lvw *•$>&•?/ *"*"*;*»?■?..*-".'.-^-."" &Mfi*&&Jrf/fs; '*, ..■•.-.-, faan tvnoiivn snidiqsw do Aavaan tvnoiivn snidiqsw do Aavaan tvnoiivn snidiqjv ' OF MEDICINE NATIONAL LIBRARY OF MEDICINE aan tvnoiivn 3nioi<33w do Aavaan tvnoiivn NATIONAL LIBRARY OF MEDICINE NATIONAl 3NI3I03W dO AdVSaiT TVNOUVN 3NIDI03W OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAl 3NI3I03W dO AaVaaiT TVNOIIVN 3NI3IQ3W aan tvnoiivn snidiosw do Aavaan tvnoiivn 1 /$* V OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL -X \ ^ aan tvnoiivn 3nidiq3w do Aavaan tvnoiivn snidiqsw do Aavaan tvnouvn 3nidiq3w sNiDiasw do Aavaan tvnoiivn ^|1 /k>7 DISEASES OF CHILDREN. •s A PRACTICAL TEEAT-ISE ON THE DISEASES OF CHILDREN. BY J. FORSYTH MEIGS, M.D. LECTURER ON THE DISEASES OS" CHILDBEN IN THE PHILADELPHIA MEDICAL ASSOCIATION ; FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA LINDSAY AND BLAKISTON. 1848. Entered, according to the Act of Congress, in the year 1848, By J. Forsyth Meigs, M.D., In the Clerk's Office of the District Court for the Eastern District of Pennsylvania. SHERMAN, PRINTER, 19 St. James Street. TO GEORGE B. WOOD, M.D , PRESIDENT OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, PROFESSOR OF MATERIA MEDICA AND PHARMACY IN THE UNIVERSITY OF PENNSYLVANIA, ONE OF THE PHYSICIANS OF THE PENNSYLVANIA HOSPITAL, ETC. ETC. $t)is ti)ork IS DEDICATED AS A TRIBUTE OF RESPECT FOR HIS HIGH PROFESSIONAL ATTAINMENTS AND EMINENT PRIVATE VIRTUES, AND AS A MARK OF GRATITUDE FOR HIS VALUABLE INSTRUCTIONS, BY HIS FORMER PUPIL, J. FORSYTH MEIGS. PREFACE. The motives which led the author of this volume of the Medical Practitioner's and Student's Library, to undertake its preparation, were the hope that the details of his own experience might prove of some utility, and the belief that a work on the Diseases of Children, executed upon a somewhat different plan from those already before the profession, might not be an unacceptable addi- tion to the medical literature of the country. In the preparation of the work no pains have been spared to make it both methodical and accurate, and as complete as the limits of the series would allow. The classification of diseases according to the systems which they affect, has been adopted by the writer as the most convenient. The divisions of each article are those employed by the most eminent among recent systematic writers. In the composition of the work the author has availed himself, as fully as possible, of every authority of im- portance placed within his reach, always, however, endeavouring to judge what came under his notice, by the knowledge derived from his personal experience in private practice. In this way he hopes that he has been able to select from the labours of others, whatever is most important to be known in the present state of medical sci- ence, and to reject what seemed fallacious or useless. The work X PREFACE. from which he has drawn most largely, is that of MM. Rilliet and Barthez, which was originally intended to have formed the basis of the present treatise. This plan was, however, abandoned very soon after the commencement of the work, from the impossibility, with proper justice to those writers, of introducing either the per- sonal experience of the author, or a great amount of very useful material to be derived from other sources. He desires, however, distinctly to acknowledge his great indebtedness for valuable as- sistance obtained from their work, especially in regard to the symptomatology and morbid anatomy of several diseases brought under consideration. In addition, the author has constantly consulted the works of Underwood, Dewees, Eberle, Stewart, Condie, Billard, Barrier, Berton, Bouchut, Brachet, and Valleix, on the diseases of children; the portion of the Bibliotheque du Medecin Praticien, devoted to the same subjects ; Tweedie's Library of Practical Medicine, Cop- land's Medical Dictionary, the Guide du Medecin Praticien of M. Valleix, and the Dictionnaire de Medecine Pratique. Various treatises on the practice of medicine, and different articles in the medical journals, which it is here unnecessary to mention in de- tail, have also been consulted and quoted. It is proper to remark in addition, that, in stating what he has himself observed, the author has endeavoured to do it with the greatest possible accuracy; and whenever the subject has con- cerned facts susceptible of numerical demonstration, he has inva- riably, if he has had the means, employed that method of state- ment, in order that the reader might be enabled to draw his own conclusions. Whatever may be the advantages or disadvantages of the numerical method of observation in medicine, it seems to him that it must be of vastly greater service in giving accuracy and certainty to the recorded results of treatment, than the plan PREFACE. XI usually followed by the older writers, of merely stating their own generalizations (often no doubt loosely and carelessly drawn), in- stead of giving to the reader the facts upon which those generali- zations were founded, and thus allowing him to judge for himself of their probable truth and correctness. The author desires to state, in regard to the use of the first person singular throughout the work, that, in the words of Dr. G. B. Wood upon the same point, he " has been actuated by no spirit of egotism, but merely by a wish to express the fact, without affec- tation, in the shortest and simplest mode." In conclusion, the writer is anxious to express his thanks to Dr. Alfred Stille, of this city, for much valuable advice in regard to the preparation of the work. Philadelphia, June 21, 1848. TABLE OF CONTENTS. PAGE. Preface ........ vii CLASS I. DISEASES OF THE RESPIRATORY ORGANS. CHAPTER L DISEASES OF THE UPPER AIR-PASSAGES, Article I.—Coryza ... - 25 II.—Pseudo-membranous laryngitis ... 31 III.—Spasmodic laryngitis - - ... 52 IV.—Simple laryngitis .... - 64 CHAPTER II. DISEASES OF THE LUNGS AND PLEURA. Article I.—Pneumonia - - - - - - 74 II.—Bronchitis - - - - - - 105 IIL—Pleurisy......U9 IV.—Hooping-cough, - - - - - 135 CLASS II. DISEASES OF THE DIGESTIVE ORGANS. CHAPTER I. DISEASES OF THE MOUTH. General remarks - - - - - • - 152 Article I.—Simple or erythematous stomatitis 152 2 XIV CONTENTS. Article II.—Aphthse -.„.-- 154 III—Ulcerative or ulcero-mcmbranous stomatitis - 158 IV.—Gangrene of the mouth - - - - 163 V.—Thrush......177 CHAPTER II. DISEASES OF THE THROAT. Article I—Simple or erythematous pharyngitis - - - 197 II-—Pseudo-membranous pharyngitis ... 204 CHAPTER III. DISEASES OF THE STOMACH AND INTESTINES. General remarks ----... 215 SECTION I. FUNCTIONAL DISEASES OF THE STOMACH AND INTESTINES. Article I__Indigestion ----.„ 218 II.—Simple diarrhoea - 232 SECTION II. DISEASES OF THE STOMACH AND INTESTINES ATTENDED WITH APPRECIABLE ANATOMICAL LESIONS. Article I.—Gastritis ---... 244 II.—Entero-colitis ---._. 254 111.—Cholera infantum - 288 IV.—Dysentery - ... . . _ 3|g CLASS III. DISEASES OF THE NERVOUS SYSTEM. General remarks ..... 322 CONTENTS. CHAPTER I. DISEASES OF THE NERVOUS SYSTEM ATTENDED WITH APPRECIABLE ANATOMICAL ALTERATIONS. Article I.—Tubercular meningitis ----- 324 II.—Simple meningitis, .... - 352 III.—Acute hydrocephalus ..... 363 IV.—Cerebral congestion .... 368 V.—Cerebral hemorrhage .... - 373 CHAPTER II. NEUROSES, OR DISEASES OF THE NERVOUS SYSTEM UNATTENDED WITH APPRECIABLE ANATOMICAL ALTERATIONS. Article I.—General convulsions or eclampsia, - - 386 II.—Laryngismus stridulus .... 407 III.—Contraction with rigidity ... - 428 IV.—Chorea - - - - - - 433 CLASS IV. m ERUPTIVE FEVERS. Article I.—Scarlet fever or scarlatina .... 445 II.—Measles, rubeola or morbilli .... 492 III.—Variola or small-pox .... 519 IV.—Revaccination ..... 539 CLASS V. WORMS IN THE ALIMENTARY CANAL. General remarks ------ 543 Article I.—Ascaris lumbricoides ----- 548 II.—Ascaris vermicularis - 564 ^ PRACTICAL TREATISE DISEASES OF CHILDREN. CLASS I. DISEASES OF THE RESPIRATORY ORGANS. CHAPTER I. DISEASES OF THE UPPER AIR PASSAGES. ARTICLE I. Definition; synonymes ; forms; frequency.—This disease, which consists in an inflammation of the mucous membrane of the nasal passages, is called in common language, cold in the head, or snuffles. Underwood describes what he calls coryza maligna, or morbid snuffles, which, he says, is very different from and a far more serious disorder than what is usually called snuffles. De- wees makes no reference to it. Eberle describes it under the title of coryza. He doubts whether coryza maligna ever occurs in this country, and takes his account chiefly from Underwood and Denman. I shall make two forms of the disease, the simple and the pu- rulent or pseudo-membranous. The first form generally occurs in connexion with some other disease, as bronchitis, pneumonia, 3 26 CORYZA. measles, scarlet fever, or pertussis. It sometimes exists, however, as an idiopathic affection, but is never dangerous unless it occur in new-born infants, and assume the purulent or pseudo-membra- nous character. It is so mild indeed, that it need not occupy our time, and is commonly spoken of as cold in the head, or snuffles. The other variety of the disease will constitute the subject of the present article, and is that called by Underwood, coryza maligna or morbid snuffles. Purulent and pseudo-membranous coryza rarely occur as idio- pathic affections, but are almost invariably connected with an- gina or other diseases. I met with one case, however, of the purulent form unaccompanied by angina or other disease, in 1841, in a child seven weeks old. The case proved fatal. I saw ano- ther fatal case of the same form, connected with simple angina, in 1846, in a child five weeks old. Besides these two cases, I have met with four others of the pseudo-membranous variety, accompa- nied by simple angina, in children between two and six years of age, all of which terminated favourably. The two varieties of the disease occur, however, as already stated, much the most fre- quently as secondary affections in the course of other diseases, par- ticularly measles, scarlet fever, pseudo-membranous angina, &c. I shall not attempt in the present article to treat particularly of the cases which accompany the eruptive fevers. Causes.—The causes of the disease in the two infants observed by myself were unknown. In one the nurse remarked a slight discharge of blood from the nose soon after birth, and the coryza dated from that time. The other, a feeble child, was attacked when two weeks old without any appreciable cause. The re- maining four cases occurred in 1845 and 1846, during an ex- tensive prevalence in this city of severe scarlet fever, measles, and pseudo-membranous angina and laryngitis, which makes it probable that they depended upon the epidemic constitution of the atmosphere. The cases of Rilliet and Barthez coincided gene- rally with primary or secondary purulent or pseudo-membranous angina. From the account given by Underwood of coryza maligna, there can be little doubt that it was epidemic when observed by himself and Denman. The latter author states that in connexion with the coryza there was general fullness of the ANATOMICAL LESIONS--SYMPTOMS. 27 throat and neck externally; that the tonsils were tumefied, and of a dark red colour, with ash-coloured specks, and in some cases, extensive ulcerations ; and that some of the children swallowed with difficulty ; all of which symptoms clearly point to severe con- comitant angina. Anatomical lesions.—The Schneiderian mucous membrane is found reddened uniformly, or in points, rough, thickened, and sometimes softened. When pseudo-membrane is present, it exists either in fragments, or lines the whole extent of the nasal pas- sages, and is mixed with mucous or muco-purulent fluid, in greater or less quantity. Symptoms. — Coryza begins with sneezing and stoppage of the nostrils, soon after which the discharge, which is the patho- gnomonic symptom of the disease, makes its appearance. This consists of serous or mucous fluid in greater or less abundance, and usually of a yellowish colour, which, at first thin and without odour, becomes in slight cases, thicker and often purulent, with a peculiar, unpleasant, but not fetid odour. In severe cases, on the contrary, and especially when the pseudo-membranous exudation is present, the discharge is thin, and often contains small granular particles, which seem to be the detritus of the false membrane, while at other times it is ichorous or even bloody. When false ■ membrane is present, it can often be seen upon examination of the nostrils in a strong light, to cover the mucous membrane in the form of thin adherent layers of a yellowish-white colour. The alse nasi, and sometimes the whole extremity of the nose, are red and swelled, and the skin, which is tense and shining, presents an erysipelatous appearance. The upper lip is generally reddened, irritated, swelled, and sometimes excoriated, by the nasal secre- tions. The respiration is generally difficult, nasal, and snoring. When the nasal passages are nearly or quite filled with the secretions, the child being no longer able to breathe through them as in health, is compelled to keep the mouth open. This is exceedingly inconvenient to children of all ages, as it causes great dryness and stiffness of the mouth, tongue, and throat, and in very young infants, who instinctively respire almost exclusively through the nostrils, is attended with such violent efforts, as to be a chief 28 CORYZA. or perhaps sole cause of the fatal termination of some cases. In one instance that I saw, the child was seized with attacks of suffocative breathing, which threatened fatal asphyxia, when- ever the passages became much impeded. Under these circum- stances the cleansing of the passages with a brush would afford complete relief, and, for a time, the little thing would appear to be quite well. Finally, however, death occurred in one of the at- tacks of dyspnoea, from sudden serous effusion into the lungs. The difficulty of respiration is greater, as I have stated, in propor- tion as the child is younger, and depends on the physiological fact, that at a very early age, respiration is performed almost solely through the nostrils, the child seeming incapable of keeping the mouth open, in order to compensate for their closure. I have never observed cough except in cases accompanied by angina. Epistaxis occurred in two cases of the pse'udo-membranous form, in children between three and five years of age. The bleeding recurred on several occasions, but ceased so soon as the coryza was cured. Infants refuse the breast when the passages are much clogged, or suckle with great difficulty and at long intervals. The character of the general symptoms depends much more upon the accompanying disease, in older children, than on the coryza itself, and it is unnecessary therefore to dwell upon them. In the two infants observed by myself, the principal symptoms were, in the case unaccompanied by angina, restlessness, weakness, ema- ciation, dry, harsh and wrinkled skin, and violent attacks of dyspnoea; and in the other case, in which angina was present, there were added to these, fever and somnolence. Berton gives the duration of the disease as from eight to fifteen days, according to its intensity. Rilliet and Barthez state that they saw a child two years old die in three days, and another of three years in the same time; but as one of these cases was complicated with an- gina and croup, and the other with pseudo-membranous angina, it is clear that the rapid death depended rather upon the accom- panying disease, than the coryza itself. The duration, as ob- served by myself, in the two cases occurring in infants, was between two and three weeks, in its severe form, in the one unat- tended by other disease, and six days in the one accompanied bv angina. In the other four cases, which occurred in older children, PROGNOSIS--TREATMENT. 29 the duration of the attack depended on the form and degree of the attendant angina. In one case it became chronic, and was accom- panied by ulceration of the nasal passages. The prognosis must depend on the age of the child, and the nature of the attack. In young infants, simple idiopathic coryza is never, perhaps, dangerous; while the idiopathic purulent or pseudo-membranous forms are extremely so. The only two cases of the latter kind that I have seen were fatal. The four cases in older children recovered without any difficulty. When it occurs in connexion with pseudo-membranous angina, or in the course of scarlet fever, the prognosis will of course depend on that of those diseases. Treatment.—Simple coryza requires no treatment in children over two years of age, except attention to hygienic conditions. I believe that young children may often be preserved from attacks of spasmodic laryngitis and of bronchitis, by calling the attention of the mother to the strong tendency which exists during infancy and childhood to extension of disease, and advising, in cases of coryza, that the child should be secluded in the house, or else very warmly clothed, if sent out. In infants, even simple coryza gives trouble, by causing ob- structed respiration, and consequent restlessness. For these symp- toms I have found nothing so useful as passing a small camel's- hair pencil loaded with sweet oil, some distance up each nostril, and directing the outside of the nose, the openings of the nostrils, and the upper lip, to be freely anointed with cold cream, simple cerate, or any soft and adhesive ointment. In infants labouring under purulent or pseudo-membranous coryza, the indications for the treatment are to remove the secre- tions as they collect, and to subdue the inflammation of the mucous membrane which produces them. The first indication may be fulfilled by means of a brush made of long camel's hair, by throw- ing water from a small syringe into the nasal passages, or when the discharges are thin and fluid, by blowing strongly into the nostrils, whilst the tongue is depressed by a finger introduced into the mouth, so as to allow the secretions to pass out of the posterior nares into the fauces. 3* 30 COR VZ A. The second indication is to be fulfilled chiefly by the application of solutions of alum, nitrate of silver, sulphate of zinc or copper, and by insufflations of different substances in powder. The best application is probably the solution of nitrate of silver, which may be made of the strength of five or ten grains to the ounce, or stronger, to be made use of several times a day, with a brush. I have also employed injections consisting of solutions of alum, of from three to six grains to the ounce. It is recommended by Rilliet and Barthez to make insufflations of powdered gum and alum, or of gum and calomel in equal parts, several times a day. There is, however, it seems to me, an objection to this method of treatment, especially in infants, which is that the powders would necessarily tend to increase the obstruction to breathing through the nose, already existing. It has been proposed also to apply a few leeches to the mastoid process, or over the frontal sinuses. This might be done in hearty children. In the form of the disease accompanied with angina, an essen- tial part of the treatment must be that of the throat-affection. This will be considered in another place. Case.—The subject of this case, a male, was born after an easy, natural labour, and appeared strong and well, with the ex- ception of a little discharge of blood from the nose soon after birth and slight coryza, the latter of which continued until the child was five weeks old, when it became aggravated, and my father was re- quested to visit the infant. I saw it at the same time. It was small and puny; the skin was harsh, dry, and wrinkled, so that the child looked like a little old woman. It was very weak, and had constant secretions from the nostrils of thick, dark-coloured pus. When the discharge collected in sufficient quantity to obstruct the passages, the respiration became exceedingly difficult, as the little thing seemed incapable of breathing through the mouth, and at such moments it seemed as though the child must die of asphyxia. If the nostrils were cleared by any means, by syringing, by the use of a brush, or by blowing into them in the manner already de- scribed, the respiration would become easy and natural, until the discharge collected again, when the same scene recurred. Durina the paroxysms arising from the closure of the nasal passages, the l'SEUDO-MEMBRANOUS LARYNGITIS. 31 child was entirely unable to take the breast, but after being relieved, had no difficulty whatever; the mouth was either kept shut, or if open, the tongue was observed to be pressed spasmodically against the roof of the mouth, so that it was impossible for more than a very small amount of air to pass through it; the respira- tion was laboured, and accompanied by a loud snoring or nasal sound. There was no other marked symptom, except a nearly constant flatulent distension of the epigastric region. On the day before death, the infant seemed better, appeared to have gained flesh, and looked more intelligent, so that the mother was greatly encouraged ; but the next day it was seized during one of the paroxysms of suffocation, which did not seem to be worse than many preceding ones, with copious discharges of bloody and frothy serum from the mouth and nose, and died in about three quarters of an hour. At the post-mortem examination we were not allowed to exa- mine the nasal passages or throat. The stomach and bowels were healthy, but much distended with gas. The peritoneum was healthy, but contained a considerable amount of clear yellow- ish serum. There was serous effusion in both pleural cavities, but no traces of inflammation. The lungs were healthy, with the exception of some ecchymosed points, and general infiltration with sanguineous frothy serum. The trachea and bronchia were natural. The heart was larger than usual, but healthy in other respects. ARTICLE II. PSEUDO-MEMBRANOUS LARYNGITIS. I shall describe three forms of laryngitis,—the pseudomem- branous, spasmodic, and simple or erythematous. It seems evident from the recent works on diseases of children, that there are two distinct disorders, which have until within a few years, and which are even now by many in this country, con- founded together under the appellation of croup. In fact it is the 32 PSEUDO-MEMBRANOUS LARYNGITIS. custom in many parts of the United States, to apply the term croup to all the affections of the larynx characterized by dyspnoea, hoarse spasmodic cough, and croupy respiration; whereas there are four different maladies which present in a greater or less degree the symptoms just mentioned. These are: pseudo-mem- branous laryngitis, or true croup; spasmodic laryngitis, or false croup ; simple laryngitis; and laryngismus stridulus, or spasm of the glottis. Underwood describes pseudo-membranous and spasmodic laryn- gitis as a single disease, under the title of suffocatio stridula; Dewees under that of cynanche trachealis, or croup; and Eberle of cynanche trachealis, tracheitis, or croup. Underwood evidently describes laryngismus stridulus in his chapter on inward fits ; Dewees has nothing in regard to it; while in Eberle's work it is easily recognised under the title of carpo-pedal spasms. Definition; synonymes; frequency.—Pseudo-membranous la- ryngitis is an acute inflammation of the mucous membrane of the larynx, attended with exudation of false membrane. It is the croup of the French writers, and is called in this coun- try slow, creeping, true, membranous, or inflammatory croup. The term given above seems most suitable, as expressive of the real nature and seat of the disease, and I shall therefore make use of it in contradistinction to that of spasmodic laryngitis or spas- modic or false croup, which is a much more common and less dangerous form of disease. The frequency of the disease is very considerable. During the ten years preceding 1845, there occurred in this city, according to Dr. Condie (Dis. of Child., Note, p. 88), 3977 deaths under fifteen years of age, from bronchitis, croup, pneumonia, hooping-cough, and other diseases of the respiratory organs. Of this number, 1149 were from croup alone; and as spasmodic croup is seldom a fatal disease, it is reasonable to conclude that much the larger number of these deaths were from the disease under consideration. It is rare however, it seems to me, in comparison with spasmodic laryngitis, or as it is called here, croup. During the last five years, I have seen twelve cases of primary pseudo-membranous laryngitis, and in the same period, thirty-one of primary spasmodic laryngitis, of which CAUSES. 33 I have kept a record, and a considerable number of additional cases of which I have no written account. Predisposing causes.—Age.—The disease is most frequent be- tween the ages of two and seven years. Of the twelve cases that I have seen, ten occurred between two and seven years of age, and the other two at eighteen months and eleven years, respec- tively. As to sex, it is said to be more frequent in boys than girls. A feeble, delicate constitution is thought by some to be a power- ful predisposing cause, though this is contrary to the experience of Rilliet and Barthez. Of the twelve cases referred to all but two occurred in healthy, vigorous children, and these two were neither very weak nor very sickly, but presented a rather more delicate appearance than usual. Season appears to exert some influence as a cause, since the disease is apt to be most prevalent in spring and autumn. It is either sporadic or epidemic, resembling in this respect pseudo-membra- nous angina. When epidemic it is very generally connected with angina, while the sporadic cases frequently begin in the larynx, and often run their course without implicating the pharynx. Du- ring the latter part of the year 1844, the whole of 1845, and a part of 1S46, the disease prevailed extensively in this city, and was in many cases accompanied by the pharyngeal affection. During those years, and particularly in 1845, measles and scarla- tina also prevailed to a great extent, especially the former. Is the disease contagious ? In the article on pseudo-membranous angina, it will be stated that some of the most distinguished autho- rities unhesitatingly pronounce that disease contagious. In regard to the one under consideration, more doubt is expressed, and both M. Valleix, and Rilliet and Barthez, say that additional facts are neces- sary to determine this point. My own experience has never given me the least reason to suppose that it is propagated in this man- ner, as I have not known it extend from one child to others in the same family. The exciting causes are but little understood. The only ones which seem to have been ascertained with any certainty, are the application of irritating agents to the laryngeal mucous membrane, and exposure to cold ; and even these are questioned by the most 34 PSEUDO-MEMBRANOUS LARYNGITIS. accurate observers. In none of the cases that I have seen, could the exciting cause be even suspected. Anatomical lesions.—The false membrane may cover the whole of the mucous membrane of the larynx, and extend into the pha- rynx, trachea, and even bronchia, or it may be confined to the larynx, forming a complete lining to the cavity of that organ, or consisting merely of patches of various sizes, with intervals of mu- cous membrane between, destitute of exudation. It would seem that the membrane is confined to the larynx and trachea in about two-thirds of the cases, while in the other third it implicates the bronchia. The proportion of cases in which the pharynx is at- tacked is.uncertain. According to M. Valleix, M. Hache found false membrane on the tonsils in only half of the cases. The false membrane is generally of a yellowish-white colour, and from a fifth of a line to a line in thickness. Its consistence is generally considerable, and it is usually somewhat elastic. The free surface is usually covered with puriform mucus, while the inner surface is adherent with various degrees of force to the mucous membrane beneath. It consists, according to Hasse, mainly of fibrine blended with mucus in various proportions. {Patholog. Anat., Syden. Soc. Edition, p. 278.) The mucous membrane presents various shades of redness, or is violet-coloured, or even blackish. In other cases it retains its normal characters, a circumstance which has given rise to the opinion entertained by some persons, that the disease is not in- flammatory, though it is altogether probable that this condition is consecutive to the formation of the exudation. The membrane is sometimes brittle, friable, and thickened, and in rare instances softened. Bronchitis and lobular pneumonia are frequent complications of the disease; the other organs are healthy in the great majority of cases, with the exception of venous congestion. In the secondary croup of measles the appearances are very similar to those observed in primary cases, while in that of scarlet fever the exudation differs in being less consistent and less uni- formly spread over the diseased part. In the last-named malady SYMPTOMS. 35 the membrane is thinner, less adherent, and softer, and in some cases puriform, soft, and of a grayish colour. It is usually poor in fibrine, and prone to decomposition. The mucous membrane is generally discoloured and softened. Symptoms.—It is highly important to ascertain the proportion of cases in which the disease commences in the larynx, and those in which it begins in the pharynx. It is difficult, however, to determine this question in the present state of knowledge upon the subject, as it has not been carefully examined by a sufficient number of observers. Rilliet and Barthez state that a majority of the cases observed by themselves, and also of those of M. Hache, commenced in the larynx. M. Guersent, on the contrary, {\Dict. de Med., t. ix. p. 339) asserts that in nineteen-twentieths of the cases, it begins in the pharynx, and I have heard some physi- cians in this city assert that the diagnosis between the disease and common or spasmodic croup, cannot be considered as positive during life, unless the pharynx contains an appreciable amount of pseudo-membranous exudation. From this I entirely differ, and believe, on the contrary, that the disease may exist in the larynx without at all implicating the pharynx in some cases, while in a considerable number the pharyngeal complication is exceed- ingly slight. Of the 12 cases that I have seen, the attack com- menced with angina only in 3 ; in 2 of the remaining 9 there was no angina ; in 3 there were no pharyngeal symptoms, so that the state of the throat was not examined ; whilst in the remaining 4, all of which began with laryngeal symptoms, there was fibrinous exudation in the pharynx, confined however entirely to the tonsils. It is probable that the disease is most apt to begin in the pharynx in epidemic cases, while in those which are sporadic, it most fre- quently begins in the larynx. When the disease begins in the pharynx the early symptoms are the same as those of pseudo-membranous angina. After a longer or shorter period, from one to seven days usually, accord- ing to the nature of the epidemic, the malady extends into the larynx, causing cough and hoarseness, and then follows the same course as when it commences in that organ. When, on the con- trary, it begins in the larynx, the invasion is marked by hoarse- 36 PSEUDO-MEMBRANOUS PHARYNGITIS. ness of the voice, and hoarse, croupal cough, which often continue for one, two, or three days, until the disease has made considerable progress, before the parents deem it necessary to send for a physi- cian. In one case that came under my observation, the child was playing about the room at a time when he had hoarse, whispering voice and cough, and stridulous respiration. In another I was not called until the evening of the third day, though the child had had stridulous cough and respiration for two nights, but, as he always seemed better in the morning, it was not thought necessary to send for me until after he had become violently ill. In a third there was hoarseness of the voice and slight croupal cough during the afternoon of one day and the ensuing night, and the next morn- ing fully developed croup, with fibrinous patches on each tonsil. These symptoms are not generally accompanied by fever at first. The appetite is usually unimpaired, the thirst scarcely augmented, and the child, though somewhat dull and languid, is disposed to be amused at times. In other and severer cases, on the contrary, the disease becomes aggravated much more rapidly, and may soon lead to a fatal termination. The change of the voice is the first symptom observed in the cases which begin in the larynx. It was always described to me as hoarse, like that which is heard in an ordinary cold. As the dis- ease progresses, the voice becomes more and more hoarse and diffi- cult, until at length it is reduced to a mere whisper. The degree of the hoarseness varies however to a very great degree, the diversities depending probably upon the amount of the spasm of the larynx at the moment, and upon the state of the exudation. I have several times observed it to become much stronger and clearer after the ope- ration of an emetic, in consequence no doubt of its relaxing effect upon the glottis. The cough is peculiar. At first slightly hoarse, it becomes, as the case goes on, very hoarse and hollow, and then short and smothered. It is variable in frequency and is apt to occur in paroxysms, which are often very troublesome from their frequent recurrence. Towards the termination of the disease in fatal cases, or whenever the case is very severe, it is altoo-ether different from what it was at the beginning, becoming short, in- stantaneous, and smothered, so that it might very well be called SYMPTOMS. 37 whispering. As the case advances it is accompanied by stridulous respiration, in which a hoarse, rough, hissing, or crowing sound is produced by the rush of the air through the constricted larynx. This sound is usually heard at first only during forced inspirations, and is therefore noticed first during the long inspiration which precedes coughing. Next it is heard during the violent respira- tory movements which accompany the act of crying; and as the larynx becomes more and more clogged with the exudation, it occurs during both inspiration and expiration, in every respiration, and is so loud as to be heard over the whole room, or even in adjoining rooms. The respiration is natural in the early part of the attack, but as the voice and cough assume their characteristic features, and the stridulous sound is established, it becomes more frequent, rising to 28, 32, 40, and 48, in the minute. At first easy and natural, it assumes during the height of the symptoms, and especially in fatal cases, the most frightful orthopnoea I have seen in any disease. Every movement of inspiration requires the whole force of the inspiratory muscles to lift the walls of the chest, and enable the air to find its way through the narrow and obstructed glottis ; each expiration, instead of being short and easy, as in health, and in nearly all other diseased conditions, requires a slow and laborious contraction of the expiratory muscles to expel from the lungs the air which they contain, and which hisses through the larynx with a sound nearly as loud as that produced during in- spiration. The orthopnoea just described occurs sometimes in paroxysms, but at other times is constant. In only one of my cases did it assume the form of paroxysms, and in that the patient recovered. In the others, both favourable and unfavourable, it was constant, or at least the variations were slight, and dependent chiefly upon the action of emetics. When the orthopnoea occurs in paroxysms, the expression of the child is that of the most terrible anxiety, or of the wildest terror. In one instance, the face became deeply red, then blue, hvid, and finally pale and white, and for a moment life seemed extinct. In the other cases, in which dyspncea was constant, the face was of a dusky 4 38 PSEUDO-MEMBRANOUS LARYNGITIS. red colour, the expression anxious and haggard, and the child either laid on its side with the head thrown far backwards in a state of somnolence or was constantly changing its position, from restless- ness, without noticing anything around it. There is no expectoration early in the disease, or it con- sists of white or yellowish viscous mucus. At a later period, there is often expectoration of false membrane, sometimes in the form of a complete tube, or much more frequently, of small irre- gular fragments, mixed with mucus, or with the matters ejected by vomiting. To detect the membrane, the substances expectorated or vomited ought to be placed in water, when it. detaches itself from the mucus and other matters, and is easily recognised. It is not present in all the cases. Thus, of the 12 cases observed by myself, it was expelled by vomiting or coughing only in 3; in 6 it was known to be present by the character of the symptoms and by its existence in the pharynx; in 2, there was expectora- tion of masses of viscid, yellowish fibrine; and in the remaining cases, there was no positive evidence of its existence. M. Val- leix {[Guide du Med. Prat., tome i., p. 330) states that of 51 cases, in which the symptoms were very carefully observed, no traces of the exudation could be discovered either in the expec- toration or in the matters rejected by vomiting in 26, though their existence was proved by post-mortem examination. Auscultation.—Barth and Roger ( Trait. Prat. oV Auscultation, 2d ed. p. 255 and 261) describe, as a sign of croup with floating false membrane, a kind of vibrating murmur, or tremblotement, as though a moveable membranous veil were agitated by the air, which can be heard when the stethoscope is applied over the larynx or trachea. If this sound is heard only in the larynx, and not in the trachea and bronchia, it indicates the plastic exudation to be of small ex- tent, and likely to be rejected by expectoration, and the prognosis is favourable. In the other case, on the contrary, it shows the disease to be of considerable extent, and the prognosis becomes much more serious. The vesicular murmur of respiration is masked by the laryngeal stridulous sound, when this is present. When absent, the respiration is natural, or altered according to the state of the lung. SYMPTOMS AND TERMINATION. 39 There is a slight febrile movement at the onset, or a day or two after the appearance of the earliest symptoms. When the disease is fully established, the fever becomes violent, and the pulse rises to 130, 140, 160, or even higher. It is generally regular and strong at first, but as the case progresses, becomes small, feeble, and very rapid. In one of the paroxysms that I witnessed, it-be- came so rapid that it could not be counted, and at last ceased to beat at either wrist for a few instants. The heat and dryness of the skin are very moderate at first, but increase as the disease reaches its maximum, to diminish afterwards gradually, and in fatal cases, to be replaced by coldness, with copious clammy per- spirations. The strength is not diminished at first, but as the disease progresses, is more or less so in proportion to its violence and duration. The digestive organs are but little disturbed by the influence of the disease, with the exception of diminution or loss of appetite, and moderate thirst during its violent period. Sponta- neous vomiting or diarrhoea are rare, though both sometimes occur. The tongue is moist, and generally covered with yellowish-white fur. Pain in front of the larynx has been noticed by several authors. I have never observed it. Tumefaction of the sub-maxillary glands, which is a frequent symptom of pseudo-membranous angina, ought always to be sought for, and if present, lends additional support to the diagnosis. In favourable cases the recovery is sometimes very sudden in con- sequence of the expectoration of a tubular-shaped membrane. This is a very rare event, however, and recovery does not always follow. In general the recovery is slow and gradual. After free vomitmg, after the expectoration of fragments of false membrane mixed with mucus, or, as happened to myself in two cases, after the expecto- ration of masses of tough, yellowish fibrine, or lastly, after the rejection of mucoid and frothy sputa only, the symptoms gradually ameliorate; the stridulous respiration slowly subsides, and at last disappears; the cough, which was short, hoarse, and smothered, became louder, stronger, less hoarse, and, what is still more fa- vourable, loose; the aphonia moderates, but very slowly; the fever disappears; appetite and gaiety return; and after a va- riable len-th of time, the child enters into full convalescence. 