x**-$*s?S ■*:^lf ' '''-t^'^^SK ?* J^- ••';-,*^^:V^ ax ^-S DOT. Surgeon General's Office erection,. «J& 1 & •SOOOO No.......^ -rQOa"TOgQic"5''3'e^S ■>/^.oo-orKoru\r,.ofXirAonor.vCnr^\x:(DU'0^» i t ON THE DISEASES OF INFANTS AND CHILDEEN. By FLEETWOOD CHURCHILL, M.D., M.R.I.A., HON. FELLOW OF THE COLLEGE OF PHYSICIANS, IRELAND\ HON. MEMBER OF THE PHILADELPHIA MEDICAL SOCIETY, ETC. ETC.J AUTHOR OF " THE THEORY AND PRACTICE OF MIDWIFERY," " ON THE DISEASES OF FEMALES," ETC. ETC. PHILADELPHIA: LEA AND BLANCHARD. 1850. N' i*tU^^ vis C5£30 mo Entered according to the Act of Congress, in the year 1849, by LEA AND BLANCHARD, the Clerk's Office of the District Court for the Eastern District of Pennsylvania. PHILADELPHIA: T. K. AND P. G. COLLINS, PRINTERS A TO ROBERT M. HUSTON, M. D., ISAAC HAYS, M.D., AND GEORGE SHATTUCK, Jun., M. D., THIS WORK IS DEDICATED, AS AN EXPRESSION OF THE HIGHEST ESTEEM FOE THEIR PERSONAL FRIENDSHIP AND PROFESSIONAL ATTAINMENTS. \ PUBLISHERS' NOTICE. The circumstances under which this work has been prepared are fully set forth in the Author's preface. The American Publishers, therefore, have only to remark, that its progress through the press has been supervised by a competent member of the profession, who has added a complete and accurate Index of Diseases, as also a copious Bibliographical List of Authors and Works referred to: these, they trust, will add to the value of the volume. Philadelphia, November, 1849. PREFACE. It is with much gratification that I acknowledge this volume to owe its existence to the solicitations of my excellent American pub- lishers. After making a considerable collection of works on Diseases of Children, I had laid them aside, hopeless of accomplishing the task of writing the work I had contemplated ; but it was impossible to decline an invitation so flattering, from a country which had shown so much indulgence to my former works. I have, therefore, in such leisure as I have been able to command during the last three years, written this volume, not as the exponent of my own experience alone, but as embracing the information re- corded by all the authors within my reach, of which I have freely availed myself; and, if it prove useful and acceptable to my Ame- rican brethren, I shall be richly repaid. There is one portion of the history of infantile diseases which has hardly received the attention it deserves. I allude to the secondary diseases; those which occur in the course of other disorders, and are, in some intimate but obscure way, connected with them almost in the relation of cause and effect. They complicate, and often confuse the symptoms of the primary affection, always seriously increase its danger, and often render it hopeless of cure. Their early detection, or what is far better, their anticipation and prevention, forms a very important part of the physician's duty; and I have endeavored, as far as I could, to facilitate this object by carefully noticing both the com- plications to which each disease is liable, and the primary disorders to which it may become secondary. Another point of great importance, in the treatment of the diseases of children, is to observe and remember the prevailing epidemic, or the atmospheric constitution of the time. All diseases are more or less thus modified, and with children this is very remarkable, not merely as regards the symptoms, but the treatment also. Without a careful attention to this matter, we shall often aggravate, instead of relieving the condition of the child. 1* vi PREFACE. I have found it extremely difficult to lay down minute and specific plans of treatment for individual cases, or for the various modifica- tions of disease; and, I fear, in this respect, my book may be thought deficient. I have, however, always indicated the principles which* must guide us in the management of the disorder; and I have pre- ferred leaving their adaptation to the sagacity and judgment of the practitioner. I have sought information wherever I had reason to believe it was to be found; I have consulted all the authorities within my reach, and have carefully referred to those from whom I have quoted, but yet I fear that many faults, both of omission and commission, will be observed. In these, I must request the indulgence of the reader, who, I hope, will bear in mind, that the work has been written in the midst of the distractions of professional business, or at hours which are usually devoted to rest. F. CHURCHILL. 137 Stephen's Gheen, Dublin, October, 1849. CONTENTS. PART I. CHAPTER I. PAGE PRELIMINARY OBSERVATIONS. . . .19 CHAPTER II. MANAGEMENT OF THE INFANT AT BIRTH. . . 33 CHAPTER III. THE FOOD OF INFANCY AND CHILDHOOD. . . 37 Choice of a Nurse, ....... 41 Weaning, ......... 44 Artificial Feeding—Spoon-feeding, ..... 45 CHAPTER IV. CLEANLINESS. . . . .50 Dress, ......... 53 CHAPTER V. AIR AND EXERCISE. . . .56 Sleep,.........62 Medicine, ......... 64 The Nursery and Nurses, ...... 65 Nurses, ......... 66 PART II. SECTION I. DISEASES OF THE CEREBRO-SPINAL SYSTEM. CHAPTER I. INTRA-UTERINE OR CONGENITAL DISEASES. Convulsions, . . • • viii CONTENTS. PAGE Hydrocephalus, . . . . . • • 71 Absence of Brain or Skull, ...... 72 Hernia Cerebri.—Encephalocele, . . . . . '3 Spina Bifida.—Hydrorachitis, ...... 75 CHAPTER II. CEPHALHEMATOMA.--FRACTURES OF THE CRANIUM, ETC. . 81 Sub-aponeurotic Cephalaematoma, ..... 84 Sub-pericranial Cephalgematoma, . . . . .84 Subcranial Cephalhematoma, ...... 87 CHAPTER III. IRRITATION OF THE NERVOUS SYSTEM.--TRISMUS NASCENTIUM. Nervous Irritation, ....... 90 Trismus Nascentium.—Nine-day fits, .... 93 CHAPTER IV. CHOREA. .... 99 CHAPTER V. CONVULSIONS. . . 110 CHAPTER VI. ACUTE MENINGITIS. . . . 127 CHAPTER VII. CHRONIC HYDROCEPHALUS. . . 151 CHAPTER VIII. INFLAMMATION OF THE BRAIN. . . . 160 Hypertrophy and Induration of the Brain, . . . 162 Ramollissement, or Softening, ...... 167 Abscess of the Brain, ...... 168 CHAPTER IX. TUMORS OR TUBERCLES OF THE BRAIN AND SPINAL MARROW. . 170 CHAPTER X. CONGESTION AND APOPLEXY OF THE BRAIN AND SPINAL MARROW. 179 Spinal Apoplexy, ....... 186 CONTENTS. ix SECTION II. DISEASES OF THE RESPIRATORY SYSTEM. CHAPTER I. INTRA-UTERINE DISEASES. CHAPTER III. PERTUSSIS. CHAPTER IV. CROUP. CHAPTER V. BRONCHITIS. CHAPTER VI. INFLAMMATION OF THE LUNGS. CHAPTER VII. PLEURISY. PAGE 189 Coryza, . . . . . . . . . 189 Epistaxis, . . . . . . . * . 191 CHAPTER II. SPASM OF THE GLOTTIS. . . . 192 205 235 268 284 311 SECTION III. DISEASES OF THE HEART. CHAPTER I. MALFORMATIONS.—INTRA-UTERINE DISEASES. . 328 Cyanosis, ........ 329 CHAPTER II. INFLAMMATION OF THE PERICARDIUM. . . 336 CHAPTER III. INFLAMMATION OF THE LINING MEMBRANE OF THE HEART. 349 CONTENTS. SECTION IV. DISEASES OF THE DIGESTIVE SYSTEM. CHAPTER I. PAGE INTRA-UTERINE DISEASES.—CONGENITAL MALFORMATIONS. . 357 CHAPTER II. DENTITION. . . . 368 CHAPTER III. INFLAMMATION OF THE MOUTH. . 37* CHAPTER IV. MUGUET. . . • 379 CHAPTER V. APHTHA. .... 388 CHAPTER VI. ULCERATED SORE MOUTH. . . 393 CHAPTER VII. GANGRENE OF THE MOUTH. . . . 397 CHAPTER VIII. TONSILLITIS. . . . 410 CHAPTER IX. PAROTITIS. .... 414 CHAPTER X. PSEUDO-MEMBRANOUS PHARYNGITIS. . . 418 CHAPTER XI. PUTRID SORE THROAT. . . . 425 CHAPTER XII. ABSCESS BETWEEN THE PHARYNX AND THE SPINE. . 431 CONTENTS. XI CHAPTER XIII. DISEASES OF THE STOMACH. CHAPTER XIV. INDIGESTION.--VOMITING.—WEANING BRASH. CHAPTER XV. GASTRITIS. CHAPTER XVI. DIARRHCEA. . . • 454 Cholera Infantum, ....••• 457 Enteritis,........4bU CHAPTER XVII. DYSENTERY. CHAPTER XVIII. HELMINTHIASIS. CHAPTER XIX. I. JAUNDICE.—II. ENLARGEMENT OF THE LIVER, SPLEEN, ETC. CHAPTER XX. PERITONITIS. . . PAGE 434 439 447 473 482 490 497 SECTION V. DISEASES OF THE SKIN. CHAPTER I. STROPHULUS.—PRURIGO.--PITYRIASIS.—ROSEOLA. Strophulus, or Red Gum, ...... 510 Prurigo,.........512 Pityriasis, ...«•••• Roseola, ...•••••• CHAPTER II. HERPES.—ECZEMA.—RUPIA. tt ... 514 Herpes, ...•••• Eczema, ..•••• Rupia, 517 xii CONTENTS. CHAPTER III. IMPETIGO.—PORRIGO. PAGE 518 Impetigo, . • • • • * 520 Porrigo, or Scald Head, • ■ 52i Porrigo Scutulata, or Ringworm of the bcalp, . • • '525 Porrigo Favosa, • SECTION VI. ERUPTIVE FEVERS. CHAPTER I. MEASLES. CHAPTER II. SCARLET FEVER. CHAPTER III. VARICELLA. CHAPTER IV. SMALL-POX. CHAPTER V. VACCINIA. 531 550 583 586 606 SECTION VII. INFANTILE REMITTENT FEVER.—WORM FEVER.— 1 GASTRIC FEVER. . . . 614 INFANTS AND CHILDREN. PART I. ON THE MANAGEMENT OP INFANCY AND CHILDHOOD. CHAPTER I. PRELIMINARY OBSERVATIONS. 1. A very limited acquaintance with statistics, or even a mode- rate experience, is quite sufficient to convince us of the high degree of mortality which prevails among infants and children: literally, they spring up and are cut down like flowers of the field. This mortality commences before the birth of the infant: from va- rious causes no inconsiderable proportion of those ushered into the world are still-born. M. Quetelet, in his very learned and able work, thus states that, in the principal cities of Europe,1 the mean proportion of still-born children is one in every twenty-two births; and the num- ber is three times greater among illegitimate than among legitimate children. 2. The same author gives a carefully compiled table of the mortality of different ages in Belgium, which shows that of the infants born alive, one-tenth died within a month—a mortality equal to that be- tween the ages of 7 and 24 years. By the fifth year, nearly one- half the number of children had died.2 3. In Prussia, during the interval from 1820 to 1828, the deaths in the first year were in the ratio of 26.944 to 100.000. In France, in 1802, it amounted to 21.457; in Amsterdam, to 22.735, from 1818 to 1829; in Sweden, to 22.453, from 1821 to 1825. From the First Report of the Registrar-General of England, it ap- pears that more than one-third of the total deaths in England and Wales occur under two years of age ; the proportion being 42.54 per 1000 of the deaths registered : and two out of every nine infants en- tering upon life die within the first year. " Assuming seventy years as the natural term of life, we may form some faint conception, from the preceding facts, how many elements of destruction must still be 1 Sur l'Homme, et le Developpement de ses Facultes, &c, vol. i. p. 121. 3 lb., vol. i. p. 167. 20 ON THE MANAGEMENT OF left in full activity, when, as is the case in England, one-third of the race is cut off within the first two years of existence."1 In the Second Report, I find that the total number of births was 480,090—of deaths, 331,007; of the latter, 72,304 were under one year, and 130,695 under five years of age. In the Third Report, the births were 501,589—the deaths, 350,101; of those under one year, 76,328 ; under five, 141,747. In the Fourth Report, the births were 504,543—the deaths, 355,622; of those under one year, 75,507; and under five, 140,089. In the Fifth Report, the births were 492,574 —the deaths, 343,847 ; of those under one year, 74,210; and under five, 133,583. In the Sixth Report, the births were 517,739—the deaths, 349,519; of those under one year, 78,704; and under five, 139,035. In the Sixth Annual Report will be found abstracts from foreign Reports, all showing the great mortality in the earlier periods of life. In my friend Mr. Wilde's admirable Report in the Census of Ireland, he states that, in the ten years ending June 6, 1841, the total number of deaths in the city of Dublin were 66,722, of which 10,553 oc- curred under one year, and 13,037 between one and five years of age. Dr. Combe has extracted the following statistics from the Liverpool Albion of April 1,1839. The deaths during the year 1838 amounted to 6596, from which must be deducted forty-three still-births, leaving 6553. Now at different periods of the first five years of life we find the following mortality:— deaths. Above 3 " and und« ir 6 months, 313 " 6 " u 9 " 319 " 9 " a 12 " 311 " 1 year, a 2 years, 802 " 2 " a 3 " 321 " 3 " a 4 " 183 " 4 " a 5 " 121 3162 4. So much for the mortality generally; if we inquire into details, we find it always great, though varying, as, for example, between the children of the poor and those in comfortable circumstances ; between the poor in towns and those in the country; or between the poor in different towns or in different parts of the country differing in hygienic conditions; proving conclusively, that the mortality depends, to a cer- tain extent, upon external circumstances, and also that it is in some measure under the control of good management. From Dr. Granville's tables of the mortality among the poor of London, we find that 458 in every 1000 children under two years of age died. From the First Report of the Registrar-General, already quoted, it appears that, " in the mining parts of Staffordshire and Shropshire, in Leeds and its suburbs, and in Cambridgeshire, Huntingdonshire, and 1 Combe on the Management of Infancy, p. 10. INFANCY AND CHILDHOOD. 21 the lowland parts of Lincolnshire, the deaths of infants under one year have been more than 270 out of 1000 deaths at all ages ; while in the northern counties of England, in Wiltshire, Dorsetshire, and Devon- shire, in Herefordshire and Monmouthshire, and in Wales, the deaths at that age, out of 1000 of all ages, scarcely exceeded 180.m Com- pare, again, Manchester, Salford, and their suburbs, where the num- ber of deaths under two years of age was 429.98 per 1000, with Westmoreland and Cumberland, where the proportion was only 276.35 per 1000. In Mr. M'Clean's Visit to St. Kilda, he states that " eight out of every ten children die between the eighth and twelfth days of their existence;" and this, he conceives, is mainly owing to the " filth in which they live, and the noxious effluvia of their homes." 5. But there are more shocking evidences still of the result of bad accommodation and mismanagement. For example, Dr. Combe states2 that, " about a century ago, the workhouses of London presented the astounding result of twenty-three deaths in every twenty-four infants under the age of one year. For a long time this frightful devastation was allowed to go on, as beyond the reach of human remedy. But when at last an improved system of management was adopted, in consequence of a parliamentary inquiry having taken place, the pro- portion of deaths was speedily reduced from 2600 to 450 a year." 6. Another illustration of the effects of management is afforded by the mortality in lying-in hospitals. Dr. Willan gives the following proportions:— From 1749 to 1758 1 in 15 children died. " 1759 to 1768 1 in 20 " " 1769 to 1778 1 in 42 " " 1779 to 1788 1 in 44 " " 1789 to 1798 1 in 77 " " In the valuable paper of the late Dr. Joseph Clarke,3 of this city, he mentions that, "at the conclusion of the year 1782, of 17,650 infants born alive in the hospital, 2944 died within the first fortnight," that is, nearly every sixth child; and that of these,—nineteen out of twenty died of nine-day fits. This Dr. Clarke attributed to want of adequate ventilation, which he proceeded to remedy with great suc- cess ; for of 8033 children born after a free circulation of air had been secured, only 419 died, that is, about 1 in 19^. This rate of mortality has continued to diminish, for we find, in the admirable Report published by Dr. Collins, that during his residence "the total number of children born was 16,654; of these, 284 died pre- vious to the mother leaving hospital; this is nearly in the proportion of one in 58|, which would be considered a moderate mortality under any circumstances; however, when it is considered that this includes not only all the deaths that occurred in children born prematurely, and in twins, but also every instance where the heart ever acted, or where 1 Report, pp. 25, 44. 3 On the Management of Children, p. 14. 3 Transactions of the Royal Irish Academy, vol. iii. Collins's Practical Treatise, p. 514. 22 ON THE MANAGEMENT OF respiration ceased in a few seconds after birth, the proportion of deaths becomes trifling indeed."1 7. Foundling hospitals exhibit another instance of the connection between the management and the rate of mortality in children. In the Foundling Hospital of this city it appeared, on inquiry by Parlia- ment, that of 10,272 children- sent to the infirmary of the hospital during the twenty-one years ending in 1796, only forty-five recovered; a statement, as Dr. Hawkins observes, which at this moment seems incredible.2 A change of plan was made, wet-nurses were employed, and children sent to them in the country, and the results were most beneficial. From June, 1805, to June, 1806,2168 infants were taken into the house, and only 486 died there,—a manifest improvement. In Vienna, in 1811, the mortality was 92 per cent.; in Brussels, from 1812 to 1817, it was 79 per cent.; in Madrid, in 1817, it was 67 per cent.; that is, three and four times greater than the average mortality in private life. About one-half of the foundlings of Paris and St. Petersburgh die during the first year, notwithstanding the care and attention bestowed. 8. Dr. Combe quotes an interesting illustration of the effects of improved management in the Orphan Asylum of Albany, U. S., " which was opened in the end of 1829, with about seventy children, but in which the average, up to August, 1836, subsequently amounted to eighty. During the first three years, when an imperfect mode of management was in operation, from four to six children were con- stantly on the sick-list, and sometimes more ; one or two assistant nurses were necessary; a physician was in regular attendance twice or thrice a wTeek, and the deaths amounted in all to between thirty and forty, or about one every month. At the end of this time an im- proved system of treatment was begun, and, notwithstanding the dis- advantages inseparable from the orphan state of the children, the re- sults were in the highest degree satisfactory. " The nursery was soon entirely vacated, and the services of the nurse and physician no longer needed; and for more than two years no case of sickness or death took place. In the succeeding twelve years there were three deaths, but they were new inmates, and diseased when they wTere received, and two of them were idiots." 9. In the last edition of Dr. Underwood's book, are given the results of an inquiry into the mortality among the children of the poor in London, made at the British Lying-in Hospital. " Several women who had borne 3 children had lost as many as . . 2. 4 " it a q 5 « it a > 4] 6 " " « \ ' 5] 7 " « « \ q[ 8 " " a 7 9 « « (t [ | g" ! Practical Treatise on Midwifery, p. 500. 2 Medical Statistios, p. 130. 3 On the Management of Infancy, p. 22. INFANCY AND CHILDHOOD. 23 10 children had lost as many as . .9. 11 " " " 8 and 10. 12 « « « 10 and 11. 14 " " " . . 11. " And several mothers of the different numbers had lost them all. During another long period, only one woman, having borne as many as five children, had reared them all; and one, having had twelve, had eight living. But some, having had four, had lost three; and five had lost four; and six, five; and seven, six; and eight, six and seven; and ten, seven and nine; and women having borne eleven and twelve had lost eight, nine, and ten; and fourteen, eight; while many, who had borne four, five, and six, one twelve, and another twenty-one, had buried them all. In addition to this may be remarked the sad and rickety state of many of the surviving children."1 10. I quite agree with the remark of Dr. Combe, that, although it be in hospitals and other institutions for children that the most fearful results of bad management have occurred, " we must not infer that the records of family practice are altogether unstained with cases of a similar nature, and that among the wealthier classes, at least, no- thing more can be done for the preservation of infant health and life. On the contrary, we have too good reason to believe, that, even among the best educated classes, many lives are cut short by mismanagement in infancy, which might be saved, if the parents only possessed in time a portion of that knowledge and practical sense which dire expe- rience sometimes impresses upon them when too late."2 11. The facts which have been laid before the reader—and which are not a tithe of what might be adduced—are sufficient to show that a large proportion of infants are still-born; that another large propor- tion die in early infancy; that this proportion is vastly increased by bad management, and may be diminished by good management; and that there will still remain a large mortality from disease, arising from causes over which we have but little control, but which may still be diminished by judicious medical treatment. Thus the work before us is naturally divided into an inquiry, first, into the causes of disease during intra-uterine life, or immediately after birth; secondly, into the management of infants and children; and thirdly, into the diseases which are peculiar to, or very prevalent during, infancy and childhood. It does not, however, form part of my purpose to give more than a brief sketch of the first division; and as the book is written for medi- cal practitioners rather than for nurses, I shall content myself with laying down the leading principles that ought to guide us in the man- agement of children, instead of minute details; reserving the main portion of the work for a full and careful consideration of the diseases incident to this period of life. 12. Let us first consider the circumstances in which the infant is placed during intra-uterine life. During nine months of gestation, 1 On the Diseases of Children, tenth edition, p. 85. 3 On the Management of Infancy, &c, p. 25. 24 ON THE MANAGEMENT OF the foetus, inclosed in the membranes, is immersed in and surrounded by the liquor amnii, which has the double effect of preserving an equable temperature, and diminishing the effect of external shocks, and of the movements of the mother, upon it. It is connected with the mother by means of the placenta and funis umbilicalis, and through the medium of these structures that change in the foetal blood is effected which is essential for the life, nourishment, and growth of the child. Apparently, whatever communication there is between the mother and child is very indirect, i. e. anatomically speaking ; but we have pathological evidence of a very direct influence exerted by the parent upon her offspring,—in those cases, for example, where mental emotion in the former has extinguished life in the latter; and those in which children have exhibited at birth traces of disease which must have been acquired through the mother. 13. What are the active organic functions during intra-uterine life? Almost exclusively those connected with nutrition. Aeration of the blood in the placenta (whioh is a vicarious and temporary substitute for the lungs) or uterine sinuses,—absorption of the contents of the vesicula umbilicalis at an early period, and of the liquor amnii by the skin, and perhaps by the stomach, at a later,—are functions which are evidently active. We have also evidences of a limited amount of excretion in the meconium contained in the intestines, and in the urine by which the bladder is often filled at birth. The circulating system is, of course, active as an agent in the growth and development of the foetus: the respiratory system is quiescent. The nervous system is, in general, so far as we can judge, inactive, except as it may be involved in the general organic development, although the sudden movements of the child, when cold is applied to the abdomen of the mother, show a quick sensibility to alterations of temperature. 