, by some action of the stomach or duo- denum, by which the very enlarged gall-bladder is compressed, part of its contents is forced out, the distended ducts are relieved, and the intestinal canal is inundated with bile. That the whole abdominal viscera are *, in an extremely irritable state, is evident from the symptoms. When it is obser- ved, during dissection, that the liver is affected; that the gall-bladder and ducts are sometimes unusually distended, at another time empty, and yet empty as if recently overcharged; when, again, it is found that no aliment is contained in the canal, but, on the contrary, that the in- 50 testines are empty and pellucid, and in some parts violently contracted, it can- not be doubted that the secretion of the liver is the principal cause of the irrita- tion, and of the distressing symptoms. The mesenteric glands are enlarged, nay, in some instances; inflamed. May not this proceed from the acrid nature of the alimentary matter to which their ab- sorbing mouths are exposed? (•) (3) May not the tabes mesenterica often arise in this way? The glands of the mesentery and mesocolon in adults are often enlarged and indu- rated from dysenteric attacks {Lempriere, Bit- eases in Jamaica, Vol. II. p. 207. Cruikshanks, Absorbent System, &c.) And in scrophulous chil- dren, where a carious tooth, a running from be- hind the ears, or a scratch on the chin, will pro- duce tumor in the neighbouring lymphatic glands of the neck, it is not improbable that a continued absorption from a mass of irritating aliment, will 51 This disease, too, chiefly arises in the autumn, a season in which scrophula is occasion incurable obstructions of the mesente- ric glands. I was led to this opinion by the fol- lowing case of a girl fourteen months old, whom I saw on the 30th of May last. CASE III. This girl is quite wasted in flesh, with a very large and prominent belly, hard, and somewhat irregular, and the liver is plainly much enlarged. Several of the lymphatic glands in both groins are swelled, and she has all the appearance of a scrophulous child. Her eye is quick, her com- plexion sallow, and her face and body are cover- ed with an eruption of small and distinctly florid pimples. Her breathing is laborious, and there appears to be a considerablee scretion in the tra- chea. Her tongue is white and furred, her gums look perfectly healthy, and she has cut five teeth. She evidently labours under two diseases, one in the abdomen, the other of the lungs. 52 not apt to become active in the constitu- tion. It arises after a material change in At four months old, she was seized with a green purging, and vomiting of sour and bilious mat- ter. The bowel complaint was so violent, that it was attended with convulsions, and reduced her to extreme weakness, from which she never re- covered. At this time, the eruption first appear- ed, and, while it kept out, she was always better, and seemed recovering, until, by some unfortu- nate circumstance, it disappeared for a time, and then she became hectic. Two or three months after the attack of the bowel complaint, her bel- ly became plainly fuller than natural; but her purging had now stopped, and she took her vic- tuals well, even greedily; and therefore the ful- ness was not much attended to, until it was ac- companied with thirst and hectic sweatings.' The sweatings were always most profuse when the eruption was absent. Her father being a com- mon soldier, little was done for her, and her com- plaints were allowed to run their course. Three weeks ago, she took the inflammation, which, as I have mentioned in note 5. p. 12. was 53 diet, (*) from a diet less irritating to one more so, and at a season when, to use then epidemical, and still she was neglected, until I saw her by accident. She has now a cough, which not unfrequently brings on distressing fits of vomiting. Since the swelling of her belly came on, she has been quite regular in her bowels. Her urine generally is high coloured, and she has had con- siderable thirst and fever. She is still sucking her mother. The gradual cahexy and swelling of the belly, with the general strumous appearance of the child, leave me in little doubt as to the mesente- ric obstruction; and surely, without straining a point, I may trace the disease to the original bowel complaint, which was of many weeks duration. How matters may have stood soon after the violence of the primary disease ceased, may be (4) For this note, see page 55 E 64 the words of Dr. Saunders, " The he- " patic system in this country is more learned from the following short case from Smel- lie's Midwifery, Vol. III. p. 369. " I was called " in to a child four months old, who had been for " three weeks afflicted with curdled green stools, " and at last was brought very low by a thin wa- " tery purging. The looseness frequently return- " ed, and all methods of cure had been unsuc- " cessfully tried. The child being opened soon " after it expired, I found all the glands of the " mesentery swelled, and in hard knots." June 13. The soldier's child died yesterday, and, upon opening the body, I found, as I expected, the mesenteric glands inflamed and enlarged; the liver nearly twice its natural size, firm and pale; the gall-bladder containing a straw-coloured liquor, scarcely resembling bile; the intestines full of flatulency. In the left side of the cavity of the chest, a considerable effusion showed that ibis side of the lungs had been chiefly affected. " A