40 PSEUDO-MEMBRANOUS LARYNGITIS. The hoarseness of the voice very generally continues for several days after all the other symptoms have lost their dangerous cha- racter, and sometimes lasts for weeks. In one case, the voice was still weak and hoarse on the tenth day, and in another during the seventh week. (See a paper on croup, by the author. Am. Jour. Med. Sci., April, 1847.) Duration.—Death has been known to occur on the first, second, and third days, but such cases are rare. The duration of the disease may be stated at from three to thirteen days, as its most common term. The cases seen by myself, lasted from five to fourteen days. Diagnosis.—The diagnosis of the disease, when it follows pseu- do-membranous angina, presents no difficulty whatever. When, on the contrary, it commences in the larynx, as we have seen that it often does, especially in sporadic cases, it may be confounded with stridulous laryngitis or sporadic croup, and with simple laryn- gitis. The mode of distinguishing between them will be described under the head of the two last-mentioned affections. Prognosis.—Pseudo-membranous laryngitis is a very fatal dis- ease. Rilliet and Barthez state that its common termination is in death. M. Valleix says that " to speak in general terms, it is fatal when not treated energetically." Guersent (Loc. cit. p. 365), after a careful consideration of the statements of different authors, says : " In fact, true croup is one of the most dangerous of all diseases, and is generally fatal." He adds that he has seen at least a hundred cases of spasmodic croup, without a single death, while of ten children attacked with true croup, it is scarcely possible to save two. The degree of mortality is very strikingly different in different epidemics. Thus of sixty cases observed by M. Ferrand in the villages about La Chapelle Veronge, not a single one escaped. Other writers speak of having cured three or four in forty, and others nearly all. Dr. Bard, of New York, says, that of sixteen cases, seven died. Of the 12 cases that I have seen, 6 died. Of the 12, 3 commenced with violent pseudo-membra- nous angina, of which 2 died. The remaining 9 began in the larynx, and of these 4 died, and 5 recovered. From personal experience I would conclude that the sporadic are less dangerous PROGNOSIS--TREATMENT. 41 than epidemic cases, though the mortality is frightful even in those. The danger is great in proportion as the child is younger and more feeble, in proportion to the rapidity of the case, and to the degree of the dyspnoea or orthopnoea. The most unfavourable symptoms are: loud stridulous sound heard both in the inspiration and expiration; laborious and prolonged expiration; whispering voice or complete aphonia; congestion of the face and neck ; somnolence; weak, rapid, and irregular pulse ; cold extremities; and cold clammy perspirations. The favourable symptoms are: expectoration of false membrane; diminution of the stridulous respiration; the change from whispering to hoarseness or clear- ness of the voice; looseness of the cough; moderation of the fever; improvement of the temper and moral state; and ame- lioration of the general condition. The case should not be abandoned as hopeless until life is ac- tually extinct. I myself saw a child recover after momentary suspension of animation, by asphyxia, on two occasions, and though these attacks were followed by a dreadful illness of two days. (See paper by the author. Loc. cit.) Treatment.—I am desirous, at the beginning of my remarks upon the treatment of the disease, to express the opinion, that none is likely to succeed, unless it be applied early in the case, and by this I mean, in the course of the first, or at the latest, second day. And not only should it be commenced early, but the most powerful remedies ought to be applied at this period, in their full force. The very moment there is good reason to suppose that a case will prove to be one of this disease, the most energetic means ought to be brought to bear upon it, and if this be done from the first, or even second day, I cannot but hope that a considerably larger proportion of recoveries may take place, than has heretofore been thought possible. Of seven cases that were treated in the manner I shall recommend, from an early period in the attack, five recovered. Of five cases not so treated, only one recovered. Of the latter cases, I saw three in consulta- tion, late in the attacks, and the other two several years since, 4* 42 PSEUDO-MEM BRANOUS LARYNGITIS. before I fully understood the importance of early and energetic treatment. In the study of the treatment, it will be necessary to rely chiefly upon the works which have been published since the dis- tinction between the two forms of croup has been correctly drawn, for it is impossible to place much dependence on the asser- tions of previous writers, inasmuch as their opinions as to the effects of treatment have been formed from indiscriminate expe- rience in two very opposite maladies. It is only necessary to re- collect the enormous difference in the mortality of the two affec- tions, to be convinced that the success of such or such a plan in the one, is no fair argument for its probable success in the other. Thus M. Guersent has seen a hundred cases of spasmodic laryn- gitis, without a single death; while he believes that of ten cases of pseudo-membranous disease, scarcely two can be saved. I have a record of thirty-one cases of spasmodic croup, and have seen a considerable number of cases besides, of which I have no notes, without a single death ; whilst of twelve cases of true croup that I have met with, six proved fatal. The most important objects to be held in view in the treatment are, it seems to us: to pre- vent, if this be at all possible, the formation of false membrane; after its production, to cause its dissolution, or render it less ad- herent ; to provoke its expectoration ; to prevent its reproduction after it is once expelled ; to subdue the inflammatory diathesis which exists ; and to allay the painful symptoms. Bloodletting.—Many authors award to bloodletting the first place in importance amongst the remedial means in our posses- sion, and it seems to be regarded by many in this country as an indispensable agent in the cure. Moreover, there are not a few who believe that, when promptly and boldly resorted to, it will seldom fail in arresting the disease. Underwood says (BelPs Ed., p. 273): «Bleeding is always necessary, if the physician be called at the commencement of the disease, or stridulous noise ■ and if the patient be visited too late to endure this evacuation, I believe no hope can remain of his being benefited without it, unless the infant be very young; which, however, in another view, can- not but add to the danger." Dewees recommends it very highly TREATMENT. 43 in fully developed cases attended with fever, and advises it to be repeated if the symptoms persist. Eberle says (Dis. of Child., p. 356): " Without doubt, however, the remedy upon which our principal reliance should be placed, for the removal of the tracheal inflammation is bloodletting." Dr. Condie (Dis. of Child., 2d edit., p. 305) recommends it as the most effectual remedy in arresting the disease, and says that " the practitioner, who in violent cases, neglects this important measure, and places his hopes on any other remedy, or combination of remedies, will have but little reason to flatter himself upon his success in the management of the disease." Unfortunately for us, the value of the opinions just quoted is very much diminished by the fact that the authors who emit them, have not clearly distinguished be- tween the two varieties of the disease, so that their experience is derived in part at least from the effects of the remedy in spasmo- dic croup; and, as it is now well known that that disease is very readily cured in the vast majority of cases, it is easy to under- stand the confidence they express in the utility of any means which they may have employed. But if we examine the works of those who have made the dis- tinction between the two diseases, we shall find different opinions from the above, expressed, in regard to the efficacy of bloodletting. Guersent (Doc. cit., p. 373) asserts that bleeding has not the power of arresting the progress of this specific inflammation,—that the disease continues with greater or less rapidity under the influ- ence of general and local bleedings, and almost always terminates fatally, though the detractions of blood may have been pushed to the utmost limit. Bretonneau is of opinion that it has no effect in pre- venting the formation of the false membrane. Valleix (Loc. cit., p. 353) says : " From the examination of a large number of cases, I am convinced, with M. Bretonneau, that bleeding, whether gene- ral or local, is not a powerful curative means, and that it does not obviously arrest the progress of the disease." Rilliet and Barthez (T. i., p. 262) are of opinion that bloodletting ought to be resorted to only in vigorous children; in the early part of the attack in sporadic cases; and in those in which the febrile reaction is vio- lent, and the suffocative symptoms strongly marked; while it 44 PSEUDO-MEMBRANOUS LARYNGITIS. ought to be abstained from in epidemic and adynamic cases ; in young, pale, and lymphatic children; when the fever is slight; the dyspnoea moderate; and lastly, that it ought never to be em- ployed in the advanced stage of the disease. Dr. Wood (Trea- tise on the Pract. of Med., vol. i. p. 788), in his remarks on the treatment of the disease, says: " Depletion, in this variety of croup, is much less efficient, than in the catarrhal." He adds that the utmost to be expected from it is, that it may moderate the severity of the inflammation, and thus probably diminish the amount of the effusion. I proceed now to state the results of my own experience as to its effects. It was employed in two of the three cases which be- gan as angina; in one the child was bled once and leeched once, and recovered; in the other, leeches were used and the case ter- minated fatally; in neither of them could I perceive that the de- pletion exerted any positive control over the symptoms of the dis- ease. In the third case, no bloodletting was employed, and it also proved fatal. Of the nine remaining cases, all of which com- menced in the larynx, it was employed in all. Of them, two of the subjects were eighteen months old ; two, two years; four, three years; and one, six. All were bled from the arm, and in two, leeches were applied to the neck besides. A single venesection of four ounces was employed in seven, while in two, a venesection of about the same amount was performed three times in each. Of the nine cases five recovered and four died. The two cases bled to the largest amount (three times each), recovered. In one of these there were small patches of fibrine on each tonsil, and rejec- tion of false membrane by coughing and vomiting. The immediate effects of the bleeding in the second series of cases were decidedly more beneficial than in those following an- gina ; they were diminution of the fever and dyspnoea. In none, however, was the relief from bleeding so great as that which fol- lowed the free operation of an emetic, and be it remarked, that emetics were freely employed in all. Emetics.—This class of remedies is recommended by all writers, and is generally acknowledged to be one of the most if not the most important, of all the means employed. M. Valleix TREATMENT. 45 (Loc. cit., t. i. p. 358), has demonstrated their importance more fully than any other writer. He states that of 53 cases of the disease, tartar emetic and ipecacuanha were chiefly relied on in 31, of which 15 were cured ; whilst of the 22 others in which they were parsimoniously given, not a single one recovered. He states other facts in regard to these cases which are highly interesting and important. Thus of the 31 cases treated with powerful emetics, false membrane was rejected during the efforts of vomiting in 26, and of these, 15 or nearly three-fifths recovered. In the 5 others of the 31, on the contrary, no membrane was expelled, and they all terminated fatally. Again, of the 22 cases in which emetics formed but a secondary part of the treatment, 2 rejected false membrane, and of these one recovered; while of the 20 others in which no false membrane was expelled, not one escaped. Of the cases that I have seen, emetics formed a principal part of the treatment in one of the three which commenced as angina, in one they were used to a slight extent, and in the third not at all. The first one recovered, the others died. In none of them was there rejection of false membrane. They were used ener- getically and frequently repeated, in 8 of the 9 cases commencing as laryngitis, 5 of which recovered. The remaining case, in which they were used as secondary means, proved fatal. In 3 of the 8 cases, fragments of false membrane were rejected, and in a fourth, a mass of viscid yellowish fibrine. Of the 4, 3 re- covered. In none of the remaining 5 was there any expulsion of false membrane, and of these, 3 died. It seems to me that these facts are sufficient, to show that emetics exert a most powerful and beneficial influence on the disease, and that they ought, therefore, to enter into the treatment as principal remedies. The emetics generally employed in Europe and this country are tartar emetic and ipecacuanha, which are given in the usual doses to produce full vomiting. I have been in the habit of em- ploying a substance as an emetic, which, so far as I know, was first recommended for that purpose by my father. The substance to which I refer is the alumen of the pharmacopoeia. In an article published by my father in the Med. Examiner, (vol. i. p. 414, 46 PSEUDO-MEMBRANOUS LARYNGITIS. 1838), he says he has been " accustomed to make use of an emetic, which, so far as I can learn, is very little employed, but which, from the certainty and the speediness of its operation, ought to be more generally admitted into' the list of available medicines for this particular case at least. I have been familiar with its effects for more than twenty years, and my confidence in them increases rather than diminishes by time." He adds, " I think that I have never given more than two doses without causing very full vomit- ing ; but I have often given large quantities of antimonial wine and ipecacuanha, without succeeding in exciting the efforts of the stomach." The alum is given in powder, in the dose of a teaspoonful, mixed in honey or syrup, to be repeated every ten or fifteen minutes until it operates. It is very seldom necessary to give a second dose, as one operates in the majority of cases very soon after being taken. I have known it to fail to produce vomiting only in two instances, both of which were fatal cases. In one the disease had gone so far before I was called, that no remedy had any effect upon the stomach. In the other, it was administered several times with full success, but lost its effect at last, as had happened also in regard to antimony and ipecacuanha. The reasons for which I prefer alum to antimony, or ipecacuanha, are the fol- lowing : antimony, when resorted to as frequently in the disease as I am of opinion that emetics ought to be, is too violent in its action; it prostrates many children to a dangerous degree, and is, I fear, in some cases, itself one cause of death. It acts inju- riously upon the gastro-intestinal mucous membrane, when used in large quantities, and for any length of time. Again, it is very apt to lose its effect, and to fail to produce sickness. Ipecacu- anha is a much safer remedy than tartar emetic, but its operation is often too mild, and it also ceases to produce any effect after it has been used several times. The advantages of the alum are that it is certain and rapid in its action, and that it operates with- out producing exhaustion or prostration beyond that which always follows the mere act of vomiting. It does not tend like antimony, and in a less degree ipecacuanha, to produce adynamia of the nervous system ; an effect which, in some constitutions or states TREATMENT. 47 of the constitution, or when it has been exhibited frequently, is often attended with injurious or even dangerous consequences. I have given alum in the dose above mentioned, twice and three times a day, for two and three days, without observing any bad effects to result from it. The alum was given in all the cases that I have seen, in which emetics were used, and was the only one employed when it was found to produce full vomiting, with a single exception,—one of the cases accompanied by violent angina,—in which ipecacuanha was substituted because of its smaller bulk. I have already said that it failed to produce vomiting only in two instances. It was the emetic employed in the three cases in which fragments of false membrane were rejected, and in that in which the yellow viscid fibrine was expelled. Although it did not occa- sion the rejection of membrane in the other cases, it operated most speedily and efficiently. Sulphate of copper has been highly recommended by several writers for its emetic operation, and by some German physicians, as exerting a specific influence upon the disease, in addition to its emetic effect. As an emetic it may be given to a child two or three years old, in the dose of from half a grain to a grain every fifteen minutes, until it operates. To obtain its specific action it is continued afterwards in doses of a quarter of a grain every two hours. There is another remedy which has been proposed as an emetic by Dr. Hubbard, of Hallowell, Maine. This is the turpeth mineral, the subsulphate or yellow sulphate of mercury, the hydrarg. sulphas, flavus of our Pharmacopoeia. Dr. H. recom- mends it on the grounds of promptness and certainty, of never producing catharsis, and lastly of not being followed by prostration like that occasioned by tartar emetic. The dose is two or three grains for a child two years old, to be repeated in ten or fifteen minutes, until it operates. He says that if the first dose fails, the second usually acts as soon as it reaches the stomach. I have made trial of this remedy in two cases. The first was one in which alum and tartar emetic had lost their power from fre- quent repetitions. The orthopnoea was intense, and as I believed that the only chance of escape for the child was the operation of 48 PSEUDO-MEMBRANOUS LARYNGITIS. an emetic, I proposed the subsulphate. The age of the child was three years. Three grains diffused in syrup were administered, which operated powerfully within a few minutes, and when I saw the patient one hour after, the distressing symptoms were con- siderably ameliorated. The improvement did not last, however ; the child died in a state of exhaustion very soon after. The other case was that of a boy nine years of age, in whom the alum had operated fully, but as it failed to dislodge the membrane, and his situation was desperate if not relieved, I made trial of the turpeth mineral. Six grains were given in two doses, at fifteen minutes interval, but they produced no effect whatever. The case terminated fatally, and the whole larynx and trachea were found filled with a thick membrane. I conclude these protracted remarks upon emetics with the statement, that from what I have read, and from personal ex- perience, I am induced to regard this class of remedies as the most important that we have to oppose to this fearful malady. The emetic, whichever it may be, ought to be given at least once, generally twice, and sometimes three times in the twenty-four hours ; the period and frequency of their administration to be de- termined by the stage and urgency of the symptoms, and the con- stitution and present strength of the patient. Calomel.—Dr. Samuel Bard states that Dr. Douglas of Boston, who published in the year 1736 an account of the angina suffo- cativa, was the first to recommend the employment of mercury in the disease. Bard says that he was induced to try mercurials after reading Dr. Douglas's little essay, and adds, "the more freely I have used them, the better effects I have seen from them." He gave calomel in the quantity of thirty or forty grains in five or six days, to children three or four years old ; " not only with- out any ill effects, but to the manifest advantage of my patient; relieving the difficulty of breathing, and promoting the casting off the slough beyond any other medicine." He recommends that the first one or two doses be combined with an opiate. He con- siders mercury as the basis of the cure. Since it has been so highly recommended by American practi- tioners, mercury has been extensively employed and relied on by TREATMENT. 49 European physicians. Bretonneau gave it in large doses, and Rilliet and Barthez recommend it in the same way. Valleix, on the contrary, doubts whether there are any cases of true croup on record, cured by calomel alone. Calomel was freely used in 8 of the 12 cases observed by myself. Of the 8 cases, 5 recovered, and 3 died. Of the 4 cases in which it was not used, 3 died. The largest quantity exhibited in any one case, was between forty and fifty grains; the smallest, eight. It ought to be observed, however, that it was given in very large doses in the three fatal cases; in one between forty and fifty, in another forty, and in the third between twenty and thirty grains. In the successful cases, the quantities given were forty, twenty- two, twenty, sixteen, and eight grains. It is proposed by some to give it in very large and frequently repeated doses. I would recommend it in most cases in the quan- tity of two grains every second hour, to children over two years of age. If the symptoms were very violent, and the danger im- minent, I would give three or four grains every hour, for three or four hours, and then administer an emetic of alum. If the child is very restless, and if the calomel purges, it would be proper to combine a'small quantity of Dover's powders with each dose. The administration of calomel in large doses, has not been followed by bad consequences in any case in which I have used it. Nevertheless, it has been known to produce gangrene of the mouth, and necrosis of the maxillary bones, and the practitioner cannot be too careful to suspend it as soon as may be consistent with safety. I would never administer it in this way without first informing the parents of the possible danger to which it exposes the child, and asking their consent to its employment. In addition to the remedies already mentioned, there are some which are supported by high authority at home or abroad. Amongst them are the sulphuret of potassium, polygala seneka, and different alkaline preparations, especially the carbonate of potash. There is much difference of opinion amongst French writers as to the merits of the sulphuret of potassium, some prais- ing it highly, while others deny it all efficacy. I have never used it, and can therefore have no personal opinion in regard to its 5 50 PSEUDO-MEMBRANOUS LARYNGITIS. utility. As to the carbonate of potash and seneka, they may be useful as adjuvants, but I am clearly of opinion that they should never take the place of emetics and mercurials; for, as time, above all things, is precious in this disease, I would never use feeble remedies, to the exclusion of those which are generally acknowledged to be more powerful. Revulsives often prove useful in allaying restlessness and mode- rating the violence of the suffocative attacks. Sinapisms and mus- tard poultices applied upon various parts of the cutaneous surface, and mustard pediluvia, are amongst the best. The warm bath is often highly beneficial in the same way. Blisters are sometimes used, but flying sinapisms are preferable. Antispasmodics are recommended, and are doubtless useful in some cases. The best in the world is, we think, the operation of an emetic; and after this some preparation of opium. Hygienic Treatment.—The child ought to be warmly clothed and confined to bed. The diet should consist only of the mildest fluids during the violence of the attack. If the patient becomes weak and feeble, milk, pure or mixed with water, may be al- lowed ; or light broths may be given. Towards the termination of favourable cases, the diet must be improved slowly and cautiously. If great prostration occurs, the powers of the constitution must be supported by stimulants and tonics, as wine whey, milk punch, and quinine. Summary of the treatment.—My own conclusions in regard to the treatment are : that bloodletting is a valuable remedy, when resorted to in proper cases, and at the proper moment. In the form which begins as angina, and which is generally epidemic, it ought to be used with more caution than in that which com- mences as laryngitis. In the latter form, which is usually sporadic, it ought to be used more freely, especially in vigorous and hearty children. In children over two years of age, I would take from three to four ounces of blood from the arm, once, twice, or three times in two days, according to the strength of the child, and the degree and obstinacy of the fever. In both forms of the disease, emetics, and I would recommend the alum in preference to any other, should be given once at least, very often twice, and in violent cases, three times in the twentv-four hours, so as to TRACHEOTOMY. 51 produce vomiting attended with a good deal of effort. At the same time, I would give, as a general rule, two grains of calomel with a quarter or half a grain of Dover's powder, every two hours, taking care not to give a dose for an hour before, nor after the time selected for the exhibition of the emetic. In cases in which there is loud stridulous respiration, heard both in the inspiration and expiration, in which previous treatment has had no effect, and in which there is threatening of speedy death, I would give four grains of calomel every hour, until three or four doses have been taken, and direct the exhibition of an alum emetic, after the last dose. Seven of the twelve cases so often referred to were fairly treated by the mixed method just described. One I saw with Dr. Rutter of this city, two with my father, and four I attended myself. Of the 7, 2 died, and 5 recovered. Tracheotomy.—The operation of tracheotomy has been seldom resorted to in this country, and is, I believe, held in slight favour amongst us. Nevertheless, it is recommended as useful and ex- pedient by many of the most accomplished French physicians and surgeons, and is frequently resorted to as offering an addi- tional chance for life. M. Valleix, (Doc. cit., t. i.,) expresses himself strongly in its favour, in very violent cases of the disease. He states that the success of the operation has, thus far, been as great as that of any treatment devised. He founds this asser- tion on the results furnished by 54 cases of unquestionable pseudo- membranous croup, great care being taken to select only the cases in which the diagnosis was positive. Of the 54 cases, only 17, or about a third, recovered, and this he states as precisely the re- sult, according to himself and M. Bricheteau, of the operation. But, as he remarks, the operation was performed in the great majority of the cases under the most unfavourable circumstances, and not till after all other treatment had been vainly tried, and the severity of the symptoms and commencing asphyxia, announced impending death. For these reasons he is of opinion, that a single cure under such circumstances, is of more weight than several obtained in cases where all the resources of the art has been ap- plied from the commencement. 52 SPASMODIC LARYNGITIS. For further information upon this subject, and for the method of performing the operation, I would refer the reader to the article on tracheotomy by M. Valleix (Guide du Med. Prat. t. i. p. 386); •to the one by M. Trousseau, in the first volume of the work of MM. Rilliet and Barthez; and to that by the same author in the Dictionnaire de Medecine (t. ix. p. 381). ARTICLE III. SPASMODIC LARYNGITIS. Definition ; synonymes ; frequency.—Spasmodic laryngitis is a superficial inflammation of the mucous membrane of the larynx, accompanied by spasmodic contraction of that organ, occasioning violent attacks of threatened suffocation. It is the disease commonly called in this country croup, or by those who make the distinction between it and pseudo-membra- nous laryngitis or true croup, spasmodic croup. I prefer the term spasmodic laryngitis, used by Rilliet and Barthez, because it is expressive of the essential characters of the disease. It is the stridulous laryngitis of Guersent and Valleix; the stridulous an- gina of Bretonneau; the acute asthma of infancy of iMillar; and the spasmodic croup of Wichmann, Michaelis, and Double. It is not the laryngismus stridulus described by the English authors, Kerr, Ley, and Marsh, which is the same as the thymic, or Kopp's asthma of the Germans, and spasm of the glottis of the French. It is called by Dr. Wood, in his recent work on practice of medi- cine, catarrhal croup. Spasmodic laryngitis is one of the most frequent of the diseases which occur during childhood in this country. It is so common in this city, that almost all mothers who have had any experience in sickness, keep some remedy for it in their houses, which they are in the habit of resorting to upon their own judgment. I met with fifteen cases of the disease during the winter months of IH.46.7, and in the last three years have seen thirty cases, of which I CAUSES--ANATOMICAL LESIONS. 53 have kept a record, besides a considerable number of which I have no written account. Predisposing causes.—Age is a powerful predisposing cause. It is said to be most frequent between three and eight years of age. From personal observation I should suppose it to be most common between one and four years of age. Of the 30 cases referred to, 3 occurred within the year, 11 between 1 and 2 years, 7 between 2 and 3, 6 between 3 and 4, and 3 between 4 and 5 years of age. It is also said to be more frequent in boys than girls. Of the 30 cases that I have seen 18 occurred in girls, and 12 in boys. The disease is undoubtedly a sporadic one, and is asserted by some authors to occur also in the epidemic form. It is generally be- lieved to be hereditary in certain families, and of this I myself have no doubt. I am acquainted with one family in this city, in which the children for three generations were extremely liable to it; with another in which the grandmother and grandchildren were frequently attacked; and with a third, in which the father and children showed the same predisposition in the most marked man- ner. The idea is, moreover, entertained by many people in this community. The state of health of the child does not seem to have much in- fluence in the production of the disease ; I have seen it occur in- differently in the weak and strong. It is most common during cold weather. Exciting causes.—By far the most frequent exciting cause is the action of cold ; either the passage from a warm into a cold atmosphere, or prolonged exposure to cold. I was assured on one occasion, by a very intelligent lady, that her little daughter had, at the age of two years, a well-marked attack of croup, after a severe and long-continued fit of crying from some contrariety. Anatomical lesions.—M. Valleix (Guide du Med. Prat. t. i. p. 290) says that the accounts of the anatomical lesions are very vague, and-that these are generally stated to be very slight. A little mucus, and slight redness have been observed in some cases, but authors have usually been satisfied with stating the larynx to be free from any alteration. Dr. Wood ( Treat, on the Practice of Medicine, vol. i. p. 779) says : " In some rare instances, no signs 5* 54 SPASMODIC LARYNGITIS. of disease are discovered in the mucous membrane, and the patient has probably died of spasm, consequent upon high vascular irrita- tion or congestion, the marks of which disappear with life." I am unable to describe the lesions found after death from personal knowledge. It appears to me, however, from the study of the dis- ease, that it must depend on slight inflammation of the laryngeal mucous membrane, for how else can we account for the fever which so often accompanies it, the hoarseness of the voice and cry, which often remains for some time after the total disappearance of the paroxysm, and the loose catarrhal cough which very generally follows the attack ? Symptoms; duration.—The invasion of spasmodic croup is generally very sudden, for though it is often, perhaps in the majo- rity of cases, preceded for a few hours or a day or two by slight coryza, hoarseness and cough, these symptoms are seldom no- ticed at the time, and the child is not supposed to be sick until it is seized with the attack of suffocation, which is pathognomonic of the disease. This attack occurs in much the larger number of cases during the night, and very generally wakes the child from "sleep. Of the 30 cases observed by myself, it occurred in the night in all. The period of the night at which it takes place is very irregular ; of 19 cases in which the time was noted, it was before midnight in 11, and after midnight in 8; which agrees very closely with the statement of Rilliet and Bar- thez, that it has been observed most frequently at 11 in the evening. The duration of the attacks varies considerably, and depends a good deal upon the treatment employed. They may last from a few minutes to several hours; but seldom less than half an hour or an hour. The number of the attacks also varies. In some cases there is but one, though very generally there are several. When the attack occurs early in the night, it is very apt to recur again towards morning, and, unless means of preven- tion are used, on the following night also, and even, though this happens much more rarely, on the third night. As a general rule, the first attack is the most severe. When the paroxysm comes on, the child is wakened from sleep by thp sudden occurrence of symptoms apparently of the SYMPTOMS--DURATION. 55 most alarming and dangerous character. These consist of loud, sonorous, and barking cough; of prolonged and laboured inspi- rations, accompanied by a shrill and piercing sound, to which the term stridulous is applied ; of rapid and irregular respiration, amounting often to violent dyspnoea, or seemingly impending suffocation : the child, alarmed and terrified at its condition, and at the fright of those around, its countenance expressive of the utmost anxiety, cries violently between the attacks of cough- ing, and begs to be taken on the lap, or sits up or tosses itself upon the bed, struggling apparently with the disease, which seems for the moment to threaten its very existence. The voice and cry are hoarse, and sometimes almost extinguished during the height of the paroxysms, but become distinctly audible, and often nearly natural, in the intervals between them; differing in this respect from pseudo-membranous croup, in which they remain perma- nently hoarse or whispering. I have never heard, in this disease, the whispering voice and the short smothered cough of true croup. The face, head, and neck, are at first deeply flushed, and as the paroxysm becomes more violent, assume a dark livid tint, which afterwards passes into a deadly paleness, if the attack be long continued. These changes in the coloration depend upon the arrest of the respiratory function and consequent partial asphyxia. The pulse is frequent during the paroxysm, and the skin heated. After a longer or shorter period, generally from half an hour to an hour, the respiration becomes more tranquil ; the stridulous sound disappears entirely, unless the child be disturbed and made to cry, when it again becomes distinct; the cough is less frequent and less boisterous, and the child generally falls asleep. The attack is very apt to recur towards morning, as has been stated, and if not then, the following night. The patient often seems perfectly well the day after the first paroxysm, with the exception, perhaps, of slight cough. This is no reason, however, for sup- posing that the disease will not return in the course of the second night, which is almost sure to happen, unless measures be taken to prevent it. The cough generally continues for a day or two, but soon loses the peculiar character expressed by the term croupal; it becomes less frequent and more loose, and the child is com- 56 SPASMODIC LARYNGITIS. monly well again in two or three days. Sometimes, however, the cough lasts for several days, becoming gradually less fre- quent, until at last it ceases entirely. There is very little fever in moderate cases, for though the pulse is accelerated, and the skin warm during the paroxysm, these symptoms disappear very soon after that is over. In severe cases, on the contrary, there is usually considerable fever, the pulse being frequent and full, and the skin hot. The febrile movement is most apt to occur after the first paroxysm, as a consequence, apparently, of the slight catarrh which remains after the attack. In the few fatal cases on record, the paroxysms have generally become more frequent and more violent by degrees, and death has occurred from suffocation. In other instances, death has been the result of prostration, which has probably depended on imperfect hsematosis. Recurrences of the disease are very common, children some- times having several attacks in a single winter. This is not the case in true croup. I have never known a child to have a second attack of that disease. The duration is exceedingly variable. Sometimes there is a single attack during the night, and the child seems well after- wards, with the exception of slight cough, lasting two or three days. More generally, there is a return in the course of the second night, or, much less frequently, the third, after which the proper croupal symptoms disappear entirely, though the child may continue to cough for several days longer. The cough usually be- comes loose and catarrhal after the last paroxysm, though in some kw instances, I have known it to retain its hard, barking sound, and to be accompanied by slight hoarseness for eight or ten days. The average duration may be stated at from one to three days. Nature of the disease.—Authors hold very different opinions as to the nature of spasmodic laryngitis. We have already seen that it is confounded by Underwood, Dewees, and Eberle with the pseudo- membranous form of laryngitis. Dr. Cheyne (Cyclop. Prat. Med. Art. Croup), treats of the two affections as one and the same dis- ease, differing only in their degree of violence. Dr. Copland (Diet. of Prac. Med. Art. Croup), describes spasmodic croup as a variety NATURE. 