14. So far, then, the condition of the foetus in utero is one of quies- cence, except as regards the functions of nutrition and development. Secluded and protected by exquisite arrangements, in its temporary abode, from all external influence and injury, it is at once, at the ter- mination of gestation, plunged into the midst of excitement, and ex- posed to influences and impressions which act rudely on organs hitherto untried. " In one instant, it is transferred from unconscious repose, solitude, and darkness, to life, and light, and action. From being surrounded by a bland fluid of unvarying warmth, it passes at once to the rude contact of an ever-changing and colder air, and to a harder pressure, even from the softest clothing, than it ever before sustained. Previously nourished by the mother's blood, it must now seek and digest its own food, and throw out its own waste. The blood, once purified and restored through means of the mother's sys- tem, must now be oxygenated by the child's own lungs. The animal heat once supplied to it by another source must now be elaborated by the action of its own organs."1 1 Combe on the Management of Infancy and Childhood, p. 180. INFANCY AND CHILDHOOD. 25 The first impression, and a most painful one, is that ofcohi, and the first act is to evince its sufferings by cries and struggles. No doubt benefit is derived from this,—it assists in establishing full respiration, and gives an impetus to the general circulation. The distress occasioned at first by cold is augmented by the compa- ratively rough handling, washing, and dressing, and by the stimulus to which each sense is exposed. The eye, hitherto closed in darkness, opens to the light, and the ear for the first time is conscious of various and confused sounds; and the brain and nervous system, so far used to but few and simple impressions, become the centre of varied and complicated ones from each awakened sense, and these impressions, for the most part, painful. Moreover, a very remarkable change takes place in the posture and muscular movements of the infant. Not that it makes no muscular exertions previously, but from the small space in which it was con- fined, these were necessarily limited and uniform; a limb could be moved to and fro, but complete extension was impossible. Now the infant lies at full length, and under the handling of its nurse stretches forth its limbs, and struggles violently in its impotent distress. Very shortly after birth, the organs of digestion are called upon to perform their functions; and although the food be mild and bland, yet the process is ordinarily a prodigious step beyond the functions hitherto performed by the stomach, if indeed it was at all active during gestation. 15. When we consider, therefore, that, from a state of quiescencer and simple organic nutrition, the infant at birth is roused into a state of functional and organic activity, with each sense exposed to vivid impressions from its own peculiar stimulus, and these concentrated, as it were, in successive and powerful impressions upon the nervous system,—it cannot be a matter of surprise that any individual organ should be liable to derangement or disordered action; much less wThen we reflect upon the sympathetic interdependence of organs and sys- tems, and remember how disorders of the one entail disorders in an- other, and how apt simple or complex disorders of organs are to en- tail serious disturbance in the nervous system. Under such circum- stances one would anticipate considerable liability to disease during the first month, even under the most judicious management. 16. But a little more detail will be necessary to exhibit fully the sources of disease to which the infant is exposed before, at, and im- mediately after birth. Although the foetus in utero be completely protected from external morbid impressions of the ordinary kind, yet we do not find it secure from indirect influences which may excite disease during intra-uterine life. From the maternal blood are derived those changes which render the foetal blood suitable for nutrition and growth; if the mother be in perfect health, these changes may be expected to be of a natural and healthy character; but if she be unhealthy, whether temporarily or continuously, then a corresponding deterioration of the fcetal blood 26 ON THE MANAGEMENT OF may take place, and individual organs or the growth of the child may suffer. Again, it seems undeniable, though not to be established by ana- tomical research, that some kind of nervous communication exists be- tween the mother and child before birth ; at least, it is certain that vivid impressions, bodily or mental, upon the former, may be transmitted to the latter, and injury or even death may be inflicted. 17. Here, then, are two external sources of disease in the foetus, originating in the bodily or mental condition of the mother; mischief may arise to her child from neglect of herself, from unavoidable ill health, or from excessive mental emotion. This consideration is of such importance, and appeals so directly to the most-powerful feel- ings of womanly nature, that it ought to be sufficient to ensure an ad- equate attention to health in all likely to become mothers. Common sense and a little self-denial will generally secure all that is in her power. The diet and regimen generally should be arranged so as to afford her sufficient nourishment without over-feeding, and only a moderate use of beer or wine should be allowed. Exercise is neces- sary to health, but it should be taken moderately, and at proper times, avoiding undue fatigue, exposure to inclement weather, and wet feet. And it should not be forgotten that rest is as necessary as exercise; so that excessive fatigue from violent or prolonged exercise, and from late hours, must be absolutely avoided. After exertion, the use of the couch or sofa, instead of a chair, is a great comfort to the patient. Her dress, too, will require care, so as to secure warmth and avoid all pressure. She ought to be contented to give up the attempt at a fashionable appearance, as she must that of a fashionable shape; and if she can be persuaded to abstain from parties and numerous assem- blages, and late hours, it will be all the better for her own and her child's health. The authoress of the Good Nurse very sensibly remarks: " When a young woman acts from principles of reason and religion, she will consider proper care of herself during pregnancy an imperious duty, not only on her own account, but from the reflection that the life of another is interwoven with her own, whom she is bound by every virtuous feeling to cherish, and that with the utmost tenderness; being aware that improper management of herself during this period may be destructive of the being for whose life she is responsible. " The most important part of her duty is to guard her mind against every innovation of temper or uneasiness. When the heart is graced with affection, its engaging influence pervades every feeling, and smooths and tranquillizes the mind upon all occasions. I am de- cidedly of opinion, that if we suffer every trifling disappointment and cross-occurrence to rufle and disturb us, it is a certain mode of corrod- ing our peace and very materially injuring the health; which at all times should be carefully guarded against, but more especially under these circumstances."1 " During pregnancy," observes Dr. Combe, " the great aim, for the 1 The Good Nurse, p. 106. INFANCY AND CHILDHOOD. 27 sake of both parent and child, ought to be, to sustain the general health in its highest state of efficiency; and in order to attain this, the mother ought to pursue her usual avocations and mode of life, provided these be such as are compatible with the laws of health. Regular daily exercise, cheerful occupation and society, moderate diet, pure air, early hours, clothing suitable to the season, and healthy activity of the skin, are all more essential than ever, because now the permanent welfare of another being is at stake in addition to that of the mother." * 18. But besides the indirect sources of disease already mentioned, another may be found in the temporary apparatus provided for the nutrition of the foetus. The placenta may be regarded as a species of gland, consisting of a congeries of vessels, and being very liable to have its circulation disturbed. This may be temporary or it may issue in inflammation, which may give rise to alterations of structure in one or more of the lobes or lobuli of which it is composed. If it be of a very great extent, it must, more or less, interfere with the perfect nourishment of the foetus, and, notwithstanding all the compen- sating powers of nature, the foetus will not infrequently suffer from disease as the consequence.3 The same may be said of any malform- ation or disease of the other portions of the foetal apparatus. Moreover, we possess ample evidence to prove that the foetal organs may be affected by almost as great a variety of diseases as after birth, without our being able to trace them to any of the causes just men- tioned ; or, in other words, that, without apparent external cause, dis- eased action may arise and morbid changes take place in any of the foetal structures. As I shall have occasion to allude to some of these pathological states hereafter, I shall at present merely refer the reader to the work of Dr. Graetzer, " Ueber die Krankheiten des Foetus," in which the author has with great industry collected examples of eighty-two different diseases which have been recorded by those in whose practice they occurred. 19. The process of transition into the world, in the vast majority of cases, inflicts no injury at all upon the child, but in some cases of difficult labour it does not escape so well. Pressure of the head, if beyond a certain amount, may injure the brain or cranium; arrest of the circulation, by compression of the navel-string or the vessels of the neck, may cause asphyxia, congestion, apoplexy, or effusion of blood into the substance, or upon the surface, of the brain or membranes. Impaired vitality or death may be the consequence. 20. After birth, exposure alone, " taking cold," as it is called, is often a cause of immediate disorder, the eyes, eyelids, or Schneiderian membrane, becoming inflamed. The unused condition of the lungs, the sudden access of air to the delicate bronchial tubes, the increased vascularity of their lining membrane, and the enormously increased circulation in the lungs, which have superseded the placenta in its function of aerating the blood, afford ample grounds for the incursion 1 On the Management of Infancy and Childhood, p. 91. 3 Simpson on Diseases of the Placenta. Edinburgh Med. and Surg. Journal. 28 ON THE MANAGEMENT OF of disease, which will be rendered still more probable if the air be too cold or in any way impure. Continued crying, from suffering or dis- comfort, may be considered as violence applied to the air-tubes, and anything which quickens or renders irregular the circulation in the lungs maybe said to add an additional stimulus to diseased action in so delicate an organ. 21. The digestive system is exposed to danger both from the quality and quantity of the food submitted to it. The process of appropriat- ing even the blandest food increases the vascularity of the mucous membrane and the entire circulation in the organs engaged; if the food should be unsuited, improper, or in too great quantity, instead of nourishment, the result will be injury both to the organs individually and to the system generally as a consequence. 22. Excitement of the brain and nervous system is of a multiplied and complex character. Possessing exquisite sensibility, each sen- suous impression is acutely felt, though transitory and obliterated probably by the one succeeding. This variety of succession of im- pressions is advantageous, for the boundary between excitement and irritation of the nervous system is so easily passed, that a deep or prolonged impression could scarcely be without injury, as we see when an infant is exposed to an excess of light or noise; but this is even more evident when we reflect that impressions from more than one sense are concentrated upon the brain at the same time. The natural or unnatural stimulus to any organ is a stimulant to the nervous system of more or less power. To give an illustration of what I mean, it is clear that a very bright light will stimulate the brain through the organ of sight, and singly it might be injurious; but if at the same time the ear communicate a painful impression of a loud noise, and the skin of rough handling, the stimulus to the brain is tripled, and the probabilities of injury so much increased. If, however, the natural action of the organs of sense upon the brain may be injurious, how much more so must be their diseased action, and that of other organs also? The relation which the organs of sense, in their normal condition, bear to the nervous system, is evident; not so that of the other organs of the body; the close tie which connects these latter is principally evidenced in cases of disease. Thus we find that, while healthy food is digested with no apparent effect upon the nerv- ous system, indigestible food may excite convulsions, &c. Many similar examples might be adduced to prove that disordered action of different and distant organs is concentrated, as it were, upon the nervous system, giving rise to secondary but very important dis- eases thereof. 23. From this cursory sketch we may see that the infant is exposed to various causes of disease both before and after birth; that previous to its entrance into the world it may receive direct injury from its mother; or, indirectly, through the deterioration of her blood; that disease in its temporary organs of nutrition or in its envelops may inflict damage upon the foetus; and that none of its organs are exempt INFANCY AND CHILDHOOD. 29 from diseases which are excited by causes beyond our means of appre- ciation. Again, the process of transition into the world may leave injurious effects upon the organ or structure submitted to pressure, or if the compression be excessive, it may prove fatal. Lastly, supposing the infant to escape with impunity so far, each organ and system has to undergo a severe trial at the assumption of its natural functions. From the newness of all impressions, and from the organs not having acquired the power of adaptation and modifica- tion which they subsequently possess, the natural food of each, the very process of nutrition and support, may excite disease. That which each organ seeks as its pabulum (e. g. light for the eye, food for the stomach, &c.) may, in its delicate state and unlimited exposure, be highly injurious from its quantity or quality. The intricate and extensive sympathies of the different systems, slightly evident in health, but very marked in disease, is another source of mischief. In childhood, scarcely any disorder exists alone for any length of time, and we shall find hereafter that the secondary diseases of childhood are not inferior in importance, and require as careful an adaptation of remedies, as the primary ones. If we add the evils that result from bad management, the cause of the great mortality in infancy will be in a great measure explained, and the best reason given for the rules I shall lay down for the manage- ment of children. 24. But before commencing this subject it may not be amiss to notice the organic peculiarities of childhood, and to say a few words upon the growth and development of the infant. Respiration being established, and the lungs distended, the volume of the chest is materially increased, and continues to enlarge for some time in its full proportion. The heart, also, having some work to per- form in transmitting the blood through the lungs, acquires greater size. The pulmonary blood-vessels are largely developed, and are oc- cupied in carrying the blood to the lungs to undergo the process of aeration. The foramen ovale, which allowed the blood to pass from the right to the left auricle before birth, is gradually closed, and the ductus arteriosus obliterated. During early infancy the circulation is rapid, the pulse being from 100 to 120 or 130, and the respiration proportionably quick; as the age increases, these both gradually subside. The principal peculiarity of the digestive system appears to be the balance there is between nutrition and excretion, and the rapidity of these functions. Children eat oftener and evacuate more frequently than older persons, and upon the due proportion between the two, their health in a great measure depends. The nervous system is remarkable for its delicacy, the rapidity with which its functions are performed, and the quick exhaustion which follows. A child will exert himself in a greater ratio than an adult, but he requires more sleep. The power of generating heat in infancy is much less than in after 30 ON THE MANAGEMENT OF life. The great sources of animal heat are respiration, digestion, and the nervous influence. " If, then, free respiration, vigorous digestion of nourishing food, and active nervous influence, are the chief sources of animal heat, it would be contrary to reason and common sense to expect its rapid evolution in infancy, the very period at which these functions are most imperfect and come into play for the first time, amidst an active revolution in the state of living and habits of the child, which is anything but favorable to their exercise. How can respiration be free and vigorous, when the lungs are still small and their air-cells still imperfectly expanded. And how can the new- born infant produce heat from chyme, which is itself the product of a digestion that has not yet taken place? Again, how can digestion be vigorous where no food has ever been swallowed, and when the first aliment derived from the mother's breast is so thin and watery as scarcely to admit of digestion at all ? And how can sustained nervous energy be healthily supplied when the nervous fibres have, for the first time, encountered their objects, and whole days are spent in sleep, and when the circulation is driven off its balance by the variety of new functions at once excited into action. To the eye of reason it seems impossible to convey these facts without acknowledging that, to ex- pect the vigorous generation of animal heat in such circumstances, would be very much like expecting an oak to grow without roots, or a fire to burn without air. Notwithstanding this, however, it was once, or rather it still is, a matter of popular belief, that infants have a great power of resisting external cold, and are even invigorated by it. But Milne Edwards has now demonstrated that, in accordance with what might be expected a priori, the power of generating heat is at its minimum in all animals immediately after birth, and that it rises progressively as their development, strength, and internal activity in- crease. In conformity with this rule, it appears that, in prematurely born children, the heat of the body is several degrees below the na- tural standard, and is very easily depressed still further by external exposure. In one instance, of a seven months' child, the thermome- ter stood at 89° Fahr. instead of at 98°, or nine degrees below the usual temperature in the adult.1 The muscular and osseous systems are scarcely completed at birth, or, when completed, they have but little of the strength or vigor ne- cessary for use, but, as in the case of the internal organs, every day- adds to their development and power. 25. Now let us take the case of an infant after the excitement to , which it is immediately exposed at birth. Under the influence of exhaustion it sleeps long, and each hour of excitement is thus followed by rest for the senses and for the nervous system, and during these periods of rest, and in consequence of them, nutrition and growth pro- ceed rapidly. Food, excitement, and sleep, divide the life of infancy, but the latter preponderates considerably in health. By degrees the 1 Combe on the Management of Infancy, p. 119. This is an excellent little work, which I would strongly recommend to the notice of all interested in the management of children. INFANCY AND CHILDHOOD. 31 organs of life become used to their food and able to employ it benefi cially; the organs of sense are accustomed to the stimulus presented to them, and cease to feel it so acutely, or (as in the case of the eye) acquire the power of limiting its extent; and the nervous system, still sensitive, gives evidence that all sensation is not painful. Further, after awhile it is clear that another step in advance has been taken, though the proof is slight at first; the child is conscious of something external to himself; he sees, not light, merely, but ob- jects; he hears, not sounds simply, but sounds proceeding from some- thing, towards which he endeavors to turn. A light object imme- diately attracts attention, and if it be moved the infant will endeavor to follow it with his eye. If the room be darkened, and a space in the curtains admit a ray of light, or if a candle be visible, we may remark that, as the infant of a fortnight old lies on its nurse's lap, it is towards this that its eye is steadily directed. After this education of the eye to light and luminous objects, and of the ear to sounds, and to the sources whence the sounds proceed, has continued for some time, we may perceive another step in advance, —the child recognizes certain of them. The mother's voice occasions a start and smile of pleasure, and as the eye has acquired not so much the power of discriminating between objects as of recognizing one or more, the mother's face becomes familiar, and sound and sight to- gether elicit from the baby its earliest expression of preference and affection. 26. But whilst this education of two of the senses for appreciating external relationship has been going on, other means of obtaining in- formation have come into use. The muscles have acquired strength and facility from incessant motion during waking hours, and the touch, too sensitive at first, has become so regulated as to be rather a source of pleasure. By degrees the child acquires the use of the great organ of feeling, the hand, not only in touching objects but in grasp- ing them, and the mind has thus opened to it another source of in- formation, as to the external world, as extensive and valuable as that afforded by the eye. By the union of touch with sight, the infant obtains a knowledge of forms as distinct from surfaces; and it is probably to touch chiefly that it is indebted for the conception of substance. This acquisition of information, concerning external sensible things, commences at a very early period: from the beginning, the infant grasps a finger or any object presented to it; the next step is to maintain its grasp and give a direction to its muscular effort, and this is attained by the endeavor to gratify another feeling. That which it seizes it speedily endeavors to convey to its mouth, at first with dif- ficulty and uncertainty, but after many failures the power of direction is acquired, which after some time is extended, and the infant can at once put forth its hand direct to an object, grasp, retain, and direct it whither it pleases. This involves both muscular power and com- mand, and mental or cerebral government. 