French 55 11 irritable than at any other, and when " the diseases which prevail are obvious- A French physician, M. Baumes, who treats of the mesenteric disease, says, " Parmi les ma- " ladies dont le carreau est, le plus souvent, la « suite, je compte la diarrhee opiniatre." Me- moire, fee. par M. Baumes. (4) My learned friend Dr. Girdlestone, in his account of hepatitis and spasmodic complaints in India, p. 24, has some important observations on the effects of great changes in diet, which I shall transcribe. " Every change of diet, from a long continued » one, seems to act as a stimulus on the biliary '< ducts. « The officers and men who were prisoner* in « chains with Tippoo Sahib, in the East Indies, « were allowed only rice, water and capsicum, " for the many months they were with him. " When 56 " ly connected with the state of the bili- " ary secretion, and approach in their " When they were released, the animal food ;i of every kind which they attempted to eat, " purged them so violently, that they could take " it only in the smallest quantities for a consi- " derable time. " The British fleet not appearing with the " store-ships, the army was reduced to the ne- " cessity of living almost entirely on animal food. " The natives of the army, whose customary diet " is chiefly rice, were all purged by this change. " The like happens both to men and officers, " after living some months at sea on the same « diet. On making a port, the vegetables always " produce such copious secretions of bile, as « oblige them to be moderate in their use. " The patent dried cabbage was laid in for the " use of the 101st regiment. They had none of it " for the first month of the voyage; but as soon " as they began to eat it, they were all purged. « From 57 " nature to those which occur in warm " climates." Children in this country are weaned generally from the seventh to the six- teenth month; and nurses, and all those who are unacquainted with the profes- sion of medicine, whose reasonings upon it are either without any foundation, or rest on the most absurd analogies, ima- gine that the weaning brash arises from some morbid change in the bowels, oc- casioned by the process of dentition, which is going on at the same time. I shall here observe, that notwith- standing my most diligent inquiries, I have seldom been able to deduce any of the derangements of the infantine sys- « From fish also the same effects have been " seen." E2 58 tern from teething; (5) and I have been inclined to think, that those physicians (5) The gentleman from whom the following quotation is taken, writes from great experience: " In paucis casibus, semitam deviam natura non- " nunquam tenet, et violentia exoriuntur symp- " tomata. Exempli gratia, Si dentis radix vel radi- " ces citius quam corpus ipsum crescit, vasa gin- " givae membranaeque investienti propria excitari " in abnormem actionem et inflammari possint. "■ Exempla hujusmodi tamen rarissima esse aes- " timo, neque judico hunc naturalem corporis *' processum inter quern nulla animalia, si homi- •" nem excipias, vel minimum molestise pati vi« " dentur, pro morbo haberi oportere." Blake, Disputatio Medica de Dentium Formatione, p. 137. In a page or two after, he gives the opinion of Dr. Hudson, which I shall likewise transcribe, respecting scarifying the gums, which is often made a cruel operation; and when it is so, it is always an unnecessary one: " Concerning your '? question about lancing the gums of children, I 59 who have represented this function as teeming with danger, have not accus- tomed themselves to that careful inves- tigation, without which these diseases ft have avoided making it a source of revenue te " myself, convinced from experience of its futi- « lity, except in inflammatory cases, and where " the teeth are near the surface. In such cases, « the lancet gave relief; and I believe seldom or *■« never on other occasions. Where I have ope- « rated by the advice of the attending physician, « it is true, many children have recovered after « the operation; but I could never fairly say, that " the recovery was in consequence thereof." P. 141. When the gum of an infant is inflamed at the base, at the same time that there is a soft whitish spot on the ridge ef it, it may be right to scarify slightly; but I shall never think this necessary at any other time; nor can I image any danger in teething, where no increased action appears in the gums, 60 cannot be understood. The weaning brash, I have the strongest reason to be- lieve, has no connection with teething, farther than that they sometimes meet in the same child. I have known this disease, in many instances, where the gums were neither swelled, nor indu- rated, nor inflamed, and where there was no salivation, nor any appearance of pain in the mouth. I have seen it where chil- dren were cutting their teeth easily; and where many of them have come without difficulty before weaning; still the dis- ease has Supervened. But perhaps the strongest argument that can be used, would arise from the observation which I have frequently made, that this disease occurs in children of three months; and I have often known it several months before teething came on. 61 The history of the disease instructs us in the precautions to be used for pro- viding against it. If the observation which I have made be just, that it hap- pens much oftener in the autumn than at any other time of the year, it will be readily agreed, that