57 or modification of true or membranous croup. He supposes that the modifications of true croup are attributable to " the particular part of the air-passages chiefly affected, to the temperament and habit of body of the patient, and the intensity of the causes." It seems to me, however, that these views as to the nature of the two diseases can scarcely be correct, and I am induced by personal observation to regard them as distinct affections, which may, in the great majority of cases, be distinguished from each other at a very early stage, by a careful observer. The comparative fatality of the two diseases alone is sufficient to esta- blish a wide difference between them. Thus, of twelve cases of the pseudo-membranous form that I have seen, six died; while of thirty cases of the spasmodic form of which I have kept a record, and a considerable number of which I have no notes, not one was fatal. M. Guersent states that of ten cases of the former disease, scarcely two escape; while of upwards of a hundred of the latter that he has seen, not a single one was fatal. (Diet, de Med. t. ix. p. 365.) The different effects of treatment in the two affec- tions again, points out a wide difference in nature. While true croup is almost inevitably fatal, unless it is attacked at a very early period by the most energetic remedies, by bloodletting, calo- mel, and emetics, the spasmodic form seldom resists the exhibi- tion of an emetic, a warm bath, nauseating doses of ipecacuanha or antimony, or, in the severest cases, a small detraction of blood by leeches. When we add to these circumstances, the differences in the mode of invasion ; in the cough, voice, and cry ; the fever; the duration; the state of the constitution; all of which will be care- fully described in the article on diagnosis: it seems to me very difficult to resist the conclusion that they are two distinct disorders, and not, as has been generally supposed by English writers, de- grees or modifications of the same. As to the precise nature of spasmodic laryngitis, I have been led to adopt the opinion that it depends on slight inflammation of the mucous membrane of the larynx, attended with violent spasmodic action of that organ. The spasm of the larynx appears to be the result of disordered action of the excito-motory inner- vation of the part, the irritant which is productive of the morbid 58 SPASMODIC LARYNGITIS. innervation being, in all probability, the slight inflammation of the laryngeal mucous membrane, which has been already stated to constitute one element of the malady. The nervous element pre- dominates in the early part of the attack, but towards the conclu- sion, the spasmodic symptoms disappear entirely, and we have left only those which depend on the laryngeal inflammation. Diagnosis.—Unquestionably the disease with which spasmodic laryngitis is most likely to be confounded is pseudo-membranous laryngitis, true, or inflammatory croup. The only certain means of distinguishing them are the presence of pseudo-membranous ex- udation in the fauces, or the rejection of false membrane from the larynx in the latter affection. But, though these are the only posi- tive single signs, the two diseases may be distinguished with very great certainty by a comparison of the different symptoms as they arise. The most important are : the invasion, in one sudden and almost invariably in the evening or night, in the other, slow and creeping, the paroxysm occurring indifferently day or night; the cough, in one hoarse and boisterous, in the other hoarse and frequent at first, but rare and smothered towards the end; the voice, in one hoarse, but never scarcely whispering, and if so, only during the height, in the other hoarse at first, and soon perma- nently whispering or entirely lost; the cry, in one hoarse and stridulous only at the moment of the paroxysm, in the other per- manently so; the respiration, in one stridulous and difficult only during the paroxysm, and in the interval perfectly natural, in the other, at first natural, becoming by degrees permanently stridulous, and attended by the most violent dyspnoea and orthopnoea, with remarkable prolongation of the expiration ; the fever, in one very slight and generally observed only during the nocturnal paroxysm, in the other much more considerable and permanent; and, lastly, the duration, in one seldom more than two or three days, in the other rarely less than six, and very often eight or ten days. M. Trousseau states that the hoarse, sounding, croupal cough, is not a sign of the presence of exudation in the larynx, but rather of its absence; but, on the contrary, « when the cough, croupal at first, becomes less and less frequent, and ends with being nearly inso- norous with suffocation, there is true croup, that is to say with DIAGNOSIS--PROGNOSIS. 59 plastic exudation in the larynx." This is precisely my own ex- perience. The rare, insonorous cough of M. Trousseau, is the condition which I have expressed by the term smothered. In order to render the diagnosis still clearer, I add the following table, which is altered from one given by Rilliet and Barthez. Spasmodic Laryngitis. Begins with coryza, and hoarse cough, or more frequently by a sudden attack of suffocation in the night. Fauces natural, or merely slight red- ness, as in simple angina. After the paroxysm, the child seems well; the fever disappears, or is very slight. Voice natural or only slightly hoarse; not whispering. If the paroxysm returns, it is during the following night, and it is less se- vere ; the hoarseness disappears; the cough becomes loose and catarrhal. Duration seldom more than three days. Very rarely fatal. Pseudo-membranoos Laryngitis. In epidemic form, begins as pseudo- membranous angina. In sporadic form, invasion of slight hoarseness for a day or two. There is fever, increase of the hoarseness, with hoarse, croupal cough; in half the cases, pharyngeal exudation, and a little later paroxysms of suffocation. The fever continues ; stridulous re- spiration; prolonged and difficult ex- piration; cough hoarse and smothered; voice hoarse and whispering. The dyspnoea and suffocation in- crease; the voice and cough are smo- thered or extinguished; stridulous re. spiration persists. Duration seldom less than five or six. The hoarseness continues for several weeks. Fatal in the majority of the cases. It may be confounded also with laryngismus stridulus, and with simple laryngitis. The signs by which it is to be distin- guished, will be stated in the articles on those diseases. Prognosis.—Spasmodic laryngitis is very rarely a fatal disease. It has already been stated that of 30 cases of which I have a record, and of a considerable number of which I have no notes, not one died ; while M. Guersent makes a similar statement in regard to upwards of a hundred cases. That it does sometimes terminate fatally, however, there can be no doubt. This is the opinion Rilliet and Barthez have arrived at, after careful study of the subject. These authors quote in proof of it, amongst others, two cases from the work of Jurine, in one of which an autopsy was made, 60 SPASMODIC LARYNGITIS. and no false membrane discovered. Copland (Doc. cit.) remarks that in the few cases of the more purely spasmodic forms that he has had an opportunity of examining, an adhesive glairy fluid, with patches of vascularity on the epiglottis and larynx, and a similar fluid in the large bronchi, were the only alterations observed. The favourable symptoms in the disease are: diminished vio- lence of the paroxysms ; clear and natural, or merely hoarse voice ; loose, catarrhal cough; disappearance of the fever ; and absence of disposition to returns of the disease, or its return in a milder form each time. Unfavourable symptoms are: obstinate continuance of the paroxysm in spite of the usual remedies ; re- turns of the paroxysm after the third night, especially if their violence increase rather than diminish; severe nausea or vomiting; feeble, soft pulse ; and weakness of' the voice, with other signs of exhaustion, even though the paroxysm may have ceased. Treatment.—Guersent (Doc. cit. p. 367-368) states that demulcent and mucilaginous drinks, with stimulating manuluvia and pediluvia are the principal means that ought to be employed in the treatment of spasmodic laryngitis, or pseudo-croup. He proscribes the use of emetics and leeches as unnecessary in most cases, and is of opinion that they have come into general use in the management of the disease, in consequence of its having been generally con- founded with true croup. In a paper on croup by my father, Dr. Charles D. Meigs, (Med. Exam., vol. i. p. 39S,) may be found the following statement in regard to the spasmodic variety : " The croup sound often ceases entirely, and never returns, after the exhibition of a small quantity of ipecacuanha, or any other emetic substance, even when no emesis is produced." He says in another place that, " a foot bath with mustard, and an emetic of ipecacu- anha, is in general all that is necessary for the cure." My own experience in regard to the treatment is contained in the following remarks. Emetics.—The great majority of cases will recover perfectly well under the use of emetics alone, or in combination with warm baths and revulsives. In cases attended with violent dyspnoea hoarse cough, and loud stridulous respiration, the emetic should be TREATMENT. 61 given until it produces a full effect. In milder cases, in which there is merely loud croupal cough, with an occasional stridulous sound, nauseating doses alone will generally suffice. Of the 30 cases observed by myself, this was the only treatment employed in 29, with the exception of some mild revulsive to the neck, a mustard pediluvium, and occasionally a warm bath. The most suitable emetic is, as a general rule, ipecacuanha. The best preparation for children is the syrup, of which from twenty to thirty drops may be given to those two years of age, to be repeated every ten or twenty minutes until vomiting is produced, or until the paroxysm is relieved. In very violent cases, the Sy- rupus Scillse Compositus, which is more active in its effects in con- sequence of the tartar emetic which it contains, might be preferable; about twenty drops of this may be given, and repeated every ten or fifteen minutes, until vomiting or the resolution of the paroxysm is obtained; but, in its employment, care should always be observed not to continue it for too long a time, lest it produce the injurious effects of tartar emetic. When the dyspnoea is very urgent, or when other means fail to produce emesis, I have found nothing so effectual as the powdered alum, in doses of a teaspoonful mixed with honey or molasses. (See treatment of pseudo-membranous laryngitis.) A simple and good method of treating the paroxysm is that recommended by my father, in the paper referred to. It is to direct a small teaspoonful of powdered ipecacuanha to be dif- fused in a wineglassful of water, and given in doses of a tea- spoonful of the mixture every ten, fifteen, or twenty minutes, according to the urgency of the symptoms. This is a plan of treatment often resorted to by parents in this community, where the disease is so common, and so well understood, that there are few mothers who have several children, and who have had some little experience, who do not know how to treat a nocturnal attack of spasmodic laryngitis. After the paroxysm is relieved, it is a good plan to direct five or ten drops of the ipecacuanha syrup to be given every two or three hours during the following day ; or, if the child seem per- fectly well in the morning, we may begin with these doses in the 6 62 SPASMODIC LARYNGITIS. middle of the day, and continue them until bed-time. By this method, the recurrence of the paroxysm during the second night may, I think, often be prevented, and the cough is rendered free and loose much sooner than when the disorder is left to pursue its natural course. Baths.—The warm bath is a very prompt and useful remedy in the disease. In all very violent cases, it ought to be resorted to immediately. It should be used also whenever the emetic fails to relieve the urgency of the symptoms, and in cases attended with much disturbance of the circulation. The temperature of the water ought to be about 96° of Fahrenheit, when the child is first im- mersed, to be raised gradually by the addition of hot water, to 100° or 102°. The child may remain in the bath from ten to twenty minutes. Bloodletting.—Depletion can rarely be necessary in spasmo- dic croup. The only cases which would call for it are those in which the symptoms tend to assume the features of the grave form of simple laryngitis, or of pseudo-membranous croup. Under such circumstances the method of treatment would be the same as that proper for those affections, to the descriptions of which the reader is referred for further information. In one case only of the 30 that came under my observation was any form of depletion resorted to. That occurred in a girl, six months old, who was leeched in front of the larynx, because the action of an emetic and the use of the warm bath had failed to relieve the paroxysm. The child was quite well on the follow- ing day. Revulsives.—The only revulsives that it is necessary to em- ploy, are mustard pediluvia, or mustard poultices applied to the interscapular space; and even these are often needless if the emetic be given. Blisters, which are recommended by some of the French writers, can only be proper, it seems to me, when the symptoms resemble those of grave simple laryngitis, or of true croup. Purgatives are required only when constipation is present, or when there is fever on the second and third days, showing a considerable amount of laryngeal inflammation. Under the latter HYGIENIC AND PROPHYLACTIC TREATMENT. 63 circumstances, some mild remedy of this class may be resorted to with a view to its evacuant effect. I have never had occasion to resort to any of the mercurials, and believe them to be unne- cessary. Antispasmodics and narcotics are recommended by some writers. They may be useful in cases occurring in children of highly irritable and nervous temperament, but I have uniformly succeeded in obtaining a cure without them. The ones generally employed are assafoetida, musk, or opium. Hygienic Treatment.—The child should be placed for the time in a warm room, and warmly clothed. If old enough, it ought to be kept as much as possible in bed during the paroxysm. If so young as to prefer the lap of the nurse, it should be clothed in a long loose wrapper in addition to its usual night-dress. It is very important to confine the child for one or two days after the noctur- nal paroxysms to a warm room, in order to prevent, if possible, an attack on the second or third nights. The diet must, be simple and of easy digestion, so long as there is any disposition to recur- rence of the disease. It may consist of preparations of milk, of bread, rice, or of thin chicken or mutton water. Meat and most vegetables had better be avoided, until the convalescence is fairly established. Prophylactic Treatment.—It is certain that much may be done by wise attention to physical education, in preventing attacks of the disease in children who have shown a liability to them. I would strongly recommend, with this view, attention to the follow- ing advice given by M. Guersent, who says (Doc. cit. p. 381): " It is possible to a certain extent, to prevent attacks of pseudo- croup, by fortifying the constitutions of children, by means of exposing them well clothed to a dry and elastic atmosphere, parti- cularly if they can be kept in constant movement. But of all the precautions which have been found unquestionably advantageous, that which seems most useful is to make them sleep in well-venti- lated, dry, carefully closed chambers, having a south exposure, and always without fire. I have several times been convinced of the utility of this habit in families the children of which were sub- ject to this kind of catarrh." Dr. Eberle says that the custom of clothing children with their necks and the upper part of the breast bare, certainly renders them liable to the disease, and men- 64 SIMPLE LARYNGITIS. tions the fact that in the country, and especially among the Ger- mans, who cover the neck and breast, croup is a very rare disease. During a practice of six years amongst that class of people, he met with only one case of the disease. It seems extremely probable that the custom which prevails extensively in this city, of dressing children between the ages of one and four or five years, in such a manner as to expose the whole of the neck and the upper half of the thorax, (for the dresses are made so low and loose, that half the chest is unco- vered), and to leave the arms bare from the shoulders, and the leg from the knee to the ankle, will account in some measure at least, for the very great frequency of the disease amongst us. I would, therefore, strongly recommend all who desire to preserve their children from the disease, to adopt the habit of dressing them with the same attention to comfort and health which they observe in regard to themselves, that is to say, to cover the body and limbs sufficiently to afford protection against our severe and fickle climate. If the child is pale, weak and feeble, and unable to bear ex- posure to the outer air, it may generally be restored to much better health, by careful attention to diet, and by the steady and long-continued use of some tonic remedy. The diet ought to consist of bread and milk, and of meat and the simpler vegetables, as potatoes and rice. The tonic most generally suitable is qui- nine, of which a grain may be given in pill or solution, twice or three times a day, while at dinner or lunch, or both, the child should be made to drink from a dessert to a tablespoonful of port wine, mixed with water. This method ought to be steadily perse- vered in for from three to six weeks or longer. ARTICLE IV. SIMPLE LARYNGITIS. Definition ; frequency ; forms.—This disease consists of simple erythematous inflammation of the mucous membrane of the larynx, CAUSES--ANATOMICAL LESIONS. 65 sometimes attended with ulceration, but unaccompanied by exudation of false membrane. The frequency of the disease, during infancy and childhood, is very considerable, so much so that not a winter passes without my meeting with a good many well-marked cases. I shall describe two forms of the disease, the mild and the grave. Predisposing causes.—The disease occurs at all periods of child- hood, but seems to be more frequent under than over five years of age. Of 48 well-marked primary cases that I have met with, 39 occurred in children under, and only 9 in those over that age. Of the former class, 10 of the children were under 1 year, 12 be- tween 1 and 2, 9 beween 2 and 3, 4 between 3 and 4, and 4 between 4 and 5. Rilliet and Barthez state, however, that grave primary cases are most apt to occur after the age of five years. The only three grave cases that I have seen, occurred between the ages of one and two years in one instance, and between five and six in the two others. Of the 48 cases, 29 occurred in boys, and 19 in girls; which agrees with the experience of the authors just men- tioned. As to the influence of the seasons, it may be stated that it is by far most common in the fall, winter, and spring months. The only exciting causes of the disease which appear to have been ascertained with any certainty, are the action of cold, the positive influence of which cannot be questioned ; the inspira- tion of irritating substances, such as gases, smoke, powders float- ing in the air, etc.; and violent efforts of crying. Rilliet and Barthez state that they have twice known erythematous and ulcerative laryngitis to follow long-continued and violent crying; and Billard also cites this as a cause. I am acquainted with one case in which a slight attack of the disease appeared to have been brought on solely by loud and obstinate screaming; but, on the other hand, I have known many children to scream most violently for a much longer time, with colic, and yet worse with earache, without any such effect being produced. The disease is very apt to occur in the course of other maladies, and particularly of measles, small-pox, scarlet fever, bronchitis, and pneumonia. Anatomical lesions.—The anatomical alterations may consist of simple inflammation of the mucous membrane, with its various 6* 66 SIMPLE LARYNGITIS. effects, or of the same changes in connexion with ulceration. The latter class Of lesions is almost always confined to secon- dary cases. In the former class, the mucous membrane varies in colour between a deep rose and violet red, which may be either uniform or only in patches. In severer cases, the tissue is at the same time softened or roughened, and sometimes thickened. When redness, softening, and thickening are present, the disease is generally confined to certain parts, and usually to the epiglottis and internal portions of the vocal cords; but when redness alone exists, it generally affects the whole of the larynx, and sometimes extends to the trachea. In cases attended with ulcerations, these alterations exist in connexion with what have already been de- scribed. The ulcerations are generally small, few in number, very superficial, linear in shape, and are almost always found upon the vocal cords. They are so slight often as to escape observation, unless a very careful examination is made; and this, perhaps, explains the circumstance of so few persons having met with them in the simple, acute disease. Symptoms ; course ; duration. — The mild form generally begins with an alteration of the voice or cry. In infants the change in the cry alone exists, so that to detect the disease, it is necessary to hear the child cry. In older children the same alteration of the cry is present, but there is in addition a change of the voice, consisting of various degrees of hoarseness. These symptoms may be so slight as to be observed in the cry only when it is strong and forcible, and in the voice so as to strike only the ear of one accustomed to be with the child ; or they may be so marked as to be heard in the faintest cry that is uttered, and in the voice so as to be evident in a moment to the most careless ob- server ; or there may be complete aphonia. They are often inter- mittent in this form, and are generally most marked in the after part of the day and during the night. Simultaneously, or very soon after, cough occurs. This is generally hoarse and rough, and early in the attack, dry; at a later period it usually becomes loose, and as this occurs loses its character of hoarseness. The frequency of the cou^h is variable, but usually moderate; as a general rule it is most frequent in the evening, and early in the morning, parti- SYMPTOMS. 67 cularly in infants and young children. The disease is almost always preceded and attended with some coryza, which, in the early stage, is marked by sneezing and slight incrustations about the nostrils, and at a later period, by mucous and sero-mucous dis- charges. The respiration remains natural, except that it is some- times nasal, and sometimes a little accelerated. There is rarely any fever, or it is slight, and occurs only at night. There is no pain in the larynx. In some cases, the hoarseness of the cry, voice, or cough scarcely exists, or is but slightly marked, and the only symptoms are dry, hard, teasing, and paroxysmal cough, which, from its sound, evidently proceeds from the larynx, and resembles very much that produced by the tickling of a foreign body in the throat. This form of the complaint is very common in our city, and, as it occurs chiefly in infants and young children, is particularly troublesome at night, by keeping the child awake. It is apt to run on for two, three or four weeks, or even longer, occasioning much trouble to the parents; the attack always ter- minates favourably, unless it runs into the severe form. The grave form may begin as such, or result from a sudden aggravation of the mild form. In either case it begins with hoarse, frequent cough, difficult respiration, restlessness, and more or less violent fever. Pain in the larynx, which often exists in adults, is rarely complained of by children, except those over six or seven years of age. As the case progresses, the symptoms either continue as they have just been described for a few days, and then gradually subside, or rapidly assume dangerous and frightful characters, similar to those of pseudo-membranous laryngitis or true croup. The respiration becomes very frequent and difficult, and, after a time, attended with the stridulous sound which accom- panies obstruction of the glottis; the cough is hoarse, dry, and croupal; there is little or no expectoration ; the voice grows more and more hoarse; the fever continues, but the pulse becomes rapid and small; the dyspnoea is very great, and all the symptoms indi- cate threatened asphyxia. If no favourable change takes place, the dyspnoea becomes suffocation ; the cough is rare and short; the voice is a mere whisper, or is lost entirely; the pulse be- comes small, extremely rapid, and then imperceptible; the counte- 68 SIMPLE LARYNGITIS. nance, at first livid and congested, assumes a pale, cadaveric ap- pearance ; the features are contracted ; the child becomes coma- tose or delirious, and death occurs from slow asphyxia, or some- times in an attack of general convulsions. In favourable cases, on the contrary, the dyspnoea, and espe- cially the stridulous sound, diminish; the cough becomes less hoarse, loose, and loses its croupal character; expectoration of mucous sputa takes place in older children, whilst in younger, the loose gurgling sound produced by the discharge of the sputa into the fauces, is heard at the termination of each cough; the voice becomes clearer and stronger; the fever diminishes; the child regains its spirits and disposition to be amused; and soon all dangerous symptoms have disappeared, and the recovery is esta- blished. In nearly all the cases that have come under my observation, I have found, upon examining the fauces, more or less decided in- flammation of the tonsils, soft palate, and pharynx. Tn cases following a rather chronic course, from two to four or six weeks, which are rarely accompanied by fever or hoarseness, except at the invasion, and sometimes in the evening, the pharyngeal mu- cous membrane presented a roughened, thickened appearance, and the tonsils and uvula were more or less enlarged and tume- fied. The duration of the disease varies according to its form and the circumstances under which it occurs. The mild form, when primary, lasts from a few days to one or two weeks, and when it becomes chronic, as I have known to happen in several instances, has lasted from two to four or six weeks. The grave primary form lasts usually from seven to eight days, but sometimes runs its course in from three to five, and in one instance proved fatal in twenty-four hours. The duration of secondary cases depends, of course, upon that of the disease during which they occur. Diagnosis.—The diagnosis of the mild form of the disease is very easy. The hoarseness of the cry, voice, and cough, the redness of the mucous membrane of the pharynx, and the ab- sence of general symptoms, will distinguish it from any other affection. In somewhat severer cases of this form, in which the DIAGNOSIS. 69 cough is more frequent and harassing, the general symptoms more strongly marked, and the respiration somewhat hurried and oppressed, they may at first view present the appearances of bron- chitis or pneumonia. The absence of the physical signs of these affections, will show at once by negative evidence, the true nature of the case. The only real difficulty in the diagnosis is the distinction be- tween the grave form, and pseudo-membranous laryngitis or true croup unconnected with angina; and this, it would appear from all evidence, cannot in some cases be made with absolute cer- tainty. The only certain and undoubted sign by which to dis- tinguish them, is the presence of false membranes in the ex- pectoration. The existence of this symptom is proof positive of pseudo-membranous disease, but its absence is no proof that the case must be one of simple inflammation; for, even though the membrane has been exuded in large quantities within the larynx, it is not always thrown off by the effort of coughing or vomiting. To show the difficulty of the diagnosis, I will cite the case quoted by M. Valleix (Loc. cit. t. i. p. 211) from M. Hache, of a child supposed to be labouring under true croup, who was sent to the Children's Hospital in Paris, in order to have the operation of tracheotomy performed. The absence of false membrane in the expectoration, and a slight remainder of clearness of the voice, occasioned the suspension of the operation. The child died, and no pseudo-mem- brane whatever was found in the larynx. The only lesions were moderate redness of the mucous membrane, without tumefaction, and without narrowing of the glottis; so that the fatal termination must be ascribed to spasmodic constriction of the glottis, or to tumefaction of that part which had disappeared after death. Nevertheless, though the diagnosis is difficult, it can generally be made out with considerable certainty by attention to the follow- in o- points. The pseudo-membranous form of the disease is often preceded or accompanied by the presence of false membranes in the fauces, which is not the case in simple laryngitis; the symptoms of invasion of the former disease are less acute than those of the latter, the fever being less violent, and the restless- ness and irritability less marked, than is usual in the simple affec- 70 SIMPLE LARYNGITIS. tion, in which the general symptoms are severe from the first. The hoarseness of the voice and cough follow a different course in the two diseases; the progress of these symptoms being slow and gradual in the membranous, and much more rapid in the simple form. The fever is violent throughout the attack in the simple inflammatory disease, whilst in the other form it sel- dom reaches a high degree of intensity. Lastly, the presence of portions of false membrane in the expectoration, in connexion with the laryngeal symptoms, affords positive proof of the exist- ence of true croup. In some cases, in which there is little or no hoarseness of the voice or cough, the symptoms strongly resemble the early stage of hooping-cough. I have met with five instances, in which it was difficult not to believe for two and three weeks, that the attack was really one of that disease. In one of these the resemblance was so close, that for several days there was a distinct hoop during the fit of coughing, and vomiting at the close of the pa- roxysm. The grounds for deciding that the case alluded to was not pertussis were, the facts that the attack came on like laryn- gitis, after measles, and that the paroxysms occurred only at night. In the other cases a correct diagnosis was arrived at only by attention to the state of the fauces, which are almost always more or less inflamed and thickened in laryngitis, whilst they are not so in pertussis, and by watching the progress of the sickness. Prognosis.—The prognosis is always favourable in the mild form of the disease. I have never known of a fatal in- stance. The grave form is, on the contrary, exceedingly dan- gerous. It is impossible, in consequence of the uncertainty of the diagnosis between it and the pseudo-membranous dis- ease, and because of the few well-authenticated cases on record, to estimate the degree of danger with accuracy. It is, however, frequently fatal. Great imminence of danger is shown by high intensity of the stridulous sound, especially as heard in the expiration; by great severity of the dyspnoea or suffocation; by lividity or extreme paleness of the face; by smallness and rapidity of the pulse ; by coldness of the extremities ; and by de- lirium or convulsions. TREATMENT. 71 The three cases of the grave form that came under my notice recovered. Treatment.—The treatment of the mild form oaght to be very simple. Seclusion in a warm room, careful management of the clothing, slight reduction of the diet if there be any fever what- ever, a pediluvium at night of simple water, or of water contain- ing a little mustard, the application of some slightly stimulating liniment to the front of the neck and throat twice a day, and the occasional internal administration of some gentle expectorant and anodyne dose, constitute all that is necessary in the great majority of cases of this kind. The best internal remedies are a few drops of syrup of ipecacuanha with paregoric, laudanum, or solution of morphia, given every evening as the child is put. to bed, or occasionally through the day also, if the cough is trouble- some. A combination of syrup of seneka with that of ipeca- cuanha, will often be found very serviceable. In the more chronic and tedious cases, the use of carbonate of potash or alum, as recommended in the article on hooping-cough, has succeeded in my hands, after expectorants and anodynes had entirely failed. In two cases in which all these remedies had failed to do good, I succeeded by touching the fauces at first twice, and af- terwards once a day, with a solution of nitrate of silver of from five to ten grains to the ounce. The pencil should be pushed low into the pharynx, in order to apply the wash as near as possible to the margin of the glottis. The only treatment used in connexion with this, was the administration of a small dose of anodyne at night, and careful regulation of the hygiene of the patient. The grave form of simple laryngitis demands, on account of the rapidity of its progress, and its dangerous character, a prompt and active treatment. The antiphlogistic system ought to be resorted to from the first, in its full force. The remedies most to be depended on are bloodletting, calomel, and emetics. Bloodletting is recommended by all writers. It should always be resorted to unless contra-indicated by great feebleness of con- stitution, either congenital or acquired as the result of previous sickness. Venesection is preferable to leeching whenever it can be performed. The quantity of blood to be drawn must depend 72 SIMPLE LARYNGITIS. of course on the age and strength of the child. From four to six ounces may be taken from a hearty child of four years of age. If no visible impression be made upon the disease in six or twelve hours, as much more ought to be drawn either by a repetition of the venesection, or by leeching the throat. Should the symptoms not yield at all in the course of twelve or thirty-six hours after the second detraction of blood, I would not hesitate, did the pulse continue full and strong, and the child not appear very much ex- hausted, to abstract three or four more ounces. Depletion was employed in the three cases seen by myself. In one, the subject of which was a girl between five and six years of age, the dyspnoea and stridulous respiration, with hoarseness of the voice and cough, continued for thirty-six hours, and were not relieved until the child had been twice bled from the arm to the amount of four ounces each time, and once leeched over the larynx. This case presented in fact, most of the features of true croup. In another, in a girl of the same age, venesection to four ounces was employed after the symptoms had refused to yield to full vomiting by hive syrup. The third .case was that of a boy between one and two years old, who was bled to three ounces. Calomel ought to be resorted to as soon as the real nature of the attack is ascertained. Its powerful sedative action upon the cir- culatory and nervous systems, and its specific influence upon local inflammations attended with increased proportion of the fibrinous element of the blood, as well as experience, indicate the propriety of its employment in this disease. A large dose, about four or five grains, may be given at first, in order to procure its purgative action, after which smaller doses, from half a grain to two grains every two hours, should be administered with a view of obtaining the aplastic influence of the remedy upon the blood. The last- named doses ought to be continued for one, two, or three days, or until the violence of the attack is evidently abating. When found to operate too much upon the bowels, a small quantity of opium must be combined with it to prevent that effect. Emetics are of great importance in the treatment, though less so perhaps than in true croup, in which it is essential to cause the rejection of the false membrane which obstructs the larynx. Yet TREATMENT. 73 they are exceedingly useful, and sometimes indispensable, in assisting to expel the viscid mucus secreted within the larynx, and in relaxing, for a time at least, the spasmodic constriction of the glottis, which plays an important part in the production of the dis- tressing dyspnoea and suffocation of the disease. They act proba- bly also by lessening immediately, or through their influence on the circulatory and nervous systems, the inflammation of the larynx. They should be used once or twice, or oftener in the day, accord- ing to the degree of dyspnoea, and the effects they produce. For their choice and mode of administration, the reader is referred to the article on true croup. Purgatives are required merely to keep the bowels soluble; they should be repeated as may be necessary throughout the dis- ease. The most suitable are castor oil, rhubarb, magnesia, or small doses of the powder of jalap combined with calomel. Expectorants are useful after the violence of the disease has been moderated by more energetic remedies. They may consist of small doses of ipecacuanha, of antimonial wine and sweet spirits of nitre, fractional doses of tartar emetic, decoction of seneka, snake-root, Coxe's Hive Syrup, or carbonate of potash. Opiates are often necessary and serviceable in calming exces- sive restlessness, and allaying the violence of the suffocative attacks, which depend, in part at least, as has been stated, on spasm of the glottis. The most suitable are Dover's powder, or some other preparation of opium, or small doses of belladonna, or hyoscyamus. A warm bath at 97° or 98°, employed once or twice a day, and continued for a period of ten or fifteen minutes, often assists greatly in lessening the sufferings of the child, in calming rest- lessness, and in moderating heat of skin and violence of the cir- culation, when the latter symptoms are strongly marked. The same effects may often be obtained by the use of counter-irri- tants, as sinapisms, mustard poultices, mustard foot-baths, etc. Blisters are of doubtful propriety in most cases. Nevertheless, I believe that I once saw good effects from the application of a small one over the larynx and trachea. 7 CHAPTER II. DISEASES OF THE LUNGS AND PLEURA, ARTICLE I. PNEUMONIA. Definition ; synonymes ; frequency ; forms.—The term pneu- monia is now, by universal consent, applied only to inflammation of the parenchymatous structure of the lungs. It is often called, in this country, catarrh-fever, lung-fever, or inflammation of the lungs. It is one of the most frequent, and therefore, one of the most important of the acute diseases of childhood. It is extremely pro- bable that a great majority of the cases, which for years past have been called, in Philadelphia, catarrh-fever, are in fact lobular or lobar pneumonia. Dr. West, in a paper on the pneumonia of children (Brit, and Far. Med. Rev. April, 1843), informs us that the English tables of mortality show pneumonia to be the cause of a larger number of deaths in childhood, than any other disease, with the exception of the exanthemata. From the third report of the registrar-general, he quotes the facts, that of all the deaths in the metropolitan districts under fifteen years of age, 13-6 per cent. were from pneumonia, 13-0 per cent, from convulsions, and 5*4 per cent, from hydrocephalus. He obtained nearly similar results from an examination of the returns from Manchester, Liverpool, and Birmingham. In the Philadelphia bills of mortality, the dis- tinction between pneumonia and bronchitis is so imperfect, that it is impossible to obtain data, on which to found an exact standard of the relative frequency of pneumonia and other diseases. It appears, however, not to be so fatal here as in England, since of 26,510 deaths under fifteen years of age in this city, during the CAUSES. 