27. After this, we find another example of muscular action directed by the nervous system to a definite object, and modified by the faculty 32 ON THE MANAGEMENT OF INFANCY AND CHILDHOOD. or power of imitation. Voice or sounds the child has produced from its birth, but it was expressive of two sensations merely, distress and pleasure; now, however, that the ear has acquired a certain amount of knowledge, and the muscles of the mouth and larynx a certain de- gree of power, an attempt is made to produce articulate sounds or words. The mother or nurse unconsciously appeals to the faculty of imitation with which children are so richly endowed, and after per- severing endeavors a simple sound is divided and rendered distinct by the lips, and the child's first words " pa-pa," "mam-ma," are ut- tered. As a general rule, though with many exceptions, labial words are first pronounced, then lingual, and lastly guttural. Success in uttering one word is at once a reward and an incentive to fresh trials, and the distinct pronunciation of one or two is a lesson and an example to the child in its further efforts. Its vocabulary in- creases with considerable rapidity, single words are accumulated, complex ones are formed, two or more are joined, so as to form an imperfect sentence, but one sufficiently intelligent for the expression of the child's wants or feelings; and now the mental state is no longer exhibited in pantomime, but expressed with a definite consciousness on the part of the child; so as to be understood by those to whom its language is familiar. Its mental operations have been extended from the simple acquisition of knowledge to the power of communicating its own impressions to another. The influence of mind upon speech is very well illustrated in the case of idiots, who always learn to speak very imperfectly, and often not at all. 28. Whilst, then, compound processes have been developing, the entire body of the child has increased in size ; the muscles of the back and lower extremities have become stronger and more active; the child has learned to use his limbs, and maintain an erect position in the arms or when placed upon the floor. If he be put upon his feet and supported, he will make clumsy efforts to advance, lifting one leg and then the other ; by degrees, he discovers how to secure his pro- gress by placing one leg before the other. Or, he may first learn to creep upon the floor ; and I think a child acquires a greater command of his limbs than when he learns to walk without first creeping. Be this as it may, by one means or another, he acquires all the muscular strength, agility, and tact, necessary to walk; and he only needs the proper degree of cerebral government, or, as we say, " a steady head," to be able to walk alone. But this is not acquired till some time after he can walk pretty well with the aid of a finger. At length, however, the power of balancing himself and the courage to do so are attained, so that he can walk alone, and, like every natural acquisition, it affords a repayment of pleasure more than adequate to the trouble it has cost. Having thus sketched the growth of the infant as to its senses mode of acquiring a knowledge of external things, faculty of speech' and power of progression, it is not necessary to follow the subject further. I shall at once proceed to consider the rules for the management of infancy and childhood. MANAGEMENT OF THE INFANT AT BIRTH. 33 CHAPTER II. MANAGEMENT OF THE INFANT AT BIRTH. 28. Immediately that respiration is fully established after the birth of the child, a ligature is applied around the navel-string, about two inches from the navel, and a second a few inches nearer to the mother, and the cord divided between them. The infant is then rolled in flannel and laid upon the bed, or taken to the fire, until the nurse is at liberty to attend to it. Common sense would teach us, as instinct teaches animals, that for some considerable time after birth great care should be taken to keep the infant warm, and observation only con- firms this necessity by showing that the change of locality at birth involves a difference of at least twenty degrees. Dr. Edwards' experi- ments have clearly proved the absolute necessity of increased warmth being afforded to the infant; and it is to be hoped that the foolish and injurious theories about hardening infants by exposure, using cold water, &c, will soon, by common consent, be exploded. 29. If the infant be very weak it may be desirable to allow it to rest awhile before washing and dressing ; but in ordinary cases the child may be taken to the fire and the nurse proceed to wash and dress it. Let the nurse so place herself that the infant may feel the warmth of the fire, but without being exposed to a bright light, and in many cases simple warm water will be sufficient to cleanse the skin. When it is thickly covered with the vernix caseosa, or creamy matter, neither warm water alone nor with the addition of soap will entirely remove it. Dr. Dewees recommends, that " every part of the child should be smeared with fine hog's lard before water is applied. This being done, the child should then be carefully washed with lukewarm water and fine soap."1 Dr. Eberle mentions that fresh butter or the yolk of an egg is equally effectual.2 Both lay great stress upon the neces- sity of its complete removal. Now, without going so far in the oppo- site extreme as the German professor referred to by Dr. Dewees, who advised its being allowed to dry and drop off spontaneously, I do think that to prolong the operation of washing unduly for this purpose is unnecessarily exposing the child to cold. Let the nurse apply the lard, and afterwards, with a fine soft sponge, or flannel and soap and water, remove what she can in a reasonable time ; the rest can easily be removed on the second washing after a few hours. The head and face should first be washed, the eyelids and ears carefully cleansed; and, the whole having been dried with a piece of soft linen, a flannel cap should be put on until exchanged for a warm nightcap when dressing is completed. In this country, it is customary 1 Diseases of Children, p. 71. 3 Diseases of Children, p. 18. 3 34 MANAGEMENT OF THE INFANT AT BIRTH. to apply a little whiskey to the head after drying it, to prevent cold. Whether it has this effect or not, I cannot say; I do not think it necessary, but neither do I think it injurious, provided it be kept from the eyes. Although the first washing of the child may be somewhat slightly performed, the second ought not, but the greatest care should be taken to cleanse not merely the general surface of the body, but all the folds and creases of the skin, e. g. those of the neck, axilla?, groins, buttocks, &c.; and, after drying them gently and thoroughly, all the parts where friction of one surface against another is possible should be well dusted with finely powdered starch or lapis calaminaris, or hair powder tied up in a little muslin bag. Eberle objects to this, as interfering with the regular transpiration of the skin, and as giving rise to a troublesome itching and harshness of the cuticle.1 I cannot say I have ever observed this except when the nurse had neglected to wash the parts so powdered, and general experience is certainly in favor of it. Excoriations are undoubtedly the result of neglecting this precaution, especially in fat infants. 30. After the child has thus been washed, dried, and dusted, the first step in dressing is to arrange the navel-string; and it is well for the medical attendant to have an eye to this himself, first examining the cut extremity, to ascertain if there be any escape of blood, and if so, applying an additional ligature nearer to the abdomen. This is ren- dered necessary in many cases by the escape of the gelatinous fluid contained in the sheath of the cord, which renders the first ligature useless, and exposes the infant to hemorrhage when reaction takes place after washing and dressing. This point being secured, the frag- ment of the navel-string is to be folded in a small piece of soft linen, and turned upwards on the abdomen, where it is to be retained by a light flannel binder, applied firmly and evenly, but not too tightly, which answers the double purpose of security to the cord and support to the navel specially, and to the abdomen and back generally.2 The nurse should be careful not to wet the dressing of the cord when wash- ing the child, and it need not be changed more than once or twice, if at all, before the separation of the fragment, which takes place sponta- neously about the fifth or sixth day. I have known it separate as early as the second day, and, on the other hand, be retained until the fifteenth ; but, however long may be the time, no effort should be made to detach it, as the risk of fatal hemorrhage would be very great. 31. The dress of the infant varies in different places, nor is it of much consequence, provided we secure warmth and freedom, that the materials be soft, that the parts be not too complicated, that too many pins be not used, and that undue and irregular compression of any part be avoided. Buffon gives a graphic description of vicious dressing in France, which may be observed at the present day: "With us in France an infant no sooner leaves the womb of its mother and has hardly enjoyed the liberty of moving and stretching its li'mbs, than it is clapped again into confinement. It is swathed, its head is 1 Diseases of Children, p. 21. 2 Dewees, Diseases of Children, p. 81. MANAGEMENT OF THE INFANT AT BIRTH. 35 fixed, its legs are stretched out at full length, and its arms placed straight down by the side of its body. In this manner, it is bound tight with clothes and bandages, so that it cannot stir a limb; indeed, it is fortu- nate that the poor thing is not muffled up so as to be unable to breathe; or if so much precaution be taken as to lay it on its side, in order that the fluid excretions voided at the mouth may descend of them- selves; for the helpless infant is not at liberty to turn its head to faci- litate the discharge."1 Dr. Dewees and others of high authority recommend that flannel should be used next the skin; from this, however, I must beg to differ; it is not necessary in order to secure sufficient warmth, and a little muslin or linen chemise is much softer and cleaner than any other inner garment; it should be changed every day, and flannel may be used outside. Except the chemise, all the garments are made long, for the sake of warmth, and if the parent possess common sense, she will not adopt the cruel fashion of short sleeves.2 The nurse should be very careful to change the napkins the moment they are soiled, as otherwise the buttocks will become inflamed and excoriated, and the child exposed to great suffering; and when changing them, warm water and a soft sponge must be used if necessary. The cap should be soft and warm, so as to protect but not compress the head. When the child is washed and dressed, which should be done in less time than we have taken to describe it, it may be placed in bed with its mother, or, wrapped in a flannel shawl, be laid in its cradle, in a warm part of the room, equally removed from light and draughts. 32. About this time, however, or shortly after, it is customary to give a grain of calomel, a few grains of rhubarb, or a teaspoonful of castor oil, for the purpose of clearing away the meconium. This has been objected to as unnecessary, on the ground that the first milk of the mother possesses purgative qualities. Granted, but then it is not available for hours, or it may be days, and certainly the infant seems uneasy until the meconium has been evacuated. It is better to take a middle course; to allow a few hours' rest after washing and dressing, and then to give a teaspoonful of castor oil in a little warm water and sugar. I think the oil a better medicine than either calo- mel, rhubarb, or magnesia. When the complexion is changing about the third or fourth day, and the skin presents an unusually yellow tinge, without being actually jaundiced, then a grain of calomel will be found very bene- ficial. 33. For some hours the child will not require food; its first neces- sity is warmth and sleep. After the oil has been swallowed, it should be placed in bed or in the cradle, and allowed to rest as long as it will. On awTaking, it will generally be found to have passed water, and perhaps to have evacuated the bowels, and as it will then feel hungry, 1 Histoire Nat., vol. iv. p. 190. ' Darwall on the Management of Children, p. 17. Dewees, Eberle, Stewart, &c, &c. 36 MANAGEMENT OF THE INFANT AT BIRTn. it will intimate the same in a way not to be mistaken. At this time, say three or four hours after birth, the secretion of milk has not gene- rally commenced, and therefore the nurse must feed the child. A little milk and water, nicely sweetened, will be the best food at this period; it is more simple, and less likely to irritate the delicate mucous membrane of the stomach, than gruel or prepared barley, &c. Dr. Maunsell states, that "Professor Joerg recommends that nothing should be given but a few teaspoonfuls of lukewarm water, and we happen to know that such is his practice, without any bad results, in the lying-in hospital at Leipsic."1 But it cannot be too constantly remembered, that the proper food for the infant is the mother's milk, and that the earlier we endeavor to obtain this, the better for both.2 To the infant it affords the sim- plest, most natural, and healthy nutriment, and the mother may be thus saved from uterine hemorrhage,3 mammary congestion, and milk fever, which latter is so frequent when nursing is postponed for three or four days. The child should be put to the breast, and allowed to make the at- tempt to suck as soon as the mother has recovered from the fatigue of labor, say in eight or ten hours; if the secretion have not commenced it will not persist, and must be fed, but in most cases it will obtain some milk, and by the effort the duct will be freed, and the secretion quickened. So long as the supply is inadequate, the deficiency must be supplied by a little milk and water with sugar, but if the breasts secrete any, the child should be applied to them when it is hungry, before we have recourse to feeding. 34. In many cases, after the first child, the mother is able to begin at once, and to continue to nurse her infant, without additional aid; but in others, especially in primiparae, we sometimes find that no milk is secreted for two or three days.4 Now in such cases to let the child suck frequently would not merely be useless, but positively injurious; it would obtain no nourishment, and the nipple would be irritated, 1 On Diseases of Children, p. 34. 2 Raulin (De la Conservation des Enfans, vol. ii. p. 177), in 1769, and Deleurye (La Mere selon l'Ordre de la Nature, p. 32), in 1772, recommend an early application of the child to the breast. The latter advises that it should be suckled as soon as the mother has rested and become tranquil. The same opinion is held by all the more sensible writers since. "The child "' says Dr. Darwall, " should be put to the breast as soon as the mother has recovered from the immediate exhaustion of labor. In this way, the breast, tender, probably, and easily ex- coriated, gradually becomes able to bear the increasing strength of the child. At first its suckling is little felt, its efforts being feeble, and scarcely sufficient to draw in any nutri- ment; gradually, the milk is more plentiful, the exertions of the infant more vigorous but at the same time the breast is become more capable of enduring them."__Plain In- structions for the Management of Infants, &c, p. 6. s Underwood, Diseases of Children, p. 29. « With women of a nervous temperament, who are excessively anxious to nurse this very anxiety may postpone or suspend the secretion of milk. No doubt every one has met with cases of this kind, which are not always easy to manage. I have found a suggestion of my friend Dr. Graves very successful. Order some "milk powders1'__a few grains of some innocuous or inert substance, e. g. Pulv. Contrayervae__to be taken three times a day, and give the patient assurance that after three or four days the milk will be produced. The anxiety thus relieved or postponed will allow nature fair plav and in the majority of cases your "powders" will have the credit of success. THE FOOD OF INFANCY AND CHILDHOOD. 37 inflamed, and excoriated.1 The child should be fed, and only once or twice a day placed to the breast. CHAPTER III. THE FOOD OF INFANCY AND CHILDHOOD. » 35. Having thus described the treatment of the infant immediately after birth, we shall next speak of its further management as regards food, clothing, air, and exercise, &c.; but as a considerable change takes place in the habits of the child in the course of the second year, we shall speak of the care necessary during the first period of life, or infancy, and the second, or childhood, separately. From what I have stated in the last chapter, the reader will antici- pate the first canon I would lay down as regards food, viz., that as a general rule the mother's milk, alone or nearly so, is the proper food of the first six months of infantile life, and that it is, with a few ex- ceptions, the imperative duty of the mother to supply it. To the credit of those who are below or above the influence of fash- ion—the most contemptible idol that ever man first made, and then worshipped—i. e. of the great majority—women in these countries anticipate the period of nursing with pleasure, as drawing closer the tie between themselves and the objects of their tenderest love. They who reject the duty may not unlikely lose a portion of the affec- tion, for the natural ordinances of the Creator cannot be violated with impunity. 36. All authors are agreed that human milk is not only the best, but one might say the only safe food for infants. The evidence ad- duced by Dr. Merriman against dry-nursing is perfectly conclusive. He says: "It has been part of my duty to endeavor to ascertain the amount of mortality among infants from this source, and, after much careful inquiry and investigation, I am convinced that the attempt to bring up children by hand proves fatal in London to at least seven out of eight of these miserable sufferers ; and this happens whether the child has never taken the breast at all^ or, having been suckled for three or four weeks only, is then weaned. In the country, the 1 Few things occasion greater suffering than cracked or ulcerated nipples, and it is not always possible to avoid tliem. I have found a modification of Professor Osiander's method the best means of avoiding them. For a month or six weeks before confine- ment the nipples should be washed night and morning with fine soap and water, and, after carefully drying them, they should be bathed with equal parts of spirits and water. Dr. Strahl recommends a lotion made by digesting six drachms of galls in six ounces of white wine for twenty-four hours, to be applied three or four times a day, beginning at the sixth month. Any mild astringent will answer the purpose,—green tea, decoction of oak bark, alum and water, &c. Dr. Dewees prefers the "application of a young but sufficiently strong puppy to the breast; this should be immediately after the seventh month of pregnancy."—p. 54. 38 THE FOOD OF INFANCY AND CHILDHOOD. mortality among dry-nursed children is not quite so great as in Lon- don, but it is abundantly greater than is generally imagined. The summer is the most favorable season for making the attempt; but if parents were fully aware of the hazard to which their children are exposed in the endeavor thus to bring them up, they would rarely choose to place them under the care of the dry-nurse."1 37. We may conclude, then, that the best nourishment for the child is human milk, and that the proper person to furnish it is un- doubtedly the mother. But then it may be asked whether this rule is universal, and without exception?—whether all mothers can and ought to nurse their children ? The answers simply that there are exceptions to this rule as to every other, depending upon constitu- tion, temperament, or physical peculiarities of the mother, or upon the circumstances in which she is placed. These exceptions I shall now enumerate. i. In some cases, malformation of the nipple presents a great diffi- culty, or even an insuperable obstacle. It may be so little promi- nent, or so much tucked in, that the infant cannot seize it.1 A little care in drawing out the nipple during the latter months of pregnancy, or the application of a strong child, or a puppy according to Dr. Dew- ees, or a breast-pump, immediately after delivery, before the breast fills, will sometimes succeed, if the malformation be not extreme; but, if this be not effected before the breasts are distended, there will be little chance of success. n. I have seen the milk abundant for a time, and then suddenly cease entirely, without apparent cause, the mother being in perfect health, and free from anxiety. In one case of this kind, the lady nursed well for three months, menstruation then occurred, and when it ceased there was not a drop of milk in the breasts. There is no- thing capable of restoring the secretion in such cases. in. Occasionally, when the nipple is good, and the supply of milk pretty fair, it is in a great measure lost during the intervals of suck- ling: there is a sort of incontinence of milk. It is secreted when not wanted, and escapes as fast as secreted. If this should happen, as I have known it, in a case where one breast is useless in consequence of former disease, there will be a very inadequate support for the in- fant, and unless feeding agree very well with it, it will be better to obtain a wet-nurse at once. It is by no means uncommon for one breast to secrete much more milk than the other, or even for one breast to be nearly quiescent, without apparent cause; but if the other breast secrete plentifully, and retain it, this will be no obstacle to the mother's nursing. iv. Women of an irritable, nervous temperament, are seldom very good nurses. They are so much excited by external and even trifling circumstances, that the milk is constantly varying both in quantity and quality, and the child will suffer in consequence. Their fears are aroused by every little change in the child's condition or appear- 1 Underwood, Diseases of Children, p. 13. 3 Ibid., p. 18. THE FOOD OF INFANCY AND CHILDHOOD. 