delicate children should, at that season, be kept a month or two longer on the breast than might be thought necessary at any other, ra- ther than be exposed to the aches and hazards which never fail to accompany this distemper. And although I do not admit, that this disease is in any degree to be attri- buted to teething, yet I should certainly recommend it as a general rule, not to wean children before they have two teeth in each jaw; for this seems to be the natural period at which the food of infants should be changed; and, if I am 62 not deceived, I have observed that those children who are late in cutting their teeth, are very much exposed to the at- tacks of weaning brash. The exciting cause of this disease I consider to be, too sudden an alteration of the diet of a child at an unfit season; and if this opinion be just, it follows of course, that children ought at all times, but more particularly in the autumn, to be weaned gradually, and well accus- tomed to the food on which they are afterwards to subsist, before they are finally taken from the breast. (6) When (6) Breast milk is the proper food for infants under six months; but, after that period, I think that they should be accustomed to bread and milk, eggs and weak broths, once a-day, and thus gradually weaned from the breast. This will be less likely to produce violent effects on the con- stitution, than weaning all at once, which is some- times recommended. 63 the children of affluent parents are de- jprived of their nurse in the early months of infancy, no time is to be lost in pro- curing another, with milk suitable to the age and condition of the child. That an accidental diarrhoea, in an in- fant leaving off the breast, may, especial- ly in the autumn, soon degenerate into this disease, is not improbable. To pro- vide against this, attention should be given to the cause of the diarrhoea. It should be carefully observed, whether it arose from cold, and in consequence of the sympathy which the intestines, and more particularly the hepatic system, have with the skin, or with the extremi- ties; or whether it was not occasioned by improper food. In the former case, no remedy proves so useful as flannel worn nearest to the skin; and with regard to the latter, I must here refer to the di- 64 rections for diet which I shall have occa- sion to deliver in treating of the cure of the disease. Before I had formed the opinion of the disease which I now hold, I limited my attempts to the alleviating of the more urgent symptoms, endeavouring some- times to restrain the purging by opiates, and at others anxious and happy to re- store it again. I therefore used opiates in all ways, with aromatics; then the tes- taceous powders, with occasional doses of rhubarb. I tried laxatives in the be- ginning of the disease, and I think that they were useful. Then imagining the disease to be dysenteric, I gave ipeca- cuan, both as an emetic, and in small doses, mixed with prepared chalk, as an antispasmodic, to restrain the irregular action of the bowels, and certainly with some effect. Although I had some sue- 65 cess from these remedies in the early stages of the disease, I found invariably, that when the disease had taken a firm root, it frustrated all my exertions. In the beginning of the disease, and even at all periods of it, when the attack is slight, I should certainly recommend a dose or two of rhubarb, to the extent of five or six grains, at the interval of two days between each dose; and that, in the mean time, the child should take half or a third part of a grain of ipeca- cuan powder, mixed with six or eight grains of prepared chalk, and a small portion of some aromatic powder, as cassia, every four or five hours. Should there be much griping along with the ■ purging, a glyster of mucilage of starch with five or six drops of laudanum in it, administered at bed-time, will be attend- ed with much advantage. F 66 The success of these remedies will depend upon a strict attention to diet. An animal diet produces less irritation than one which is solely composed of vegetable matter. Eggs, the finer kind of light ship biscuit, or arrow root, cus- tard, the juice of lean meat, plain animal jellies, and broths freed from their oily part, and milk, are the chief articles of nourishment which I have ordered: The last is often the only one which children will take. I have wished for an opportu- nity of restoring the breast milk to a child, as I am convinced that it would be useful, (*) more particularly where (7) This opinion is strengthened by the follow- ing history. It is a description of the disease in question, pretty accurately represented, although the author from whom it is taken does not ap- pear conscious that he is describing a frequent and specific disease. His object is to prove, that breast milk is the proper and only food for in- fants; a proposition which no one will deny. "The 67 children have been prematurely weaned; but I never yet had it in my power. " The little infant alluded to was very healthy u when it was three months old, and was then " weaned, on account of the sickness of the wet " nurse, but soon afterwards ceased to thrive, " and had continual bowel complaints. At the •*" age of nine months, I was requested to visit it, " and was informed that it slept very little, was " almost incessantly crying, and had for many " days brought up nearly all its food; was be- " come very rickety, and had the appearance of " an infant