75 ten years preceding 1845, only 2764, or 10-4 per cent., occur- red from pneumonia and bronchitis combined. (Condie's Dis. oj Children, 2d ed. note, page 88.) I shall describe two forms of the disease, the lobular and lobar, the former of which is also designated broncho-pneumonia. Au- thors describe another form, to which the term vesicular is given, and Rilliet and Barthez refer to one which they call carnificatwn. Predisposing causes.—It is generally believed that pneumonia is most apt to occur in the course of other affections. This is cer- tainly true in regard to the disease as it prevails in hospitals, and probably amongst the poorer classes of society also. Rilliet and Barthez state that of 245 cases observed by themselves, only 58, or very little more than a fourth, occurred in children previously in good health. The proportion of secondary cases is smaller in private practice, since of 51 that I have seen, 30, or more than half, occurred in children in good health. Age forms a strong predisposing influence. Of the 245 cases above quoted, 172 oc- curred under 5 years of age. Dr. West (Doc. cit.), says, that dur- ing the first five years of life, the cases of pneumonia were in the proportion of 10*3 per cent, to the total of diseases, while in the succeeding five years, they were in the proportion only of 1*3 per cent. It is most prevalent during the season of greatest activity of the first dentition, that is, from the 6th to the 18th month. Sex.—A larger number of cases occur in boys than girls. The excess is little more, however, than may be accounted for by the preponderance of male over female children. Constitution.—It is doubtful whether constitution has much or any influence upon the liability to the disease. Dr. West says that weak health is not a predisposing cause according to his ex- perience. I am convinced that I have met with it as often in strong and vigorous children as in those of more delicate con- stitution. Season.—The disease is most prevalent during the winter months. According to the third report of the registrar-general of England, the greatest mortality under fifteen years of age takes place in December. 76 PNEUMONIA. Previous diseases.—It is apt to occur as a complication of all the diseases of children, and most frequently in measles, pertussis, typhoid fever, enteritis, and bilious remittent fever. I have met with three cases in the course of the latter disease. Bronchitis.—Some writers of high authority have advanced the opinion that lobular pneumonia is always the consequence of a precedent bronchitis. This is denied by Rilliet and Barthez, who say " it is incontestable that lobular pneumonia may exist in chil- dren without bronchitis." They agree, however, in the opinion that the form of broncho-pneumonia is much more frequent than simple lobular pneumonia. Other predisposing causes are general debility from previous diseases; prolonged dorsal decubitus; the breathing of a vitiated atmosphere, especially that of hospitals; neglect of cleanliness, and other bad hygienic conditions. Exciting causes.—The continued action of some of the predis- posing causes must be regarded as the exciting cause in the ma- jority of the cases. External violence, as a severe fall, or blow upon the chest, will sometimes act as an exciting cause. The action of cold is almost always alleged to be the immediate cause of the attack. M. Grisolle states that it is impossible to determine the exciting cause in more than a fourth of the cases, and that in nearly all of those it is cold. Anatomical lesions.—Dobular pneumonia.—By the term lo- bular pneumonia, is meant the form of inflammation which attacks one or more lobules of the lung, the others remaining healthy. Like lobar pneumonia it presents three stages, congestion, hepatization, and suppuration. In the first stage, the appearances are as follows: when the lung is cut into the surface is seen to be marbled with spots of a reddish or grayish rose colour, which are more or less dis- tinctly limited, rather less resisting than the neighbouring portions, and which float when thrown on water. When squeezed they exude a frothy, bloody fluid, and crepitate under the finger. In the second stage, the lung is usually soft and flaccid exter- nally, and of a more or less deep rose-gray colour; it presents here and there circumscribed spots, which are prominent, solid under the finger, do not collapse when the thorax is opened like the surrounding tissue, and are of a purple-red colour. These spots, ANATOMICAL LESIONS. 77 which are usually circular, though sometimes elongated in shape, are most common on the posterior surface of the lung, but may sometimes be seen throughout the organ. In some cases they appear to be absent, and the lung presents externally a healthy appearance, but, on pressure with the fingers, they may be felt in the form of nodosities, at a greater or less depth from the surface. On cutting into the lung, it is found marbled with spots of a rose-gray and violet-red colour, of which the exterior ones cor- respond to the red points seen on the outer surface. These spots, both those on the surface, and those in the centre of the lung, form hardened masses, presenting the characters of ordinary pneumonic inflammation; they are smooth when cut into, gra- nulated when torn, easily penetrated by the finger, and do not swim when thrown upon water. When squeezed, the hardened tissue crepitates but little, or not at all; its outer portions furnish a frothy, sanious fluid, while the centre of the mass contains a red and bloody fluid, which, like that of lobar pneumonia, is not frothy. The third stage presents the following appearances : the inflamed portions are of a yellowish, grayish-yellow, or simply grayish co- lour, caused by the infiltration of pus into the parenchyma; the tissue is very friable, and pressure causes the exudation of a puru- lent fluid. When the pus is equally diffused through the diseased portions, so as to produce an uniform gray colour, they present nearly the same appearances as the surrounding healthy tissue, so that a careless examination might easily lead to a mistake as to the nature of the fatal lesion. The error may be avoided by an attentive examination, which would show that some of the lobules project above the cut surface of the lung; that the vesicles of those lobules are not collapsed as are those of the surrounding parts, and that they yield a purulent, and not a serous fluid, when squeezed between the fingers. Lobular pneumonia has been divided by recent authors into two varieties, the partial and generalized. In the former, the number of inflamed lobules is small in proportion to those which retain their natural characters, and they are consequently thinly disseminated through the healthy portions of the lung; while in the latter, much 7* 78 PNEUMONIA. the greater portion of the affected lobe is diseased, leaving only a few healthy lobules scattered here and there. The morbid appear- ances are the same in both forms, except as regards their extent, which is so great in the generalized as to cause it to present many of the features of lobar pneumonia. Of the two forms the partial is much more common than the generalized. In the immense majo- rity of cases, lobular pneumonia is double. Of 203 autopsies of this form made by Rilliet and Barthez, the inflammation was con- fined to one lung only in 5. The generalized form is infinitely more common in the lower than in the upper lobe, and is most frequent on the left side. It is not uncommon to meet with abscesses as an accompaniment of lobular inflammation. The authors referred to found them in 26 out of 203, and Dr. West in 2 out of 11 autopsies. They are rare, however, according to M. Bouchut (Malad. des Nou- veaux-nes, p. 318), under the age of two years. They occur as a result of the third stage of the disease, so that in the same lung may be observed hepatized lobules in the first, second, and third stages, and abscesses. The cavities of the abscesses are generally circular, sometimes oval, and measure from half a line to three- quarters of an inch in diameter. Sometimes the abscess is mul- tilocular, each of the purulent cavities being partially separated from its neighbour, by a wall of hepatized tissue. They are found in various portions of the lung, but seem disposed generally to approach the surface of the organ. When the latter event hap- pens, adhesive inflammation between the pleura pulmonalis and costalis usually takes place; but should this fail to occur, the ab- scess ruptures into the pleural sac, and produces pneumothorax. Rilliet and Barthez have met with this accident twice in their post- mortem examinations, and report another case in which the child recovered. I have met with one case of pneumothorax which oc- curred during an attack of secondary pneumonia, complicating bilious remittent fever. The boy, who was eleven years old, re- covered perfectly, after a desperate illness. The number of the abscesses is exceedingly variable. Some- times there is but one, or they may be so numerous as to make it impossible to count them ; but the latter condition is very rare. It ANATOMICAL LESIONS. 79 is much more common to meet with them in one lung only than in both, and in the left than in trie right. They would seem to be most frequent between the ages of two and six years. Dobar Pneumonia.—The anatomical characters of this form are the same in children over a year and a half old as in adults, and it is, therefore, unnecessary to occupy our time with descrip- tions which may be found in any standard work on practice of medicine. Under the age just mentioned, the anatomical lesions are not the same as in adults, but resemble very closely those of generalized lobular pneumonia, so that it is often difficult to dis- tinguish one from the other. The affected lobe is never inflamed throughout, but presents outside of the indurated portions, lobules which retain their normal appearances, while even in the inflamed part of the lung, may be seen lobules in a less advanced state of change than those around. Lobar pneumonia is generally confined to one lung, and occurs more frequently on the right than on the left side, and at the base than at the summit of the lung. Pneumonia of the upper lobe is more common on the left than on the right side. Of 84 autopsies of lobar pneumonia, made by Rilliet and Barthez, the disease was double in 9 ; confined to the right side in 48, and to the left in 27. Of the 75 cases in which the pneumonia was single, it was seated in the lower lobe in 48, and in the upper in 27. Of the 27 cases of pneumonia of the upper lobe, 23 were on the right, and 4 on the left side. It is important to determine the relative frequency of the two forms of the disease. The authors just quoted, report 245 cases of pneumonia, of which 161 were lobular, and 84 lobar, showing a great excess of the former. Dr. West, on the con- trary, is of opinion that the lobular form is not so much more frequent than the lobar at least in London, as some persons are disposed to think, for of 37 cases that he has observed, 22 were of the lobar, 11 only of the lobular, and 4 of the vesicular form. According to my own experience, the lobular form is much more frequent than the lobar, since of 51 cases of pneumonia that I have seen, 38 were of the former, and only 13 of the latter form. Lobular pneumonia generally occurs in children under six years 80 PNEUMONIA. of age, while the lobar form is more frequent after that period. Ne- vertheless, the lobular form is not uncommon after the age men- tioned, as is proved by the fact that of 203 cases in which autop- sies were made by Rilliet and Barthez, 43 occurred in children between 6 and 15 years of age. Nor is lobar pneumonia confined to children over 6 years of age, as was thought by Gerhard and Rufz, since of 29 cases reported by Dr. West, 19 occurred under 5, and 10 under 2 years of age. Gerhard, Rilliet and Barthez, and West, all agree that the lobular form is much more frequent as a secondary than as an idiopathic affection. Of 161 cases ob- served by Rilliet and Barthez, 158 were secondary ; while of 11 cases reported by Dr. West, 5 followed hooping cough, 1 mea- sles, and though the remaining 5 are said to have been idiopathic, the bronchi were found to be either greatly injected, or filled with secretions. Dr. Gerhard, in his second paper (Am. Journ. Med. Sci., November, 1834, p. 106) says, "the lesion known by the name of pneumonia of young children, is, therefore, not simi- lar to the idiopathic inflammation of the lungs, but is a mere secondary lesion occurring during the course of numerous affec- tions of childhood, especially bronchitis, measles, and chronic diar- rhoea, and should be described as the lobular induration of the lungs." If, however, bronchitis, which by some persons is held to be an integral portion of lobular pneumonia, were not taken into consideration, the latter would be entitled to rank as a pri- mary affection in a much larger proportion of the cases. The great preponderance of secondary over primary cases of lobular pneumonia, does not seem to hold good in private practice, at least if we regard bronchitis as an essential part of the dis- ease, and not as constituting a primary affection, in the course of which pneumonia occurs as a secondary one. Taking this view of the subject, I find that of 38 cases that have come under my observation, all attended with more or less bronchitis, 26 were pri- mary, and only 12 secondary. The lobar form of pneumonia, is much more frequently a pri- mary affection than the lobular, since of 84 cases observed by Rilliet and Barthez, 55 were primary, and only 29 secondary. This does not agree exactly with my experience in private prac- COMPLICATIONS. 81 tice, as of 13 cases of this form that I have seen, only 5 were primary, and 8 secondary. Complications.—Bronchitis exists to a greater or less extent in most of the cases. The inflammation varies from simple in- creased vascularity with augmented mucous secretion, to intense congestion with purulent or pseudo-membranous secretions. It is most marked and most constant in the lobular form. The exces- sive secretion, especially that of pus and pseudo-membrane, is generally found in the same form. The inflammation usually attacks the smaller bronchia, and in a considerable number of cases, is accompanied by dilatation of those tubes. Dr. West met with this alteration in 11 cases. When slight, it was limited to the smaller bronchi, but when more extensive, implicated the larger ones likewise. It always presented the tubular form, and was most marked in the cases supervening upon pertussis. It is very rare in lobar pneumonia. Pleurisy is a frequent complication, occurring in about a fourth of the cases of the lobular, and in half those of the lobar form. Emphysema is another common complication. It generally occupies the upper part of the lung, or its free edge, and is found most strongly developed in the lung which presents the greatest amount of inflammation, or in both, when both are diseased. Its degree depends upon the extent of the pulmonary inflammation and bronchitis, and the severity of the dyspnoea. The vesicular form is very much more frequent than the interlobular. Symptoms; sketch of the disease; course; duration.—In order to present a faithful account of the disease, a general sketch of the symptoms will first be given, after which the most important ones will be considered separately under the head of particular symp- toms, so that the reader may first obtain a notion of the course of the disease, and then become intimately acquainted with its details and peculiarities, by reference to the remarks on each par- ticular symptom. Pneumonia almost always begins in infants and children at the breast like simple catarrh. The child is restless, uneasy, peevish, easily made to cry, indisposed to take the breast as usual, and after a 82 PNEUMONIA. short time, is attacked with fever, cough, and acceleration of the re- spiration. Auscultation reveals mucous and sub-crepitant rhonchus in both lungs. Percussion yields only negative results. If the dis- ease progresses, the child becomes exceedingly restless, takes the breast with difficulty, and often starts back from it with a loud cry as though in pain. The skin becomes very hot, the pulse frequent, the respiration rapid and anxious, and the cough more frequent. Mucous, sub-crepitant, and sometimes crepitant rhonchus can be heard on both sides, and after a time bronchial respiration and resonance of the cry. At this period, the percussion is often dull or flat over the seat of disease. If the child recovers, the cough diminishes in frequency and force, and becomes loose ; the rest- lessness subsides; appetite returns ; the fever disappears, and the physical signs gradually cease to be heard. If, on the contrary, the case is to prove fatal, the respiration becomes more difficult, and often slower ; the fever continues with exacerbations and re- missions ; the child is exceedingly restless; the surface becomes pale and cold; and death occurs from asphyxia. In older children, it begins with violent fever, increased fre- quency of breathing in all the cases, pain in the side in some, and short, dry cough. Auscultajtion, practised very early in the dis- ease, reveals crepitant or sub-crepitant rhonchus, and sometimes bronchial respiration, confined to one side, and usually to the base of the lung, in the lobar form ; and general sub-crepitant rhonchus, and in rare cases, bronchial expiration, in the lobular form. Vo- miting sometimes occurs on the first day. There is acute thirst, and the appetite is entirely lost; there is generally a good deal of restlessness in older children, often drowsiness in younger, and in some few cases, convulsions. As the case proceeds, the fever in- creases, and the extent over which the bronchial respiration is heard augments, whilst the rales diminish in abundance. The dyspnoea increases; the alse nasi are widely dilated; the respiration some- times becomes unequal and jerking; the cough is frequent, short, dry, and often painful, as shown by the child's crying at each /cough; and the countenance becomes anxious. Expectoration commences, and consists of sanguinolent and rarely of rust- SYMPTOMS--COURSE--DURATION. 83 coloured sputa. It is usually small in quantity, and in very young children is entirely absent. About the fourth or fifth day, the ac- celeration of the pulse and respiration, and the extent of the hepa- tization reach their height. The bronchial murmur is loud, per- ceived both in the inspiration and expiration, and is accompanied by bronchophony and resonance of the cry, and by dulness over a large surface. After remaining stationary for one or two days, the disease begins to subside generally about the seventh or eighth. The heat of skin and frequency of pulse diminish ; the respiration becomes slower ; the alse nasi no longer dilate ; the flushing of the face disappears, while its expression is more natu- ral ; and the cough becomes loose. On auscultation, the bronchial respiration is found to be confined to the expiration, the voice is dif- fusely resonant, and an abundant sub-crepitant rhonchus is heard. The dulness on percussion is much less marked. A little later the fever ceases entirely; the respiration assumes its natural rhythm; the appetite returns; the thirst disappears; and the cough subsides very much. About the tenth or fifteenth day, convalescence is fairly established, though auscultation still re- veals prolonged expiration, and diffuse resonance of the voice. In unfavourable cases, death rarely occurs early in the disease; but usually at some distance of time from the invasion. When the fatal termination occurs within the first few days, the symptoms assume great severity from the beginning. In this class of cases there is great oppression of breathing; the pulse is rapid and very small; the face pale, with a purple tint of the cheeks; moist rales are heard extensively over the thorax, mingled with dry rhonchi, or bronchial expiration and diffuse resonance of the voice; the general symptoms become more and more aggravated, and death occurs in three, four, or five days. When, on the contrary, the fatal termination occurs at a later period, the case generally pur- sues the course we have described up to the period of resolution. Instead, however, of resolution and convalescence taking place, the fever continues, though in a diminished degree; the face be- comes pale; emaciation occurs ; the appetite does not return ; the pulse remains frequent; diarrhoea persists or comes on ; and the 84 PNEUMONIA. cough, which had diminished, again becomes troublesome and painful. Auscultation and percussion reveal imperfect resolution, or an extension of the disease; and after some weeks of strug- gling, the child dies in a state of emaciation and debility. Particular symptoms.—Physical signs.—The physical signs of pneumonia in children are much less certain than in adults. The degree of the uncertainty is very different in the two forms of the disease; for, while the lobar may almost always be de- tected by an attentive and competent observer, it is confessedly often impossible for the most practised physician to distinguish between bronchitis and the lobular form. Thus M. Grisolle (Pathol. Int. t. i. p. 348) says: "Yet it is almost impossible to diagnosticate lobular pneumonia." M. Chomel (Diet, de Med., t. xxv. p. 185) says: " As to lobular or disseminated pneumonia, its phenomena are generally obscure, and in many cases it has been recognised only at the autopsy." Rilliet and Barthez, how- ever, whose opinion on this point is deserving of the greatest con- fidence, believe that it is generally possible to distinguish between lobular pneumonia and bronchitis, by strict attention to the phy- sical and rational signs combined. In order to practise auscultation on a young child, it should be placed by the mother in a sitting posture on her knee and held there, while the physician, by kneeling on the floor, or sitting on a low chair, makes the examination he deems necessary. If the child be old enough to take notice, it should be attracted and amused by some toy or glittering object. Even, however, should it cry violently, much valuable information is to be obtained from auscultation, for we can ascertain the presence or absence of rhonchi, and their characters, during the deep inspirations between the cries; we can observe resonance of the cry and cough, and practise percussion. The physical signs of lobular pneumonia depend upon the proportion which the pneumonic holds to the bronchial inflamma- tion. When the inflamed lobules are few in number, and situated at a distance from each other, whilst the bronchitis is extensive, the physical signs of the latter affection obscure entirely those of the former; and it becomes impossible to ascertain by auscul- PHYSICAL SIGNS. 85 tation or percussion, the existence of the pneumonic inflammation. Wc are compelled under these conditions, to depend exclusively on the rational symptoms. But, when the number of inflamed lobules is more considerable, and they are consequently situated nearer together, they occasion induration of the lung, which gives rise to certain stethoscopic phenomena, which will betray to the attentive observer the presence of the pneumonic inflammation. These phenomena are mucous or sub-crepitant rhonchus, pro- longed expiration, rude respiration, and resonance of the cry and cough. The sub-crepitant rhonchus is an extremely important sign, especially in children under the age of five years. It is ge- nerally heard on both sides behind, and most distinctly over the in- ferior portions of the thorax. It is often the only stethoscopic sign of lobular pneumonia during the whole course of the disease. It frequently follows the mucous rhonchus, and when this is the case, and especially when associated with prolonged expiration, with rude or bronchial respiration, heard here and there, we may be certain of the existence of lobular pneumonia. If to the above signs are added dulness on percussion, diminution of the sub- crepitant rhonchus, crepitant "rhonchus, and bronchial respiration during inspiration and expiration, it becomes certain that the disease is running into the lobar form. When lobular pneumonia pursues an acute course, the signs of hepatization rarely appear before the third day, and generally somewhere between the third and eighth. When, on the contrary, it goes on more slowly, the first signs of pulmonary inflammation do not occur until a much later period. The resolution of the inflammation is much more tardy in this than in the lobar form. The physical signs of lobar pneumonia are crepitant or sub- crepitant rhonchus, feeble respiration, bronchial respiration, bron- chophony, resonance of the cry and cough, and dulness on per- cussion They are, in fact, the same in the great majority of cases as in adults. Under five years of age, this form begins, usually, with sub-crepitant rhonchus, while after that penod, the earliest stethoscopic signs are crepitant rhonchus, or feeble re- spiration The bronchial respiration makes its appearance soon after the sub-crepitant or crepitant rhonchus, is heard first in the 8 86 PNEUMONIA. expiration, and then in both inspiration and expiration, and is ac- companied by bronchophony, resonance of the cry and cough, and dulness on percussion. These alterations of the auscultatory phenomena are confined to one side, in the great majority of cases, and are best observed over the posterior inferior portion of the lung. Rilliet and Barthez state that they have never known the bronchial respiration to disappear, in favourable cases, before the fifth day, and in the majority not before the seventh, eighth, or ninth; whilst in fatal cases, it continued to the moment of death. Its persistence is always a highly unfavourable symptom in very young children, whilst in those who are older, as in adults, it sometimes remains for several days or weeks, though the general symptoms have en- tirely disappeared. Dr. West regards bronchial respiration as a very grave sign, since out of 20 cases in which he noted it, 11 proved fatal. It may now be stated in recapitulation, that in children under five or six years of age, hepatization of the lung is indicated by sub-crepitant rhonchus appearing subsequently to mucous rhonchus, or associated with it; by bronchial respiration heard first in ex- piration, and afterwards both in inspiration and expiration ; by resonance of the cry, voice, or cough ; by crepitant rhonchus in rare cases ; and by more or less marked dulness on percussion. In general these signs exist on both sides, and are confined to the middle and inferior portions of the thorax behind. In children over five or six years of age, on the contrary, the signs are the same as in adults, with the exception of the expecto- ration, which is very often, though not always, absent. They are feeble respiration ; crepitant rhonchus ; bronchial respiration ; bron- chophony ; resonance of the cough ; and dull or flat percussion, confined in by far the greater number of cases to one lung, and to the inferior portion of that lung behind. Rational symptoms.—Cough is stated to be invariably present, except in children within the month, in whom it is sometimes, but very rarely absent. At all other ages, it is nearly a constant, and therefore most important symptom. It is dry at first, and not very frequent, but in one or two days becomes more frequent, often RATIONAL SYMPTOMS. 87 very troublesome, and from dry and harsh, is more or less humid and loose. It continues until the disease moderates, lasting generally from nine to sixteen days. In fatal cases it usually persists to the last. In infants it is not very frequent, occurs in short paroxysms, and in fatal cases often ceases one or two days before death. Rilliet and Barthez remark that in pneu- monia of the upper lobes, it has a peculiar character, It is little, short, smothered as it were, or piercing, teasing or slightly hoarse. I will merely add that cough is sometimes scarcely noticeable in cases which simulate hydrocephalus, during the early part of the attack. In the case of a child between -three and four months old, there was absolutely no cough whatever during the first six days. On the sixth day, with a respiration of 100 in the minute, with somnolence and occasional vomiting, no cough could be detected either by the mother, nurse, or myself, though I saw the child frequently. On the seventh, the respiration being at 96, a little, short, dry cough was heard occasionally, and on the eighth, the respiration having fallen to 63, the cough was decided and perceptibly loose, and slight coryza had made its appearance. In three other cases the cough was so slight in the early stages of the disease, during the continuance of the cerebral symptoms, as not to have been noticed unless particularly inquired after. Later in the attack, after three, four, or five days, and as the cerebral symptoms moderated, the cough became frequent and loose, and the pneumonic symptoms pursued their regular course. Expectoration is almost invariably absent under five years of age. Rilliet and Barthez, and Gerhard, have never observed rust- coloured sputa under the age mentioned. In older children there is sometimes, though not very often, voluntary expectoration. Even in them, however, the sputa seldom present the character- istic rust-colour and viscidity observed in adults, but consist simply of mucus tinged with blood, or of whitish, brownish, vis- cous or non-viscous phlegm. I once, however, saw a child three and a half years old, voluntarily expectorate viscid mucus, tinged copiously with blood ; and I have a patient under my charge at the present moment, seven years old, with lobar pneumonia super- vening upon pertussis, who expectorates freely a tenacious mucus, 88 PNEUMONIA. sometimes streaked or dotted with blood, sometimes brownish, and at other times rust-coloured. Valleix mentions a whitish or sanguinolent viscous froth, as sometimes escaping from the mouth of new-born children labour- ing under the disease. I have never met with this symptom, but know of one case of a child within the month, who, during an attack of pneumonia, vomited mucus tinged with blood. The child died, and presented the lesions of pneumonia. The nipples of the mother were perfectly healthy, so that the blood could not have been sucked by the child from them, but must have been the sputa which had been swallowed, after being coughed into the fauces. It is scarcely necessary to say that the absence of expectoration is only seeming, for children undoubtedly reject the sputa into the fauces, and then swallow them. Thoracic pain.—It is impossible to ascertain the presence of this symptom with certainty, prior to the age at which children talk, and very often not for some time after, as they refuse, or do not know how to describe their sensations. After the age of four or five years, it is often present, and frequently complained of. Indeed I am disposed to believe that it exists in most of the cases at all ages, from the fact that the act of coughing is so generally accompanied or followed by a cry like that produced by pain from other causes. I have so often remarked this disposition to cry after coughing, that I always ask the question, in the case of a young child, whether the cough is followed by crying, or by a momentary change in the expression of the features, like that occasioned by pain. In one case particularly, of a child twenty months old, labouring under lobular pneumonia, which had become lobar on one side, the movements during coughing were very peculiar. The patient always inclined the body strongly towards the side chiefly affected, forcibly stretched out the arm of that side, and cried violently. The pain generally comes on at the onset of the disease, is seated in the affected side, and is aggravated by coughing, and sometimes by the decubitus and percussion. The respiration is always quickened, except where the consti- tution of the patient has been greatly deteriorated by long and RATIONAL SYMPTOMS. 89 severe illness or other causes, under which circumstances it re- mains at the normal rate, or is very slightly accelerated. This symptom usually dates from the invasion, and soon the breathing rises as high as 40, 50, and 60 in the minute, in older children; and from 60 to 80 in the younger. It is more rapid commonly in the lobular, than in the lobar form; in the former, I have often counted it at 60, 70, and 80, while in the latter, it has seldom gone over 40 or 50. In some rare cases of the lobular form it rises as high as 100 in the minute. In favourable cases, the acceleration subsides usually about the seventh, eighth, or ninth days. In most of the cases the breathing is even and regular, while in others it is short, abdominal, uneven, and jerking. When the dyspnoea is very great in a young child, the nostrils dilate widely, the mouth remains open, and its angles are drawn downwards and out- wards ; the last of these symptoms is almost a fatal one. Some- times the rhythm of the function is changed, so that it begins with a sudden, active, and moaning expiration, followed by the inspiration, after which comes the interval of rest. Rilliet and Barthez state that unequal, jerking respiration occurs almost ex- clusively in cases of inflammation of the upper lobes. Physiognomy.—The face is almost invariably flushed. The colour, at first scarlet, becomes after a day or two deeper and darker, and in severe cases assumes a livid red tint. I have no- ticed in extensive lobular pneumonia, in addition to the deep red tint, a peculiar glazed appearance of the skin, which looks as though it had been varnished, while the edges of the flush are dis- tinct and abrupt. The lips are generally deeply coloured, simul- taneously with the face. The flush commonly subsides about the same time, or a little before the diminution of the rate of the re- spiration. In fatal cases, the face is apt to lose its colour and become pale and sallow, as the unfavourable symptoms become more and more marked. The pallor of the face is most striking in severe and fatal cases occurring in infants ; the face is blanched, and the features pinched. The expression of the face is one of anxiety and oppression in the early stage ; in very severe cases, or those about to terminate unfavourably, the features become drawn and contracted. 8* 90 PNEUMONIA. Fever exists in all the idiopathic cases. The pulse, at all ages, is rarely under 120 from the first to the sixth or seventh day ; in the youngest children it rises as high as 140, 160, and even 180 ; while in those who are older, it is seldom above 140. In favour- able cases it diminishes about the fifth, sixth, or seventh day. In fatal cases, it is apt to diminish at the same period, but soon be- comes more frequent and continues so to the end. The skin is hot in the beginning, and continues so until the disease subsides. The heat is intense in severe, but not so great in milder cases. The nervous system shows more or less marked symptoms of disorder. There is restlessness, peevishness, and irritability during the day, which increase towards evening. As the night advances the child becomes still more restless; infants will not sleep except in the arms, and wake crying or fretting every few minutes or hours; older children sleep uneasily, talk in their sleep, or start and cry out, and are often delirious. In some instances, the irri- tability is most distressing, both to the child and those around. The child is constantly fretting and whining; it wants its play- things, but will not touch them ; food, but rejects it; and slaps and scolds at everything about it. Convulsions sometimes occur at the invasion. They last an uncertain length of time, and are usually followed by insensibility, from which the child wakes with fever, accelerated respiration and cough, indicating the true seat of dis- ease to be the lungs, and not the brain, as might at first be sup- posed. Rilliet and Barthez state that they have observed convul- sive symptoms almost exclusively in pneumonia of the upper lobe. I have met with convulsions in 5 out of 51 cases. In one they appeared at the beginning of lobular pneumonia in a child two months old; it recovered. In a second, they appeared on the third day of lobular pneumonia, which had supervened upon per- tussis, in a child five months old. This also ended favourably. In the other three cases, they occurred at the termination, and were all fatal; two of these occurred in the course of pertussis, and one of measles. Digestive organs.—Complete anorexia is generally present from the first; the thirst is intense, greater probably than in almost any DIAGNOSIS. 91 other affection of childhood. The tongue is moist, as a general rule, and covered with a whitish or yellowish fur. Vomiting and diarrhoea occur at the invasion of about half the cases in hospi- tals : in private practice, vomiting often occurs, but diarrhoea much less frequently. Diagnosis.