39 ance, and they suffer so much distress that they are not unlikely to cause in this way the very danger they fear.1 Moreover, in women of this temperament, the constitutional dis- turbance excited by nursing is too great for their own health or that of the child. I have seen a quick pulse, nervous tremors, night sweats, languor, and cough, which were alarming the patient's friends, disappear in two days on weaning her child. Drs. Gooch and Ashwell mention cases of mental disturbance depending on nursing, and I could add several more. For their own sake, then, and for their infant's, women of a nervous excitable character should abstain from nursing their first child at all events. v. It is quite out of the question for any woman to nurse who is laboring under severe organic disease, fever, exhausting discharges, or complaints which are hereditary or transmissible, such as phthisis, epilepsy, scrofula, syphilis, mental disturbance, &c. Nay, even a known tendency towards these latter diseases, their occurrence in any member of the family, or a general delicacy of constitution, should give rise to very serious consideration on the part of the physician, before he permits his patient to run the risk of perpetuating in her offspring such formidable disorders. Children of very delicate parents, when nursed by healthy countrywomen, are often found to grow up with constitutions more resembling their nurse than the mother. The chain of transmission has been broken. vi. Experience will show in many cases, where it would not have been anticipated, that the mother is unfit to continue nursing. Some- times, without any apparent cause, the milk evidently disagrees with the child ; either it vomits it all, or it is griped and purged, and does not thrive. In such cases, it will be advisable to make a change. When menstruation occurs during lactation, the milk is apt to disa- gree temporarily; but if pregnancy take place, the disturbance may be more permanent. In the former case, the infant should be given the breast less frequently for a few days, but in the latter it should be removed altogether. vn. The mother may be so circumstanced, that she cannot under- take the office of nurse. Imperative (or imperial) duties and occupa- tions may require her absence from her baby for so long a time during the day as to prohibit her undertaking the office without injury to the child. Fashionable life makes such heavy demands upon the time, energies, and health of its votaries, that it is fortunate for the child when mo- thers, who cannot give up their amusement, do not add to their folly by attempting to nurse. vm. Lastly, great mental emotion, such as grief for the loss of re- latives or dear friends, anxiety and worry from domestic trials or great -public calamities, have an injurious effect upon the milk, and may seriously injure the child, although the mother's health may not apparently suffer. I have met with an instance of two sisters, who continued to nurse 1 Underwood, Diseases of Children, p. 19. 40 THE FOOD OF INFANCY AND CHILDHOOD. their infants during a time of .severe domestic trial, and although the children were both healthy previously, yet shortly after one was at- tacked with arachnitis, and the other with an aggravated form of scrofula: both died. 38. These cases, and some others which may possibly occur, form exceptions to the rule laid down, that every mother ought to nurse her own child. I have already stated, that the sooner the infant is put to the breast, after the mother has obtained a little rest, the better both for mother and child. If the milk be deficient in quantity, a little food may be given, but if the natural supply be adequate, or as soon as it becomes so, the child should be nourished by the mother alone, if strong enough, for some months, both night and day. The frequency with which the child should be put to the breast will vary a little according to its appetite; but it is desirable that, as far as possible, it should acquire regular habits of feeding. Every two or three hours will not be too frequent, if no food be given; and it will be well, if the nipples be tender, to bathe them with spirits and water each time after suckling, and with warm water before the next nursing, in order to prevent cracks or excoriations. 39. After four or five months, it will be advisable to feed the child regularly once a day, so that, in case of an interruption or diminution of his natural supply from any cause, he may not suffer. As the child grows older, and his app'etite increases, the mother may not have sufficient, and the feeding must be increased in quantity and frequency; at the same time, he ought to have the benefit of all his natural food. Of the varieties of food, and modes of administering it, I shall have to speak fully by and by; at present, therefore, I shall merely observe that the food should be given as thin as possible at first. The nurse prefers it thick, "because," she says, "it is more satisfying," and no doubt the child is quiet and heavy afterwards; but it is because his stomach is overloaded, and if it did not reject its load he would be liable to serious illness in consequence. In conclusion, I would repeat, that, supposing the mother to be in good health, and her milk good and abundant, it is to form the staple nourishment of the child until within a short time of weaning; that he is to get all she has to give, and that any deficiency, whether from diminished secretion or increased appetite, is to be supplied by feeding. 40. So far, I have assumed that the mother is able and willing to suckle her child, but this may not be the case, or after a trial she may be obliged to give it up. Then the choice lies between a nurse and artificial feeding. There can be no hesitation in preferring the former, when a good one can be obtained ; but as the well-being of the child, and much of the comfort of the parents, are involved the medi- cal attendant should be extremely careful in his THE FOOD OF INFANCY AND CHILDHOOD. 41 CHOICE OF A NURSE. Of what may be called the domestic qualifications of the nurse, the mother, or some one deputed by her, will be the judge; but the deci- sion as to her suitability as a nurse is very properly, almost always, left to the physician or surgeon. At the same time, there are one or twro points, not strictly medical, which are of importance, and should be inquired into. For instance, her temper, habits of life, and any peculiarity of her position, may be serious inconveniences. If she be liable to fits of passion and ill-temper, or indulge any vicious propen- sities, or be exposed to anxiety on account of her husband or children, the quantity and quality of milk will be depreciated, and she will not be a good nurse. Again, it is desirable that she should be naturally fond of children, that she may bear patiently and kindly their " tracasseries," and of a lively disposition, that she may amuse them, and keep them cheerful and happy. 41. There is a general prejudice against taking as a nurse a woman after her first confinement; on the ground, I believe, that she has less experience, that there is greater liability to menstruation, and conse- quent impregnation whilst nursing, and that the milk is less certain in quantity, and apt to cease suddenly, after the first child, than sub- sequently. It is desirable to choose a nurse whose child is about the age of the one she is to suckle, or rather younger, if anything. At the same time, if the mother have suckled or fed her child for some weeks, or if it suffer from diarrhoea, it will be injurious to give it very young milk. Dr. Merriman observes: " Some ladies are very anxious to procure wet-nurses who have not lain in more than a fortnight or three weeks. I have seldom found the milk of such nurses answer so well as those whose children are eight or ten weeks old. They are not suffi- ciently recovered from the effects of parturition, to undertake the duties generally required of a wet-nurse."1 Both mother and child should have the appearance of firm, good health ; the nurse should have a clear, sound skin, without eruption or traces of scrofulous disease. Her mouth should be examined, and the state of her teeth and tongue ascertained ; if the former be per- fect, and the latter clean, we may be satisfied that the digestive system is healthy. The breasts should be of moderate size, both equally good, and firm, the bulk evidently formed by the enlarged mammary gland, and not by adipose tissue. Large, flabby breasts yield a very inferior supply of milk. The nipple should be of moderate size, well formed, and prominent, and we should observe whether the milk escapes involuntarily, or only when demanded by the infant.2 1 Underwood, Diseases of Children, p. 71. 3 •• Nurses who have not a good supply of milk will occasionally be found to adopt a practice, commonly employed with milch cows when brought to market, and called 42 THE FOOD OF INFANCY AND CniLDIIOOD. Let the nurse squeeze a little milk into a wineglass, in order to judge of its quality; it ought to be thin, clear, of a bluish-white color, very limpid, very sweet, and, if allowed to stand for awhile, covered with cream. 42. But a still more minute examination must be made to ascertain, as far as possible, whether the nurse is suffering from any disease, local or constitutional, which she may transmit to the child. "Diseases of the skin, as the itch, and some species of tetter, have been so frequently propagated, as to become familiar to the observation of everybody ; and in two instances we had the immediate care of those who had received from the nurse the most loathsome and horrible of all diseases ; it was communicated not only to the children who were at the breast, but also to four older ones."1 Rosenstein mentions the case of a family in Stockholm, in which the father and mother, three children, the maid-servant, and two clerks, were infected with vene- real from the nurse I saw very lately an infant who had been intrusted to a nurse for one day, and which was then transferred to another ; by the first it was infected, and it again infected the new nurse. Many such cases might be adduced, but enough has been stated to show, that any carelessness on the part of the medical attend- ant may inflict great injury and distress upon the infant and those connected with it. Some light will be thrown upon these by a careful examination of the nurse's child, which should never be omitted. It ought to be clean, free from all eruptions (except red or white gum) about the head, neck, buttocks, and groins, and from excoriation at the different folds of the skin. Its mouth should be carefully examined and its general condition. Its flesh ought to feel firm, and it ought not to vomit more than a portion of the suck. 43. If we find the child and mother healthy, and if the milk be good and abundant, we may safely recommend the nurse; but, as the change is very great for her, care must be taken to counteract or avoid the evils which might result from an increase in diet and a diminution of active employment. People of the class from which the best nurses are obtained suffer their share of the hardships of life. Plain, coarse food, and probably a scanty supply of it, insufficient clothing, confined and uncomfortable dwellings, and hard labor, are the lot of almost all. From this state she is taken to what is to her a luxurious dwelling, with warm clothing, abundant or it may be extra diet and compara- tive idleness, having little to do but to attend to the infant. It cannot be surprising that such a change should in many cases be unfavor- able to the health of the nurse, and that the milk should occasionally disagree with the infant. This, however, may be avoided by a little attention to diet and 1 stocking' by the cattle-dealers; that is, they allow the milk to accumulate in their breasts for several hours before presenting themselves for examination, so as to cause the exa- miner to believe that they are very abundantly provided. Young practitioners should be especially on their guard against this deception."—Maunsell and Evanson on the Diseases of Children, p. 40, note. ' Dewees, Diseases of Children, p. G8. THE FOOD OF INFANCY AND CHILDHOOD. 43 regimen. It is neither necessary nor advisable that a nurse should be highly fed ; it will be much better to give her plain, good food, with a moderate allowance of malt liquor at dinner, and a bowl of milk or gruel at bed-time; the quantity being not much more at first than that to which she has been used. The large allowance of ale or porter so commonly given, is not only unnecessary but injurious. Daily exercise in the open air is essential; a good smart walk will promote digestion and favor the secretion of milk, if she take care not to over- heat herself. The bowels should be moved every day; if not spon- taneously, then by mean« of medicine.1 It is very desirable that the nurse should be provided with sufficient occupation, and care must be taken that personal cleanliness is duly attended to. Dr. Bull recommends that " sponging the whole body also with cold water, with bay salt in it, every morning, should be insisted upon if possible; it preserves cleanliness, and greatly invigo- rates the health."2 Early habits are desirable; she should be allowed to retire early to bed, and be required to rise early in the morning. 44. Most of the observations here made upon the regimen and diet of the wet-nurse apply equally to the mother who undertakes to suckle her child. For her, moderate and good diet, air, exercise, and occupation, with calmness and tranquillity of mind, are equally necessary; but in two points she is more likely to fail. Having been accustomed to good living, in her anxiety to produce milk she will try to do so by taking more food or richer than usual, and by drinking more ale and porter, and it is very likely that in so doing she will de- feat her own object. Dr. Dewrees remarks, that " we have often been consulted upon the subject of the failure of the milk, when an anxious mother herself or a hireling nurse was concerned, and been informed by them, that they had tried everything with a hope of improving it, such as rich victuals, porter, ale, beer, milk punch, &c, without success, or it was followed, perhaps, by a diminution of it. In such cases, we have often succeeded in producing a plentiful supply of milk by adopting the opposite plan of treatment; for it must be borne in mind, as an important truth, that this failure proceeds more frequently from an over than from an under quantity of food or of drink. It is a fact well known to all who have paid attention to the consequences of arterial excitement, that, when it amounts to even moderate fare, the milk almost immediately diminishes in quantity; and also when the action is diminished (provided it had not continued too long) by suit- able remedies, that the secretion of milk again becomes more abundant. Upon this principle, we have frequently prescribed evacuants and ab- stinence to promote the secretion of milk.3 The other point in which the mother not unfrequently fails, is in calmness and tranquillity of mind. Having a nearer interest in the baby, she is more sensitive as to its well-being, and more apt to fret 1 Darwall on the Management of Infancy, p. 11, note. 1 Maternal Management of Children, p. 33. a On the Diseases of Children, p. 99. 44 THE FOOD OF INFANCY AND CHILDHOOD. if anything be wrong, and being at the same time the mistress of the family, she is more exposed to external irritations and annoyances. Against the effects of these causes, she must firmly strive; knowing that distress of mind will injure her child, she must shun all occa- sions of irritation, and exert all the self-control she possesses. Before speaking of artificial food, it will be better, I think, to con- clude the subject of nursing by a few words on weaning the infant. WEANING. 45. The term of nursing will depend upon various circumstances, such as the health of the child or mother, the abundance of milk, &c. &c. Some women are not able to suckle more than six or seven months; some continue for two or three years. I know a lady who nursed a child (now a tall, strong man) until he was able to draw down the blinds and bring her a footstool previous to his taking his meal. Astruc and others advise nursing for two years, and the lower orders occasionally practise it to avoid pregnancy. But these cases are exceptions, and I believe it will generally be found that nursing prolonged beyond twelve months is unnecessary for the child and positively injurious to the mother in most cases.1 Taking this as one extreme, we may fix the other at nine months, and conclude that it is desirable that a child should not be weaned before nine months nor suck after twelve. By this time he will be provided generally with a sufficient number of teeth to make use of the proper food, and he will have retained the comfort of suckling until he has passed through the first trouble of teething. 46. However, there are circumstances which may require an earlier change: thus the mother's health may suffer from the excitement of nursing at the commencement, or from the constant drain afterwards. "If the suckling be continued, the appetite and digestive powers fail; severe pains in the head ensue; the nervous system becomes greatly disturbed ; transient pains, alternating with spasmodic twitches or numbness, occur in various parts of the body; the debility and ema- ciation advance rapidly; a multitude of anomalous nervous symptoms constantly harass the patient; a most distressing sense of sinking and emptiness is at times felt at the region of the stomach ; the mind be- comes disturbed and tormented often with an intense dread of dying, or a constant apprehension of some dreadful accident. At last delirium and even mania sometimes supervene."2 Dr. Gooch alludes to mental affections, caused by nursinc, in his valuable work. I have seen such myself more than once, and which yielded almost instantly after weaning. Again, an attack of acute or chronic disease in the mother, or a change in the character of the milk, may oblige us to anticipate the 1 Dr. Ashwell has also published an excellent chapter on Prolonged Lactation in his work on Diseases of Females. 3 Eberle, Diseases of Children, p. 64, et seq. THE FOOD OF INFANCY AND CHILDHOOD. 45 ordinary age of weaning; and if the child be not too young, especially if he have teeth, and food agree with him, he may be weaned safely; if not, it will be necessary to exchange the mother for a nurse. 47. If it can possibly be avoided, weaning should never take place when the infant is unwell, or when suffering from teething; a suitable opportunity, when it is free from distress, should be chosen, and it is desirable that the season should be favorable. As to the weaning itself, there is ordinarily little or no difficulty, with good management. The daily feeding for some time previously. will have in a great measure prepared the child ; and if the frequency be increased, it may gradually be made to supersede nursing in the course of a week or two, almost without the child missing the breast. Or the mother may give the child suck during the night or day only. By this means, the child will easily be reconciled, and the milk, the supply of which is proportioned to the demand, will gradually lessen, and at length cease to be secreted. After the child is entirely weaned, if the breasts should continue active and uncomfortably full, the milk may easily be squeezed out or drawn off by a pipe or bottle, or the breast-pump. Some purgative medicine will be advisable. 48. There is occasionally a little trouble, however, with children who have not been accustomed to, or have refused, food whilst nursing. The child will be very cross and fretful, and lose some nights' rest; but if the mother persevere, hunger will conquer at last. Dr. Under- wood observes : " I have remarked that infants, who are indisposed to feed at all while at the breast, are nevertheless weaned, and feed just as well as others, when once wholly taken from it. There is, how- ever, in a few children, a little difficulty for the first two or three days under any circumstances; but it is remarkable that the instance at- tended with the greatest aversion to common food that I ever wit- nessed was an infant who had been allowed a little chicken broth once a day for two months before the weaning was entered upon. The child was very healthy, slept well, and scarcely cried at all upon its being deprived of the breast, and yet would not receive the food it had been accustomed to; so that for six and thirty hours it continued averse from everything that was offered to it, though it appeared in very good humor. After the second day, however, it took a moderate breakfast, and in a little time it fed as readily as other weaned children."1 ARTIFICIAL FEEDING--SPOON-FEEDING. 49. The next point for us to consider is, the best mode of rearing infants by spoon-feeding, as it is termed. After what has been said, and the facts which have been advanced (36), showing the greater mortality of infants thus nourished, we should never voluntarily choose this method; but circumstances may occur which preclude the mother from nursing, and which prevent the employment of a nurse, whether from prejudice, the difficulty of procuring one, &c. &c. 1 On Diseases of Children, p, 75. 46 THE FOOD OF INFANCY AND CHILDHOOD. No matter from what cause, if the decision be made, it is our duty to secure for the child a wise administration of proper food. 50. The earliest food should resemble mother's milk as nearly as possible. Mr. Pereira has given the following analysis of different kinds of milk:— CONSTITUENTS. cow. ASS. WOMAN. GOAT. EWE. Caseine Butter . Sugar of milk Various salts Water . 4.48 3.13 4.77 0 60 87.02 1.82 0.11 6.08 0.34 91.65 1.52 3.35 6.50 0.45 87.98 4.02 3.32 5.28 0 58 86.80 4.50 4.20 5.00 068 85.82 Total . 100.00 100.00 100 00 100.00 100.00 Solid substances . 12.98 8.35 12.02 13.20 14.38 From this analysis, we learn that women's milk is the poorest of all, but that it contains most saccharine matter; next to this comes asses' milk ; and in choosing our substitute we should either prefer the one which approaches nearest to the natural food of the child, or endeavor to modify the differences in that we do take. Thus, a large propor- tion of water and sugar should be added to cow's milk; a less amount of each to goat's milk, &c. Any of the milks thus modified will generally agree well with the child, and may form the staple food for some months; but feeding differs practically from nursing in this, that, whilst a child will thrive upon mother's milk alone for nine months or a year, it seems absolutely necessary to change the food occasionally, or the child will suffer from derangement of the stomach and bowels. Dr. Dewees has laid down some very important rules for feeding with milk, a portion of which I shall extract: " 1. The milk should be pure, i. e. not skimmed, nor previously reduced by water; and should be used as quickly as possible, especially in warm weather, after it has been drawn from the cow. 3. The milk should be given as soon as possible after its mixture with the water and sugar, lest it should be disposed to ferment before it is exhibited. 4. It should never be mixed but when wanted, and no more should be provided than the child will take in a short time ; for it is much better to pre- pare fresh than to run the risk of its becoming sour before it is used. 6. In weather that is unfavorable for keeping milk, it should be placed in the coolest place that can be commanded, or kept in often- changed cold water. 7. Should the slightest tendency to acidity be observed in the milk, it should be rejected without hesitation- nor should an attempt be made at its supposed restoration, by using an additional quantity of sugar, as this will eventually but increase the evil."1 51. Various kinds of food are in daily use, many of which are very valuable. 1 Diseases of Children, p. 91. THE FOOD OF INFANCY AND CHILDHOOD. 