nearly starved. Trial had been made " of almost every kind of food, except the breast; " and the child had been many weeks under the " care of an experienced apothecary, was con- " stantly in a state of purging, and seemed to be " kept alive by art. " On the first sight of the child, and on the " face of this account, it was very evident that " this infant was not nourished by the food it re- " ceived, and that the complaint lay wholly in the « first passages. But reduced as it was, I had little 68 Thin rice, or barley water, mixed with a small proportion of skim-milk, is a very proper drink for children under this dis- ease. Vegetables of all sorts, particular- ly fruits, acids, and compositions of " expectation from medicines, and therefore gave " it as my opinion, that either the child still pined " for the breast, in which case I doubted not that " it would take it, though it had now been weaned " six months; or that it ought to be carried im- " mediately into the country, and supported for " some time upon asses' milk only, or perhaps be " fed now and then with a little good broth. " My advice being taken, a good breast was " procured, which the infant seized the mpment " it was put to it, and, after sucking sufficiently, " soon fell asleep for several hours, waked with- " out screaming, and took the breast again. It is " sufficient to add, that the child ceased to puke " or be purged, and recovered from that hour, " and, after sucking eight or nine months longer, " became in the end a fine healthy child." 69 which sugar or butter form a part, and fermented liquors of every kind, have been strictly prohibited. Every one is aware of the bad effects of cold feet to those whose stomachs and intestines are irritable. I have, therefore, always recommended woollen stockings, and every precaution against cold irre- gularly applied; and I have added to the flannel which is worn nearest to the skin, a broad bandage, tied firmly round the loins. To take off the continual spasms, I have generally ordered that fomenta- tions, and the warm bath, should be fre- quently used. But I found that the utmost attention to regimen and medicine failed in the advanced stage of weaning brash. After having, with the greatest mortification, witnessed in one season, the death of F2 70 seven children, I thought myself war- ranted in changing the medicines, which I had used, for others which might have a greater effect on the liver, and produce a change in the biliary secretion. From the powerful influence of calo- mel on the body, and more particularly on the system of the liver, and from ob- serving that, in many diseases and con- stitutions, after the first or second dose, it ceased to exercise its cathartic pow- ers W; and, lastly, from considering it as (8) In one child, Who, in three days, took be* tween forty and fifty grains of calomel, in croup, I found that the bowels became exceedingly slow, and at length I was obliged to excite them by a dose of jalap. It happens with the use of other laxative medicines, that the bowels become cos- tive. " After Wyatt had long taken an ounce of " cream of tartar a-day, she even became costive " with that dose, and required the use of gam- " boge." Ferriar, Medical Histories and Reftec"- tions, Vol. I. p. 90. 71 a less violent medicine with children than adults, I was.led to the trial of it in this disease. 1 began with a child who had been ill for some months, and who appeared not likely, under the common treatment, to survive long. She was the second of a family, and, I may almost say, she was predisposed to the disease; for her eider sister had been very ill, and had with difficulty recovered from wean- ing brash. She had unfortunately been weaned in her fourth month, as her mo- ther was deprived of her milk by a fever; so that likewise, in the exciting cause, every thing was unfavourable. She had half a grain of calomel evening and morn- ing; and although the other directions which I had given, I had reason to be- lieve, were disregarded, yet under this medicine she was in a fortnight perfectly restored. 72 Since this case, I have had the useful- ness of calomel evinced by many addi- tional cases, and now I have the firmest belief, that it will prove effectual, at a stage of the disease, when no other me- dicine that I am acquainted with, would be attended with any permanent benefit. As, however, it must be a day or two before the calomel has any effect upon the liver, it may be proper, in the mean time, to prevent the disease from debili- tating the child by a continued griping, purging, or vomiting. This can often be done, in a certain degree, by glysterscon- taining a few drops of laudanum. I have seldom, of late, ventured to give lauda- num by the mouth; for I think that no accident connected with the disease, can account for the changes which I have ^een take place after laudanum and 73 large doses of absorbents have thus been given. The success which I have had with calomel has induced me to give it in di* arrhceas (fl) of children. Wherever I have (9) Calomel is recommended both by Drs. Armstrong and Underwood, in different diseases of children. The former prescribes it in what he calls The Hectic Fever, during the time of teeth- ing, and in The Tooth Rash. The latter, in the fourth edition of his treatise, which I saw only a few days ago, in some very desultory remarks upon diarrhoea, recommends calomel. " In a cer- " tain disordered state of the bowels, which