—The pneumonia of children is most liable to be con- founded with bronchitis, pleurisy, and hydrocephalus. There is little probability that lobar pneumonia would be mistaken for bronchitis by any but a careless or incompetent observer; for the presence, in the former, of sub-crepitant, and very often of crepitant rhonchus, of bronchial respiration, bronchophony, resonance of the cry and cough, and dull or flat percussion, confined to one side, would easily distinguish it from bronchitis, which is marked by mucous and sibilant rales over both sides of the chest, and by a normal condition of the percussion. The difficulty in the differential diagnosis of the two diseases concerns, therefore, the lobular form of inflammation. The cause of the difficulty is the existence, in the vast majority of the cases of that form, of bronchial inflamma- tion, coincidentally with that of the parenchyma of the lung. The degree of the difficulty will depend upon the proportion which the two inflammations hold to each other. If the amount of the pneumonic inflammation be great in proportion to the number of bronchia affected, as is the case in generalized lobular pneumonia, and where, in what we have called the partial form of the disease, the number of lobules inflamed is considerable, or they are placed close together, the difficulty is generally but slight. But when, on the contrary, the bronchitis is extensive in proportion to the pneu- monia, or the physical signs of the former disease are present in a high degree, it becomes impossible to do more than suspect, from the age of the patient, and character of the rational signs, the pre- sence of pneumonia. The symptoms which are most charac- teristic in such cases, are: resonance of the voice and cry, the phenomena furnished by very careful percussion; and lastly, the age and circumstances under which the disease has been de- veloped. The two last-named conditions are very important; if the child be under six years of age, and the attack secondary, it is 92 PNEUMONIA. almost certain to be broncho-pneumonia; whereas, if over that age, and the attack primary, it is probably simple bronchitis. In newborn children and those at the breast, sub-crepitant rhonchus is the diagnostic mark of pneumonia, which, as has been already stated, is, at that age, almost invariably of the lobular form. In partial lobular pneumonia, we must depend chiefly on the sub-crepitant rhonchus, while in the generalized form, there is added to that, bronchial respiration, dulness on percussion, and in some very rare cases, crepitation. Add to these the violent cha- racter of the general symptoms, the intense dyspnoea with expira- tory respiration, as has been described, the play of the nostrils, the violent contraction of the chest, the distension of the abdomen at each respiration, and there can be little difficulty in the detec- tion of the true nature of the case. It has been stated that pneumonia might be confounded with pleurisy. This could not happen except in regard to the lobar form, as the abundance of humid rhonchi, and the absence of dulness on percussion, would prevent such a mistake in regard to the lobular form. The lobar form may be distinguished by attention to the fact that pleurisy is rare under six years of age; by the greater severity of the pain, by the absence of rhonchi, by the effect of change of position on the sounds yielded by percus- sion, by the shorter duration and greater mildness of the general symptoms, by the entire absence or small amount of expectoration, and by the continued dryness of the cough in pleurisy; and, lastly, by the disposition on the part of pleurisy to become chronic, while pneumonia nearly always remains acute. Dr. West (Doc. cit.,) states that pneumonia in the early stage is often mistaken for hydrocephalus. Since reading his paper, I have had several occasions to test the correctness of the asser- tion, and have no doubt that it is perfectly true. The vomiting, constipation, extreme irritability and restlessness, and complaints of headache occur in both, while the absence of symptoms to draw attention to the true seat of the disease in pneumonia, may readily mislead. The cough in the early stage of pneumonia is often very slight, and not being observed by the attendants, is not reported to the physician. The frequency of the respiration DIAGNOSIS. 93 is overlooked, or, if noticed, is ascribed to the fever, which is sup- posed to depend on the cerebral inflammation. In pneumonia, however, the vomiting is not usually very frequent, nor very ob- stinate, nor are the bowels so much constipated as in hydroce- phalus. These variations from the ordinary symptoms of hydro- cephalus, minute though they be, ought to attract the notice of the physician, and lead him to examine the case more carefully; when, in all probability, the physical signs would immediately reveal the pneumonia. I may mention, in illustration, that I attended a boy six years old, who, for three days, suffered from violent fever, and excruciating headache, which last was the only symptom complained of. There was neither cough, expectoration, nor any marked ac- celeration of the respiration. After three days the headache mode- rated, and he had slight pain in his side ; on examination, I found him labouring under, well-marked lobar pneumonia. Another child, four months old, was suddenly seized with convulsions, followed by fever, vomiting, excessive irritability and drowsiness, so that I supposed the case to be one of meningitis. After the third day, the cerebral symptoms having moderated, and cough, with dyspnoea, making their appearance, I detected the exist- ence of extensive lobular pneumonia, of which the child died a few days after. In April, 1847,1 was called to see a boy nineteen months old, who had been taken sick with slight fever, a little hoarse cough, and mild pharyngitis. After remaining in this condition for five days, he began to be drowsy and very irritable; the surface became pale, and the extremities rather cooler than natural. From the sixth to the tenth day, there was great somno- lence, the child sleeping nearly all the time; when waked from sleep, he was always exceedingly irritable and cross, scarcely opening his eyes, and then shutting them again immediately, to avoid the light, which was evidently painful. During this time he took scarcely any food, but little drink, and vomited several times freely; the bowels were moved without medicine; the surface re- mained very pale, and the extremities often cool; the pulse was frequent and small; the respiration perfectly regular, and there- fore attracted no attention ; there was no cough whatever. Under these circumstances, I hesitated between regarding the case as me- 94 PNEUMONIA. ningitis, or hydrocephaloid disease, as described by Dr. M. Hall. I took the latter view, however, and treated it with small quanti- ties of brandy, cold to the head, and the frequent employment of mustard pediluvia. From the eleventh day the child began to improve; it would open its eyes from time to time, and look round for a few moments; the face began to show a slight degree of colour, and the palms of the hands, which had been white and transparent, exhibited a tinge of the natural pink hue which they have in children. Observing about this time that the respiration was accelerated, though perfectly free and regular, and without cough, I counted it, and was astonished to find it 80 in the minute. I now examined the chest carefully, and find- ing slight dulness on percussion with bronchial respiration, over the inferior half of the left side behind, immediately understood the nature of the case : it was one of latent pneumonia, simulating hydrocephalus. The child was now treated for pneumonia, and after an illness of twenty-seven days longer, recovered perfectly. As the case progressed, the rational signs of pneumonia were more and more apparent, the cough becoming frequent and pain- ful, and after a time loose, while the cerebral symptoms gradually disappeared. In addition to these cases I have met with three others, two in children within the year, and one in a child between one and two years old, which, during the early stages, re- sembled very closely the invasion of cerebral disease. Attention, however, to the rate of the respiration and the physical signs, and the presence of slight cough in two of them, revealed, after a little hesitation, the true character of the attacks. The third case, which occurred in the child within the year, was unattended by any cough during the first few days, and was, therefore, very obscure, until my attention was attracted by an acceleration of the respira- tion, when the physical signs, and at a later period, cough, ex- plained the real nature of the attack. I may remark, in addition, that in all these cases, the absence of constipation, the infrequency and short duration of the vomiting, and some clearness of the in- telligence when the child was fairly roused, though but for a few moments, from its state of somnolence, were other motives for doubting the attacks to be meningitis. PROGNOSIS. 95 Dr. West also states that pneumonia is often overlooked in teething children, in whom the cough is called a tooth-cough, whilst the diarrhoea, which frequently occurs, and becomes the prominent symptom, is supposed to depend upon dentition, and is alone attended to. The diarrhoea is obstinate, and when, at last, the cough attracts attention, it is ascribed to phthisis, and the physi- cian is astonished to find at the autopsy purulent infiltration of the lungs, but no tubercles, and no disease of the intestines. The diagnosis is to be correctly made, under such circumstances, only by careful physical examination. Prognosis.—It may be stated in general terms, that pneumonia is dangerous in proportion to the earliness of the age at which it occurs and the form of the attack, whether primary or secondary. Lobular pneumonia, for the reason that it prevails almost entirely amongst children under five or six years of age, is much more dangerous than the lobar form, which occurs after that age. Of 12 cases of lobular pneumonia under one year, that I have seen, 5 were fatal. Of the 12 cases, 8 were primary, of which 3 died, and 4 secondary, of which 2 died. Of 17 cases of the same form, occurring between the ages of one and two years, only 3 were fatal. Of the 17, 11 were primary, all of which recovered, whilst of 6 secondary cases, 3 died. Again: of 9 cases of lobular pneumonia between 2 and 9 years of age, none died; of these, 7 were primary, and 2 secondary. Lastly, of 13 cases of the lobar form, only 2 of which occurred under three years of age, and the remainder between the ages of 4 and 10, all recovered. Of these, only 5 were primary. In hospitals, and whenever the disease occurs under bad hygienic conditions, as amongst the poor, the prognosis is very unfavourable. Thus, of 128 cases in new-born children ob- served by MM. Valleix and Vernois, in the Foundling's Hospital at Paris, 127 died; while, according to M. Bouchut, of 55 cases between the ages of a few days and two years, observed at the Necker Hospital, 33 died; and lastly, of 61 cases between the ages of two and fifteen years, observed by M. Barrier, at the Children's Hospital, 48 died. It will be observed, that of 51 cases observed by myself in private practice, 8 were fatal. 96 PNEUMONIA. We may conclude, therefore, that pneumonia under two years of age is always dangerous, and that when secondary during that age, very much more dangerous than when primary; that primary pneumonia, whether lobular or lobar, between the ages of 2 and 5 years, will terminate favourably in the great majority of cases in private practice; and that when the disease attacks children between 6 and 15 years of age, the termination is nearly always in health. The following are some of the most unfavourable symptoms of the disease : convulsions ; small, weak pulse; extreme rapidity of the respiration; persistence of the bronchial respiration in young children (of 20 cases in which it was noted by Dr. West, 11 died); incomplete resolution of the disease within the ordinary period; excessive and obstinate diarrhoea; cerebral symptoms; great emaciation; greatly altered physiognomy; excessive irritabi- lity ; and a yellowish tint of the skin. M. Trousseau regards as an unfavourable symptom the occurrence of swelling of the veins of the hands, which he supposes to depend on an obstacle to the function of hsematosis. Treatment.—The treatment of pneumonia has been studied with the greatest care during the last several years. The re- searches of Louis, Grisolle, Rilliet and Barthez, and West, have given a completeness and certainty to this part of our subject, not possessed in regard to any other malady. I shall confine my re-- marks to the remedies which are now generally acknowledged to be most important, leaving those of doubtful value unnoticed. Bloodletting.—It is very generally conceded at the present time, that the loss of blood, whether by venesection, leeching, or cupping, exerts a more powerful influence upon pneumonia than any other remedy. Its effects are to relieve, and m some cases, to remove, with very great rapidity, the general symptoms. It reduces the frequency and force of the circulation, moderates the heat of skin, calms the restlessness, and relieves the dyspnoea, thoracic pain, and headache. It is very doubtful, however, whether it shortens the duration of the disease, or exerts much influence on the extent of the hepatization,—at least such is the conclusion of several of the French observers. Dr. West awards to it the first place in TREATMENT. 97 importance amongst the remedies for the disease; and with him I entirely agree, though fully aware of the fact, that whilst the gene- ral symptoms are mitigated by bloodletting in the manner above described, the local disease is apt to run its usual course of several days. I once saw a boy, five years of age, with lobar pneumonia of the left side, from whom eight ounces of blood had been taken by venesection and leeches, walking about the room apparently well, after a week's sickness, in whose case there was still present over the inflamed lung, dulness of percussion, bronchial respira- tion, and crepitant rhonchus; and I have now under my charge a girl four years of age, who, on the seventh day of the attack, after being leeched on the fifth, had a respiration of twenty, a pulse of ninety, and a cool natural skin—who was, in fact, entirely convale- scent ; in whom, nevertheless, there was dulness of percussion over the lower half of the right lung, with bronchophony and bronchial respiration. The amount and manner of the depletion must depend on the age of the patient and form of the pneumonia. It is usually re- commended to make use of leeches and cups in children under two years of age, and of venesection after that age. The quantity of blood to be drawn must depend on the age and strength of the pa- tient, and violence of the attack. At the age of two or three years, and in idiopathic cases, about four ounces may be taken from the arm at once. Should this fail to produce some relief to the symp- toms in twelve hours, the bleeding may be repeated; or better still, some scarified cups or leeches applied over the seat of the disease. I feel quite sure that I have seen more benefit derived from cups than leeches under these circumstances, and would therefore prefer to use them where there is nothing to prevent. It is a common idea that scarified cups are too painful to be applied to young children, but this is not the case when they are properly selected. The cups should be much smaller than what are used for adults, and the scarificator of a size to suit the cups. With these precautions, it will be found that the operation of cupping a child within the year, and still more from the age of a year up- wards, is less annoying to the child and more expeditious than that of leeching. I would, on these accounts, strongly advise coun- 9 98 PNEUMONIA. try practitioners, who often complain of the difficulty or impos- sibility of procuring leeches, to provide themselves with cups of a size suitable for children, to be used in the place of leeches. Whether leeches or cups be preferred after general bleeding, about two or three ounces of blood should be taken from over the inflamed portion of the lung. In children under two years of age, leeching, as has been stated, is generally preferred to venesection. I have not hesi- tated, however, to employ venesection in the course of the second year, when the symptoms have been very acute. The number of leeches should seldom exceed ten or twelve, which will commonly take about two ounces of blood. In cases of secondary pneumonia, depletion must be used with great care, as they have been found not to bear the loss of blood well. This is the opinion both of Rilliet and Barthez, and of Dr. West. It is best, therefore, in most of these cases, to employ only local bleeding. Antimony.—~This remedy is well known to exert a power- ful influence over pneumonia. Like bloodletting, it diminishes the force and frequency of the circulation and relieves the oppression; but like that, too, while moderating the constitutional symptoms and tending to keep them within safe limits, it fails to cut short or jugulate the inflammation. Dr. West recommends it particu- larly in cases preceded by catarrhal symptoms and those occur- ring during measles or hooping cough, and in cases of the lobar and idiopathic forms, where bleeding has failed to give efficient relief. In the first class of cases, he gives it " in doses of a quarter of a grain to a child of two years old, repeated every ten minutes till full vomiting is produced, and continued afterwards every two or three hours, for forty-eight or sixty hours." In the second class he gives the same doses every two hours for twenty. four hours, and thinks it " paves the way for the advantageous employment of mercury." When, however, the pneumonia had been neglected, so that the period for depletion had passed, and when distinct bronchial respiration was audible, he has " not found the large doses, recommended by the French practitioners, to produce beneficial results." Rilliet and Barthez give to younger children TREATMENT. 99 from two to four grains, and to those who are older, as much as six grains of the tartar-emetic, in solution, in the twenty-four hours. They administer the solution in spoonful doses every half hour. If the first doses cause vomiting they are repeated less frequently. The quantity given on the first day is continued for the two, three, or four following days. They recommend caution, however, in the administration of the remedy, especially in very young children; and should it produce excessive vomiting or severe diarrhoea, ad- vise its instant suspension. Should the state of the inflammation still require its administration, they employ it in very minute doses, and abandon it immediately should the intestinal symptoms return. For my own part, I have not found such large doses of antimony necessary in private practice, and I believe them to be often inju- rious. The attention of the reader is requested to the following extracts from pages 467 and 468 of the first volume of Rilliet and Barthez. " One of the chief causes of gastritis and softening of the stomach in children has been, according to our experience, the employment of energetic treatment directed upon the gastro-intestinal mucous membrane. We refer particularly to the tartar emetic solution given for several days in succession. Though the doses were not carried to a great extent, and the quantity of the vehicle was ample, the disease has often occurred, thus proving the susceptibility of the mucous coat." They recommend great reserve in its use, "be- cause two-thirds of the cases of gastritis that we have observed, and some of the cases of softening, followed the employment of that remedy." They remark afterwards, however, that the gastro- intestinal lesions generally followed the exhibition of the anti- monial in secondary, while it seldom occurred in idiopathic cases of the disease. It seems to me that the facts just quoted ought to cause us to hesitate in the administration of antimony in the large doses generally recommended. My own experience inclines me to be- lieve that it is seldom necessary to give to children of two and four years old more than half a grain or a grain in the day, and to younger children still less. I have met with some children, and 100 PNEUMONIA. in a few instances this is true of all the children of a particular family, who would bear only the smallest doses. I have known the hundredth part of a grain repeated every hour, to produce nausea and vomiting in children of two and four years of age. This very winter, I had under my charge a child two years old, who could take only half a drop of antimonial wine every two hours. My own practice has been to give the remedy after depletion, in doses of the thirtieth, fortieth, and even sixtieth parts of a grain every hour, to children of the age of two or three years, and even in this quantity it often produces vomiting or painful nausea. If the fever, oppression, and heat of skin, persist in the same de- gree after several doses, the quantity should be increased ; if, on the contrary, they subside, the doses ought to be diminished. In the cases of children over the age of three years, the dose must be increased according to circumstances. A very convenient and satisfactory mode of exhibiting antimony to children, is to give the vinum antimonii, combined with sweet spirits of nitre, in the doses of two, three, or four drops of the former, with eight or ten of the latter, repeated every two hours; the proportions of the former to be increased or diminished as the stomach is found to tolerate it. To infants within the year, antimony ought to be given, it seems to me, with the very greatest caution. Many at that age do not tolerate well more than from half a drop to two drops of the wine, every two hours. Beyond that dose, it is very apt to produce exhausting nausea or diarrhoea. The use of the antimony ought to be persevered in until the acute symptoms have moderated, when it should be left off gradually. Before concluding my remarks upon antimony, it is proper to state that I am well aware of the fact that the doses recommended by the authors quoted above, and by many others of the highest authority, come at last to be tolerated by the stomach in a great many cases. I cannot but think, however, from personal expe- rience, and from the evidence adduced by many observers in regard to the injurious effects of such doses upon the stomach and intes- tines, in at least some of the cases, that we are scarcely justified in resorting to them, particularly as it has been found (by myself TREATMENT. 101 at least), that the disease is curable by smaller doses, in connexion with other means. Calomel.—I am induced to believe from personal experience in private practice, that calomel is seldom necessary in the treatment of pneumonia. I have found a fair proportion of the cases that have come under my hands to recover without a resort to it, and, as I deem it a violent remedy that ought to be administered only when really called for, I have seldom prescribed it, and when I have done so, it has been in one or two full doses during the acute stage of the malady, for the purpose of procuring its sedative and cathartic action. MM. Rilliet and Barthez oppose its employment in secondary pneumonia as injurious, and in idiopathic cases as unnecessary, because in the latter form, the treatment by depletion and antimony has succeeded very well in their hands. Dr. West, on the contrary, awards high praise to it as a remedy after deple- tion ; but as he gave it largely combined with tartar emetic, I am disposed to ascribe a great part of the favourable effects of the treatment to the antimony. Dr. West also recommends it very highly in cases of neglected pneumonia, after the time for depletion has gone by. In such cases its internal employment is often contra-indicated by the existence of diarrhoea ; under these con- ditions he uses it externally. In children of four years of age, he directs one drachm (of mercurial ointment I suppose), to be rubbed into the thighs or axillse every four hours. He says he has never known salivation to follow this plan, but has found the symptoms to diminish gradually in severity, and the solid lung to become once more permeable to air. Of the success of this plan of treatment I have had no personal experience, as such cases are very rare in private practice. I would, however, under these circumstances, prefer the employment of the iodide of potassium, which I have found of great service in the chronic pulmonary complaints of children. From half a grain to a grain of that remedy, dissol>jed in compound syrup of sarsaparilla, may be given three times a day, to a child three or four years old. ° Expectorants ; purgatives.—Ipecacuanha is preferable to the antimonial preparations in the treatment of pneumonia under the following circumstances: when the disease occurs in infants 9* 102 PNEUMONIA. within the year; in children of highly nervous temperament, or of feeble and delicate constitution; in many cases of the secondary form; in some of those in which bronchitis is the predominant ele- ment of the attack ; in mild cases ; and lastly in subjects who from idiosyncrasy do not bear antimony well, and of such there are many. The most convenient preparation is the syrup, of which from ten to twenty drops may be given every two hours, at four years of age; from five to ten drops, between one and three years ; and from one to three drops to infants of two or three months. It is useful to combine sweet spirits of nitre with the syrup, in doses to suit the age. In lobular pneumonia, when the child is much oppressed by the presence of large quantities of mucus in the bronchia, the operation of an emetic is often highly beneficial. Ipecacuanha is the most suitable remedy under these circum- stances, as it answers the indication perfectly well, and produces less exhaustion and depression than any other. Either after or without the emetic, I have found decided benefit in such cases from the administration of decoction of seneka and spiritus Min- dereri. For a child two years old I direct two drachms each of seneka and liquorice root to be boiled in a pint of water down to twelve ounces, and strained. A teaspoonful of this decoc- tion is to be given every two hours, with twenty drops of the spiritus Mindereri. A purgative dose is useful at the beginning of the attack as a derivative and evacuant, but after that period, remedies of that class need to be used only to such an extent as to keep the bowels soluble. It is scarcely necessary to say that when antimony is employed, especially in any considerable quantity, it almost always supersedes the necessity of purgative medication. The patient ought, however, to have a stool once a day or every second day. At first, a dose of castor oil, a moderate quantity of magnesia or syrup of rhubarb, is all-sufficient. In the after-treatment of the attack, a repetition of the same remedies in smaller quantity, or, what is often better, an occasional enema, is all that is necessary. Violent or frequently repeated doses of purgatives are injurious by exhausting the patient, or by setting up gastric or intestinal irritation. External applications.—Rilliet and Barthez say that they have TREATMENT. 103 never found either blisters, Burgundy pitch or tartar emetic plas- ters, exert the least influence upon any one of the symptoms of pneumonia, but that, on the contrary, they increase the fever. Dr. West has been led to abandon the use of blisters entirely, in consequence of the irritation and fever they occasion, and the dis- position to sloughing he has observed amongst the poor. I think I have observed great benefit in a few instances from the appli- cation of a blister, when depletion and antimony or ipecacuanha have failed to produce some moderation of the symptoms after four or five days. I have always been careful, however, even in chil- dren two or three years old, never to allow the blister to remain longer than an hour and a half or two hours. I direct it to be removed commonly in an hour and a half, whether the integument be blistered, of a scarlet colour, or unchanged. A warm bread and milk poultice is then used as a dressing, and rarely fails to cause vesication in a few hours, if it has not already occurred. Many times I have been told by the mother that the skin was still white and unchanged beneath the blister when she removed it, and yet the poultice has produced full vesication. Treated in this way, blisters cause very little irritation, and I have never known but one to slough in my life, which happened in a child whose skin had been very much irritated by frictions with amber oil and ammonia. Since the spring of 1845, however, when I was led to make frequent use of mustard poultices and pediluvia in the treatment of the bronchitis and broncho-pneumonia of measles, I have rarely employed blisters, but have preferred the employment several times a day of the remedies just indicated. Two parts of indian meal and one of mustard, for young children, and for those who are older equal proportions, are to be mixed with warm water, and spread thickly like a poultice on a piece of flannel or rag five or six inches square. This is to be covered with fine muslin, linen, or gauze, and applied over the back of the thorax. It may remain from fifteen to forty minutes, or until the child cries or complains or the skin is reddened. The mustard foot-baths may be employed at the same time with the poultices. These applications are useful whenever the oppression is very 104 PNEUMONIA. great, and, when resorted to in the evening, often allay irritability and dispose the child to sleep. The number of applications to be made in a day must depend on the urgency of the symp- toms. I have employed them from once a day to every two or three hours. Tonics and stimulants are to be resorted to in cases which manifest undoubted signs of debility. When, therefore, the attack occurs in a feeble child; when the inflammation remains unre- solved after depletion and other remedies, and when, as Dr. West says, extensive bronchial respiration persists, though the fever has moderated, attention must be paid to the state of the constitution, to the neglect of the local disease. The system must be sustained and strengthened in order to give it time and power to carry on the operations ^necessary for the removal of the local obstruction. With this view, all depleting means should be abandoned, and the child put upon a nutritious diet and the use of tonics and stimu- lants. The diet may consist of preparations of milk, of soups, eggs, and small quantities of meat carefully prepared. The best stimulants are weak brandy and water, milk punch, wine whey, or wine whey and arrow-root water. The most suitable tonics are quinine and the preparations of iron. A grain of quinine, suspended in a mixture of equal parts of syrup of gum and syrup of ginger, and given three or four times a day, has succeeded best in my hands. Opiates are sometimes necessary in cases occurring in children of highly nervous and irritable temperament, in the secondary and cachectic forms of the disease, and whenever the cough is very fre- quent andjiarassing. After the acute symptoms have moderated a little, an evening dose of the Dover's powder, or a few drops of laudanum or paregoric, with sweet spirits of nitre, are often of great service. General management.—The diet ought to be very strict in idiopathic cases. The child should have nothing for two or three days except demulcent drinks, or weak milk and water sweetened; no solid food ought to be permitted. After the severity of the symptoms has moderated, pure milk, milk toast, or chicken water may be allowed; and when all fever has disappeared, the usual food BRONCHITIS. 105 may be given, at first, however, in small quantity. A child at the breast ought not to nurse as freely as usual. At all ages, care should be taken to give water from time to time : very young chil- dren often suffer severely for want of attention to this point. I have seen the most violent and obstinate screaming in a child a year old, quieted at once by a copious draught of cold water. The patient should be kept closely confined in a well-ventilated room, with the temperature as nearly as possible between 68° and 70° F. A direction given by some of the French writers, and by Dr. Gerhard, is not to allow very young children to lie for too long a time in one position in bed or in the nurse's arms, as it is apt to produce a stasis of blood in the dependent portion of the lungs, and thus maintain or increase the disease. Dr. West recommends, whenever the inflammation has reached an advanced stage, or in- volved a considerable extent of the lungs, that the patient be moved with great care and gentleness, lest, as he has often seen occur, convulsions be produced. ARTICLE II. BRONCHITIS. Definition; synonymes; frequency ; forms.—The term bron- chitis is now universally employed to express inflammation of the mucous membrane of the bronchia. It is usually called in this country catarrh, and catarrhal fever. It has been stated under the head of pneumonia, that many of the cases known amongst us by the popular term catarrh-fever, are, in fact, cases of lobular pneumonia. I shall, on account of this mis- application of names, endeavour to draw the distinction between bronchitis and lobular pneumonia with great care. Bronchitis is not treated of either by Dewees or Underwood. Dr. Eberle con- founds it with pneumonia under the titles of catarrh, catarrhal fever, acute bronchitis, and pleuritis. Bronchitis is one of the most frequent of the diseases of child- hood. We have already seen that pneumonia causes a larger 106 BRONCHITIS. proportion of deaths amongst children in London, than any other disease except the exanthemata. It appears from the tables of mortality published by Dr. Condie (Dis. of Children, note, page 88), that of 26,510 deaths under fifteen years of age in Philadelphia, during the ten years preceding 1845, 1592 were caused by pneumonia, and 1172 by bronchitis, and that of the different diseases of the respiratory organs, bronchitis was the most frequent after pneumonia. It is more common as a secondary than as an idiopathic disease. Of 115 cases observed by Rilliet and Barthez, only 21 were idiopathic. Of 23 cases that I have recorded,, 11 were primary and the remaining 12 secondary. The diseases during the course of which it is most apt to occur, are pertussis and measles. I shall describe three forms of the disease: 1, acute bron- chitis of moderate severity ; 2, acute suffocative bronchitis, or catarrhus suffocativus, the congestive catarrhal fever described-by Eberle and by Dr. Joseph Parrish of this city; 3, subacute or chronic bronchitis. Causes.—Amongst the predisposing causes of the disease, age is one of the most important. Rilliet and Barthez suppose it to be much more common in children over, than in those under five years of age. Of 115 cases observed by them, 37 occurred be- tween the ages of one and five years, and 78 between six and fifteen years of age. It is scarcely fair, however, to compare a period of nine years with one of only four, as is done in the above statements. Of 23 cases that I have seen in private practice, 8 occurred between birth and two years of age; 10 between two and four years ; 3 between four and six ; and 2 between six and ten years of age. It would seem also that the simple acute, and the acute suffocative forms are most common under six years of age, while the secondary cases occur more frequently after that age. The fact of its being more frequently a secondary than a primary affection, has already been noticed. The diseases in which the largest number of cases occur are measles, pertussis, and typhoid fever. The secondary cases are most common, of course, during the prevalence of the diseases whose progress they complicate, whilst the primary cases are most common in the cold CAUSES--ANATOMICAL LESIONS. 107 months of the year, and especially in the autumn and spring. Bronchitis is sometimes epidemic amongst children as it is amongst adults. The only exciting causes whose effects in the production of the disease seem clearly proved are, sudden transitions from a warm to a cold atmosphere, and sometimes the contrary change; pro- longed exposure to cold, particularly when combined with mois- ture ; and the inspiration of irritating gases. Anatomical lesions. — Acute form.—The morbid alterations always exist in both lungs; and, according to M. Bouchut, are most intense in the right. The appearances observed in most of the cases are redness, caused by injection of the minute vessels of the mucous and subjacent tissues, softening of the mucous mem- brane, which can be ascertained only in the larger bronchia, and sometimes a thickened, unequal, and rough appearance of the same membrane. Ulcerations are extremely rare. In mild cases, the bronchia contain a viscid, transparent, frothy, or opaque yellowish mucus; in more violent cases, they are filled with a yellowish, yellowish-white, or whitish fluid, which is thick, not frothy, and mixed with pus and mucus, or with grayish, thin, not frothy, and liquid pus. The fluid escapes at the open extre- mities of the bronchia. Portions of pseudo-membrane are some- times found mixed with the secretions just described, while in other cases, false membranes alone are present. In some instances, the false membrane exists in the form of patches, and in others it constitutes a lining to the whole extent of the bronchial ramifica- tions. It is usually soft and but slightly adherent, and the mucous membrane beneath is either very pale and of its usual consistence, or red, softened, and rough. The different kinds of secretion are commonly most abundant in the bronchia of the inferior lobes. In most of the severe cases, another lesion, dilatation of the bronchia, is also found upon examination. This change evidently occurs under the influence of the inflammation; it may affect - either the length of the air-tubes, or only their extremities. In the former condition, the tube continues of the same size, or be- comes gradually larger from one of its early subdivisions, until it reaches the surface of the lung; in the latter condition, a sec- 108 BRONCHITIS. tion of the lung presents an areolar appearance, from the presence of a multitude of little rounded cavities, communicating with each other, and with the bronchia, of which they seem to be a con- tinuation. These cavities are generally central, though they are sometimes found upon the surface of the lung, in which case they are formed of the pleura, lined by the thinned membranes of the dilated bronchus. Chronic bronchitis.—The lesions just described as character- istic of acute bronchitis, are also met with in the chronic disease. The dilatation of the air vessels, however, presents different fea- tures. The calibre of the enlarged tube is often much greater, its walls are whitish and uneven and cry under the scalpel, and beneath the mucous lining may be seen hypertrophied transverse fibres. The mucous membrane itself remains smooth and polished, while the tissues beneath are thickened and hypertrophied. Symptoms ; sketch of the disease ; course ; duration.—Acute simple bronchitis generally begins with a moderately frequent cough, which, dry at first, soon becomes loose, and is neither paroxysmal nor painful. The expression of the face remains na- tural, with the exception of an appearance of slight languor. The pulse and respiration are but slightly accelerated; the external phenomena of the latter, an important means of diagnosis in in- fants, remain natural; it occurs without jerking, the rhythm con- tinues even and regular, and there is no violent action of the aloe nasi. The percussion is not modified. Auscultation reveals in very young children, a mixture of mucous and sibilant rales on both sides, which come and go, and are of short duration; in older children, the moist rales predominate, and commonly last several days. These sounds are seated in the larger bronchia. The temper of the child is not much changed; the appetite is not en- tirely lost; there is neither vomiting nor diarrhoea; and the fever is usually slight. The disease remains nearly stationary, or in- creases for a variable length of time, after which the cough be- comes looser, and in children over five years of age, is sometimes attended with expectoration of frothy or yellowish mucous expec- toration, whilst under that age there is no expectoration. The fever and other symptoms, with the exception of the cough, now SYMPTOMS. 