47 i. The most common is gruel, made from groats or prepared barley, strained and sweetened. The great mistake (if it be not in many cases wilful) made by nurses, with this as with other kinds of food, is, that it is given far too thick, so that it overloads and deranges the stomach. It should, on the contrary, be made very thin, especially at first, and diluted with water or milk. When continued very long without a change, it is apt to occasion flatulence, griping, and some- times diarrhoea; but, with an occasional variation, it is one of the best, as it is the most common kind of food for infants. n. A very nice kind of food may be made from biscuit powder, pre- pared rusks, or " tops and bottoms," by steeping them in boiling water, and then adding water, or milk and sugar, in proportion to the age of the infant; the younger it is, the less milk should be given. in. Pap or panada, made in the usual way, by soaking bread in water and adding sugar to it; but from the quantity of salt, alum, &c, used in making the bread, it is apt to disagree with the infant. iv. The best food I know, and one which I have found to agree best with my own children, is "bread jelly," and it is made thus: A quantity of the soft part of a loaf is broken up, and boiling water being poured upon it, it is covered and allowed to steep for some time; the water is then strained off completely, and fresh water added, and the whole placed on the fire and allowed to boil slowly for some time until it becomes smooth; the water is then pressed out, and the bread on cooling forms a thick jelly, a portion of which is to be mixed with milk, or water and sugar, for use as it is wanted. The steeping in hot water, and the subsequent boiling, removes all the noxious matters used in making the bread, and it both agrees very well with the child and the child likes it very much. v. Arrow-root made with water alone, or with the addition of milk and sugar, is very good food; but, as it is somewhat astringent, it is more particularly suited to cases where the bowels are relaxed. In such cases also, boiled milk or boiled rice-milk is very beneficial. vi. " Two excellent kinds of food for infants," observes Dr. Mar- shall Hall, " are sago, thoroughly boiled in very weak beef tea, with the addition of a little milk; and Leman's rusks, called ' tops and bot- toms,' soaked in boiled milk. The former of these has rather a tend- ency to confine the bowels, and the latter to open them; they may be mixed together in such proportions as effectually to regulate the bowels."1 vn. In some cases of illness, to be hereafter noticed, rennet whey or white wine whey is a useful temporary addition or substitute for the ordinary food. An irritable stomach will sometimes retain whey when it will reject milk, and wine whey is perhaps the best form of giving wine in the collapse from diarrhoea. 52. Scarcely less important than the kind of food is the quantity and the mode in which it is given. Many of the minor disorders of children arise from over-feeding, and much discomfort may be occa- sioned by the mode of administering it. The child should not be fed 1 Underwood on Diseases of Children, p. 64. 48 THE FOOD OF INFANCY AND CHILDHOOD. too often; every two, three, or four hours, according to circumstances, will be often enough, and about a teacupful may be taken at a time, but the nurse must be guided in great measure by the habits of the infant and its facility of digestion. It will let her know very clearly when it is hungry, and it is quite as easy to discover when it has had enough. "Much, after all, must be left to the discretion of the nurse ; but, when the infant withdraws its mouth from the bottle, and shows little disposition to resume its work after being once solicited by the nurse, it will be a good general rule to conclude that it has taken as much as its constitution demands or its appetite inclines to, and no means should after this be adopted to force it against its desires."1 53. There are three modes of administering food to the infant: by the spoon, by the sucking bottle, or out of a small cup. The first is the most common, and answers very well, especially when the food is thickened as the child grows older. The nurse should place the in- fant in a reclining posture, with its head a little raised, and the food should be poured slowly into its mouth. If it be poured too rapidly, it may be drawn into the opening of the larynx, and the child be in danger of choking. The best imitation of the natural process is the use of the bottle, as the child, obtaining its food by suction, can regulate at will the rate of supply; but it is only practicable whilst the food is thin. The only care, beyond cleanliness, required, concerns the nipple; it may be formed of chamois leather, in shape and size like the little finger of a glove, with a perforation in the end, and it should be changed every time it is used ; or a prepared calf's teat may be tried, and this I think better, as it has more firmness, and does not collapse and close from the pressure of the infant's mouth, which the chamois leather is apt to do unless prevented by the insertion of a small piece of sponge. After each feeding, the teat should be removed, rinsed, and put into spirits of wine and water until again wanted, and the bottle should be washed carefully with hot water. It is of consequence that the nipple (whether a teat or of leather) should be so long as to prevent the gums of the child coming in contact with the bottle-neck; the in- fant, it must be remembered, does not suck with the front of its mouth, but mainly with the back part. As a substitute for chamois leather or a calf's teat, M. Dardo, of Paris, has invented a nipple of thin elastic cork; and some one else, whose name I do not know, one of ivory from which the earthy mat- ter has been removed, and which is flexible and elastic. I have tried them both, but have not found them so satisfactory as the calf's teat: they appear to me far too short. In some cases, the child may be fed from a small cup, with its edge gently inclined to the mouth; the infant will partly suck, partly drink its food. All children will not do this, but I have seen it adopted even from the birth, and it appeared a very good method; the infant took its food quietly, and without the fretting which frequently ac- companies spoon-feeding, and without the risk of a sour nipple from 1 Underwood, Diseases of Children, p. 59. THE FOOD OF INFANCY AND CHILDHOOD. 49 the carelessness of the nurse. It is very necessary, however, to be careful that the food is not poured too rapidly into the mouth. 54. Either of these methods will answer very well; it is of more importance to impress upon the nurse that the infant is not to be fed too often, nor too largely at once (though this error will generally be remedied by the stomach rejecting the surplus), nor to have the food too thick whilst young. The food must be gradually increased in substance as the child advances in age, and then the sucking-bottle must be laid aside. If possible, at any rate in the day time, the food should be fresh made each time, and the vessels used, carefully washed afterwards. In order that these matters be properly attended to, it is absolutely necessary that the mother should keep a vigilant supervision over the nurse and nursery. Common sense, and the tact which is acquired by experience, will very soon afford her sufficient guidance. As the infant grows older, the diet will admit of extension, and re- quire a change. After the sixth or eighth month, although farinaceous food will constitute the bulk of the nourishment, we may allow chicken broth or beef tea occasionally for dinner, or an egg, by way of va- riety. Until the child is prepared wTith teeth to masticate solid food, we may fairly conclude that such is not its natural food, and what- ever is unnatural, is certainly mischievous with children. Dr. John Clark wisely observes: " If the principles already laid down be true, it cannot be reasonably maintained, that a child's mouth without teeth, and that of an adult furnished with the teeth of graminivorous and carnivorous animals, are designed by the Creator for the same sort of food. If the mastication of solid food, whether animal or vegetable, and a due admixture of saliva, be necessary for digestion,- then solid food cannot be proper where there is no power of mastica- tion." A crust of bread, rather tough than crisp, for the child to suck, is of great use not only in amusing it, but in preparing the gums for the exit of the teeth; it is far better than rings and corals, and such like. 55. Bread and milk early in the morning, or, if the child be old enough, a little bread and butter and a drink of milk, will be neces- sary to satisfy the first demands of the appetite; afterwards, at a con- venient time, the breakfast may consist either of bread and milk, or of • bread and butter, with milk and warm water and sugar. Dinner, which with all children should be early, may consist of chicken, mutton, or beef broth, every day, or alternately, with farina- ceous food, as may seem best. If there be much irritation with the teeth, the broth had better be suspended. When the child has teeth to masticate it, a little solid food may be given, such as chicken or mutton chop, alternating with a dinner of egg and bread, potatoes and milk, stirabout and milk, simple puddings, &c. The only drink allowable is water, or milk and water. The supper should be taken about six or seven o'clock, and may consist of the same food as the breakfast; and very soon afterwards the child should be put to bed. 4 50 CLEANLINESS. 56. Although it is well to make regularity as to meals the rule from the earliest age, yet it is a rule which admits of many excep- tions. If the child complain of hunger between meals, he will be glad of a piece of bread or a biscuit, and to such deviations there can be no reasonable objection; but if the pretended hunger is only for " nice things," we may safely refuse. No doubt, simplicity of diet and regularity of living, are essential to the well-being of chil- dren, but yet it is quite possible for parents to be too particular and restrictive. I am satisfied that a foundation is often laid for epicurism and gluttony in after life, by the habit of allowing children to see dainties on table, of which they are not permitted to partake. They naturally value unduly that which they see others enjoy, and the more that it is forbidden to them. I confess, for my own part, that I do not think a moderate allowance of fruit, pastry, or sweets, to a child above two years old, will do it any harm ; and I know that such an indulgence prevents them seeking to gratify their appetite in an illicit manner. Except on extraordinary occasions, it is much better to have nothing brought to table of which the children who dine there may not take their share. A little self-denial, if it be such, is surely better than the risk of physical or moral injury to one's child. On the other hand, the practice of giving a young child a taste of everything it may fancy,—cakes and sw-eetmeats at all hours, and in improper quantities,—is a monstrous invasion of nature, which will inevitably entail its own punishment in delicacy, ill-health, and suf- fering. After the third or fourth year, the diet of the child gradually ap- proximates to that of the adult; he takes a mixture of animal and , vegetable food in such proportions and quantities as are suitable to his age, constitution, and appetite; and the intervals between meals lengthen. There is one article of diet, which, under ordinary cir- cumstances, should be prohibited to children under fifteen or sixteen years of age. I mean wine or malt liquor. Neither are at all ne- cessary, as their digestion requires no stimulus, and reparation is effected perfectly by food and rest. To accustom children to them is, to say the least, a very bad habit, and it may have very injurious consequences. CHAPTER IV. CLEANLINESS.—DRESS. 57. It can scarcely be necessary to impress upon my professional readers the necessity of cleanliness and thorough ablution, but it is very desirable to impress upon mothers the necessity of their seeing that this is observed. Not merely does careful washing cleanse the CLEANLINESS. 51 skin from impurities, and prevent the irritation which might arise, but it is in itself of the greatest value in promoting health. " I consider bathing," remarks Struve, " as the grand arcanum of supporting health, on which account, during infancy, it ought to be regarded as one of those sacred maternal duties, the performance of which should on no account be neglected for a single day." I have already spoken of washing the infant at birth in warm water, and this practice must be continued daily. Dr. Armstrong and others advise the immediate or speedy use of cold water, but in my opinion this is a practice utterly indefensible. It causes a great shock and much distress to the child; the circulation is disturbed, and may not easily regain its equilibrium; and there is very great chance of cold. Dr. Merriman remarks: "So many instances have occurred within my knowledge, of cold bathing, improperly and injudiciously adopted, having been productive of serious ill-effects, that I should ill perform the duty of an editor, did I not caution my unprofessional readers to be extremely circumspect, before they adopt the use of so powerful an agent as the cold bath, not only as regards infants, but children further advanced in life."1 58. Each morning the infant should be well washed all over with a soft sponge or flannel and warm water, and in the evening at least partially so, before putting it to sleep, after which it should be care- fully dried with a soft towel. Particular care must be bestowed upon those parts which are liable to friction, as the folds of the groin and buttocks, the arm-pits, the creases of the neck, &c. &c.; after drying them well, they are to be powdered with starch or lapis calaminaris. Very little soap will be necessary, and it should not be applied to the face at all, because of the risk of its gettingintothe eyes.2 Great gen- tleness is necessary in both washing and drying, as the skin is ex- tremely tender, and easily irritated. Properly employed, friction along the back and limbs is both pleasant and beneficial. In addition to these regular and stated washings, the nates should be washed and powdered after each movement of the bowels, in order to escape excoriation. Moreover, the nurse should watch the infant carefully, and change the napkin as soon as it is wet, or after the bowels have been moved; and as the child grows older it may be taught to intimate its necessities to the nurse. Allowing the child to remain with a wet napkin about it, is to expose it to cold, exco- riation, and distress, to escape a little trouble. "But it should be well understood, when we speak of keeping the child clean, that we do not consider the repeated reapplication of the same diaper, because it has been hung in the air, or before the fire, and dried, as coming within our direction. There can be but two reasons for this filthy practice,—laziness and poverty. The first should never be considered as a valid reason for employing the same diaper several times, nor will it, perhaps, ever be urged as one in direct terms; but it is un- questionably the only one that influences upon this subject, when the 1 Underwood on Diseases of Children, p. 27. a Condie, Diseases of Infants, p. 26. 52 CLEANLINESS. second does not obtain to render this, even in appearance, excusable. If the second reason exist, and the child has not a sufficient change, it were much better that it be without a diaper from time to time, than have those returned to it, stiffened with salts, and reeking with offen- sive odor."1 59. For the first few days, care must be taken not to disturb the remains of the navel-string during wrashing. After the washing is over, the rag which envelops it may be changed if necessary, but no effort should be made to hasten its detachment, as the consequences may probably be unmanageable, and even fatal. It will fall naturally about the fifth or sixth day, and then a little scorched rag, or sperma- ceti spread on linen, may be applied. If the navel be red and swol- len, a little bread poultice may be applied. 60. When the child is three months old it will be able to bear cold water in washing, if it be healthy, and will be greatly refreshed by it. In order to obtain the greatest benefit from it, the washing should be concluded quickly, and followed by rapid and gentle friction with a warm towel. Or, instead of deliberate washing with a sponge, a cold bath may.be given every morning, provided that it be not win- ter, that a proper degree of reaction takes place immediately after, and that the child is not frightened. I know of no good to compen- sate for the convulsive screaming and extreme distress which some children exhibit on being put into a bath. Dr. Marshall Hall observes : " The bath should indeed never be used so as to leave an impression of coldness, or actual loss of warmth, or lividity of any part of the surface. And when we consider how readily infants lose their tem- perature, and how slowly they regain it, we shall view the cold bath as one of those measures requiring great precaution in infancy. The best kind of bath is a shower bath of great simplicity. It consists of a tin vessel in the form of a large bottle, pierced at the bottom like a cullender, and terminating at the upper part in a narrow tube; when put into water it becomes filled with this fluid, which is retained by placing the finger upon the tube; on removing the finger the water flows out gradually. The quantity and temperature of the water must be proportionate to the age and powers of the child, the wea- ther, and the season. It should be warm or tepid for infants at first; afterwards it may be used a little cooler. Its tonic effect maybe aug- mented by the addition of bay salt, and by much active rubbing. The first few baths may be quite warm, and made a sort of commence- ment, until the infant is familiar with the little shower. It may gra- dually be made a remedy."2 61. As the child advances in age some modification of the general ablution becomes necessary, but great care should be taken to insure sufficient and frequent washing, even after it has become able to wash itself. A large, shallow tub, in which a child can either sit or kneel, is an admirable appendage to a nursery. It is rather an amusement to the child, and insures a thorough washing, and may be continued 1 Dewees, Diseases of Children, p. 88. a Underwood, Diseases of Children, p. 33. DRESS. 53 long after he is able to wash and dress himself. In addition to gene- ral ablution at this period, a little extra attention must be bestowed upon the hands, face, ears, hair, &c.; and it is of great consequence, in doing so, to inculcate upon the child itself habits of cleanliness, so that it shall not be a task to be washed and clean, but a pleasure. It may be made a sine qua non that the child shall not appear in the family, unless with a proper attention to its person ; and that which at first is irksome soon becomes associated with the pleasure of staying with its parents. Careful attention should be paid to the state of the hair and scalp. At first it is of course washed all over every day, but after the child is a year old, once a week or fortnight will be sufficient, if it be well brushed night and morning. Soap will be necessary in washing, or the yolk of an egg, which is much better, and leaves the hair beauti- fully soft and clean. A good deal of trouble is sometimes occasioned by the scurf which accumulates on the top of an infant's head, and the efforts made to remove it by means of a small comb only make it worse, from the irritation it causes: the best means I know is rubbing a little poma- tum gently over it at night, and washing it off with mild soap and water in the morning. Boys' hair will of course be kept short, and perhaps little girls' hair would be none the worse for being so: but this is a point which every mother will decide for herself, independent of medical advice; and, provided that the increase of care as to cleanliness (washing and brushing, &c.) keep pace with the increase of its length, I should not be inclined to interfere. DRESS. 62. In connection with what has been said of cleanliness, it may be observed, that the inner and outer garments of an infant should be changed every day at least, and that the oftener they are changed with older children the better. It would be better for the health and comfort of the child if the money that is expended upon fine clothes were employed in augmenting the number of its under garments, so as .to facilitate repeated changes. During infancy, the principal object of dress is to protect the infant from cold, yet we constantly see this end overlooked for the sake of fashion or preconceived opinions. Parents are but slightly aware of the suffering and injury which may result. Dr. Edwards, in his admirable work, "On the Influence of Physical Agents upon Life," remarks, that the mortality from cold "is not confined to children whom the misery of their parents cannot guard from the rigor of the weather, but it operates to a great extent, without being either perceived or suspected, in families enjoying affluence, and in which it is believed that the necessary precautions are taken ; because, cold beino- relative, it is difficult from our own feelings to judge of its ef- fects on others, and because it does not always manifest itself by 54 DRESS. determinate and uniform sensations. They do not feel the cold, but they have an uneasiness or an indisposition which arises from it; their constitution becomes deteriorated by passing through the alternations of health and disease ; and they sink under the action of an unknown cause. It is the more likely to be unknown because the injurious effects of cold do not always manifest themselves during, or immedi- ately after, its application: the changes are at first insensible; they increase by the repetition of the impression, or by its long duration, and the constitution is altered without the effort being suspected." 63. Admitting the truth of this statement, we may lay down the essential qualifications of an infant's dress to be warmth, simplicity, and ease. The instinct of animals provides the former for their young, and both reason and observation concur in its greater neces- sity for the infant. If the dress be complex, it will be the source of great inconvenience to the mother and nurse, and render dressing and undressing a period of torment to the child; and if, in addition, part of it be tight, or undue pressure be made by it, more serious injury may be inflicted. I have already given the description of the swath- ing of infants in France, according to Buffon, of which the great ex- cellence seems to be so to fix and restrain the child that it can neither move hand nor foot, nor turn its head. At first, one is inclined to disbelieve this, or to fancy it a story of ancient times, but I remem- ber within twenty years seeing a child thus fastened and bound in Paris. That French children so treated grow up into healthy and graceful men and women, is no more an argument in its favor than the custom of squeezing the heads of Carib children, which does not apparently enfeeble their brain in after life. The question is, not how far we may interfere with, or trespass upon nature, but how we can best aid, or at least, not impede her efforts. We may do either, but we are accountable to our children and to so- ciety for the use we make of our power. 