fre- " quently occurs, and is disposed to continue for " a long time, during which infants, though not " precisely ill, do not thrive, nor look well." The species of diarrhoea which he alludes to, I suspect is weaning brash, from what follows: " The stools " are said to be always bad, being sometimes of " a green colour, at others of a pastey consist- " ence; sometimes very numerous, and at others, " infants^are for several days costive." He re- 74 suspected a morbid state of the bile, which is one of the most common causes, I have used it with great success. I have, by half a grain of calomel evening and morning, or by giving a grain every even- ing for a week or ten days, removed di- arrhoeas, even when the medicine was administered under the most unpromis- ing appearances. I have also found it a most effectual medicine in the chronic state of the bilious diarrhoea of children at the breast. After the third or fourth dose of calo- mel, there is generally a great change in the colour of the alvine discharge. It be- commends calomel in the following vague terms: " In this as well as in other bowel affections be- " fore described, when laxative, alkaline, and ab- " sorbent medicines have been found to procure u no permanent good effect, calomel often proves " a sovereign remedy." Article Diarrhaa. 75 comes of a dark mahogany colour, and is in general more noisome. When this change takes place, it promises a favour- able crisis in the disorder. Soon after- wards, the children become free from fever, more placid, and in a day or two after their appetite returns, with their former complexion, and every other de- monstration of health. I never found, in the many cases in which I have given calomel, that it produced salivation, or any other unpleasant effect; and I am now convinced, that it is not only one of the most general and active medicines in the pharmacopoeia, but that it is likewise one of the least hurtful. ■*»>. * CASES 07 WEANING BRASH. I n e e n scarcely mention, that the first ' * four cases which I am to detail, occurred before I had tried the effects of calomel. G 79 CASE IV. October 5. p____S----'s child, twelve months old, blue eyes. A month ago this child was weaned. Nearly a week after the weaning, a purging commenced, fre- quent, but particularly so during the night. The stools were very liquid, and generally green. The evacuation was at- tended with griping pains, and the child, who was healthy before, became pale and weak. After the purging had continued a fortnight, a vomiting came on, with which the child was frequently seized. He had scarcely any appetite for food, but a very great thirst; he was intolera- bly fretful, and was becoming emaciated. He had little intermission from fever; and this febrile state had been encou- raged, by small quantities of ardent spi- 80 rits, which his parents ignorantly were frequently giving him. He was very fond of this kind of medicine, and was in some degree continually intoxicated. About eight days ago this was the state of the boy. I then put him on the following diet: Boiled skim-milk and bread for breakfast, and, to be taken oc- casionally, the yolk of an egg, or a little weak beef tea, for dinner; a small pro- portion of milk, in thin rice gruel, as his usual drink; and, when griped, a tea spoonful of prepared chalk stirred up in it. He had a small dose of rhubarb, and next day I began to give him a third of a grain of ipecacuan every three hours. Under this medicine, which has been continued since, the frequency of the 81 purging has gradually abated, and now he is recovered from every thing but weakness. G2 82 CASE V. October 10. Benjamin H----n's child, near thir- teen months old. She was weaned at eleven month's, and about a fortnight after, a purging came on. This lasted about a month. Her stools were in general green, and sour smelling, and the disease was slow- ly gaining ground. About a week ago, the purging was checked by testaceous powders; and whether from this, or from a sudden change in the disease, the day after the purging stopped she was seized with slight but general convulsions, which daily increased, until yesterday morning, when they carried her off. When the spasms commenced, the re- turn of the purging was procured by 83 laxative medicines; then she had ano- dyne injections given, and every imagin- able antispasmodic, without the smallest effect. The day after the purging was check- ed, I observed an irruption all over her skin, which, upon examination, proved to be the strophulus candidus (*). In this child, the original disease had by no means arrived at so great a height as I have seen it. The emaciation was not so great as is usual, nor the purging nor derangement in the alimentary canal so determined. I had permission to ex- amine the abdomen. (1) See the first number of Dr. Willan's ex- cellent book on eruptive diseases. 