109 subside ; the cough remains some days longer. The duration of this form is generally short ^ the idiopathic cases last usually from six to fifteen days, and more rarely from sixteen to twenty-five; the duration of the secondary cases depends in great measure upon the nature of the diseases during which they occur. The acute suffocative bronchitis, or congestive catarrhal fever of Parrish and Eberle, and suffocative catarrh, capillary bronchitis, or bronchial croup of other writers, may succeed to the form just described, or appear as an idiopathic affection. Under either con- dition, the general symptoms are more threatening than in the preceding form. The child is much more restless, irritable, and cross; violent fever soon comes on, the pulse being full and fre- quent, running up to 130 and 180; the face is flushed; the tongue moist and*furred white; the thirst acute; and the appetite lost. The respiration soon quickens; the cough, if it existed before, increases, and if not, soon makes its appearance, and is generally dry ; it occurs in short paroxysms, with or without stridulous sound, and after a few days, is accompanied by yellowish, or more rarely by pseudo-membranous expectoration. It is sometimes painful. The resonance on percussion is not modified. Auscul- tation reveals snoring or sibilant, mucous, and sometimes sub- crepitant rhonchi. In very young children, tte vesicular murmur is rather more feeble than usual ; the dry rhonchi are less abun- dant than the moist, are observed only at times, and at other moments are absent: the mucous rale is very abundant, and varies in sound according to the size of the bubbles by the break- ing of which it is produced ; it is present both in the inspiration and expiration, but especially in the inspiration, and is heard on both sides of the chest. It is fugitive and irregular, disappearing sometimes after an effort or after coughing, to be replaced by sub- crepitant rale or even natural respiration, and soon after returning with its usual characters. The sub-crepitant rale, which is always present in young children, is subject to the same changes and irregularities as the mucous rale. * If the disease increases, and in some instances from the begin- ning, the respiration is very frequent, irregular, and difficult. When the oppression is very great, it is accompanied by paleness or dark 10 110 BRONCHITIS. congested colour of the face, particularly after coughing; by violent action of the ala? nasi, and by coolness or coldness of the whole surface. The pulse becomes still more frequent, and at the same time small and irregular. The decubitus is dorsal, with the shoulders more or less elevated. If the attack is prolonged, irregular remissions of the symptoms occur. Towards the close a great change in the expression of the face takes place; the cough becomes very difficult, the respiration extremely frequent, the pulse imperceptible ; the child is soporous or very restless; and at length death closes the scene. The duration of this form is variable. According to Dr. Eberle, it seldom lasts longer than two or three days, and in very young infants, death sometimes occurs on the first day. M. Bouchut gives as the duration in children at the breas^ from two days to a week, and states that it generally runs into lobular pneumonia. In older children it usually lasts from three or four to six or eight days, but sometimes eighteen days or more. Sub-acute and chronic bronchitis generally follows one of the acute forms of the disease. The phenomena yielded by ausculta- tion are very irregular both in character and degree; the fre- quency of the respiration, and the attacks of dyspnoea persist; the cough is loose and paroxysmal; the pulse is frequent and small; evening exacerbations of fever take place; the face, and sometimes the rest of the surface, are often covered with perspiration. Aus- cultation reveals tubal blowing, with mucous or loud sonorous rhonchus, which seem to indicate the presence of dilatation of the bronchia. Emaciation makes rapid progress; the face is pale and blanched, the eyes sunken, the nostrils are covered with mucous or bloody crusts, and the lips ulcerated. Strength diminishes pro- gressively ; the appetite is lost, and the thirst acute; colliquative diarrhoea appears ; and after twenty, forty, or more days, the child perishes in the last stage of marasmus. This form of bronchitis often simulates phthisis very closely, and may last for a long time, even several years. It rarely occurs under the age of five years. The expectoration consists of purulent or pseudo-mem- branous secretions in variable quantity. Particular symptoms.—Physical signs.—The dry rales are SYMPTOMS. Ill amongst the most frequent alterations of the respiratory sound in bronchitis. They may be sibilant or sonorous; they seldom exist alone, but are accompanied by mucous rale, and diminish as the latter becomes more abundant. As the dry rales cease to be heard, they are replaced by mucous or sub-crepitant rhonchus, or by feebleness of the respiratory murmur. The sibilant rale is often heard over the whole thorax, though sometimes confined to the posterior portions. It is not confined to cases of inflammation of the larger bronchia only, but is also present in capillary bron- chitis. Humid rales.—Mucous and sub-crepitant rhonchus do not exist in all cases without exception, as they may be absent in such as are very mild. They may generally be heard on both sides be- hind, more rarely over the whole of the chest, and almost always both in inspiration and expiration. They are generally persistent, but are sometimes suspended for a moment and replaced by sibilant rhonchus, or feeble respiratory sound. Their duration is in proportion to that of the disease. The value of the sub-crepitant rale as a symptom of bronchitis depends chiefly on the age of the patient. In children under five years of age, who, after presenting the signs of bronchitis for a few days, exhibit a fine and equal sub- crepitant rhonchus on one or both sides behind, there is strong ground for suspecting the formation of pneumonia. It is not cer- tain that the child has pneumonia, but it is very probable, since acute bronchitis in very young children is almost always associated with pneumonia. After the age mentioned, sub-crepitant rhonchus is indicative only of bronchitis, unless it be heard during the course of some disease in which lobular pneumonia is a frequent com- plication, when it will be as likely to indicate broncho-pneumonia, as simple bronchitis. Feeble respiratory murmur is sometimes observed. It is not permanent, occurs during the interruptions of the sub-crepitant or sonorous rale, and does not occupy the whole extent of the thorax, but is limited; it is intermittent, and is not accompanied by dimi- nished sonoreity. When dilatation of the bronchia exists to a considerable extent, it gives rise to bronchial or even cavernous respiration, and to 112 BRONCHITIS. resonance of the voice, cry, and cough. The bronchial respira- tion differs from that of pneumonia by its tone, and by its inter- mitting. The percussion is generally sonorous. The physical signs above described, are not invariably present in bronchitis. Cases do occur, though they are very rare, in which auscultation fails to reveal the presence of the disease. Rational symptoms.—The rational symptoms are of the utmost importance in informing us of the severity of the attack. Cough generally exists from the beginning, being in mild cases more or less frequent, and either dry or loose; while in severe cases it is frequent or very frequent, at first dry and then moist, and very rarely hoarse. In acute or sub-acute capillary bronchitis, the cough has a particular character. From the first day, it occurs in short paroxysms, lasting from a quarter to half a minute. The paroxysms vary greatly in violence, occur at irregular inter- vals, and generally continue without interruption to the fatal ter- mination, though they are sometimes replaced by simple loose cough a few days before that event. The cough is rarely painful, so long as the inflammation remains simple. Expectoration is never present in very young children. When it occurs in those over five years of age, it consists, in the mild form, of a sero- mucous or yellowish mucous frothy liquid. In general bronchitis, it is sero-mucous at first, becoming after a few days yellowish and more or less viscous; it is sometimes nummular, and some- times amorphous. The respiration varies in its characters according to the extent and violence of the disease. In mild cases, it is not much in- creased in frequency, being generally between 28 and 40 in the minute. In more violent cases, and particularly when the disease implicates the smaller bronchia, it becomes very frequent. The acceleration is slight in the beginning, but increases regularly as the case progresses; thus it may be 30 at first, and rise after- wards to 50, 60, 80, and even 90. When not very much quick- ened, it remains even and regular; when more so, it becomes somewhat laborious, and the movements of the chest are full and ample ; in severe cases, attended with much dyspnoea, it is often ir- regular, or assumes the characters to which M. Bouchut has applied SYMPTOMS. 113 the term expiratory; that is, the order of the movements is in- verted, each respiration beginning with the expiration, leaving the pause between the inspiration and expiration, instead of between the expiration and inspiration. In chronic bronchitis with copious purulent or pseudo-membranous expectoration, the dyspnoea is generally habitual. Fever.—The fever is slight in mild cases, the pulse rising very little above its natural standard. The heat is not great, and the febrile movement usually subsides before the termination of the disease. In the grave or capillary form, on the contrary, the pulse is always frequent, and continues to increase in rapidity as the disease advances. It varies between 104, 120, 160, and in very violent cases, rises as high as 200. Early in the attack, it is vibrating, rather full and regular, whilst in fatal cases, it always becomes small, irregular, trembling, and unequal. The skin is generally hot in proportion to the activity of the pulse, except towards the termination, when the extremities often become cool. It is almost always dry. In very young children it is often pale and cold, and covered with perspiration from the beginning. The expression of the face is unchanged in mild cases, but when the disease is violent and extensive, becomes deeply altered after a few days. The eyes are then surrounded by bluish rings ; the expression is uneasy, anxious, and sometimes, but less frequently, exhibits an appearance of profound exhaustion. The anxiety of the countenance increases with the oppression; the alse nasi are dilated ; the nostrils dry or incrusted ; and the lips and face, which are extremely pale or momentarily congested, assume a purple tint, particularly after the paroxysms of cough. The decubitus is indifferent at first, but as the disease progresses the child lies with its thorax more or less elevated, or is restless and constantly changing its position. In dangerous cases there is great distress and restlessness after the first few days, or even from the beginning. In some instances the irritability and peevishness are excessive and uncontrollable, while in others, there is heaviness and somnolence, especially to- wards the termination of fatal cases. Some of the disorders 10* 114 BRONCHITIS. of the nervous system just mentioned are present in all the grave cases. Digestive organs.—There is moderate thirst and incomplete anorexia when the disease is mild, but, when severe, the thirst is generally acute, and the appetite entirely lost. The state of the bowels varies. The tongue and abdomen present no special cha- racters in idiopathic cases. Diagnosis.—The mild form of bronchitis, in which the inflam- mation is confined to the larger bronchia, is not likely to be mis- taken for anything but the early stage of hooping cough. The diagnosis can be made only by attention to the different characters of the cough, which is more spasmodic and paroxysmal in per- tussis, by the absence of fever in that disease, and by the deve- lopment of the peculiar symptoms of each, as the case progresses. The severer forms of bronchitis, and particularly the suffocative, may be confounded with lobular pneumonia. In very young chil- dren, it is often impossible to distinguish between extensive bron- chitis and lobular pneumonia, the physical signs being the same in both. M. Bouchut states, however, that the diagnosis can be made in very young children, by careful attention to the external phenomena of respiration. He says that in generalized bron- chitis, the respiration is frequent, abdominal, without constriction of the base of the thorax, and without agitation of the nostrils; while in confirmed pneumonia, on the contrary, the respiration is inverted as to its rhythm, and is jerking or moaning, like that of an adult in whom a sudden sigh is followed immediately by a quick inspiration; it is in fact expiratory. Chronic bronchitis may be mistaken for tuberculosis of the lungs or of the bronchial glands. The distinction can be made only by careful study of the history of the case, and of the phenomena afforded by auscultation and percussion. Prognosis.—Bronchitis is a much more serious disease in children at the breast and those under five years of age, than after that period, because of the strong disposition it has to pass into pneumonia. For that reason it ought always, even in its mildest form, to be carefully watched in its symptoms and pro- gress, when it occurs under the age mentioned. PROGNOSIS--TREATMENT. 115 The acute simple form is in itself a mild affection of but little consequence, but requires to be watched for the reason just given. When, on the contrary, the disease is more extensive, affecting all the bronchial ramifications, and constituting the suffo- cative form, it is at all ages a most dangerous malady. Rilliet and Barthez state that all their own patients, and those of M. Fauvel also, died. I have seen but two well-marked primary cases of this kind. One occurred in a child nineteen months old in the month of December 1846. The child had been sick for three days with an attack of the mildest form of acute simple bronchitis, when it suddenly became alarmingly ill. The dyspnoea was ex- treme ; the respiration between 80 and 90 ; the face pallid, anxious, and suffering ; the surface cool and covered with cold perspiration ; the cough paroxysmal, moderately frequent, short and painful; and the pulse very rapid and small. The child was satisfied only when resting erect in the arms of its mother, with the front of its chest lying upon her breast, and its head over her shoulder. There were abundant sibilant, mucous, and sub-crepitant rales over all the posterior portion of the thorax. It continued very ill with these symptoms for thirty-six hours, then began to mend, and in two days more, was convalescent. The other case occurred in a boy between one and two years old, and presented the same symp- toms, except that they were less severe. The symptoms indicating great danger are: increase of the dyspnoea, extreme anxiety, small and irregular pulse, coolness or coldness of the skin, with clammy sweats, much jactitation, and delirium, drowsiness, or coma. With such symptoms, the danger is greater and the fatal termination more imminent in proportion as the child is younger, less robust, and its constitution exhausted by preceding or coincident disease. Treatment.—The acute simple disease requires, when mild, little other treatment than careful attention to the hygienic condi- tion of the patient and the administration of some mild expecto- rant. The child ought to be confined to an apartment with a well- regulated temperature, and kept quiet, either in bed or on the lap. The clothing ought to be. warm, and yet not sufficient to produce free perspiration, which would expose to chilliness. The diet 116 BRONCHITIS. must be simple, and may consist of some of the preparations of milk with bread. As an expectorant, an occasional dose of syrup of ipecacuanha through the day, either alone, or if the cough be frequent and troublesome, combined with a little paregoric, lauda- num, or solution of morphia, is proper and useful. The bowels ought to be moved once in the twenty-four hours, either naturally or by an enema. A warm pediluvium, with the addition of salt or mustard, in the evening, will generally assist to procure a quiet night. When, in the same form, the symptoms assume greater seve- rity, when the signs of reaction are prominent, the dyspnoea con- siderable, and the cough frequent and harassing, it is sometimes, though not always, advisable to take a little blood. In children under three years of age, it is best, as a general rule, to make use of leeches, by which from one to two ounces of blood may be taken from the interscapular space ; in those over that age, from two to four ounces may be drawn in the same way, or by vene- section. It seems to me, however, that the great majority of cases of this form of bronchitis will do perfectly well without bloodletting of any kind. A gentle purge ought to be given, unless the bowels have already been freely moved. This may consist of castor oil, rhubarb, magnesia, or what is a very convenient dose for children, half a teaspoonful of fluid extract of senna mixed with a tea- spoonful of spiced syrup of rhubarb. At the same time some febrifuge and diaphoretic may be exhibited with much advantage. I am in the habit of using the antimonial wine or syrup of ipe- cacuanha, combined with sweet spirits of nitre, as in cases of pneu- monia. When the fever is considerable and the patient over a year old, the antimonial preparation is the best; from one to four drops, with five drops of sweet nitre, may be given every two hours. In some few children and in young infants, half a drop only of the wine will be borne without nausea and exhaustion. If the ipecacuanha be preferred, and it is generally most proper for children at the breast, the dose must be proportioned to the age, constitution, and present condition of the patient. If, as the case progresses, the bronchial secretions become very abundant and the dyspnoea severe, the proper remedy is an emetic. TREATMENT. 117 This may be ipecacuanha, either in powder or syrup, the syrupus scilloe compositus, or a teaspoonful of powdered alum, to be re- peated, if necessary, in ten or fifteen minutes. The latter sub- stance is, as I have stated under the head of croup, a very certain, efficient, and safe emetic. Great benefit may be obtained in all forms of bronchitis, from the more or less frequent application of mustard poultices to the front or back of the thorax, and from mustard pediluvia. If the symptoms are obstinate, a small blister over the sternum, or still better, the interscapular space, allowed to remain not more than one and a half or two hours, and then dressed with a poultice, is often very useful, though they should be avoided in young children as long as possible. The mercurial preparations, so much recommended by many of the English and by some of our own writers, appear to me to be very seldom really necessary in this, or indeed, in any of the forms of bronchitis in children. Rilliet and Barthez recommend, when the cough and sibilant rale persist after the disappearance of the febrile symptoms, the use of small doses of the flowers of sulphur. I have myself known this remedy to prove useful in such cases. About four grains may be given every three hours to a child four years old. The grave acute or capillary form of the disease must be treated more actively than the preceding. While the pulse remains full and strong, the face flushed, and the skin hot, depletion is the most efficient remedy. The amount of blood to be taken must depend on the age, constitution and present condition of the child; if over two years old, if of strong and robust appearance, and not reduced by preceding disease, from three to six ounces might be drawn from the arm. In younger children it is better, in general, though not in all cases, to employ leeches, taking within two ounces at a time as a common rule. I am in the habit of applying leeches, in the cases of children, to the interscapular space, as most conve- nient and most effectual, because of its proximity to the roots of the lungs. After the child has recovered from the immediate effects of the bleeding, an emetic of ipecacuanha or alum may be admi- nistered with great benefit; two hours after the emetic, small 118 BRONCHITIS. doses of antimonial wine and nitre, or fractional doses of tartar emetic should be prescribed, and repeated every hour or two hours. At the same time a mustard poultice to the thorax and a mustard pediluvium may be directed, and advantageously resorted to again in four or six hours, or, if the oppression be very great, in a shorter time. In still more severe cases, in which the dyspnoea is excessive; the pulse very rapid and small; the skin cool and pale ; the jacti- tation very great; and when there is present extensive mucous and sub-crepitant rhonchus, the treatment recommended by Rilliet and Barthez, and by M. Fauvel, is the frequent employment of emetics. Depletion i3, it seems to me, entirely contra-indicated under such circumstances. In one very severe instance of the kind already referred to, the dangerous symptoms subsided under the use of cup- ping, mustard poultices and pediluvia frequently renewed, and the internal use of decoction of seneka and spiritus Mindereri every hour. Six small cups, of which only two were scarified, were ap- plied over the back of the thorax. In another case, which occurred in a child eighteen months old, during an attack of measles, the symptoms yielded, and the eruption made its appearance, under the use of mustard pediluvia and poultices applied every two hours, and the internal use of spiritus Mindereri and sweet spirits of nitre. In both cases, the symptoms of exhaustion were so strongly marked, that I feared to employ emetics, lest they might fatally increase the already dangerous prostration, though the dyspnoea and abundant mucous and sub-crepitant rales seemed to call for them. If the exhaustion were to become excessive, it would be proper to resort to stimuli, amongst which wine whey, or weak brandy and water, would be the most suitable. Chronic bronchitis.—The most important points in the treat- ment of chronic cases consist in a rigorous and persevering regu- lation of the hygienic conditions of the patient, and in the use of tonic, balsamic, and expectorant remedies. The child should be carefully and warmly clothed; it ought to be taken as often as possible into the air in fine weather, and only in fine weather; and the diet should be selected with a strict view to the improve- ment of the strength and vigour of the constitution. The food may PLEURISY. 119 consist, if the child be of proper age, of light meats, of potatoes and rice, as the only vegetables, and unless there is some contra- indicating circumstance, of a small quantity of wine, with the mid- day meal. The best wine is port, of which one or two tablespoon- fuls may be given, in a considerable quantity of water. Tonics must be administered throughout the course of the dis- ease, or until the appetite and strength shall have improved to such an extent as to make them no longer necessary. The best is probably quinine, in the dose of a grain morning and evening, to be continued for several weeks ; or, the citrate of iron and quinine in the dose of half a grain or a grain three times a day, or from one to three drops of the solution of iodide of iron, used in the same way, may be substituted. In one case of chronic bronchitis, which came under my care, the child recovered under careful regulation of the hygiene, and the use of a decoction of seneka prepared by boiling a drachm each of seneka and liquorice roots, in a pint of water, to half a pint. The decoction was strained, and a large teaspoonful given three times a day. The remedy was used during a period of two months; under its use the child grew fat and strong, and recovered entirely from the disease. Other remedies, proposed by different authors, are the various re- sinous preparations ; the balsams of tolu and copaiba, benzoin, and the sulphurous mineral waters. While these means are employed, it is recommended also to make use of counter-irritants. If any are used they ought to be such as will not produce too much in- flammation of the skin, as for instance weak Burgundy pitch plasters, daily frictions with hartshorn and sweet oil, a simple diachylon plaster, or very mild pustulation with croton oil. ARTICLE II I. PLEURISY. Definition; frequency; forms.—Pleurisy consists in inflam- mation of the pleural serous membrane. 120 PLEURISY. Idiopathic pleurisy is a very rare disease under five years, and especially during the first and second years of life. After the age of five years it becomes more frequent. Secondary pleurisy, on the contrary, or that which occurs in the course of other diseases, is common at all ages. M. Bouchut met with it in 23 out of 68 autopsies of new-born and suckling children. Of the 23, 9 ac- companied acute pneumonia, 6 tubercular pneumonia, 5 entero.-co- litis, and 3 different other diseases. This form of the affection is rarely detected during life, being masked by the concomitant ma- lady. I have met with only three idiopathic cases, two of which occurred between the ages of four and five, and one at seven years of age. I shall describe two forms of the disease, the acute and chronic. Predisposing causes.—As to the influence of age, it has already been stated that idiopathic pleurisy is very rare between birth and five years of age. Secondary cases, on the contrary, are most common between the ages of one and five years. The disease is more frequent in boys than girls. The idiopathic form is most apt to occur in vigorous and hearty subjects, while the chronic and cachectic forms attack those who are feeble and delicate. It is often, as already stated, a secondary affection, occurring particu- larly during pneumonia, and after that disease, during rheumatism, scarlet fever, and Bright's disease. Season is another predisposing cause. It is most common during winter and spring, especially the latter. The exciting causes are very obscure in most cases. The only ones which seem to have been ascertained with any certainty, are long exposure to cold and to sudden changes of weather. It has been said to follow external violence. In one of the cases that came under my observation, the child had struck the affected side severely against a pointed stick on the day of the attack. Anatomical lesions.—The serous membrane may retain its na- tural characters, which happens in the majority of cases, or it may present the different appearances indicative of inflammation. These are more or less minute and abundant injection and punc- tuation, spots or patches of an ecchymotic appearance, observable particularly at the points where deposits of false membrane have ANATOMICAL LESIONS. 121 taken place. Another change produced in the pleura by inflam- mation is the loss of its natural polish, which is replaced by a more or less granular and rough appearance. In chronic cases it becomes whitish or opaline in colour, and thickened. It is very rarely softened. In addition to the lesions of the pleura itself there are various dis- eased products of secretion which require notice. These may be either solid or liquid. The solid products are the false membranes which exist so generally in all serous inflammations. These are found both upon the costal and pulmonic pleura. In their recent state they are of variable size and thickness, being in some cases very soft and deposited in small points; in others, more extensive, but thin like paper; and in others again thicker (one or two lines in thickness), firmer, and decomposable into several layers. The outer layers are yellow, elastic, and soft, while the inner ones are red, more resisting, and marked with vascular arborizations. When observed some time after their formation, the false membranes are found to have been converted into cellular adhesions, which may either be very loose, or fasten the lung tightly to the costal pleura. The adhesions are generally, however, thin, transparent, and in the form of loose bridles. After a length of time, the false membranes come to present the appearances of true serous tissue, and like that, are susceptible of inflammation. The fluid found in the pleural cavity usually consists of trans- parent or turbid serum, holding albuminous flocculi in suspension. Sometimes, but more rarely, it consists of purulent serum, and still more rarely of pure pus. The liquid generally occupies the lowest portion of the thoracic cavity, but is sometimes circum- scribed at various heights, or between the lobes of the lung, by abnormal adhesions, or by some part of the lung which has been rendered incompressible by inflammation. The lung presents" various alterations from its healthy con- dition. It is pressed backwards towards its root to a greater or less extent. The tissue of the organ is generally found in one of two conditions: either hard, not crepitating, impenetrable to the finder, and presenting a smooth surface when cut into, a state of things which has been expressed by the term carnificaiion, and 11 122 PLEURISY. which is a mechanical effect of pressure ; or else the lower lobe, which is in contact with the fluid, is large, heavy, fleshy, rather hard, not so easily penetrable by the finger as in simple hepatiza- tion, yielding under pressure only a small quantity of blood, and but slightly retracted towards the spinal column. The latter con- dition, depends in all probability on an effusion which has occurred after, or coincidentally with, hepatization. In some cases, in which the effusion is but small, or where it has been absorbed, the lung is found to be elastic and crepitating. Whatever the amount of effusion may be, it is said that the lung can always expand to its normal size if the fluid be absorbed. Pleurisy, whether complicated with pulmonic disease or not, is much the most frequently confined to one side. In idiopathic cases, it is more common on the right than left side; when it ac- companies pneumonia, it is, on the contrary, more common on the left than right. Symptoms.—In describing the symptoms, I shall treat first of the physical, and afterwards of the rational signs and course of the disease. The physical signs are exceedingly important, as they often constitute, especially in young children, the only means of recog- nising the disease. The pleural friction sound is less important than some other physical signs, as it is scarcely ever heard in children under five years of age, and only during the absorption of the fluid, as a general rule, in those above that age. Bronchial respiration may commonly be detected from an early period in the attack. At first it is heard during inspiration, but afterwards exists both during inspiration and expiration, or in the former alone. In the majority of the cases it is heard over the posterior portion of the thorax, and upon one side only. At first it is audi- ble over nearly the whole height of the affected side, while later in the disease, it can be perceived only at the inferior angle of the scapula or in the interscapular space. Its duration is varia- ble ; it may disappear in a few days, or last for a much longer time. In favourable cases it is usually replaced by feeble vesicu- lar respiration, more rarely by friction sound, and sometimes by pure respiration. This sign is almost always present at all ages PHYSICAL SIGNS. 123 in acute cases, but is often absent in those which are slow and tedious. In suckling children it is not constant, but intermits oc- casionally, so that it may be heard at one and not at the next examination. JEgophony can rarely be detected in children less than two years old. Under that age, there is heard instead of it resonance of the cry, especially in the region beneath and on a line with the spine of the scapula. It is intermitting like the bron- chial respiration. In children over two years old, segophony can often be distinguished by careful examination, but never, of course, unless the quantity of effusion is considerable. It is heard at an early period of the attack, and chiefly in acute cases, and must be sought for in the lower portion of the interscapular space, and the inferior dorsal region. It coexists almost invariably with bronchial respiration; lasts but a short time, disappearing after one, two, three, or four days; and is intermitting. In older chil- dren, it is sometimes replaced by diffuse resonance of the voice, as it is by resonance of the cry in infants. Feebleness or absence of the respiratory murmur seldom exist at the beginning of acute cases, but in the sub-acute or chronic form are generally present from the invasion. In the latter class of cases feeble respiration is noticed first over the inferior portion of the dorsal region, but, as the effusion increases, it is heard also in the upper and anterior regions, and becomes more and more feeble, until at length no sound whatever is audible: the respira- tory murmur is suppressed. In acute cases, on the contrary, the absence of the respiratory sound is observed at variable periods of the attack ; when soon after the invasion, it is generally coincident with bronchial respiration, which, heard at first over the whole or inferior three-fourths of the dorsal region, becomes afterwards perceptible only in the interscapular space, or at the inferior angle of the scapula, while the respiration is feeble or absent over the lower portions of the lung. In very acute cases the feeble respi- ration remains limited to the dorsal region, and disappears after a few days, while in chronic cases it extends over a larger surface, and continues for several weeks, or even months. Percussion.—This means of diagnosis is very important in all cases of the disease accompanied by effusion of liquid, unless the 124 PLEURISY. quantity is exceedingly small. When, on the contrary, the in- flammation results merely in the product'on of thin false mem- branes, percussion furnishes no useful information. Percussion is of no assistance, however, at the moment of in- vasion, as it is not until the period at which effusion takes place that the resonance of the thorax begins to be altered. In acute cases, the resonance is generally duller than natural, though seldom entirely dull, on the second, third, or fourth day. As the effusion augments, the dulness increases over the region occupied by the fluid, until at length all resonance ceases, and the sound is perfectly flat. The degree of dulness can be properly appreciated only by comparing the two sides together. The degree, extent, and duration of this sign will depend of course upon that of the effusion. In children as in adults, the sounds afforded by percus- sion vary with the position of the patient, which influences of course the situation of the fluid in the pleural cavity. In regard to the physical signs of pleuro-pneumonia, it may be stated that when a pleuritic effusion takes place in a child labour- ing under pneumonia, it happens as a general rule, that the bron- chial respiration occasioned by the inflammation of the lung in- creases in intensity, though in some few cases it is diminished or suppressed. Rilliet and Barthez lay down the following principle : " that when a pleuritic effusion occurs in a child affected with hepatization of the inferior portion of the lung, all the abnormal sounds which tcere perceptible over tlie diseased point are con- siderably exaggerated, and the sonoreity disappears." Inspection of the thorax affords no assistance at the invasion of the disease, nor generally in acute cases which last but a short time, and in which the amount of effusion is small. When, however, the effusion is large, it may be observed upon close examination, that the movements of the affected side during respiration are more limited than those of the opposite one, and that the intercostal spaces are more projecting than natural, in consequence of distension by the fluid within. At the same time mensuration will show that the side on which the effusion exists is larger than the other. The difference may amount to a third or two-thirds of an inch. In acute cases, in which the quantity of liquid is small, mensuration RATIONAL SYMPTOMS. 125 will of course show no difference. When the effusion is large, palpation is a very important sign. The hand applied over the diseased side feels no vibration of its walls either during respira- tion, crying, or speaking. This sign exists in the cases of infants as well as of older children. Rational symptoms; course; duration.—Acute pleurisy is very rarely met with, as already stated, in children under six years of age, except as a secondary affection. In idiopathic cases it begins with severe pain in the side, cough, some difficulty of respiration, increased frequency of the pulse, loss of appetite, thirst, bilious vomiting, sometimes headache, and in rare instances delirium. The pain in the side or stitch, is almost always present in acute cases occurring in healthy children, while in those which are slight, or occur in weak and debilitated subjects, or very young children, it very often cannot be detected. Sometimes, however, its existence may be ascertained in very young children by tenderness of the side shown during the act of percussion. It is aggravated by coughing, by full inspirations, by change of posi- tion, and by percussion. The seat of pain is almost always in front; but it may extend irregularly over the whole of one side, or be confined to the false ribs, or less frequently, to the neigh- bourhood of the nipple. The pain generally lasts from three to six days, though it sometimes continues longer. This symptom was complained of in the three cases that came under my notice. In one it lasted a week, and in the second only two days, though in both the effusion was extensive, and required several weeks for its absorption. In the third case, it continued for five days. In the last, the effusion was very slight. It was aggravated in all by coughing, by the act of respiration, especially when this was deep, and by motion. Cough exists in nearly all idiopathic cases, and generally from the onset, though sometimes not before the second or third day. Usually frequent and dry, it commonly retains these characters in acute cases, for four or six days, and then diminishes rapidly. In more tedious cases it continues for a longer time, but moderates in violence after some days. In secondary cases it has no special cha- racters. Cough existed in only two of the three cases seen by 11* 126 PLEURISY. myself. In one it was frequent, rather dry, and very painful for the first few days, after which it became looser, and though the inferior two-thirds of the right side were filled with effusion for a period of two weeks afterwards, it ceased entirely. In the other it was frequent, dry, very painful, so as to elicit loud complaints, and lasted a week, after which the child recovered with only slight effusion. In the third case, in which the whole of the left side was occupied by the effusion, there was no cough whatever ; neither the mother nor myself ever perceived any. The expectoration is very slight, or there is none. It was absent in the three cases referred to. The respiration is usually accelerated in acute cases ; but re- mains natural in other respects; the dyspnoea, however, is slight compared with that of pneumonia. In the chronic form it is gene- rally regular and but little increased in frequency. The difficulty of breathing is commonly great in proportion to the earliness of the age, and to the extent and rapidity with which the effusion takes place. In one of the cases observed by myself, it was between 40 and 50 during the first two days, after which it fell, as the effusion took place, to 30. In the second it was 45 at first; at the end of a week 38 ; at the end of the third week, as the effusion was being absorbed, it was 28, and then gradually fell to 20, the natural rate. In the third it was at 60 for the first few days, but at the end of a week had nearly regained its natural condition. In the last case the effusion was very small, and the convalescence rapid. The fever is not usually very great, and seldom lasts more than a few days, or a week. During the first three or four days, the pulse rises to 110, 120, or 130, and seldom higher, after which it commonly falls again, so that by the end of a week it is seldom over 70, 80, or 90. The heat of skin is not very great in most instances, and generally subsides rapidly and disappears after a few days. In acute secondary attacks, the febrile symptoms are more marked as a general rule, than as has just been described, because of the existence of the concurrent disease. In chronic cases the fever sometimes assumes, after a while, the hectic type. The countenance presents no particular characters, except that RATIONAL SYMPTOMS. 