64. It is obvious that the materials of dress ought to vary accord- ing to the climate and the season of the year, but yet the difference should not be so great as in the dress of adults. A considerable dif- ference should be made between its night and day dress. A broad binder of fine, soft flannel is first swathed firmly, but not tightly, around the child's body, and then comes a little shirt of lawn or French cambric. Condie1 and others recommend that a flannel dress should be always next to the skin, but this appears unnecessary, at least in this country; it is certainly more apt to irritate the deli- cate skin of an infant, and unless it be changed every day, as the inner garment of an infant ought always to be, it is much less cleanly. After the shirt will come long flannel petticoats, and other articles of dress, of divers fashion, according to the customs of the country, and lastly, the frock or robe. All these should be long, easy, and warm, so as to protect the infant from cold, and yet leave it as much freedom of movement as is necessary. The sleeves of the frock should also be 1 Diseases of Children, p. 28. DRESS. 55 long. As far as possible, the dress should be fastened with strings instead of pins •/ and when the latter are indispensable, large pins are better than small ones, as being much less liable to fall out or to prick the child. Some authors have recommended that the infant should not wear a cap, and some time ago this practice became for a short time the fashion; experience, however, has proved the folly of this attempt at braving natural laws to gratify a theoretical prejudice. In this and similar ways, I dare say, a race may be hardened, but it is by cutting off the weaker members. The cap should be made of warm, soft material, fitting nicely, so as not to press upon the head, and in tying it, care must be taken that the string neither chafes the skin, nor impedes respiration. As the infant grows older, the material may be lighter, until at six or eight months, if the weather be mild, it may be laid aside altogether. "As a general rule, the clothes worn at night should be both lighter and looser than the day clothes. The additional warmth pro- duced by the bed and its coverings, renders unnecessary the same amount of garments as are required during the day, and would be liable, were no change made, to overheat the body, or to exhaust it by causing profuse perspiration; while the least restraint or compression of the limbs, chest, or abdomen, renders the sleep disturbed, and, by its impeding the free action of the heart and lungs, is liable to produce various uneasy sensations, or even partial or general spasms. Every article of dress worn during the day should be changed on retiring to bed; this is demanded for the promotion of the comfort, as well as the health of children; it allows the different portions of the clothing to be aired at short intervals, and prevents any injury that might result from the gaseous and vaporous exhalations given off by the skin, and imbibed to a greater or less extent by the clothes being retained too long in contact with it."2 65. Dr. Dewees, with his usual good sense, recommends " every' mother with her first child to try her skill daily at washing and dress- ing her infant, a week or ten days hefore her nurse leaves her, that she may become familiar with the routine, and gain a little experience in the method. Indeed, this cannot be too seriously recommended; the mere handling of the child requires, to do it in the best manner, some experience; a mother may learn much as respects this from a handy, experienced nurse, and will be amply repaid for looking on during the operation."3 I would add to this, and especially during the first year, that the mother ought repeatedly either to wash her babe herself, or to be pre- sent the whole time; this will insure cleanliness, and be a check upon the carelessness and slovenly habits of the nurse, and it applies with equal force to the process of dressing, as of washing. 66. As the child grows older, its dress will undergo several changes. At five or six months, if the season be suitable, its clothes may be 1 Underwood, p. 36, note. 2 Condie on Diseases of Children, p. 29. 3 Diseases of Children, p. 97. 56 AIR AND EXERCISE. shortened; and at the end of the year they maybe still further reduced, so as to allow of greater freedom of motion. After this the dress remains pretty stationary for a time, and then assumes the character proper to little boys and girls. The same prin- ciples should regulate it throughout,—warmth in winter, lightness in summer, simplicity and freedom. The entire person should be well covered ; the child should be early taught to dress himself wholly or in part; and there must be no restraint or undue pressure by strings, or straps, or waistbands. Any attempt to reduce the rounded form of a young boy or girl to what fashion has pronounced to be a good shape, will be exceedingly mischievous to the frame-wrork of the body and to the organs it contains; and, instead of a graceful, free-moving child, we shall produce an abortive imitation of a man or woman, lacking the grace of one, and the ease of the other. I have already (64) objected to the use of flannel next to the skin in infants, but what I then said does not apply to older children. In so variable a climate as this, a slight waistcoat of thin, fine flannel, put on in November and left off in May, I have found of the utmost service in protecting from, colds; it should, however, only be worn during the day. 67. The same principles ought to be the guide of every sensible mother as to the dress of her daughter, until the bodily development be complete. Scrupulous cleanliness, thorough ablution, frequent changes of comfortable clothing, no undue exposure of neck, arms, or legs, and an entire avoidance of unequal or undue pressure by corsets, shoulder-straps, tight shoes, &c. "The only way we can assist in forming a really fine figure is to remove all restraint, and secure as far as possible so free an action to the muscles as will lead to their perfect development."1 CHAPTER V. AIR AND EXERCISE.--SLEEP.--MEDICINE. 68. Pure fresh air, of a proper temperature, is essential to the health of the infant; but for some time this must be obtained without leaving the house. For some days the baby should be kept in its mother's bedchamber, and that should be well ventilated; the second or third week it may be taken into the nursery during the day, and subse- quently to other warm, ventilated rooms in the house ; this will afford sufficient change of air. The period at which it may be taken out of doors will depend partly upon the weather and partly upon the constitution of the child. If 1 Underwood on Diseases of Children, p. 38. AIR AND EXERCISE. 57 the infant be strong, and the season fine and mild, it may be carried out, well wrapped up, and shielded by the nurse's shawl or cloak, soon after the completion of the first month; if the weather be severe, this must be postponed until it becomes more favorable. But if the in- fant be delicate we must be more cautious. Sir James Clarke, in his valuable work on Consumption, remarks, " A delicate infant, born late in the autumn, will not generally derive advantage from being carried into the open air in this climate until the succeeding spring; if the rooms in which he is kept are large, often changed, and well venti- lated, he will not suffer from the confinement,, while he will probably escape catarrhal affections, which are so often the consequence of the injudicious exposure of infants to a cold and severe atmosphere." Whilst the child is out, the nurse should constantly walk about; most of the colds caught by infants arise from her loitering about, sitting down, or standing to gossip with her friends.1 Nothing so tranquillizes an infant as a walk in the open air ; it generally sleeps nearly the whole time, and few things so materially promote its health and strength. 69. But although I have spoken thus favorably of fresh air, let me not be supposed for a moment to sanction the indiscriminate exposure of even healthy children for the purpose of hardening the constitution. Nothing can be more senseless than such a delusion, except the argu- ments brought in favor of it. The infants of uncivilized nations are exposed from birth, and survive. But we are not told how many die; and, moreover, we are not savages, and our climate is severe. The children of the poor, are hardy little fellows. Yes, those that survive; but we know that a large proportion are destroyed by this very ex- posure. There are no finer men than the Highlanders of Scotland, and yet their children are exposed at an early age to all weathers. But many die ; and it has been truly remarked that, of large families, it is rare to find more than two sons reared to manhood. We may leave such arguments as these, and attend to the expe- rience of Dr. John Clarke and Dr. Merriman, who have been more « conversant with the habits and diseases of children than most of their cotemporaries. The former observes: "It is a subject of very common observation, that children who have been inured to cold and brought up hardily (as it is called), are the strongest in adult age ; and this has induced many parents to expose their children, thinly clad, to all the severities of weather. It is in part true, since children who survive the seasoning are generally strongest. The original strength of their constitution probably enabled them to bear it in the first instance; and if they are able to encounter it in early life, they will lose in some measure the susceptibility of being readily affected by changes of temperature afterwards. But all medical men who have had opportunities of attending much to the diseases of children, must have observed that those families in which children are least exposed to cold in winter, are generally most healthy, whilst those ' Underwood on Diseases of Children, p. 39. 58 AIR AND EXERCISE. who act on the erroneous principle of hardening them, by the exposure of their tender bodies to severe weather, are scarcely ever free from disease of some kind. Disorders which might otherwise have re- mained dormant, are thus brought into activity by this mode of treating children; and many fall sacrifices to pulmonary consump- tions and scrofulous complaints, in more advanced life, from this error alone, of being exposed in childhood to cold, with the intention of being made strong and hardy. The* present fashion of clothing young children, founded upon the same erroneous notion of hardening them, is also very injurious to their health. Their arms and chests are entirely uncovered. They generally wear no stockings at all, and from the stomach downwards they are almost in a state of nakedness, even in winter.1 Dr. Merriman remarks: "I am afraid that Dr. Underwood's strongly expressed opinion of the absolute necessity of inuring very young infants to endure the cold air, as essential to their health, supported as it is by other popular writers, has been productive of great and extensive mischief." "True it is, that some very robust infants endure the cold in a very remarkable manner, and these are often quoted as examples of the benefit to be expected from the hard- ening system; but a wise man will be cautious how he follows that as an example, which is mentioned only because it is extraordinary. The rules which are to guide our practice, should be drawn from what is usual, not from what is uncommon; yet we are too often led away to imitate what is marvellous, and despise that which is more accordant with nature's laws and precepts. Thus, on the evidence of one strong vigorous infant, the hardening system is applauded and adopted, and we neglect to inquire what numbers have sunk into the silent grave, in the vain attempt to render them, by exposure to the cold, equally vigorous and robust."2 70. During infancy, the only exercise is of a passive kind, owing to the delicacy of the organization at that period; and yet exercise is as essential then as afterwards, and this will be obtained by being carried about the room in the nurse's arms; not sitting up, for which its back and neck are too weak, but in a horizontal or reclining posi- tion. When the child acquires sufficient strength, it may be allowed to sit up, and take its exercise in this posture. The nurse should be accustomed to carry the infant on either arm alternately, for otherwise it may acquire a species of deformity from the habit of leaning always to one side. Another kind of exercise highly useful to infants, con- sists in gentle friction to the back and limbs, which may be applied night and morning in the nursery, taking care that there is no undue exposure to cold. A very common custom of giving the infant of some weeks old, exercise, is by tossing or hoisting it, and no doubt most children like it very well, but care should always be taken not to do it too vio- lently, as great mischief may result. Moderate tossing, with a gentle, equable motion, and swinging backwards and forwards, is both pleasant and useful, if it be continued for a few minutes only at a time. 1 On the Diseases of Children, p. 9. 2 Underwood, pp. 43, 44. AIR AND EXERCISE. 59 I agree with Dr. Combe in strongly objecting to the nurse lifting the infant by the arms, as is so commonly done. The sockets of the joints are very shallow in infancy, and the bones so feebly connected together, that dislocation or even fracture may be the result. The nurse should place a hand on each side of the chest, under the arm- pit, and so raise the infant. 71. When the infant is a few months old, it will voluntarily extend its exercise by an almost constant movement of its limbs, in which it evidently finds great delight. At this time it may be laid on a bed, sofa, or on the carpet, and allowed to exercise and amuse itself; the comfort of a habit of this kind will be equal to the mother and infant, and nothing will so tend to induce a child to creep about. I have remarked that children who commence progression by creeping, suffer far less from falls afterwards than those who commence by walk- ing with assistance. When assistance is afforded, it should be done very cautiously, so as not to induce the child to make exertions beyond its strength, nor to prolong them too much. Dr. Combe observes very truly, that, left to creep about by itself, "the infant will be much better strengthened, and learn to walk much sooner, and with a more free and erect carriage, than if prematurely set on its feet, and supported either by the arm or by leading strings. The chest, also, will be more fully developed, and the whole system consequently benefitted. With moderate caution on the part of the attendant there is nothing to fear in thus indulging the infant, for it is even amusing to see how careful it generally is about its ow7n safety, when left to itself. When a mother takes the entire charge of the exercise of an infant, and judges of its risks by her own excited feelings, she is sure to err. But remove all external sources of injury, and Jeave the child to its own direction, and it will very rarely hurt itself by its owrn procedure. It will crawl till its bones become firm enough to bear the-weight of the body, and its muscles powerful enough to move them.1 72. Mothers and nurses are so proud of a child being able to walk at an early age, that they are apt to place them on their feet and (with more less support) keep them moving about in that way before the legs have acquired sufficient strength; and in many cases the result is actually to defer the period of walking alone, and perhaps to give a curve inwards or outwards to the legs. We may be very certain that, when a child is able to walk, he will show his ability in a way that cannot be misunderstood ; and then a little help, rather to enable him to balance than to support himself, will be sufficient. Remem- bering that walking alone requires not merely physical strength but the power of balancing, we should be cautious of forcing a child to step alone until the latter as well as the former has been acquired. Timid children attain the latter very slowly, and if they are forced, the fear of falling will prevent their making the attempt, and will only 1 On the Management of Infancy, &c, p. 269. 60 AIR AND EXERCISE. serve to distress them. I would say, then, that the child should itself decide upon the different steps of its progress; and a little watchful- ness on the part of the mother or nurse (if she be a mother) will easily discover the indications. It is, of course, necessary to watch that the child do not hurt itself in its earlier efforts, and as far as possible to guard against falls; but over-anxiety on this point may injure the child by destroying his con- fidence. A few falls on the ground will do no great harm and will probably convey a useful practical lesson to the infant. Certain it is that, left to themselves, they do display a wonderful degree of care and judgment in taking care of themselves. "An instance is given of a child (in the back woods of America) under a year old being seen crawling on all fours along a sadly mutilated bridge, with a roaring stream flowing under, within sight of the mother's house, where she was quietly engaged in washing, and not troubling herself about the apparent danger which startled the traveller so much. On the latter expressing his alarm, the mother quietly replied, that the child was accustomed to take care of itself, and knew well what it was about; and then made him observe the deliberate and cautious way in which it made even the slightest movement; adding that, to run anxiously to its assistance, would be the sure way to frighten it and make it drop into the water. There may be exaggeration in this anecdote, but assuredly the principle upon which the mother is stated to have acted is sound, and might advantageously be carried out in practice much further than it has ever generally been."* Such exercise as I have described, with a walk once or twice a day, when the weather is fine and temperate, or a change of apart- ments when the weather is unfavorable, will be sufficient during the first twelve or eighteen months. 73. But as the child increases in strength, air and exercise become even more indispensable; in fact, a child from two to ten or twelve years will be almost always in motion, and cannot have too much fresh air, provided there be no undue exposure. The child should be allowed (within certain wide limits) to choose the mode and amount of exercise; if unrestrained, he will rarely exceed the bounds of reasonable fatigue, and a free, unfettered use of each portion of the body will best promote health and gracefulness of carriage. I scarcely know anything more unnatural than the strings of unfortu- nate school-children taken out to walk for exercise, and obliged to put in practice the orthodox rules of turning out the toes, keeping the step, walking uprightly, and holding up the head; and at the time envying every little child whom they see scampering about as nature intended. If, however, the child be too delicate to take sufficient exercise on foot, it may obtain both air and exercise, the more necessary on ac- count of its delicacy, by means of a donkey or pony, with amusement and gentle excitement in addition. Exercise on horseback is par- 1 Combe on the Management of Infancy, p. 272. Eberle on Diseases of Children, p. 50. AIR AND EXERCISE. 61 ticularly good for children of both sexes with delicate lungs, as they grow older; not merely do they obtain an equal amount of air and exercise, but they breathe purer air, and derive peculiar benefit from passing rapidly through it. 74. Up to a certain period, girls and boys share their plays and exercise, and walks, together, and it is far better that the former should be allowed as much liberty as the latter, than that they should be prematurely confined. The time, however, will come when the association of brothers and sisters will, to a great degree, be broken. Boys, however, will obtain sufficient air and exercise for themselves, and even the madness of parents for the precocious advancement of their sons will hardly obstruct this. Any one who is so deluded as to force forward the intellect of his son, should remember that he can only do so at the expense of health; that the deprivation of adequate air, exercise, and play, will be followed by a delicate, enfeebled manhood, and probably by a premature death. But little girls are more frequently victimized. From the moment of her separation from the sports of childhood, the great object is to make a little woman of her. Her mind is crammed and confused, with a little of every kind of knowledge; and her body cramped and confined by stays and the endeavor to maintain a womanly carriage; and her feet are cased in tight shoes, so that the pleasure of free movement is not only forbidden but destroyed. And the result is, not grace. but formality. Grace cannot exist without freedom, and the tutored effort to be graceful or ladylike is necessarily destructive of success. Little girls, as they grow up, may very properly be restrained from boisterous plays, but at the same time free air and exercise should be secured for them, without the inconvenience of tight dress. A brisk walk, a race after a hoop, or a canter on a pony, will give bloom to the cheek, and brightness to the eyes; and the structure of the body being well developed and allowed free play, easy and natural grace will be the consequence. 74. One word as to the exposure of the child to Ught. Light is the natural food of the eye, and within certain limits it is pleasant and agreeable, but it requires regulating according to the age. During early infancy, the eyes should not be exposed to a concentrated or strong light. The light of the sun may be tempered by window- blinds, and the infant need not be held near to a lamp or candle. But after a while the eye becomes accustomed to light, and whilst we still avoid the extreme I have mentioned, we should equally avoid the op- posite. A dark, dull room, or one from which light is more or less excluded, is injurious to the eyes, health, and spirits, of children. "Every one is aware," says Dr.. Combe, "that vegetables are blanched by the exclusion of light; and that corn, growing even under the shade of a tree, is paler, sicklier, and later in ripening, than that growing in the open field; but we do not keep sufficiently in mind that on man the operation of light is scarcely less striking. Deprived of its wholesome and enlivening stimulus, he becomes pale and sickly 62 SLEEP. in appearance, his blood is imperfectly oxygenated, and a proneness to diseases of debility arises. Of these results we find numerous ex- amples in the narrow lanes and dark cellars of every large towTn, and in the members of the sedentary professions, and others rarely exposed to the full light of day ; and especially in children, we see them all in an aggravated degree."1 Plenty of cheerful light, when the child is awake, then, is essential, and it is equally so to moderate or exclude it during sleep. Too much light then will not merely prevent or interrupt sleep, but may act as a very injurious stimulus to the eyes and brain. SLEEP. 