84 DISSECTION. Upon opening the belly, the intestines appeared peculiarly white and free from blood, unless on some places on the mesentery, where there were some small congeries of turgid veins, but which were far from being inflammations. In several parts of the intestinal canal, there were remarkable contractions of the diameter of the gut, even to the di- mensions of a common earth worm; and of these contractions, at least five or six were apparent, without deranging the natural situation of the viscera. This was exactly the state of the in- testines, which should have led me to expect intus-susception of some portion of them; and accordingly, upon turning up some of the convolutions of the ilium, I observed a perfect intus-susception of 35 a few inches of the gut, but without in- flammation or adhesion of the inclosed portion. Upon spreading out the mesentery, some of the lacteal glands were ob- served much enlarged and considerably inflamed. The liver was enlarged and firm, and the gall-bladder, and the hepatic and cystic gut were gorged, and greatly distended, with a light green-coloured bile, 86 CASE VI. December 11. William B—'s child, thirteen months old. In this child, the weaning brash was seen in its last stage. He was weaned at eleven months, and was at that age healthy. Three days after he was taken from the breast, he was attacked with a purg- ing, which was neglected, and allowed to become habitual, the stools, however, varying very much. After the purging had continued five weeks, and emaciated and weakened the child, it became less frequent, but his health did not improve; he took little sustenance, and had a con- stant fever, with colic pains. The purg- 87 ing was suspended in frequency only; for the stools were still lose and clay-colour- ed, or rather okery; but, instead of troub- ling him incessantly during the night, they only occurred once in thirty-six hours. After a week passed in this way, the purging returned, and it was so con- firmed, that his mother observed that he purged within three or four minutes af- ter taking drink of any sort. At the end of the seventh week, his extremities swelled, and were with difficulty kept in heat; his purging was again repressed, but still he continued declining. He has been ill now for two months; he has con- stant fever, thirst, and fretfulness. His limbs are swelled, but he is quite flabby and wasted in flesh; he sleeps very little, and requires to be kept constantly in mo- tion in his mother's arms; he has much of that peevish expression which appears to be the effect of .he irritation of con- 88 stant pain; his urine is scanty and high- coloured, like the urine of a jaundiced person. Round the anus there is a con- siderable excoriation, from the acrimony of the dejections. His breath has a heavy, sour, and singularly disagreeable smell; his tongue is foul and sore, and, together with the rest of his mouth, is threatened with aphthae. I do not recollect that he was troubled with the vomiting which so often attends this complaint. His mother remarked to me, that when the purging comes on after the costive state of the bowels, the excrement is greener than when the stools are less frequent. In this boy, the tunica albuginea has lost its beautiful transparent colour, and is of a dead yellowish hue. December 18. This boy died yesterday. 89 DISSECTION. The intestines, floating in a consider- able quantity of deep yellow fluid, ap- peared white, and almost pellucid. In several parts, there were the same strait- enings, from spasmodic stricture, as in the preceding case. I reckoned seven such contractions in the course of the canal: The most remarkable was a con- traction of the sigmoid flexure and rec- tum, which at first seemed impervious; and at one part of the canal there was an intus-susception. The mesenteric glands were some- what enlarged and inflamed, but so slightly, that I was in doubt whether I should note this deviation. The gall-bladder was greatly distend- ed, insomuch, that from the acute turn which the cystic duct took, it required H 90 such pressure of the gall-bladder betwixt the fingers, as I feared should have burst it, in order to force the dark bile from the common duct into the duodenum. The liver was large, firm, and of a deep red colour. The bladder was so much distended, as to rise from the pelvis, and its fundus reached the umbilicus. The ureters were likewise enlarged, and the kidneys felt small and hard. 91 CASE VII. I did not see the child who is the sub- ject of this case, until within a few days of his death. The disease came on soon after weaning, and he had been ill many weeks. The appearances of the stools were various; but the purging gradually wasted him. The purging had abated before he died; but its effects were fatal. His limbs were swelled, and his feet, al- most to bursting; and in each of his hams there was a large discoloured spot, of a copper colour. His pain was often very great. Towards the end of his illness, his stools were paler than before. He had always been subject to diarrhoea, from the slightest causes. DISSECTION. In this case, the whole of the intestinal canal was not so pale nor transparent as 92 I have seen it, but it was so in mahy parts. The arch of the colon was so much dis- tended, as to fill the upper part of the abdomen. The small intestines were very irregu- larly contracted. This was observable in all the contractions, that they were firm and solid to the feeling, but, when fin- gered or distended, the thickness and solidity entirely vanished, and they were in no way distinguishable from the other portions of the gut. Again, when a por- tion of the gut, thus contracted, was lift- ed up, it was not round, but irregular, as if moulded by the surrounding intes- tines. In one of the contracted portions, there was an intus-susception. The gut had slipped in but a very little way, and was easily withdrawn; and, from the de- gree of stiffness which remained, it ap- peared as if the gut had been doubled 93 before it was drawn in. The stomach was