127 an expression of pain passes across it occasionally when the child coughs, or takes a deep breath. It is seldom deeply flushed as in pneumonia. The alee nasi are dilated only during the continuance of the difficulty of respiration. The decubitus is generally dorsal or indifferent. In the two cases observed by myself in which the effusion was large, the number of inspirations was always from three to five greater when the child laid on the sound, than when on the affected side. Headache is often present during the first few days, in children over six years of age. Convulsions are said to occur sometimes at the onset in very young children. The strength is not usually much diminished, except during the acute period. The appetite is generally dimi- nished and the thirst acute, but neither of these symptoms is so marked as in pneumonia. The tongue is usually moist, and sometimes covered with a coat of whitish fur ; the abdomen is natural. Bilious vomiting is said to occur in more than half the cases. The stools are generally regular, or there is some constipation. Auscultation practised soon after the invasion generally re- veals bronchial respiration without any rhonchus. The percus- sion is dull; the cough, pain, fever, and difficulty of breathing continue for several days ; after which all but the cough generally disappear, while that commonly persists. In acute cases, the appetite now begins to return, the thirst moderates, and ausculta- tion reveals only feebleness of the respiratory murmur and slight dulness on percussion. The general symptoms cease soon after this, and the patient is entirely convalescent in from one to three weeks, though feeble respiration and diminished sonoreity some- times persist for a longer period. Chronic pleurisy may follow the acute form, or occur as an idiopathic disease. In the former case, the acute symptoms diminish after a variable length of time, but the fever does not cease entirely and often recurs towards evening. In the latter case there is very slight fever or none at all, and the pain is vague, uncertain, and attracts but little notice. The effusion takes pla'ce gradually, and is generally large. The percussion is now 128 PLEURISY. entirely dull over a greater or less extent of the side, and the re- spiratory sound is suppressed. The side is evidently enlarged, the increase of size being visible to the eye and ascertainable by measurement. If the case continues and terminates unfavourably, the child emaciates, grows pale, has night-sweats and hectic fever, and dies at last in a state of profound exhaustion. In favourable cases, on the contrary, the effusion is gradually absorbed, and the patient recovers with a contraction of the side. In some rare in- stances the fluid has been evacuated by an opening through the parietes of the thorax, caused by ulceration or made by a sur- gical operation ; and in others again by an opening into the lung, through which the fluid has been expectorated. The recovery by absorption has been known to take place two and five months after the invasion. In one case that I saw, the duration from the time when the effusion took place to its complete absorption was five weeks, and in the other between six and seven. Diagnosis.—Pleurisy may be confounded with pneumonia or hydrothorax. From the latter affection it is to be distinguished by the absence of pain in that disease, by the existence of the effusion on both sides of the thorax in most cases, and by the fact that hy- drothorax generally follows as a consequence of some previous dis- ease, particularly the eruptive fevers or nephritis. The distinction between acute or chronic pleurisy and lobular pneumonia is, as a general rule, very easy. Lobular pneumonia occurs almost always in children under six years of age; it is ac- companied by a great variety and abundance of humid rhonchi on both sides, and by very slight dulness on percussion; the vibra- tion of the parietes of the thorax continues: pleurisy, on the con- trary, occurs very rarely under six years of age, except as a se- condary affection; it is unaccompanied by rhonchus of any kind; the auscultatory signs are feeble respiration, bronchial respiration, and when the effusion is large, absence of all sound ; the vibration of the walls of the chest ceases to be perceptible; and lastly, the percussion is much more dull than in lobular pneumonia, or it is flat. The distinction between acute pleurisy and lobar pneumonia is more difficult than either of the points which have just been con- DIAGNOSIS. 129 sidered, and in some instances is subject to considerable doubt. It may generally be arrived at, however, by attention to the diffe- rences laid down in the following table, which is taken from the Bibliotheque du Medecin Praticien. Acute Idiopathic Pleurisy. Acute Idiopathic Pneumonia. Frequent after six years of age; Frequent after six years of age; rare under that age. more rare under that age, but much less so than pleurisy. Begins with dry cough, sharp tho- Begins with cough, slight thoracic racic pain, bronchial and metallic re- pain, and crepitant or sub-crepitant spiration during inspiration, either on rhonchus; at a later period there is the first day or later, and more rarely bronchial respiration during the expi- with obscurity of the respiratory sound, ration and bronchophony. Modification of the physical signs No modification under like circum- by change of position. stances. Fever and acceleration of the re- Fever violent; considerable accele- spiration usually moderate. Rapid ration of the respiration. Diminu- diminution of these symptoms from tion of these symptoms less marked, the fourth to the seventh day. less rapid, and not before the sixth or ninth day. Expectoration absent or very slight. Expectoration mucous, sometimes sanguineous, very rarely rust-coloured. No rhonchi. Rhonchi preceding, following, and often accompanying the bronchial re- spiration. Absence of vibration of the thoracic Augmentation of vocal resonance parietes during speaking or crying. very sensible in older children, and in a less degree in all. Course of the disease irregular; ra- Course of the disease regular; stea- pid disappearance in some cases, pro- dily increasing, in most cases, and longed duration in others. The bron- then diminishing from the sixth or chial respiration is substituted or ninth day. Bronchial respiration masked by feeble respiration. more disseminated. The chronic form of pleurisy with extensive effusion, may be easily distinguished by the history of the case, by inspection, pal- pation and mensuration of the chest, by the nearly total absence of sonoreitv and of the respiratory murmur except at the inner edge of the'scapula, and by attention to the character of the gene- ral symptoms. 130 PLEURISY. Prognosis.—Acute pleurisy is rarely a fatal disease in healthy subjects. When it occurs as a complication of some other malady, on the contrary, it is much more apt to terminate unfavourably. The degree of fatality in secondary cases will depend, in great measure, on that of the primary disease. Pleuro-pneumonia is a more dangerous disorder than either alone. Of 5 cases of pri- mary pleuro-pneumonia, observed by Rilliet and Barthez, 2 died; while of 10 secondary cases, 8 died. Chronic pleurisy is generally a serious, and not unfrequently, a fatal disease. Of 5 cases, observed by the authors just quoted, 2 proved fatal. The three cases of pleurisy observed by myself, all of which were acute in the beginning, though two became chronic after- wards, recovered. Treatment.—The hygienic treatment in this, as indeed in all the diseases of children, is of the utmost importance, and ought to be regulated by the practitioner himself. In all forms of the disease, the child should be carefully protected from cold, and in the acute form, kept at rest, and if possible, in bed. The diet must be very strict, and should consist for a few days of nothing but the weakest preparations of milk. After the fever has disappeared, bread and milk, vegetable soup with a few oysters boiled in it to make it agreeable, and gradually rice, potatoes, and at last small quantities of meat may be allowed. In the chronic form the diet ought to be less strict, but regulated with equal care, as to quantity and material. In that form the patient should be taken into the air if the weather be mild and dry, and in winter the chamber ought to be well aired from time to time. Bloodletting.—Depletion ought to be employed in acute pleu- risy, as a general rule. Blood may be drawn either by venesection, cups, or leeches, the quantity to be regulated by the age and con- stitution of the patient. Venesection is preferable to local deple- tion, unless there be some contra-indicating circumstance. From four to six ounces may be taken generally from a child between four and six years of age. It is seldom necessary to repeat the operation ; when, however, the acute symptoms are not at all re- lieved by the first detraction, it would be proper and useful to resort TREATMENT. 131 again to a small venesection, to leeching, or to take two or three ounces of blood by cups, as recommended in the article on pneu- monia. Depletion ought to be avoided in most of the secondary cases unless the symptoms are very acute and the child strong and vigorous; also in all chronic cases, after the febrile symptoms have been dissipated, and in feeble, delicate children, or, if resorted to, it should be used with very great circumspection. Antimonials.—A moderate use of the antimonials is of great service in the acute stage of the disease. Small doses of antimo- nial wine and sweet spirits of nitre, or fractional doses of tartar emetic, as recommended in the article on pneumonia, will gene- rally cause the fever, dyspnoea, and cough to subside rapidly. Large doses seem to be unnecessary in any case, and are liable to be injurious in many. Alteratives.—Many writers recommend the habitual employ- ment of the mercurial preparations in connexion with bloodletting. It seems to me, however, that they are, to say the least, seldom necessary in acute cases, since the majority of these are nearly certain to recover without a resort to them ; and it is better, as has already been said, to avoid the use of mercury in children when there are other and less powerful remedies which may be resorted to instead. When, however, acute pleurisy tends to assume the chronic form, and in confirmed chronic cases also, they would seem to be more clearly indicated, though under such circum- stances, I have succeeded in curing two cases, as I shall presently show, without a resort to them. Nevertheless, calomel combined with digitalis, has been recommended by very high authority under these circumstances. From a quarter to half a grain of that pre- paration, with a quarter of a grain of powdered digitalis, may be given every two or three hours. The remedy employed by myself, after the disappearance of the acute symptoms and when the effusion had taken place, was iodide of potassium in syrup of sarsaparilla, according to the fol- lowing formula : R. Potass, iodidi grs. xvi.; Aquse, Syrup. Sarsap. comp. aa gi.—M. Give a teaspoonful three times a day to chil- dren three or four years old. Under this treatment the effusion 132 PLEURISY. disappeared rapidly, though diuretics had failed to make any im- pression on the cases. Diuretics are highly recommended in the treatment of cases in which effusion has taken place. Those chiefly employed are squills, digitalis, and nitre. The squill is given alone, or in com- bination with calomel or digitalis, or both. The dose of the powder of squill or digitalis is about a quarter of a grain every two or three hours. The squill may be used also in the form of syrup or oxy- mel, and the digitalis in tincture. These two substances were em- ployed by myself in the following formula: R. Acet. Scillse 3ii.; Aquae fontis giv.—M.~ Give a teaspoonful with a drop of Tinct. Digit., three or four times a day to children two years old. This formula was made use of for several days in the two cases already referred to, without any perceptible diminution of the amount of the effusion, whereupon it was suspended, and the iodide of potas- sium as above recommended substituted, and with much better effect. Purgatives ought to be used during the acute stage of pleurisy to an extent sufficient to keep the bowels soluble, and to act as mild evacuants. In chronic cases, on the contrary, they are par- ticularly recommended as evacuants, in order to deplete the blood- vessels, and thus hasten the absorption of the effusion. So far as my experience goes, this treatment is unnecessary, as diuretics and alteratives are generally sufficient, without a resort to violent re- medies which must irritate the intestinal mucous membrane, al- ways extremely susceptible in children, to a dangerous degree. External remedies.—Blisters are very generally employed in the acute form to relieve pain and dyspnoea, and in the chronic form to hasten the absorption of the effused liquid. I did not apply them in the cases under my charge, having succeeded very well without; but would not hesitate to make use of a small one applied for a not longer period than two hours, if the pain and oppression continued after sufficient depletion and the use of'antimonials. In chronic pleurisy, the application of a large Burgundy pitch plaster, made rather weaker than what is used for adults, and large enough to cover nearly the whole side, would, it seems to me, be preferable to blisters. TREATMENT--CASE. 133 Tonics are often necessary in chronic, and sometimes after the febrile symptoms have subsided in acute cases occurring in feeble and delicate children. The most suitable are quinine in the dose of a grain morning and evening, small quantities of very fine port wine, and the preparations of iron. Paracentesis.—When, in chronic pleurisy, the effusion is very large; when there is no disposition to absorption, notwithstanding the use of proper remedies ; when the child is becoming very de- bilitated, and is attacked with hectic fever and night-sweats; the operation of paracentesis has been recommended by very high authority, and has been performed with entire success on several occasions. M. Heyfelder (Arch, de Med., 3 serie, t. v., p. 59,) performed it in one case eight weeks, and in another four months and a half after the beginning of the attack. Both cases recovered; the lung expanded again, the opening closed, and the respiration was nearly alike over both sides. Case of chronic pleurisy of the left side, beginning with acute symptoms ; extensive effusion with displacement cf the heart to the right of the sternum ; recovery.—February 12th, 1846.—The subject of the case is a boy four years old, of delicate stature and appearance, but enjoying good health. I saw him first at 1 p. m. He was perfectly well yesterday, slept soundly last night, and rose apparently in good health this morning. He ate his usual breakfast, but complained afterwards of feeling unwell. Soon after this he complained of headache, of soreness and weak- ness of the knees in going up stairs, and then of violent pain in the left side beneatlyhe armpit. At the time of my visit he was in bed, in the following condition: Pulse 130, full and strong; skin warm and moist; headache; sharp, severe pain at the praecordia, extending backwards under the armpit, and aggravated by motion, crying, and by deep inspira- tions ; respiration quick, and jerking. No cough at all, absolutely none. Abdomen natural; neither vomiting nor diarrhoea. Tongue slightly furred, moist. Action of heart violent; impulse strong, and felt over a large space; sounds loud and strong, to the left and beneath the nipple, a soft murmur in second sound. Per- cussion dull over a larger space than natural. 12 134 P L E V R 1S Y. Behind, percussion dull over whole of left side; natural on right side. Respiration natural on the right side ; feeble and indistinct, without bronchial sound on the left. Ordered a teaspoonful each of extract of senna and syrup of rhubarb, to be given immediately. To have a warm bath in the evening, and to take one of the following powders every two or three hours, beginning in the evening. R.—Pulv. Opii. et Ipecac. grs. iij.; Potass. Nitrat. grs. vi. In pulv. No. vi. February 13.—Passed a restless night. Better to-day. Pulse 130, softer; skin moist. Impulse of heart less violent. Pain not so severe. Respiration still quick, and when the child is ex- cited or irritated, it becomes jerking, while at other times it is quiet. Physical signs as before, except that the murmur in the second sound of the heart is no longer heard. Ordered three ounces of blood to be drawn by leeches from the left side; pow- ders to be continued so as to allay restlessness and pain. February 14.—Has had a better night. Pulse less frequent. Respiration 30, and without jerking; no cough at all; makes no complaints of pain. The appetite is returning. February 15.—Better in all respects; no fever nor pain; no cough. Physical signs as before. The case went on until the 27th of March, when I paid my last visit, making the duration of the whole case over six weeks. During the last two weeks of February, there were no acute symp- toms. The fever had disappeared entirely. The respiration con- tinued, however, from 28 to 30 during all that time. The effu- sion occupied nearly the whole of the left side, which was mani- festly larger than the right, and the intercostal spaces were en- larged. Behind, there was total flatness on percussion from the spine of the scapula downwards, and in front from a short distance below the clavicle. The respiratory murmur was absent in the lower three-fourths of the dorsal region, and feeble above. In front, respiration was heard only above and just beneath the clavi- cle. In the course of this period, the heart was gradually forced over to the right side of the sternum, so that at last its impulse was felt, not to the left, but to the right of the sternum. The car- diac sounds were loudest and most distinct in the same region. CASE. 135 The displacement was so remarkable that the mother discovered it herself, I having avoided telling her, to save her from anxiety. The new position of the heart did not seem to produce any incon- venience, in addition to that occasioned by the pleuritic effusion. During the last two weeks of March, the child was kept in bed; his diet was milk and bread; a large Burgundy pitch plaster was kept on the side, and he took internally vinegar of squill, and tincture of digitalis. Finding that the effusion remained stationary under this treat- ment, I prescribed a grain of iodide of potassium to be given three times a day, in a teaspoonful of compound syrup of sarsaparilla. The diet was changed at the same time. He was allowed small quantities of meat every day, and was taken from bed and placed in a chair by the window. Under this treatment, he gradually improved, so that by the 27th of March, when I paid my last visit, the effusion had in great measure disappeared, and he was able to play about the room all day. The side was slightly con- tracted ; the respiration was pure and vesicular, but rather more feeble than on the left side; the heart had returned to its natural position. I have examined this child in the course of the present year (1847), and find him to be in as good health as before his sick- ness. Excepting a slight contraction of the left side, there is no perceptible difference between that and the right. ARTICLE IV. HOOPING-COUGH, OR PERTUSSIS. Definition; synonymes; frequency.—Hooping-cough is cha- racterized by a hard, convulsive cough, occurring during expira- tion, and accompanied by long, shrill, and laborious inspirations, which are called hoops. The cough occurs in paroxysms, which are terminated by the expectoration of tough phlegm and often by vomiting. The disease is known by various other names, of which the 136 PERTUSSIS. most common are tussis ferina, chincough, and kincough. The frequency of the disease is exceedingly variable, as it occurs both in the sporadic form and as a widely prevailing epidemic. Some idea of its frequency may be gained from the facts that during the ten years preceding 1845, there were 781 deaths from it in Philadelphia, under fifteen years of age. During the same time there were 1592 deaths from pneumonia; 1149 from croup; and 1172 from bronchitis. (Condie, Dis. of Child., 2d edit, note, p. 88.) Causes.—Age.—It occurs generally in young children. Of 130 cases in children, collected by M. Blache, 106 were between 1 and 7 years of age, and only 24 between 8 and 14. Of 29 cases observed by Rilliet and Barthez, there were 26 between 1 and 7 years, and 3 between 8 and 12. Of 49 observed by myself, there were 9 under 1, 37 between 1 and 7, and 3 between 8 and 10 years. It is stated by MM. Blache, Rilliet and Barthez, and Valleix, to be most common in girls. Of the 49 cases observed by myself, 27 occurred in boys, and 22 in girls. Some writers have asserted that certain constitutions and hereditary influence predispose to the disease. So far as my own experience goes, it has seemed to attack indifferently those who were simultaneously exposed to it. The fact of its being propagated by direct conta- gion is proved beyond doubt by numerous observations. I have rarely known one child in a family to be attacked without its extending to all the others not protected by having had the disease previously. That it often appears also in the form of an epidemic, is established by the testimony of many writers, so that at present no doubt is entertained upon this point. Symptoms.—It is customary to describe three stages of hooping- cough. The first is called the stage of invasion, or the catarrhal stage ; the second the stage of increase, or the spasmodic stage; and the third the stage of decline, which is characterized by an amendment of all the symptoms. First stage.—The great majority of the cases begin with the or- dinary symptoms of simple catarrh. These are coryza, sneezing, slight injection of the conjunctivae, and dry cough. The cough rarely has any peculiarity in the beginning which will enable us SYMPTOMS. 137 to distinguish it from that of an ordinary cold, though some per- sons have asserted that they could recognise it. I have often listened with great care to the sound of coughs which parents sup- posed might be hooping-cough, but was always obliged to confess my inability to determine, until time gave them more decided characters. In addition to the symptoms enumerated, there is generally more languor, lassitude, drowsiness, and irritability, than are commonly present in simple catarrh. In a small propor- tion of cases the first stage is wanting, and the disease assumes its peculiar features from the first. The duration of this stage is very uncertain, and is ascertained with difficulty. My own ex- perience would fix it at about two weeks as the average, though it may last undoubtedly a much shorter, or longer period. Second stage.—At the beginning of this stage the disease has assumed its peculiar convulsive and paroxysmal characters. It consists of violent fits or paroxysms, or as they are often called, kinks of cough, recurring after longer or shorter intervals. Just before the paroxysm the child seems restless, anxious, and irritable, or else keeps perfectly quiet and evidently tries to retard its approach. When it begins, the child, if lying down, rises up suddenly, or if playing about runs to take hold of some fixed ob- ject, by which to support itself during the accession. The cough is dry, spasmodic, and sonorous, and occurs in a succession of short, rapid expirations, by which the thorax seems to be emptied of all its air, with violent efforts. It is followed by one or two long and deep inspirations, which are accompanied by the peculiar hoop to which the disease owes its name, in consequence of the drawing of the air through the narrowed glottis, which is spas- modically closed. During the fit the face becomes deeply suffused or even purple, and swollen; the eyes are watery, and the coun- tenance expressive of great anxiety, and after the fit is over, of fatigue and exhaustion. The latter symptoms are, as M. Valleix remarks, the signs of partial asphyxia, and are the result doubtless of the complete expulsion of air from the thorax, and consequent momentary suspension of the function of hsematosis. There is almost always an expectoration of colourless ropy fluid, often accompanied by vomiting, at the close of the fit of coughing, and 12* 138 PERTUSSIS. the patients usually appear weak and languid for a short time, after which they return to their play. In very severe cases there are other symptoms in addition to those just mentioned. Hemorrhages from the mouth, ears, nose, lungs, and beneath the conjunctiva, are not unusual. I have seen several instances of epistaxis, and one of extensive sub-conjunctival ecchymosis myself, and I am well acquainted with the history of another, in which there was bleeding both from the nose and ears. In another, in a girl two years of age, which came under my own observation, a species of syncope, a state of insensibility without convulsive movements, accompanied by great paleness, occurred after many of the paroxysms. I have met with general convul- sions in four cases, two of which were fatal. In two other cases, both occurring in infants under six months, the paroxysms of cough were accompanied by the most violent struggling and op- pression, and by deep blueness of the hands and feet, like that of severe cyanosis. In some instances, after the paroxysm is apparently over, the child will begin within a few instants to cough again, and may in this way have several fits in such rapid succession as to make an almost continuous paroxysm. It is quite common for this to happen twice, and in one case which I saw, it occurred three times on several occasions. The ordinary duration of a paroxysm or kink, is from a quarter to three quarters of a minute, though it may last as long as two minutes, or according to some even longer. The number of accessions in twenty-four hours is very irregular. It depends chiefly on the stage and violence of the attack. During the height of the disease, I have generally found them to number about 40. In some rare cases, however, they are much more numerous, and amount to 70 or 80. They are gene- rally most frequent in the course of the third or fourth week, after which they remain stationary for two or three weeks, and decline gradually. The paroxysms may occur spontaneously, the child being often disturbed from sleep by their sudden occurrence, or they may be excited by various circumstances, such for instance as contrarieties, a fit of crying, change of position, eating, violent exercise, and imitation. I have frequently seen an attack brought on SYMPTOMS. 139 by the sight of another child in a paroxysm of the disease. The duration of the second stage is stated by Rilliet and Barthez to be about 30 or 40 days in most cases. Third stage.—It is impossible to fix a precise limit from which to date the beginning of this stage. It is generally, however, said to commence from the time when the disease is evidently on the decline. The paroxysms now grow less frequent and less vio- lent, the cough reassumes some of the catarrhal features which it had at first, and gradually loses its peculiar spasmodic character. The child's general health improves; the appetite becomes vigor- ous, the strength is invigorated, the sleep again becomes sound and tranquil, and the disease disappears. The duration of this stage is uncertain like that of the two others. Rilliet and Barthez state it to be short in uncomplicated cases (ten to fifteen days), and are of opinion that when it has been supposed to have lasted several weeks or months, it has been the result of some complication, as chronic dilatation of the bronchia, tubercular disease, etc. It hap- pens not unfrequently, however, that after the disease has appa- rently ceased, all the distinctive characters of the cough recur, if the child chances to take cold within a few weeks or even longer after its disappearance. In cases of pertussis unaccompanied by complications of any kind, there are no marked general symptoms. There is seldom any fever, the appetite continues good, and with the exception of occasional languor and fatigue, and irritability of temper, the child appears to be well. The total duration of the disease, in simple cases, may be stated at from one to three months, according to Rilliet and Bar- thez. 1 have never known a case to last so short a time as a month, and have rarely found the whole duration much within three months. Complications.—Though it has happened to me on several oc casions, to meet with children who have been very ill from the violence of the disease under consideration, in its uncomplicated condition, I have never known a case to prove fatal, except in consequence of some kind of complication. It seems to me very important, therefore, that the various complications liable 140 PERTUSSIS. to occur in the course of the disease, should be carefully con- sidered. Convulsions.—This complication is not a rare one, since it oc- curred in 5 of 29 cases observed by Rilliet and Barthez, and in 3 of 49 observed by myself. It. is one of the most dangerous accidents liable to occur in the course of the disease. • Of the 7 cases reported by the authors quoted, (5 of their own, and 2 be- longing to M. Papavoine,) 6 died. Of my 3 cases, 2 died. In all that I have seen, the convulsions were general, extremely violent, and accompanied by insensibility in the fatal cases to the last, and in the favourable one, for several hours. In the two fatal cases the pertussis had lasted nearly two months, and was accompanied by extensive lobular pneumonia. The fatal event took place within twenty-four hours from the supervention of the spasms. The subjects were eight and nine months of age respec- tively. The favourable case occurred in a child five months old, who had been attacked with lobular pneumonia three days before the occurrence of the convulsions, which came on during the height of a severe paroxysm of coughing. The convulsive movements were general and continued for about half an hour, after which the child was drowsy or irritable for some hours longer. The hoop- ing-cough continued to be severe for two weeks after this, as many as 42, 46, and 48 paroxysms occurring every day. At last, how- ever, perfect recovery took place. It is proper to call the attention of the reader to the fact, that the 3 cases observed by myself occurred under one year of age. Bronchitis is a very frequent complication. The authors above quoted found it to exist either alone, or combined with pneumonia, in half of the fatal cases. Of the 49 cases observed by myself, it existed to a greater or less extent, in its simple form, in 16. All of these recovered, so that it cannot be regarded as a very dan- gerous accident. In fatal cases it has often been found accompa- nied by continuous dilatation of the smaller bronchia. Pneumonia, according to the authors above quoted, is about as frequent as bronchitis. When, however, the fatal termination took place soon after the beginning of the disease (18th, 26th, or 27th COMPLICATIONS — DIAGNOSIS. 141 days), it was not generally present. After these periods, on the contrary, it was almost always observed. 1 have met with well- marked pneumonia only in 5 of the 49 cases referred to, and in 1 other, making 6 in all. Of these, 4 were lobular and 2 lobar. Of the 4 children affected with lobular pneumonia, 3 were under one year, and the fourth between one and two years of age. Two of these died in convulsions, and one in a state of marasmus. The cases of the lobar form of the disease occurred in girls of seven and nine years of age respectively, and both recovered. This complication is much more dangerous therefore than simple bron- chitis ; the degree of danger is in proportion to the earliness of the age at which the disease occurs, and to the extent of the inflam- mation. Emphysema has been supposed by some to be a common result or accompaniment of the disease. This is denied, however, by others. I have never observed it myself, and as nearly all the children whom I have attended with pertussis continue to be under my observation, I should certainly have noticed it, were it of com- mon occurrence. Vomiting is a very frequent incident in pertussis, but ought not to be regarded as a complication unless dependent on some dis- ease of the digestive organs, or symptomatic of cerebral disease. Where it occurs in simple cases, or in those complicated with bronchitis or pneumonia, it has always seemed to me to be advan- tageous. Tuberculization is not infrequent, according to the French au- thorities, as a sequence of the disease. In the majority of the cases the tubercular deposit is concentrated in the lungs and bronchial ganglions. I am disposed to believe that it is of rare occurrence in this city, at least amongst the better classes, as I very seldom meet with it, or indeed with any form of tubercular disease in children. Diagnosis ; prognosis.—The diagnosis of pertussis is difficult only during the first stage of the complaint. It seems to me, in- deed, impossible to distinguish, during that stage, between it and simple mild laryngitis, or the mild catarrhal attacks which are so common in our climate. After it has once fairly entered upon the 142 PERTUSSIS. second stage, it is scarcely possible to confound it with any other malady. Rilliet and Barthez state, however, that acute bronchitis with paroxysmal cough is not unfrequently mistaken for pertussis. The mistake will scarcely be made, if it be recollected that in acute bronchitis with paroxysmal cough, the invasion is sudden; that there is violent fever, great dyspnoea, and the physical signs of bronchitis; that the hoop is generally wanting, or feebly marked, and that the disease is violent and rapid in its course; all of which circumstances are widely different from what occurs in pertussis. The same authors assert that tuberculosis of the bronchial ganglions gives rise to a cough which may be mistaken for per- tussis. The following table extracted from their work will show the differences between the two disorders. Pertussis. Often epidemic, attacking several children at once; transmissible by contagion. Three distinct stages, of which only the second accompanied by kinks. Kinks attended with hooping, ropy expectoration, and vomiting. Pure respiration in the intervals be- tween the kinks. In the intervals between the kinks respiration and pulse natural, so long as the disease is simple. Voice natural. Course generally acute. Tuberculosis of the Bronchial Ganglions. Always sporadic; non contagious. No distinct stages. Kinks generally very short, with- out hooping, ropy expectoration, or vomiting. Physical signs of tuberculosis of the ganglions; but in certain cases, absence of these signs. Accessions of asthma in some cases, with the kinks; continuous febrile movement, with evening exacerba- tions ; sweats; progressive emacia- tion, &c. Voice sometimes hoarse. Chronic course. Prognosis.—Pertussis is rarely a dangerous or fatal disease so long as it remains simple. Of the 49 cases observed by myself, 27 were simple, all of which recovered. Nevertheless, even the PROGNOSIS — NATURE. 143 simple disease does sometimes terminate fatally, from the exces- sive violence of the paroxysms of coughing. The danger in hooping-cough, which is considerable, depends, therefore, almost entirely on the complications which are so apt to occur, for which reason the physician should watch with the closest attention, in order to prevent their occurrence, and that he may recognise and treat them in their earliest stages. The most dangerous complication is convulsions, and after that bronchitis and pneumonia. So long as the child seems well and lively, and without fever or dyspnoea in the intervals between the fits, there is nothing to be feared. But if, on the contrary, it becomes languid and irritable, with indisposition to take food, feverishness, and some increase of the rate of respiration, the practitioner should be upon his guard. A very early age and natural delicacy of con- stitution are unfavourable circumstances in the disease. I have already stated that complications occurred in 22 of the 49 cases observed by myself. Of these, 3 died, one at the age of eight, one at that of nine months, and the other at that of a year and a half. Nature of the disease.—There is no essential anatomical lesion in pertussis, except, perhaps, slight inflammation of the bronchial mucous membrane. In most of the cases, the membrane lining the larger and smaller air-tubes, and very rarely that of the tra- chea, is reddened and perceptibly thicker than natural, and the tubes contain a considerable quantity of frothy mucus, or a thick, viscid, and tenacious phlegm. As to the nature of the disease, it seems to me very clear that it ought to be regarded as containing two elements of morbid action, one of which consists in slight inflammation of the respi- ratory mucous membrane, and the other of disordered action of the respiratory system of excito-motory nerves. It is neither a pure neurosis nor a pure inflammation, but partakes of the cha- racters of both, and much more of the former than of the latter. The authors of the Compendium de Medecine Pratique (t. ii., p. 526) regard it as a neurosis on the following grounds: 1. "In the greater number of cases, the respiratory apparatus presents no kind of alteration, or else the lesions are so multiplied or variable that they are surely not the real origin of the disease; 2. The 144 PERTUSSIS. clearly remittent course of the symptoms and the total absence of fever, unless some complication is present, are not observed in ordinary or even specific inflammations ; 3. The cessation or sudden return of the paroxysms under the influence of moral emotions or change of place, belong to a disorder of innervation and not an inflammation, which commonly passes through cer- tain stages before it is resolved; 4. The complete return to health, the integrity of all the functions in slight cases, the resis- tance which it opposes to treatment, the uselessness of antiphlo- gistics, and the success obtained from narcotics and antispasmo- dics, are all so many circumstances peculiar to hooping-cough and to many of the neuroses." Treatment of simple pertussis.—Bloodletting.