75. For some weeks after birth an infant's life is divided between feeding and sleeping; it aw'akes when hungry, and falls asleep again when satisfied; and in this there is a great advantage, not merely by facilitating digestion, but by the repose afforded to the brain and nerv- ous system. There should be no attempt to interfere with this, for the more the infant sleeps the better; but by degrees its wakeful mo- ments lengthen, and, as it is very desirable that these should occur during the day rather than the night, some little effort may be made to attain this. At first, and for some months, the child should sleep with its mo- ther, both on account of the greater warmth to itself, at a time when it needs it most, and for the convenience of the mother, who is thereby saved the necessity of rising to attend to her child. This, at least, is the natural way, and unless there be some special obstacle, I should regard it as an imperative duty, although it is a very common practice to let the nurse-maid take the infant to the nursery, and feed it during the night, from a dislike, apparently, to be disturbed. As for any danger to the child which the mother may fear, that clearly must be greater with a hireling than with the mother, whose maternal instincts are on the watch. If the infant be placed with its head resting on its mother's arm it is all but impossible that it should slip down, or be in any danger of being over laid. Care should be taken not to cover it too heavily or too closely with the bed-clothes. As the child grows older, it may be left in its cradle the first part of the night, until it requires to be nursed, and then be taken into bed to its mother; but when weaned it should be accustomed to sleep al- together by itself. 76. The head of the cradle should be lined, to guard against draughts of air, and the bedding should be warm and soft, without being too soft, or the bed-clothes too heavy or too warm. The infant should be carefully placed on its side, with its limbs free and its face uncovered, so as to allow free access of air. The less effort that is made to put the child to sleep the better; when sleepy, it will generally be suffi- 1 On the Management of Infancy, &c, p. 147. SLEEP. 63 cient to place it in the cradle or bed, and keep the room still and dark. Without precisely objecting to rocking or hushing the infant to sleep, I have no hesitation in saying, that much trouble is saved to child and nurse by accustoming it to go to sleep without it, and because it is placed in bed. Young children are so completely creatures of habit, that anything may be taught them, and it is better that they should be taught good and regular habits than the contrary. The advantage of the plan of which I am speaking is seen peculiarly during sickness, when the child will be fretful, and require much more than the ordinary coaxing to sleep, if it have been accustomed to it at all. Gradually the amount of sleep during the day diminishes, but for three or four years a child is greatly benefited by an hour's sleep in the middle of the day, and this is a habit should be encouraged and prolonged as much as possible; for during waking hours children ex- pend far more vital energy than adults, and a midday sleep recruits them, and prevents them being over-fatigued and fretful in the even- ing. For this reason, also, children should be put to bed early; during the first year or twro, half-past five, or six, and for five or six years more, seven, or half-past, is quite as late as they ought to be allowed to stay up: the worn, weary look of children who sit up late is a sufficient proof of its injurious effects. Besides, children are morally and physically the better for acquiring early habits; but a child cannot rise early who goes to bed late. Ten hours' sleep are barely enough for a night's rest for a child, and no- thing should induce parents to shorten a child's full allowance of it. For this reason a child should not be awoke in the morning, but simply sent to bed earlier at night, and it will awrake itself. Once awake, it should, if possible, be washed and dressed immediately, as lying in bed awake merely promotes indolent habits, without any benefit to the health. Regularity of habits may be applied to sleeping quite as much as to eating or any other natural operation, and it is no less desirable for the comfort of mother and child. 76. But what is to be done when the child is restless, and will not sleep? we are often asked. Can you not give it something to make it sleep ? Certainly; but the question is, ought you to do so; and I would unhesitatingly answer in the negative. At proper intervals, it is natural for the child to sleep, and it will do so if there be nothing preventing it; our duty, therefore, is, to find out the obstacle and remove it. The child may be placed uncomfortably in bed; there may be undue pressure upon some part; the bed may be rough and uneven; its feet may be cold; it may have eaten too much; or it may be teeth- ing. Any of these circumstances will make the child fretful and restless, and they must be relieved: if none of them exist, the child must be unwell, and should be treated accordingly, but not dosed with laudanum, syrup of poppies, Godfrey's cordial, or any of the mischiev- ous remedies which nurses are too ready to employ. " The mischief done in this way is inconceivably great, and astonishment would be excited, if it were generally known what quantities of' quack cordials,' ' anodynes,' and even spirits, are recklessly given with the view of 64 MEDICINE. producing quiet and sleep."1 If the child be really restless and un- easy, without ascertainable cause, it may be put into a warm bath for a few minutes, which will soothe it, and often cause it to fall asleep. When the child is up and dressed, its night-clothes and bed-clothes should be exposed to the air, as the effect of fresh coverings is ex- tremely soothing and healthful. MEDICINE. 77. Very few words will comprise all I have to say on this mat- ter, because I think that the less medicine a child takes the better for his health; i. e., so long as the child is in health, the natural functions will be performed, according to his constitution, without medicine; and if the child be sick, the less tampering with medicines by mother or nurse the better. A mistake has arisen from the notion that the constitution of all children is alike, and that their evacuations ought to be alike, whereas nothing can be more erroneous. An in- fant's bowels are moved four or five times a day ordinarily, gradually diminishing in frequency, as the child grows older, to three, two, or one evacuation per diem; but we are not to insist upon this as an in- variable rule, and administer medicine until it is complied with. In the case of one of my own children, and one of the most healthy, the bowels, after the first few weeks, were only moved once a day, and he took no medicine from the first dose of castor oil until he was nine months old, nor had he one hour's sickness. A dose of castor oil is usually given at birth, and may be repeated, if necessary, until the meconium is cleared away. -After that, nature should be allowed fair play, and medicine should not be given unless there be sufficient reason. If the child appears uneasy and hot, and the bowels are confined, a dose of oil or rhubarb may be given, or a warm bath: but if the child exhibit no signs of suffering, why should we interfere? There is, however, one exception to this rule, and that is, when the child is teething; at this time, a certain amount of irritation is excited, which, if it localize itself in any organ, may prove highly injurious. The most common and least mischievous accompaniment is a bowel complaint, and, to prevent a worse evil, it is advisable to determine to the bowels by an occasional dose of medicine. 78. To children who suffer much from flatulence, a little fennel water, or caraway-seed water, with sugar and plain water, may be given ; or a carminative composed of rhubarb, magnesia, syrup, and aniseed or caraway-seed water. Beyond these, the nurse should be allowed the command of no medicine whatever, unless ordered by the medical attendant; nay more, she should be' absolutely prohibited from having any in her possession; for it is not unusual for her to pro- 1 Combe on the Management of Infancy, p. 281. THE NURSERY AND NURSES, i 65 vide herself with a little Godfrey's cordial, syrup of poppies, or even laudanum, and administer it for the purpose of quieting the child, and avoiding the trouble of rising in the night. Dr. DewTees remarks: " Nurses generally make a point to have a certain period of the day at their command; and should they find this hour repeatedly inter- fered with by the wakefulness of the child, they will soon have re- course to such means as shall prevent its future recurrence. We have known a number of cases where laudanum was administered for this purpose, with so much cunning as to elude detection for a long time, even after the suspicion had been excited. In one of these instances, the wily nurse boasted to the abused parent of her good management in establishing so much regularity in the child's sleep- ing. " x THE NURSERY AND NURSES. 79. So much of the health and comfort of children depends upon the nursery and their attendants, that I cannot omit a few words upon each. As the infant will spend a considerable portion of its time for the first few years in the nursery, its situation and suitability cannot be a matter of indifference. Plenty of fresh, pure air and light is the first requisite, but this will of course depend upon the situation of the house. In the country it is easily obtained, but in towns other cir- cumstances determine in a great measure the choice of a house. The choice of a room for the nursery, however, is in our power, and any sacrifice should be made to secure one which may promote the health of those who are so dear to us. It should be large, airy, light, well ventilated, and easily warmed.2 Generally speaking, the upper room in the house is the best, it has freer access of air, and more light and greater cheerfulness. It should be neatly papered and painted, and so arranged that perfect order may be preserved. Just so much furniture should be allowed as is necessary, and no more, as the more space without obstruction for the child to play about the better. The beds should be so placed as to be easy of access, and they should be provided with partial curtains, just enough to shade the eyes from the light. I think the light iron bedsteads, with heads and castors, by far the best, for many reasons. It is better not to have a carpet, or.at most a very small one, as it accumulates dust, and is an obstacle to a young child in its early efforts to walk. The floor should be scoured once a week, or oftener if necessary, and the most minute cleanliness and order observed about everything used in the nursery. After dressing in the morning, it is very desirable that the children should all leave the nursery for an hour, during which time the win- dows and door should be opened, so as to secure perfect ventilation after the night, and a fresh, wholesome room'on their return ; and this should be repeated occasionally during the day, when they are absent. ' On the Diseases of Children, p. 65. 2 Combe on the Nursing of Children, p. 151. 5 66 NURSES. 80. The temperature must be regulated according to the season and the aspect'of the house; it should range somewhere between 60° and 70°. During winter, and a portion of spring and autumn, a fire will be necessary during the day, but not during the night, unless in case of sickness, and care should be taken that the nurse, for her own enjoyment, does not make it too large. During summer, if the room be exposed to the sun, it will become warm enough, but if there be any doubt it is better to have a little fire, as warmth is essential to the comfort and health of children. "From pure ignorance on the part of the parents, it is also a com- mon practice not only to crowd several children and one or two nursery maids into a small room, but to allow cooking, washing, and other household operations connected with the nursery, to be carried on in it. Nothing, however, can be more injudicious, or more directly at variance with the duty of parents to promote to the utmost the welfare of their offspring." "If the size of the house will admit of it, the day nursery should always be separate from the sleeping one. Where- ever one or two persons sleep the air is always considerably contami- nated before morning, and the impurity is of course so much the greater where, as is often the case, several children sleep in the same apartment. If there is only one bed-room, it is impossible to remove the impurity by adequate ventilation, because even in summer the draught from the open windows is attended with risk, and during at least two-thirds of the year in this country the cold and damp of our climate would render it utterly impracticable to keep them open for a sufficient length of time. But the case is altogether different when there is a day room in addition. The children can then be re- moved from the vitiated air and impurity of their sleeping apartment into a wholesome and bracing atmosphere, and the bed-room be thoroughly cleaned, the bed-clothes and everything else well aired, and the room itself effectually ventilated, without risk to any one."1 There can be no doubt of the advantage of this plan, but it is not often practicable in towns, where the family is large; and in such cases, if the children be allowed to descend to the parlor in the morn- ing, after being washed and dressed, the nursery may be very well ventilated in half an hour. I would repeat, that cleanliness and order ought to be rigorously enforced in the nursery, not merely for the sake of health, but as a part of the practical education of children. NURSES. 81. Considering how many hours, days, and weeks children spend alone with their nursery attendants, and also the extreme impressi- bility of early life, it is certainly surprising that more care is not be- stowed on the selection of a nurse and nursery maids than we usually 1 Combe, p. 161. NURSES. 67 find. First impressions are the strongest, and especially when those are evil; and I have no doubt that much of the trouble that parents experience in the moral government of children might be traced to the lessons, practical and verbal, that they have received in the nursery. Habits of irregularity, disorder, equivocation, and self-in- dulgence, are daily taught them by example ; and if they be dis- couraged by precept, we know that the former lessons are far more permanent. Evil words and selfish actions leave an impression long after their source is forgotten. I have often heard parents express their astonishment at vulgar habits and low expressions from their chil- dren, who never thought that they were indebted for their acquisition to themselves, through the nurses they had chosen. The nurse who has the charge of the children, or the principal nurse, if there be more than one, should be a woman of middle age—if possible, one who has been a mother herself—and somewhat above the station of a servant, so as to secure better education and better manners. She ought to be upright, kind, and religious, for she who has not reverence towards God is utterly unfit to mould the character, or govern the habits of young children. Her temper should be mild, cheerful, and forbearing; for the management of children may tax her good-nature severely, and yet if she give way to irritation she may injure the child's temper irretrievably; and cheerfulness is so much the character of childhood, and so necessary for mental and moral health, that a nurse would be essentially deficient in whom it was absent. A love of truth and an abhorrence of lying in any form, whether in the shape of excuses, deceit, concealment, or falsehood, is essential, unless we wish the ruin of children; for they will learn from the ac- tions of the nurse rather than from her precepts, and the instruction of a wise mother will be entirely thrown away, if counteracted by the conduct of the nurse. It will also be a great advantage if she be able to read and write. I need not dwTell upon the necessity of habits of order, cleanliness, and personal tidiness; these are hardly likely to be overlooked by a careful mother, although she may not appreciate their influence upon the habits and character of her child. PART II. THE DISEASES OF INFANCY AND CHILDHOOD. The plan I propose, in each section of the present division of the work, is, first, to notice the diseases by which the foetus is most frequently attacked during intrauterine life; then to treat of those which it presents to us at birth, whether of long standing or acquired during childbirth, together with certain malformations which require treatment; and lastly, to enter at length into the consideration of the diseases which affect infancy and childhood. These I propose arranging neither according to the period of life at which they occur, nor according to their pathological characteristics, but simply accord- ing to the systems affected, so far as this can be done: thus grouping together diseases of the nervous, respiratory, digestive systems, &c. &c. Whatever may be lost, in a scientific point of view, by this arrangement, will, I trust, be more than compensated by the prac- tical advantages of exhibiting the morbid conditions of organs in their systematic rela- tions. Afterwards, I shall treat of fevers, diseases of the eyes and ears, and other affec- tions, which do not admit of much classification. SECTION I. DISEASES OF THE CEREBROSPINAL SYSTEM. CHAPTER I. INTRA-UTERINE OR CONGENITAL DISEASES. CONVULSIONS. 82. Many authors have maintained that the foetus in utero is sub- ject to epileptic or convulsive attacks. Duettel states: " Nullus autem affectus familiaria solet esse proli in utero quam epilepsia." And Segerus relates a case of a pregnant woman who suffered severely from this disease, and in whom the foetus exhibited similar convulsive movements1. Lowenheim held that it was not uncommon, and Hoogeveen and Feiler relate examples. Hufeland thinks that these convulsive movements are dependent upon, or derived from, the mother.2 There are few practitioners of any standing who have not been consulted on account of the distress caused by the violent movements of the foetus; in many cases the annoyance arises from excess of uterine sensibility, but in others the movements appear to be exces- sive, irregular, and of temporary duration, subsiding after a time, to return in moderate degree, or to recur again in paroxysms, or perhaps to cease altogether. Such cases I have several times observed, and in the latter instances the child has been still-born, and the period of its death referred to the close of the violent convulsive movements. Whether these are cases of epilepsy may of course admit of a ques- tion, but it is of little consequence, as during intra-uterine life nothing remedial can be attempted. HYDROCEPHALUS. 83. The occurrence of hydrocephalus in the foetus is not a discovery of modern times. Thus Blanchard relates a case of a foetus of seven 1 M. N. C, Dec. 1, An. 3, Obs. 160, p. 291. * Graetzer, Die Krankheiten des Foetus, p. 259. 72 INTRA-UTERINE OR CONGENITAL DISEASES. months, where a large quantity of water was found between the dura and pia mater;1 and Rusaeus another where the head was so distended with fluid that it weighed more than the rest of the body.2 Leche- lius, Schurig, and Hoogeveen give similar cases. In more modern times the disease has been described by Voigtel, Meckel, Otto, Alibert, Rudolphi, and as an impediment to delivery, by almost all midwifery authors. It is not very uncommon among the lower classes; I have seen at least five or six cases. Some writers have attributed it to an arrest of development, but this appears quite inadequate; it appears more likely, as Rudolphi has observed,3 to be a special disease, arising from excessive conges- tion of the membranes, or from inflammation. During foetal life, of course, we can obtain no evidence of its existence. In many cases the foetus is dead before birth; in others, when the fluid is considera- ble, it has to be destroyed even if alive, in order that labor may be completed; and in very few cases is the child born alive. Should the disease not have proved fatal, and the enlargement of the head be so moderate as to permit of its transit through the pelvis without an operation, then the treatment will be that of chronic hydrocephalus, of which I shall speak hereafter. ABSENCE OF BRAIN OR SKULL. 84. Examples of an arrest of development in the brain or cranial vault may be seen in every museum, and many plates of such cases are given by Geoffrey St. Hilaire in his learned work on monsters, and by other authors who have entered fully into the many interesting questions depending thereupon, and to whom I must refer my readers.4 It is enough for my purpose to state, that the brain and skull are more or less defective in such cases. I have one preparation in which the brain presents the appearance of a bunch of tumors; another where a portion only of the brain exists; and a third where it is en- tirely wanting; and in all the cranial vault is absent, the base of the skull alone remaining. That these are cases of arrest of development, and not the result of disease, can admit of no question; and that they afford a wide field of physiological investigation, which has been but partially explored is equally true. This malformation does not necessarily prohibit the full growth and development of the foetus, nor its being born alive and apparently healthy, but they seldom live more than a day or two. In one case which occurred at the Western Lying-in Hospital, the child was large and healthy, but it had neither brain nor skull, except the base, and it had cleft palate and double hare lip. It lived two days. Formerly it was considered right to destroy such monsters; 1 Collect. Phys. Med., Cent. i. Obs. 75, fol. 65. 2 De Extract Foetus, cap. 23, 1562. 3 Abhandl. der Konigl. Acad, zu Berlin, 1824, p. 121. See also the article Anencephalie in Diet, de Med. et de Chir. Prat., vol. ii. p. 377. INTRA-UTERINE OR CONGENITAL DISEASES. 73 under the wiser legislation of modern times it is considered to be criminal, and punished accordingly. HERNIA CEREBRI.--ENCEPHALOCELE. 85. This malformation is also due to an arrest of development in the ossification of the cranium, by which the fontanelles and sutures are left incomplete. It has been called podencephalie by Geoffrey St. Hilaire, when the deficiency is at the upper part of the cranium, and notencephalie, when the arrest takes place posteriorly. Through the space thus left the brain protrudes, forming a tumor above or behind the head, covered in the majority of cases by the integuments. The tumor is soft, rounded, and pulsating in accordance with the pulse, yielding to pressure, and disappearing, without discoloration of the integuments, and circumscribed at its base by the defective bone. The size will vary according to the amount of brain which escapes through the opening; those which are situated superiorly at the an- terior fontanelle appear to be the smaller. Sanson mentions a case in which the entire brain escaped by a round opening corresponding to the posterior fontanelle ; the infant lived fifteen hours, and its func- tions were all naturally fulfilled.1 86. If the sutures be very defective, the cerebellum may protrude. " In 1813, two such cases occurred at Paris. In one, Professor Lalle- ment mistook the disease for a common tumor, and commenced an operation for its removal, when, after making some of the necessary incisions, his proceedings were stopped by his seeing the white silvery color of the dura mater, and that the swelling came out of an aper- ture in the occipital bone. The day after the operation the child was seized with violent pain in the head, had a hard pulse, prostration of strength, vomiting, &c, and died in the course of the week. On dissection, a part of the tentorium and an elongation of the two lobes of the cerebellum about as large as a nut, were found in the protruded sac of the dura mater. Several abscesses were also discovered in the substance of the cerebellum. "The other example fell under the observation of M. Baffos: upon the death of the child the dissection evinced similar appearances."2 A more remarkable instance of cerebral hernia is mentioned by M. Sanson, as having been observed by M. Serres, in which the brain protruded through a fissure in the base of the skull, and projected into the pharynx. 