much contracted. The liver was large, firm, and of a bright red colour. The gall-bladder was large and empty, at least it appeared so, although there was a large spoonful of bile contained in it. The bile was of a dark green colour, and had flakes float- ing in it. H2 94 CASE VIII. July 12. Mr, \j----'s daughter was weaned at six months, when she was fed upon pa- nada chiefly, and weak broths. Three weeks after and about a fortnight ago, the disease began. The stools were slimy and sour smelling, and the disease was reducing her very fast. A severe vomit- ing came on the day before yesterday, and has been constant ever since. Yes- terday the purging was suspended, but it returned in the night, and is very se- vere. Her urine is high coloured; the child is alarmingly weak; she has great thirst; her tongue is very foul, and she has a hectic glow upon the cheek. 95 July 13. She died last night, quite exhausted by the vomiting and purging. The dissection was not allowed. In this case, no attempt had been made either by medicine or change of diet to check the progress of this disease, and the rapid termination of it is to be ascribed to the stimuli, which had pri- marily occasioned it, continuing to act * upon the highly irritable intestines. 96 CASE IX. February 12. Mr. T---~'s child, eight months Old. This child was weaned between her fourth and fifth month, from her mother having been deprived of her milk by an epidemic fever about the beginning of November. About eight days after wean- ing, she took a purging, which has never left her since. She is now constantly fretful; her sleep is unrefreshing, and her appetite is much depraved; her counte- nance is alternately of a sallow paleness and flushed. She has a considerable heat of skin, and thirst, and her urine is scanty and high coloured, dying linen cloths of a deep yellow; her stools are quite wate- ry, very frequent, and of a brownish co- lour. She generally vomits every thing 97 which she takes at her meals; and some- times the aliment thus rejected is mixed with bile. * With strict attention to be paid to her diet, I ordered her to have half a grain of calomel, mixed with six grains of prepared chalk, and four grains of pow- dered cassia, night and morning, and a flannel dress. February 13. She was last night no better; her purg- ing was rather more frequent. February 14. Last night much as before; her purg- ing not quite so frequent; the dejections are changed to a dark brown colour. 98 February 15. Her mother declared, that since this child was weaned, she has not had so good a night, which she attributes en- tirely to the powders. She had only two stools in the last twelve hours, which were very dark and fetid; her thirst and fever are somewhat abated. February 17. Her stools are exceedingly dark. She continues to recover her health. And now I have an additional proof that the calomel has had the principal effect in her amendment; for the flannel which her mother was desired to apply, had been neglected or withheld. February 24. The looks of this girl are much im- proved, and I consider her as rapidly re- 99 covering. All the febrile symptoms are gone. She has not more than two stools in the twenty-four hours, and they are of a more natural appearance, although it does not appear from them as if the nu- tritive process were as yet perfect, as part of her diet passes crude and unconcocted. February 26. This child continues very well. Upon examining the mouth to-day, I observed the first tooth about to pierce the under gum. In summing up this case, I am natu- rally led to compare it with the sixth case. The children seemed to me, when I first saw them, to be very much in the same state. The course and termination of the cases will suggest a useful lesson. 100 In the beginning of April, the same little girl had a return of the purging, which was again removed by a short oourse of calomel. 101 CASE X. May 6. Mr. N----'s child, eleven months old, had been remarkably healthy and cheer- ful, and had never taken any thing but breast milk, until the day she was wean- ed. Her mother, from having had an at- tack of acute rheumatism, was forced, without preparation, to wean her exactly five weeks ago. On the day after wean- ing, she was taken with a purging, which has been violent ever since. The dejec- tions were green at first, and attended with tenesmus, which made her com- plain violently before each stool. Her stools have varied much—yesterday they were quite watery, so that the linen look- ed as if it had been stained by the mat- ter of a gonorrhoea; and by their acrimo- ny they have occasioned some excoria- I 102 tion. Her urine is high coloured and hot, her tongue is white, and her breath is heavy smelling. As usual, she has be- come ill tempered, particularly during the night; she has lost her former rosy complexion; and there is rather a loose- ness in the muscles, than an absolute emaciation. She has great thirst. The drink she takes is chiefly milk and water, and, for these two days she has vomited it curd- led. Before she was weaned, she had two teeth in each jaw, which came without any difiiculty. About a fortnight ago, two more came through in the upper jaw; but the disease has been more violent since. The gums are perfectly healthy, and there is, for the present, no appearance of any more teeth coming forward. 