—Depletion is very rarely necessary in simple pertussis. The only cases in which it can be called for are those occurring in sanguine children, where the paroxysms are so violent as to endanger the brain by over-dis- tension of the vessels. In these cases a small bleeding, or the ap- plication of a few leeches to the temples or behind the ears, may be proper; but even these may often be safely treated by reduced diet and by a few doses of saline cathartics, without a resort to the more powerful and more permanently exhausting means of deple- tion. As for the treatment of simple pertussis by repeated vene- sections, in the hope of curtailing its duration, or under the idea of their being rendered necessary by the violence of the malady, it seems to me forbidden by the present state of medical knowledge, which informs us that pertussis, like the exanthemata, has a certain course through which it must pass, and that the greater number of the cases do not endanger life so long as they remain simple, however violent they appear to be. Of the 27 simple cases treated by myself, depletion was not used in any, and all re- covered. Antispasmodics.—Of the different remedies of this class which have been used in the disease, I shall only mention assafoetida, which is recommended upon very high authority, and is doubtless useful in moderating the severity of the paroxysm. It is much employed in this city as a domestic remedy. I have used it my- self on several occasions with some benefit; but, as I have ob- TREATMENT. 145 tained better and more constant success from other means, I now seldom resort to it. Dewees speaks of it as " occasionally useful, but never decidedly efficacious" in his hands. Kopp recommends it very strongly, in the dose of six grains three times a day in pills, for a child four years old. This seems to me a large dose. I have generally given two or three grains three or four times a day to a child of that age. Narcotics.—Of the various narcotics which have been more or less extensively employed, the most important are belladonna, opium, and hydrocyanic acid. Belladonna is highly recom- mended by several German authors, by Rilliet and Barthez, who state that it is beyond contradiction the one most deserving of confidence, by Trousseau and Pidoux, and by Dr. Eberle. It ought to be given with great care, and not continued for too long a time. Eberle says that it ought not to be exhibited where there is fever and bronchial inflammation. Trousseau and Pidoux employ the following formula : R.—Pulv. Belladonna gr. iv; Extract. Opii aquos. gr. iv ; Extract. Valerianae 3ss. Ft. in pilul. no. xvi. Give from one to four in the course of the day. If the child dis- like the pilular form, they give it in syrup, according to the fol- lowing formula: R— Extract. Belladonna gr. iv ; Syrup. Opii, Syrup. Flor. Aurantii, aa 3j. Misce. Of this, from one to eight teaspoonfuls are to be given in twenty-four hour*. I have seldom made use of belladonna, and can, therefore, give no personal opi- nion as to its efficacy. Opium is confessedly a very valuable remedy in the disease, not as a curative, but as a sedative and palliative. When the cough is frequent and fatiguing, especially if the patient have an irri- table and nervous constitution, some opiate preparation is of the utmost service in moderating the frequency and violence of the paroxysms, and in allaying irritability and restlessness. It is best given in the evening, and in combination with ipecacuanha, or very minute doses of antimony. Hydrocyanic acid has been employed by various observers, and is highly spoken of by some. Its poisonous properties, how- ever, have deterred many, and amongst them, myself, from re- sorting to it. Inasmuch as there are other and safer means for 13 146 PERTUSSIS. conducting the disease to a favourable termination, it seems to me useless to venture upon so potent a preparation as this. Dr. Atlee, of Lancaster, gave it in the following formula: R.—Acidi Hy- drocyanic rftj; Syrup. Simpl. 3j.—M. A teaspoonful given morning and evening; and if no uneasiness, dizziness, or sickness be produced witnin forty-eight hours, the dose to be repeated, three times a day. This prescription is for a child six years old ; one drop of the acid being added for each year of the child's age beyond one year. He has never repeated the dose more than four times a day. (Condie's Dis. of Child. 2d ed. p. 337.) Emetics and Nauseants are amongst the most important reme- dies in the treatment of hooping-cough, since they exert a powerful influence upon the disease, and unless carried to excess, are not in themselves likely to be injurious. Some authors recommend the administration of an emetic every day or every other day, while others give them according to the necessity of the case. Believing that frequently repeated emetic doses are unnecessarily severe, and productive of too much fatigue and exhaustion, I have preferred in the simple disease, to give only small doses of ipecacuanha from time to time, so as to moderate the violence of the cough. Tartar emetic is seldom necessary, and ought to be avoided if pos- sible, on account of its disposition to irritate and inflame the gastro-intestinal mucous membrane. The syrup of ipecacuanha is the preparation T have almost always used. From ten to twenty drops, given three times a day to a child three years old, will very generally moderate the severity of the paroxysms. Purgatives are necessary in the simple disease only when con stipation is present. The mildest ought to be preferred, in order to avoid irritation and exhaustion. Castor oil, magnesia, or syrup of rhubarb are the best. Particular remedies.—Of the different specific remedies that have been employed, none have attained and maintained so high a reputation in this city as the carbonate of potassa, which, in the form of the cochineal mixture, is constantly used both by physi- cians and as a domestic remedy. The following formula is the one generally administered: R.—Potass. Carbonat. 9j; Cocci 9ss ; Sacch. alb. 3j; Aqua fontis, 3iv.—M. Give a dessert spoon- TREATMENT. 147 ful three times a day to a child a year old. Believing the carbo- nate of potash to be the active agent in the mixture, I have gene- rally left out the cochineal and used the potash alone, dissolving it in equal parts of syrup of gum and water. I have frequently employed this remedy and believe that, with the exception of alum, to which I shall presently refer, it is the most useful agent in keeping down the violence of the disease with which I am ac- quainted. I have given it in the dose of a grain three and four times in the twenty-four hours, to children one and two years old, for several weeks at a time, without witnessing any injurious effects from it. Alum is highly recommended as a remedy in pertussis by Dr. Golding Bird (Guy's Hospital Reports, April 1845). He states that in the second or nervous period of the disease, when "all inflammatory symptoms have subsided, and when, with a cool skin and clean tongue, the little patient is harassed by a copious secretion from the bronchi, the attempt to get rid of which pro- duces the exhausting and characteristic cough, alum will be found to be of much value." He adds that he " has not yet met with any other remedy which has acted so satisfactorily, or afforded such marked and rapid relief." From reading Dr. Bird's remarks on alum, and prompted by my knowledge of its admirable quali- ties in the treatment of croup, I was led to make trial of it in the disease under consideration, and I believe I may say that it has exerted a more decided influence in'moderating the violence of the disorder, than any that I have ever made use of. I have admi- nistered it in 15 cases, beginning in the course of the second stage. In all it was beneficial, and in some the effects were strik- ingly useful, the improvement being more rapid than I had ever seen to result from other remedies, or to occur when the disease has been allowed to pursue its natural course. In a boy between five and six years of age, who had been coughing violently for two weeks, the paroxysms diminished so much in intensity and frequency after he had taken the remedy two days, that he was not once disturbed at night, though before he had always been waked several times, and the spells which occurred during the day were much less severe. After continuing the remedy for 148 PERTUSSIS. ten days, the disease had subsided so much that its employment was suspended. Soon after, however, the paroxysms again be- came severe and troublesome. The alum was resumed, and with the same results as at first. In another family in which there were three children, all of whom had been taking syrup of ipe- cacuanha, and carbonate of potash for some days, without any good effects, the alum was given, and acted as in the case first referred to. The nights were comparatively quiet, and the spells occurring through the day, very much moderated. I may repeat that, so far as my experience in the above 15 cases goes, the effects of alum have been more decided and satisfactory than those of any other remedy. I have never known it to produce bad consequences either at the time of its administration or subse- quently, though I have given it to children from two months to seven years of age, and have continued its use from one to five weeks at a time. If administered in large doses it produces vo- miting. It does not constipate, but on the contrary, is apt to in- duce diarrhoea, when continued for some time. Dr. Bird gives from two to six grains every four hours. His formula is as fol- lows : R. Aluminis, gr. xxv ; Ext. Conii, gr. xii,- Syrup. Rhoea- dos, 3ii; Aqua Anethi, 3iii.—M. Give a medium-sized spoonful every six hours. I have not generally used it in such large doses. To children under one year I give from half a grain to a grain, three or four times a day; and to those over that age, two grains every six hours. The formula I have employed is the follow- ing : R. Aluminis, Diiss; Syrup. Zingib., Syrup. Acacia, Aquas fontis, aa 3i.—M. When this is prepared with good syrups, it tastes very much like lemonade, and is not at all unpleasant, so that children take it without difficulty. The dose is a teaspoonful three times a day, or every six hours. Sulphur.—Some of the German authorities make frequent use of, and greatly commend the effects of flowers of sulphur, both at the beginning and throughout the course of the disease. Rilliet and Barthez state that they saw it succeed several times in the hands of M. Jadelot. I have never employed it. It is given in doses of three grains two or three times a day, to children from two to four years of age; and to those who are older, in doses of TREATMENT. 149 fifteen grains or more in twenty-four hours. It may be admi- nistered in powder diffused in milk or syrup, or made into an emulsion. It is said not to be purgative in the doses mentioned. Various other remedies have been recommended by different authors, the most important of which are the subcarbonate of iron used by Dr. Steyman, and by Lombard of Geneva; the misletoe, (Viscum Album), employed by Baglivi and J. Frank, and recently by Guersent and Blache, who give it in powder, in the dose of twelve or fourteen grains four times a day ; and the cicuta, which is highly spoken of by several German authors. Revulsives.—The milder revulsives are useful in certain com- plications of pertussis, and as palliatives. To make them the chief basis of the treatment, however, which has been done by some, appears to me to be wrong. In order to produce a decided im- pression upon the disease, it would be necessary to resort to the more powerful remedies of the class, such as moxas, issues, tartar emetic ointment, blisters, etc., the use of which is not, I believe, warranted by the nature of the disorder. Treatment of the complications.—If any of the diseases which have been mentioned as apt to occur during pertussis should arise, the treatment which is proper for them in their idiopathic form, must be adopted without regard to the hooping-cough, with the following rese vations: that care must be taken not to use means of too powerful and exhausting a nature, or such as have a tendency to irritate the organs with which they come in contact. For, it must be recollected, that after the complication is cured, the patient still has the original disease to go through with, and therefore re- quires all his strength ; and, moreover, the various organs of the body are predisposed by the very fact of the existence of the ori- ginal malady, to assume diseased action, should any irritation in the shape of a violent remedy be applied to them. The cases of bronchitis which came under my observation were treated in the simplest manner. The children were put to bed, their diet carefully regulated, the bowels gently opened with castor oil or syrup of rhubarb, and small doses of syrup of ipecacuanha or antimonial wine, with sweet spirits of nitre, administered every two hours. Mustard poultices were applied once or twice a day 13* 150 PERTUSSIS. to the inter-scapular space, and mustard pediluvia used every night, or more frequently if the dyspnoea were considerable. If the bronchial secretions were very profuse, and the cough trouble- some, the decoction or syrup of seneka was given in connexion with occasional doses of laudanum or paregoric. The complication of pneumonia was treated somewhat differ- ently. In the two cases of the lobar form, in children seven and nine years old respectively, one, the eldest, was bled from the arm, and the other leeched. The rest of the treatment consisted in the administration of small doses of antimonial wine and nitre, in the manner pointed out in the article on pneumonia, in the use of small doses of Dover's powder, and of the foot-bath. Both re- covered. The four remaining cases of pneumonia were of the lobular form, of which three proved fatal. The subjects of the fatal cases were eight months, nine months, and eighteen months of age respec- tively. They were treated principally with ipecacuanha, occa- sional laxatives, small doses of anodynes, and with mustard poul- tices and pediluvia. In one a blister was applied between the shoulders, but with most unfortunate results; since the vesicated surface sloughed, and added very much to the sufferings of the child. The fourth case occurred in a boy five months of age. In this a violent attack of convulsions occurred on the third day of the pneumonia. The child was immediately placed in a warm bath, and large sinapisms applied over the front of the chest and upon the extremities, after'which he was treated with half grain doses of alum, repeated every three or four hours, mustard pediluvia and poultices, and small doses of wine of opium. On the sixth day the pneumonia was resolved with copious sweats and cold hands and feet, for which small quantities of brandy and water and wine whey were used. The recovery was perfect. When convulsions occur they must be treated according to the cause which produces them, and the constitution and present state of the child. If the patient be strong and sanguine, and not ex- hausted by previous sickness, the treatment should consist of de- pletion by venesection, or by leeches to the temples, or behind the ears ; of cold applications to the head; the warm bath ; cathartics TREATMENT. 151 or purgative enemata ; and revulsives in the form of sinapisms, or of a small blister to the nucha. If, on the contrary, the patient is of delicate constitution, or exhausted by long illness, we must be content to resort to warm baths, revulsives, antispasmodics and anodynes, and stimulating enemata. Of the 4 cases of convulsions which came under my notice, the 3 already referred to, and one other, two proved fatal. Both of these occurred in children who had long been labouring under lobular pneumonia, that had baffled all treatment. Death took place within twenty-four hours from the appearance of the convul- sions, which were in fact the result of the diseased condition of the lungs. No treatment further than the warm bath and sinapisms, was resorted to. Of the two favourable cases, one has just been described under the head of pneumonia. The other occurred in a hearty boy nine months old, and seemed to depend on congestion of the brain, brought on by a severe fit of coughing. In this instance a venesection to a small amount was performed, the child was placed in a warm bath and cold applied to the head. No return of the spasms took place and the child recovered without difficulty. Hygienic Treatment.—This part of the management of the disease is of the highest importance, for it is by careful attention to its details, that the complications which constitute the chief danger of the malady, are to be prevented. In a considerable number of cases of pertussis, nothing more need be done than to insist upon strict attention to hygienic rules. The chief indications are to preserve the child from taking cold, and to prevent indiscretions in diet. The clothing ought to be warm, and during the autumn, winter, and spring, flannel should always be placed next to the skin. The child ought to be kept in the house during damp weather at all seasons, and in the winter season, whenever it is intensely cold. The diet should be nutritious, but of easy digestion. All heavy, rich food ought to be absolutely forbidden during the continuance of the malady. Treatment of the Paroxysm.—-It often happens that the parox- ysms are so violent, that the child seems to be in imminent danger of suffocation or convulsions. This is especially true of infants. In three cases which I have seen, in infants of two, three, and five 152 PERTUSSIS. months old, the kinks lasted so long, and the spasm of the larynx was so unyielding, that the children struggled as though labouring under tetanus; the countenance was disturbed and anxious; the face and hands, at first flushed, became purple from deep conges- tion ; and on some occasions the breathing was suspended for several seconds, so that life seemed for the time in the greatest danger. The difficulty in these cases depends on the spasmodic closure of the glottis, which is, sometimes, no doubt, completely shut. I have never known these alarming symptoms of asphyxia to occur when the hoop has been clear and distinct, for when that is present, the larynx is much less tightly closed. When the symptoms above described occur in older children, they should be raised and supported in the sitting posture; when in infants, they ought to be held lightly in the arms, so that they may take any position which instinct prompts them to. At the same time cold water ought to be sprinkled from the fingers upon the face; the child should be gently fanned, or, if the weather be warm, taken to the open window ; if there be time, it is well to put the feet into mustard water. It has been recommended on such occasions to apply compresses dipped into cold water to the sternum. I would propose the trial of a means which my father found very successful in arresting tonic spasm of the respiratory muscles, in a case of laryngismus stridulus. This is the sudden application of a piece of ice wrapped in linen to the epigastrium. When the laryngeal spasm is very intense and obstinate, a Small blister to the front of the neck, is useful in controlling it. CLASS II. DISEASES OF THE DIGESTIVE ORGANS. CHAPTER I. DISEASES OF THE MOUTH. I find myself much embarrassed in regard to the classification of the diseases of the mouth most proper to adopt. So much con- fusion reigns amongst authors as to their nature, and consequently as to their nomenclature, that it is very difficult to reconcile the various discrepancies which exist. After much consideration, however, I believe that the following arrangement is the one best suited to the existing state of knowledge upon these affections: 1. Simple or erythematous stomatitis. 2. Follicular stomatitis, or aphtha. 3. Ulcerative, or ulcero-membranous stomatitis. 4. Gangrene of the mouth. 5. Thrush, or stomatitis with curd-like exudation. ARTICLE I. SIMPLE OR ERYTHEMATOUS STOMATITIS. This form of stomatitis consists of simple diffuse inflammation of the mucous membrane of the mouth, unattended by vesicular or pustular productions, by ulceration, or by membranous exuda- tion. It is a disease of infrequent occurrence, except in the forming stage of other kinds of stomatitis, and of little impor- tance, seldom requiring the attention of the physician. 154 A PIITH.E. The causes of the disease are the introduction of irritating sub- stances, such as hot drinks, and acrid or caustic preparations, into the mouth ; difficult dentition ; and probably sympathy with dis- ordered states of the stomach. It occurs not unfrequently as a secondary affection, particularly in the course of measles, scarlet- fever, and small-pox. The symptoms of erythematous stomatitis are more or less vivid redness of the mucous membrane, which is sometimes diffused, and sometimes punctuated or disposed in patches ; slight swelling of the same tissue ; heat, and tenderness to the touch, and in the act of sucking or eating. The child is generally fretful and rest- less, and either loses its appetite, or refuses to nurse or take food freely, on account of the tenderness of the mouth. There are seldom any general symptoms except in secondary cases, in which they are those of the primary affection. The treatment is very simple. It consists in the use of some demulcent wash, as gum water, sassafras pith mucilage, a little honey put on the tongue occasionally, and if the inflammation be at all considerable, in the application of some astringent prepara- tion. This may consist of honey and borax, two or three parts of the former to one of the latter, or of the following wash, recom- mended by M. Bouchut. R.—Mel. Rosa 3i; Aluminis 3ss ; Aqua distillat. 3ss.—M. The application of any of the washes recom- mended is best made by means of a thick and soft camel's-hair pencil: or it may be done with a soft rag, which should be dipped in the wash, and then conveyed into the mouth on the point of the finger. The remedy ought to be used several times a day. If signs of gastric or intestinal disorder are present, they should be attended to. ARTICLE II. APHTHAE. Definition ; synonymes ; frequency; forms.—The term aphtha ought to be restricted to the vesicular and ulcerous form of disease CAUSES--SYMPTOMS. 155 of the buccal mucous membrane, in w;hich that tissue is covered with an eruption of vesicles which break, and are followed by small rounded ulcerations.. Under this title writers formerly confounded the affection we are now considering with ulcerative stomatitis and thrush. It is called by Billard follicular stomatitis, and by several other writers vesicular stomatitis. The frequency of the disease is very considerable. I shall describe two forms, the discrete and confluent. Causes.—The only causes which seem to have been ascertained with any degree of certainty are early age, and the process of den- tition ; the contact of irritating substances, particularly stimulating and acrid articles of food, with the mucous membrane of the mouth ; and the existence of some morbid irritation of the digestive tube, especially of the stomach. The confluent form is often connected with severe general disease of the constitution. Symptoms ; duration.—Aphtha begin in the form of small red elevations, having little white points upon their centres, which con- sist of the epithelium of the mucous membrane raised into vesicles. The vesicles are small in size, oval or roundish in shape, and of a white or pearl colour. They soon break and allow the fluid which they contained to escape, after which there remains a little round- ed ulcer, with excavated and more or less thickened edges, and surrounded almost always by a red circle of inflammation. The bottom of the ulcers is usually of a grayish colour. There is seldom any diffuse inflammation of the mucous membrane in this disease. The number of aphtha varies in the two forms. In the discrete variety there are but few, whilst in the confluent form they are of course much more numerous. They generally appear first on the internal surfaces of the lips and gums, and then on the inside of the cheeks, edges of the tongue, and soft palate. The discrete form is generally accompanied by symptoms of slight disorder of the digestive organs, consisting of thirst, acid eructations or vomiting, imperfect digestion, and a little constipa- tion or diarrhoea. The confluent form, which is much more rare, especially in very young infants, usually coincides, as has already been stated, with severe general or local disease. The duration of aphtha is different in the two varieties of the 156 A PHTHjE. affection. he discrete form generally pursues a rapid progress, lasting usually from the beginning to the time of cicatrization, between four and seven days. Sometimes, however, when the vesicles are formed successively, one after the other, the disease lasts much longer. The confluent variety pursues a much slower progress, and is much more difficult of cure. Diagnosis and Prognosis.—The diagnosis of discrete aphtha is not at all difficult, in consequence of their being isolated and suc- ceeded by small and limited ulcerations. The confluent form, on the contrary, may be confounded with ulcerative or ulcero-mem- branous stomatitis, and with thrush. From the first mentioned disease it may be distinguished, however, by attention to the cir- cumstances that that affection begins by small white patches, and not by pustules, as do aphtha ; that the ulcerations which follow the patches are covered with true pseudo-membrane; and that the white patches just spoken of appear first upon the gums, whilst aphtha generally begin upon the posterior surface of the inferior lip, and upon the tongue. From thrush it is to be distinguished by the facts that that disease commences by white points which are not pustular, which, running together, form a creamy exudation, and by the absence or very small number of the ulcerations. Discrete aphtha constitute a very mild disorder. They always recover without much difficulty. The confluent disease is more serious, because its progress is much slower, its cure more diffi- cult, and because it is often connected, as has been stated, with some other severe disease. Treatment.—Aphtha, particularly the discrete variety, require in general very simple treatment. The means to be employed are general and topical. The discrete variety usually requires only topical remedies, re- gulation of the diet, and when there are marked symptoms of gas- tric derangement, the exhibition of some mild emetic, or of a laxa- tive dose. The local treatment should consist of applications of demulcent preparations, as the mucilages of slippery elm, sassa- fras pith, flaxseed, marsh-mallow root, quince seeds, etc., which are to be used pure when there is no pain, or with the addition of a few drops of laudanum or wine of opium, when the mouth is TREATMENT. 157 sore and tender; the aphtha ought to be touched occasionally with the mixture of borax and honey, or the aluminous preparation recommended for simple stomatitis. The applications must be made several times a day with a camel's hair pencil, a pencil made of charpie or cotton, or with a soft rag covering the finger. When the ulcers which follow the vesicles fail to cicatrise rapidly under the above applications, or when they are numerous and painful, their cure may be very much hastened and the pain quickly relieved, by touching them lightly with a stick of nitrate of silver, or a piece of alum sharpened to a point; or we may employ a pencil dipped into a strong solution of nitrate of silver, or into a mixture of one part of muriatic acid to two of honey. The general treatment of discrete aphtha need consist of no- thing more than the prescription of a simple, unirritating diet in most of the cases. If, however, the digestive apparatus is deranged, the case must be treated according to the symptoms; by antacids or a gentle emetic, when the tongue is foul and the secretions acid, aqd by the use of a mild laxative, as castor oil, magnesia, or rhu- barb, when there is constipation. When diarrhoea is present, we should resort first to a small dose of castor oil or syrup of rhubarb, with the addition of half a drop to two drops of laudanum, ac- cording to the age of the child, and afterwards to astringents and opiates, as will be recommended in the article on simple diarrhoea. The treatment of confluent aphthce must depend on their cause. The local treatment is the same as that for the discrete variety, except that cauterization should be resorted to at an earlier period. When they seem to depend upon a general morbid condition of the constitution, as congenital debility, a scorbutic diathesis, or upon chronic affections of the digestive organs, they must be treated in the first case by properly regulated, nutritious diet, and by the exhibition of tonics and gentle stimulants, particularly iron, quinine, and small quantities of very fine old brandy; and in the second case, in the manner which will be recommended for chronic derangements of the stomach and bowels, when I come to treat of the diseases of those organs. 14 158 ULCERATIVE STOMATITIS. ARTICLE III. ULCERATIVE OR ULCERO-MEMERANOUS STOMATITIS. Definition ; synonymes ; frequency.—This form of sore mouth is characterized by the secretion upon the mucous membrane of a plastic exudation in thick, yellowish, adherent patches, and by inflammation, erosion, or ulceration of the subjacent tissues. It is the same disease as the aphtha gangrenosa, and I believe the cancrum oris also of Underwood ; the ulceration of the mouth of Dewees and Eberle ; the stomatite couenneuse, and the ulcerative and pseudo-membranous forms of the stomatite gangreneuse of M. Valleix; the stomatite pseudo-membraneuse or diphtheritique of some writers; and the stomatite ulcero- membraneuse of Rilliet and Barthez. It is the disease described under the title of gangrenous sore mouth by Dr. B. H. Coates (North American Surgical and Medical Journal, vol. ii, 1826), with the exception of a few cases which were what I shall treat of as gangrene of the mouth. It is treated of by Dr. Condie (Dis. of Child. 2d edit. p. 142), under the title of gangrene of the mouth, and partly confounded, as it seems to me, with a much less frequent and vastly more dangerous disease, which I shall de- scribe hereafter as a separate affection under that name. Of the different titles given above, I prefer that of ulcero-mem- branous stomatitis, as most expressive of the distinctive features of the disease. This form of stomatitis is not very frequent in pri- vate practice, but sometimes prevails extensively in hospitals, and other public institutions for children, where it often assumes an epidemic character. Causes.—The predisposing causes are epidemic influence, of the existence of which I believe there is no doubt; according to some observers, contagion, which, however, has not as yet been positively shown; and bad hygienic conditions as to cleanliness, ventilation, food, clothing, and habitation. It is most frequent be- tween the ages of five and ten years, though it may attack all ages, SYMPTOMS. 159 and is more common in boys than girls. It occurs during the convalescence from severe diseases, as pneumonia, the eruptive fevers, typhoid fever, entero-colitis, and other affections of children. The exciting causes of sporadic cases are unknown, with the exception, perhaps, of the presence of a carious tooth in the mouth, and fracture or necrosis of the maxillary bones. Symptoms ; course ; duration.—The disease begins with slight pain and uneasy sensations in the gums, which then become swelled, red, bleeding when touched, and are soon after covered with a grayish, pultaceous exudation of varying thickness. The exudation extends from the gums to the internal surface of the lips and cheeks, and sometimes, but more rarely, to the soft palate, and even to the pharynx and nasal passages. The plastic deposit occurs in the form of small, and slightly projecting, yellowish patches, which approach each other, unite, and form bands of pseudo-membrane, somewhat uneven upon the surface, and ad- hering with considerable force to the tissue beneath. When the exudation is detached, the mucous membrane is found to be of a red or purple colour, bleeding, and excoriated or ulcerated. The ulcerations which exist under the false membrane are of various depths, of a grayish, livid, or blackish colour, with swelled, soft- ened, and livid red, or bleeding edges. Those which are formed upon the inside of the lips are rounded in shape, whilst those seated in the angle between the lips and gums, are usually elongated. When the disease is mild, and when it is properly treated, the false membranes are detached, leaving the mucous tissue merely excoriated, in which case it soon regains its natural condi- tion ; or else the ulcers which exist beneath, rapidly become healthy and cicatrise. In violent cases and in those badly treated, the inflammation, on the contrary, persists; the pseudo-mem- branes increase in thickness, or if detached, are formed anew; the ulcerations become deeper; the disease extends ; and the case lasts an indefinite period of time. Other symptoms, beside those we have mentioned, characterize the disease. The breath is always more or less fetid, and in bad cases, al- 160 ULCERATIVE STOMATITIS. most gangrenous. The salivary and sub-maxillary glands are generally more or less swelled, hard, and painful, and accord- ing to some authors, the surrounding cellular tissue is in the same condition, though this is denied by others. The movements of the lower jaw are stiff and painful in severe cases. Deglutition is not affected unless the disease extends to the pharynx. In vio- lent cases there is usually a copious discharge of bloody serum, which flows from the mouth during sleep. When the ulcerations are deep and large, the tissues beneath are more or less swelled; the swelling, however, rarely assumes the hard, resisting, circum- scribed characters, with the tense, smooth, hot, and shining ap- pearance of the skin which exists in true gangrene of the mouth. In most of the cases there is but little febrile reaction, especially at the invasion, though it sometimes increases afterwards if the disease becomes extensive. The disease begins, as already stated, on the gums, and unless limited to these parts, as sometimes happens, extends to the lips and cheeks. In many of the cases it attacks only one side of the mouth, and this is more frequently the left than the right. The course of the disease is usually rapid in epidemic cases, and in those which are properly treated. Where badly treated, on the contrary, it may last from one to several months, or terminate in gangrene of the mouth. Diagnosis ; prognosis.—The diagnosis is, as a general rule, very easy, if proper attention be paid to the characteristic features of the disease. It has, as already stated, been very often con- founded with gangrene of the mouth. The method of distinguish- ing between the two will be given in full in the article on that disease. From thrush it is to be distinguished in the manner which will be pointed out under that subject. The prognosis is favourable in the great majority of the cases. Sporadic cases probably always terminate favourably. The epi- demic disease, though rarely fatal, is sometimes so from its exten- sion to the pharynx and larynx, or from its termination in gan- grene of the mouth. Of upwards of 120 cases of this kind, observed by Dr. Coates at the Philadelphia Children's Asylum, in a period of three months, all but one recovered (Doc. cit. p. 21). TREATMENT. 161 The cases which occur in the course of other diseases are not dangerous in themselves, but are so as the sign of great severity of the primary affection. Treatment.—The treatment may be divided into general and local or topical. The general treatment should consist in most of the cases of attention to the diet, which ought, in healthy and vigorous children, to be simple and unirritating, and in those who are weak and debilitated, nutritious and digestible. No internal remedies are required in the majority of th« cases. If, however, the bowels are costive, or the child feverish and uncomfortable, a laxative dose may be given with advantage ; or some simple diaphoretic, as nitre and water, or the neutral mixture, may be used through the day, and a warm pediluvium or an immersion bath given in the evening. When the constitution is feeble, and the child weak or anemic, tonic remedies are indicated. The best is probably quinine, or one of the ferruginous preparations; or the compound infusion of gentian, with addition of Huxham's tincture of bark, may be resorted to. If the inflammation be severe, and accom- panied with tumefaction and tenderness of the glands and some febrile reaction, it would be proper to apply a few leeches to the neck. The local treatment is all that is necessary in a large number of cases. When the attack is slight, we need only to keep the mouth clean by means of demulcent washes, used in the manner recommended in the article upon aphtha, and to employ from time to time some mild astringent application. This may consist of honey and borax, of weak solutions of acetate or sulphate of zinc, or of sage or rose-leaf tea, with alum and honey. When the disease is more severe and extensive, and especially when it is attended with many and deep ulcerations, it should be treated with more energetic local applications. In such cases cauterization with a strong solution of nitrate of silver (B'\ to 3ss of water), or with muriatic acid, either pure or mixed with honey, should be resorted to. M. Bretonneau employs the pure acid, applying it twice in forty-eight hours in recent cases, which almost always cures the disease; or, when the case is chronic, using the acid in the same way, with the precaution, however, of suspending its 14* 162 ULCERATIVE STOMATITIS. employment from time to time. He applies it between the teeth by means of a small roll of paper, and to the other surfaces with a mop made of rag or sponge. I would merely remark, in refe- rence to cauterization with these powerful preparations, that I have never found it necessary in private practice, having always succeeded with less severe and less painful remedies. Dr. Dewees recommends the following combination in cases of ulceration of the mouth, and says of it that it" has so far never failed us :" R— Sulph. Cupri gr. x ,-*. y 1 <. ,iX I M \, \ v-x I MEDICINE NATIONAL LIBRARY OF MEDICINE " NATIONAL LIBRARY OF MEDICINE NATIONAL -X T xx^x g c x- .a ..x = x x\ r©~~. i -a- X\Tr4W y y>( 3 w -"J-y, ! ■' X "" \ ' . < v-tU/' i~»-y/ i X < -. V"* <« ~X/* s. Xx ... | x-XX/ i XX' X f xyXXv' <. XX, s ..X g /3 - s !-.X s Xs -■ 1VNOIIVN 3NIOIQ3W dO Aava8IT TVNOIIVN 3NIDIQ3W dO AavaaiT TVNOIIVN 3NI0IC] x X">r I X" XXii | j^X % X >-,h a &. ' " "\X \/X| #x/ I K /^ |# ^ X : ■! v v f MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL x/ ^ V - v.f & A^! - W: « * /" ? XV s xx ? f yx s xX. > ? < lX.X | XyxXX v -§ XX^fl Xx^ > -§ , ,-X^ "• - ;7 MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL '' v i *^ ^ * >x,y\ l > * —a r- C -o aXx^ f XrXf-J X^-X s= \cFfi)' > i C X^,X" y X^ X^y ^ \,^ :;l TVNOIIVN 3NIDIQ3W dO AaVa8IT TVNOIIVN SNiDiasw do Aavaan tvnoiivn snioici ■ ■j$ - ": X' ry °- X>y^i s X ;X MEDICINE NATIONAL LIBRARY OF MEDICINE < NATIONAL LIBRARY OF MEDICINE NATIONAL ./ \ x-x? s. ^>.x; X i ^ X&- j "V E / :° ~x^;"^ ^1 'O—-. ft-1 x-x®r^ l /'^^f l x^ S \ \X'i 1VNOIIVN 3NIDta3W dO AaVa9IT TVNOIIVN 3NIDIQ3W dO AavaaiT TVNOIIVN 3NIDIQ s ✓ ss -1' EDICINE X J ;4" X 3 N. .X- X i. NATIONAL LIBRARY OF MEDICINE NATIONAL w&fLxM. :■••• '.o'X/V^Aa ■■" -.X- xyx:x^x^ X.-. VXXX -^y4,'£**%& ~, • 'rv^^x-^XM^^g -• r ,XX:hX^X^^:XX;$S«! ^'V^:-v-v;:XXXxJp}, ' X ':.i. '■>',■■.■«■ v.;»''jf^^Si^.Wft X. . v ■., ':• -,v X '.'• X^ X\^XVr,xF>-'n X .' ' ';: V-;;^v'^\V..-x«; - :»■- • VX 'j-^VrvJyV^i^fc ■•; ■•■. ' ■.-.•-.■ ■■;.-. *>XX^V -Vw ■ . •■• " ' , . XX-; "Kt'i fXX&x •, -x x^a^x\:^ v . ■ X v',v>> vk-x*^ • .x :; £■}$&&*&$ :,':-V'-XXfe^ ■■ .--x-V' X'.-;xVa&} :■-•--X- ;yy^ , ... • vv, 0; :-^ ...'■>■ v.X.kX>X.'^\X^