106 May 7. She had an anodyne glyster last night, which she kept a good many hours. She had half a grain of calomel, which is to be repeated every night and morning. May 8. She has had four doses of calomel, and her belly is already more regular. The stools appear of a very brown colour. May 11. Since bed-time last night, she has had only one motion. Her looks are improv- ed, and her thirst has left her. She is in every respect better. In this child, the disease was increas- ing. It had not, however, arrived to such a height as to make it improbable that it 104 should yield to the remedies which I used before I thought of calomel. But I had observed, that children so immedi- ately recover their appetite upon the ad- ministration of calomel, that 1 thought it proper to give the medicine which would most speedily restore the patient to per- fect health. ( 105 CASE XI. September 9. C----A----, two years three months old, has a frequent purging, which began four days ago, and which arose from the carelessness of his attendant, in having permitted him to eat some potatoes. The excretions from the intestines are green- ish and slimy. The child is so much re- duced by them, that he totters as he walks, and is quite pale and sickly. He has considerable thirst; his appetite, how- ever, is not much impaired; his skin is hot,, and his pulse is quickened by the least exertion. This child has been, all his life, liable to diarrhoea, from the slightest causes. He had it frequently while on the breast; and, upon being weaned, he had a severe 12 106 attack of weaning brash; since which time, from the least deviation in the re- gimen or diet which is pointed out for him, he invariably suffers in his bowels. He has had several attacks similar to the present; and indeed, to a certain degree, he has had an habitual looseness, which has kept him a pale and puny child. He has afforded several proofs of the efficacy of calomel in removing these complaints; for he has always recovered in a few days after the administration of it. September 15. I ordered for this child, previously to giving him the powders with calomel, a dose of eight grains of rhubarb, from thinking that the irritation might be kept up by some indigested food lodging in the bowels (a thing which I have known to take place many days after it had been taken); and after the rhubarb had produ- 107 ced a considerable effect upon the bowels, I recommended that a dose of calomel should be given twice a-day. The child very soon recovered from the purging, and is again restored to his usual state of health. 108 CASE XII. Saturday, September 19, 1801. To-day I was again sent for, to visit the child whose case is related in p. 15. I had not seen her since the 16th of June; but I understand that she has never been altogether well, that she has, ever since, had a looseness, although to no very great extent. About three weeks ago, she was sent to the country, in the expectation that she would benefit by change of air; but, being thus removed from the more immediate observation of her mother, she was not so well attended to in her diet; in particular, she was allowed con- stantly to swill down new milk. This nourishment proved too heavy for her stomach, and aggravated the purging, and brought away great quantities of slime, mixed with green faeces. She was 109 brought home some days ago much worse, and on Thursday her mouth was observed to be sore. To-day her friends were much alarmed at the appearance of it, and at the state of her bowels. On her tongue there are several ulcers, each about the size of a herring scale, with inflamed edges, and, judging from the expression of the child when any dry food is put into the mouth, very painful. The lips resemble the dry and chopped lips of a person in typhus, smeared with sordes, and with the ragged cuticle hang- ing from them in shreds. She has just got one double tooth in the upper jaw; and, judging from the breadth of the gums of the under jaw, there are double teeth about to free themselves on each side. The excretion from the belly is slimy, frequent, and sour. The child sleeps none, has considerable thirst, 110 would take sustenance, but is almost convulsed with pain when any thing is put into her mouth. Hab. Pulv. Rhei, gr. vi. September 22. She has had half a grain of calomel morning and evening since the 19th. The looseness is somewhat checked in fre- quency; the aphthous state of her mouth is not worse; the child is still in conside- rable pain, and does not sleep at night. The diet has been particularly attended to, and no drink allowed, but rice gruel, with a little milk in it. R. Mucil. amyl. % ij. Tinct. Kin. 3 fb. Theb. gt. v. M. f. Enem. Injic. h. f. September 25. The prescribed plan has been adhered to, and the child is strikingly relieved. in + / \o * i; 'ft The glyster has procured regular sleep for the child, and the ulcers in the mouth are skinned over. The dejections are much less frequent; and, although it will require a longer course of the calomel to effect a complete restoration, yet they are much more of a healthy and concocted nature. From my Notes, I could add a great many cases more which have been for- tunately treated by calomel; but I think it unnecessary to multiply the proofs, as those which I have adduced will demon- strate its usefulness. The examples which I have already given, are quite sufficient to illustrate the symptoms of this disease, which indeed admits of less variety than might be imagined. the end I MecL • Hist, VIZ 3.70 C53I Ul*t v. 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