87. But though in the greater number of cases* the skull alone is deficient, the integuments covering the tumor are perfect, yet in some cases there is a deficiency more or less of the integuments of the head. This occurs most frequently about the posterior fontanelle, and then the brain hangs like a bag at the back of the neck. The children are generally still-born. Richerand mentions that several ' Art. Hernie, Diet, de Med. et de Chir. Prat., vol. ii. p. 496. 3 Cooper's Surgical Dictionary, Art. Hernia Cerebri, p. 754. 74 INTRA-UTERINE OR CONGENITAL DISEASES. such examples are preserved in the museum of the Faculty of Medi- cine at Paris.1 A curious case of more extensive deficiency, both of bones and integuments, was published in 1810 by Dr. Burrows: "The whole of the forehead, summit, and a great part of the occiput, were defi- cient, and instead of them a substance projected, of a light mulberry color, and of the mushroom form, except that it was proportionably broader. From the deficiency of bone the eyes appeared to project much more than usual."2 On dissection, the scalp, os frontis, the parietal, and a great part of the occipital bones, were wanting. Through the parts at which these bones were deficient the cerebrum projected, exhibiting its usual convolutions. It was covered with the pia mater, was of a mulberry color, appeared to be more vascular than the pia mater usually is, and the edge of the scalp adhered to the neck of the tumor. The cerebellum was not more than one-fourth of its usual size, for the posterior part of the os occipitis was much nearer to the cella turcica than natural. The child was destitute of the power of voluntary motion, and all the secretions appeared to be stopped. This case resembles a good deal the case I have already (84) men- tioned, in which the vault of the cranium was absent, and the brain and cerebellum, enclosed in (apparently) the dura mater, was divided into several round tumors, the size of small potatoes. These cases, however, strictly speaking, scarcely come under the definition of hernia. 88. Diagnosis.—The only diseases with which congenital encepha- locele might be confounded are cephalsematoma of the scalp and accidental tumors; but a little care will generally be sufficient to enable us to distinguish them. Hernia cerebri is almost always in the line of the sutures, where a space is left from the arrest of bony growth: cephalaematoma, on the contrary, are very seldom, indeed, and then only partially, situated over the sutures or fontanelles; formed by pressure of the os uteri, and increased by the pressure of the os externum, they will always be found on the exact part which presented, and in no case is any suture more than slightly involved in the presentation. Moreover, in hernia, the absence of bone beneath the tumor can be ascertained; and in cephalhematoma, although the circular ridge gives at first a feeling of there being a perforation, yet on pressing the swelling on one side, the unbroken surface of bone may be felt. Lastly, there is a constant pulsation, synchronous with the pulse, in hernia, and the tumor can be de- pressed to the level of the skull; but in cephalaematoma there is no pulsation, or an uncertain one communicated from the fontanelle and the tumor does not disappear under pressure. The situation of the tumor, the absence of cranium underneath the marked pulsations, and its disappearance under pressure, will dis- tinguish hernia from any other kind of tumor which is formed upon the scalp. 1 Nosographie Chirurg., vol. ii. p. 316. * Med. Chir. Trans., vol. ii. p. 52. INTRA-UTERINE OR CONGENITAL DISEASES. 75 89. Treatment.—All writers, I believe, are agreed that the best mode of treatment consists in the application of gentle and equable pressure. M. Salleneuve used a piece of thin sheet lead, softly padded, and fastened to the child's cap at the part corresponding to the tumor, and the pressure was increased or diminished by tightening or loosening the cap. By thus depressing the tumor gradually, and without injury, an opportunity is given lor the growth of the bone, and the completion of the defective space, which of course is the radical cure of the hernia. M. Salleneuve related a case which was thus cured to the Royal Academy of Surgery of France.1 Callisen and Sanson concur in the propriety and feasibility of this mode of treatment, when the tumor is small; but when it is large, and at the occiput especially, little more can be done than some contrivance to protect it from injury. SPINA BIFIDA.—HYDRORACHITIS. 90. In some respects this congenital disease bears a strong analogy to the one last described, depending as it does upon an arrest of development in some portion of the spinal canal, which is indicated by the presence of a soft tumor, varying in size from a walnut to a foetal head. The most frequent situation of this malformation is in the lower lumbar vertebras, next in the dorsal region, and occasionally in both at once, next in the bones of the sacrum,2 then in the cervical region, and lastly, in the lower portion of the sacrum, as in the case published by M. Vrolik.3 The disease consists in a deficiency of the spines and bodies of the vertebral canal, and the different degrees have been grouped into three classes by Fleischmann4 and others. i. When the entire vertebra is divided; this case is extremely rare. Ollivier recites three cases related by Tulpius, Malacarne, and Zuringer, in which it existed. ii. An absence of a greater or less portion of the lateral arches of the canal: this is the most common variety. And in. Where the arches are well developed, but without union pos- teriorly: here, however, the separation can be but a few lines, re- sembling a groove rather than an aperture. Ruysch, Acrell, and Isenflamm5 have each described a case of this kind; the former in the lumbar region, the second in the sacrum, and the latter in the first cervical vertebra. In each class, the limit of the deficiency is marked by the edge of the bone, sometimes smooth and level, sometimes irregular, and sometimes with the edges turned a little outwards. Ordinarily, the 1 Mem. de l'Acad. de Chir., vol. xiii. p. 103. 1 Ollivier, Mai. de la Moe'lle epin., vol. i. p. 184. s Ibid. 4 Vitiis congenitis circa Thoracem et Abdomen. Erlangen. * Arch. Gen. de Med., vol. iv. p. 299. 76 INTRA-UTERINE OR CONGENITAL DISEASES. spines of the vertebra share in the malformation, and are divided or altogether absent. It must be remembered, however, that the absence of the spinous processes is no proof of spina bifida. Beclard has found them absent several times as a simple malformation, the bodies preserving their integrity. The tumor, varying in size, and of a round or oblong shape, or occasionally, as in Mr. Brewerton's case,1 consisting of two cysts, is generally covered by the skin, which, when it is very small, may be of the natural color, but which, as the tumor increases, becomes thin, transparent, and generally marbled with reddish or violet shades. In some cases it appears worn through, and the outer envelop has none of the characters of the skin, but resembles a very fine vascular membrane, which .is indeed the dura mater of the cord, beneath which we find the arachnoid and the pia mater. Occasionally, though rarely, the dura mater is defective, and the arachnoid becomes the external covering. The fliiid contained in the tumor is generally limpid serum, resem- bling that secreted in hydrocephalus, and containing, according to the analysis of Bostock, Marcet, and Lassaigne, water, albumen, ozma- zome, mucus, and salts of potash or soda, in small quantities. It is occasionally turbid or tinged with blood. The quantity varies : Siebold saw more than a pint escape, Vogel two pints, and Mr. Innes about seven pints. The condition of the.spinal marrow is of considerable interest. Ollivier states, that when the case is not complicated with hydroce- phalus he has generally found the spinal marrow traversing the sac unaltered, except that in some cases it seems lengthened.2 But if co-existent with hydrocephalus, or if the canal of the spinal marrow be distended with fluid, the cord may be flattened out, as it were, so as apparently to line the sac.3 Or either from the extreme distension, or from some morbid process, the cord may be partially or wholly destroyed, leaving at most some shreds or filaments. Ruysch and Greeve observed the remains of the cord thin and softened, covered with watery vesicles, and Acrell discovered it covered with hydatids. In some few cases the spinal cord seems to have left the canal, and to be contained within the tumor, forming what some authors have improperly called hernia of the spinal marrow. This happens only when the deficiency is at the lower end of the spine. 91. To the touch the tumor feels soft and fluctuating, and by a little care we may detect the deficiency in the spinal canal, at the base, or a little underneath the base of the tumor. Pressure upon the tumor causes uneasiness, convulsions, or coma. The effect of this malformation upon the portion of the body sup- plied with nerves by the lower part of the spinal marrow varies in degree, depending, most likely, on the degree of pressure from within or without upon the cord. In almost every case, the child has less power than usual in its legs; however, Mr. Cooper has related a remarkable i Edin. Med. and Surg. Journ., vol. xvii. 2 Op. cit., vol i p 197 3 Duges, Diet, de Med. et de Chir. Prat., vol. x. p. 138, Art.' tfydrorachis.' INTRA-UTERINE OR CONGENITAL DISEASES. 77 exception in a child who had one of the largest spina bifida he ever beheld, and which was unattended with any such weakness; "indeed the child was, to all appearance, as stout, healthy, and full of play as possible. The fatal event, however, took place after a time, as usual; and a little before death a remarkable subsidence of the swell- ing occurred, which, however, never burst externally."1 I have seen more than one case in which the infant retained the power of voluntary motion, but none that could walk. In other cases, the limbs are atrophied and completely paralyzed; and in the worst instances, the bladder and rectum are equally affected, and the child can neither control the urine nor fasces. 92. The tumor may burst before birth with or without the de- struction of the child.2 Generally, however, we find it unbroken, but in a few clays or weeks the surface becomes inflamed, small patches of superficial ulceration appear to coalesce, until a large and deepening ulcer is formed, which soon perforates the sac, evacuates the fluid, and, by exposure of the spinal marrow, occasions inflammation, convulsions, and death very shortly; or the opening may be small and fistulous, with like results. The age at which this termination occurs varies, although it seldom exceeds three years. However, Bonn relates a case that lived to the age of ten years; Warner one aged twenty; Camper one aged twenty-eight years; and Swagermann mentions an individual thus affected who lived fifty years.3 Mr. Samuel Cooper relates that he saw under the care of Mr. C. Hutchinson, a young woman, nineteen years of age, who had a spina bifida, which was of astonishing size, and situated at the lower part of the vertical column. One curious circumstance in the case was, that the patient used to menstruate through a sore in the thigh. I conclude that this is the same case as is described by Mr. Innes, and who states the measure- ment of the swelling to have been thirty inches in its vertical line. The urine and faeces used to pass involuntarily."4 With the exception of the paralysis, so long as the child lives the bodily functions continue but little disturbed. I have found the in- fant to take'its food eagerly, and to sleep well until the bursting of the tumor. But in many cases malformation is not limited to a portion of the spine ; the bones of the skull may exhibit a similar deformity; the bladder may be extroverted, or the child may have congenital hydro- cephalus; the fluid in the lateral and third ventricles passing into the fourth, through the aqueduct of Sylvius, and rupturing the calamus scriptorius, escapes into the vertebral canal. In these cases, the volume of the head has been observed to diminish after the rupture of the spina bifida. 93. From the details already given, it is evident that, though not in every case fatal, yet that the prognosis is in all cases unfavorable : so 1 Surg. Diet., Art Spina Bifida, p. 1171. 2 Ollivier, de la Moe'lle epin., vol. i. p. 200. 3 Ontleed HeelUund, Verhandl. Amst. 1767. * Surg. Diet., p. 1171. 78 INTRA-UTERINE OR CONGENITAL DISEASES. few cases escape that we can indulge but little hope of any one in particular. In addition to the case of recovery already mentioned, I may add that Morgagni,1 Keilmann,2 and Jervis,3 each relate one, and Sir A. Cooper two, in which the patients have lived. These are, I believe, all, or nearly all, on record; and, without diminishing the serious character of the disease, they just afford a reasonable ground for attempting some kind of treatment. The symptoms which mark the approach of death are nearly alike in all cases. When the opening is small and fistulous, the fluid changes its character and becomes turbid, then more or less purulent, and perhaps fetid, after which convulsions set in. When the open- ing is larger, inflammation occurs more rapidly, and the convulsions follow speedily. The termination is rapid, in proportion as the in- flammation extends up the vertebral canal. 94. Treatment.—Various methods of treatment have been proposed and tried but with very little success, as we have seen. Mr. Aber- nethy recommended a slight degree of pressure on the tumor from the commencement, with the double object of limiting the distension of the dura mater, and promoting the absorption of the fluid. Should the fluid increase, notwithstanding, he proposed to lacerate it by a fine instrument, to anticipate its bursting. The wound is then to be closed and allowed to heal, and the pressure to be resumed. He tried this plan in one case, where ulceration had commenced ; the punctures were repeated every fourth day for six weeks; the wounds healed very well, until at last one of them became ulcerated; the dis- charge became purulent, and the child died.4 Heister mentions a case of compression under the care of a surgeon named Stenber. Sir Astley Cooper relates a case of preservation of life, though not of radical cure, by compression, which I shall ex- tract. "James Applebee w-as born on the 19th of May, 1807, and his mother, immediately after his birth, observed a round and transpa- rent tumor in the loins, of the size of a large walnut. On the 22d of June, 1807, the child was brought to my house, and I found that, although it had spina bifida, the head was not unusually large, and the motions of its legs were perfect, and its stools and urine were dis- charged naturally. I applied a roller round the child's waist, so as to compress the. tumor, being induced to do so from considering it a species of hernia, and that the deficiency of the spine might be com- pensated for by external pressure. The pressure made by the roller had no unpleasant influence on its voluntary powers; its stools and urine continued to be properly discharged; but the mother thought that the child was occasionally convulsed. At the end of a week a piece of plaster of Paris, somewhat hollowed, and that hollow filled with a piece of torn lint, was placed upon the surface of the tumor, a strap of adhesive plaster was applied to prevent its changing its 1 De Sed. et Causis Morb., Epist xii. Art. 9. a Prodrom. Act. Havn, p. 136. 3 Journal Gen. de Med. 1106, vol. xxvii. p. 162. * Cooper's Surgical Diet., Art. Spina Bifida, p. 1172. INTRA-UTERINE OR CONGENITAL DISEASES. 79 situation, and a roller was carried around the waist to bind the plaster of Paris firmly on the back, and to compress the tumor as much as the child could bear. This treatment was continued until the month of October, during which time the tumor was examined about three times a week, and the mother reported that the child was occasionally convulsed. When the child was five months' old, a truss was ap- plied, similar in form to that which I sometimes use for umbilical her- nia in children, and this has been continued ever since. At the age of fifteen months it began to make use of its limbs; it could crawl along a passage, and up two pair of stairs. At eighteen months, by some accident, the truss slipped from the tumor, which had become of the size of a small orange, and the mother observed when it was reduced, that the child appeared in some degree dull; and this was always the case if the truss was left off for a few minutes, and then re- applied. At fifteen months he began to talk, and at two years of age he could walk alone. He now goes to school, runs, jumps, and plays about just like other children. His powers of mind do not appear to differ from those of other children. His memory is retentive, and he learns with facility. He had the measles and the small-pox in the first year, and the hooping-cough at three years. His head, pre- viously and subsequently to the bones closing, has preserved a due proportion to other parts of the body. The tumor is kept by the truss entirely within the channel of the spine ; but when the truss is removed, it soon becomes of the size of half a small orange. It is, therefore, necessary that the use of the truss should be continued. When the truss is removed, the finger can be readily passed through the tumor into the channel of the spine."1 For success in this operation it is requisite that the tumor be small, the skin unbroken, and the disease local and uncomplicated. 95. Richter has proposed the insertion of two caustic issues at a little distance from the tumor, but it does not appear that his sug- gestion has been adopted. 96. Forestus, in the first instance, and Mr. B. Bell, more recently, advised the application of a ligature round the base of the tumor, provided the disease be local, and a mere distension by fluid in con- sequence of the imperfection of the bones, and not a disease of the spinal marrowT, or membranes, and it be not complicated. It does not appear that either of them tried it, but it failed with a case of Heister's. 97. Dessault2 and Mathey3 proposed the insertion of a seton through the tumor, but this would be to quicken the ordinary chances of meningitis by admitting the air. Portal saw an infant die three days after the insertion. 98. Sir Astley Cooper, some time after the beneficial employment of compression already mentioned, attempted, and with perfect success, to cure the disease radically, by evacuating the fluid, and then apply- 1 Med.-Chir. Trans., vol. ii. p. 323. 3 Traite de Mai. Chirurg., 1779, vol. ii. 3 Seance pub. de la Soc. Roy. de Paris, Dec. 9, 1779, p. 32. 80 INTRA-UTERINE OR CONGENITAL DISEASES. ing pressure. The case is as follows: "Jan. 21,1809.—Mrs. Little, of Limehouse, brought to my house her son, aged ten weeks, who was the subject of.spina bifida. The tumor was situated on the loins; it was soft, elastic, and transparent, and its size about as large as a billiard-ball when cut in half; his legs were perfectly sensible, and his urine and fasces were under the power of the will, &c. Having endeavored to push the water contained in the tumor into the channel of the spine, and finding that if the whole were returned the pressure would be too great for the brain, I thought it a fair opportunity of trying what would be the effect of evacuating the swelling by means of a very fine-pointed instrument, and by subsequent pressure to bring it into the state of the spina bifida in Applebee's child. I therefore immediately punctured the tumor with a needle, and drew off about tw*o ounces of water. On the 25th of January, finding the tumor as large as before it had been punctured, I opened it again, and in the same manner, and discharged about four ounces of fluid. The child cried when the fluid was evacuated, but not whilst it was passing off. On January 28, the tumor was as large as at first. I opened it again, and discharged the fluid. A roller was applied over the tumor and around the abdomen. Feb. 1, it was again pricked, and two ounces of fluid discharged. On the 9th, the same quantity of fluid was eva- cuated as on the 4th, but instead of its being perfectly clear as at first, it was now* sanious, and had been gradually becoming so in the three former operations. On the 13th, the same quantity of fluid was taken awray, a flannel roller was applied over the tumor and around the abdomen; a piece of pasteboard was placed upon the flannel roller over the tumor, and another roller over the pasteboard to con- fine it. On the 17th, three ounces of fluid, of a more limpid kind, were discharged; the pasteboard was again applied. On the 27th, the surface of the tumor inflamed; the fluid, not more than half of its former quantity, was mixed with coagulable lymph, and the child suffering considerable constitutional irritation was ordered calomel and scammony, and the rollers were discontinued. On the 26th, the tumor was not more than a quarter of its former size; it felt solid, the integuments were thickened, and it had all the appearance of having undergone the adhesive inflammation. On the 28th, it was still more reduced in size, and felt solid. March 8, the swelling was very much lessened, the skin over it thickened and wrinkled; a roller was again had -recourse to; a card was put over the tumor, and a second roller applied. March 11, the tumor was much reduced, the skin covering it was a little ulcerated. On the 15th, it was flat, but still a little ulcerated. On the 27th, the effused coagulable lymph was consider- ably reduced in quantity, and of a very firm consistence. On the 2d of May nothing more than a loose, pendulous bag of skin remained and the child appearing to be perfectly well, the bandage was soon left off."1 No further inconvenience was felt by the child and Mr. S. Cooper had an opportunity of examining both this case and the ' Med.-Chir. Trans., vol. ii. p. 326. CEPHALHEMATOMA. 81 previous one (Applebee) in January, 1838, Mr. Little being then twenty-eight years old, and Mr. Applebee twenty-nine. Both were active and in perfect health.1 The operation by puncture has been several times performed since, but without success. Dr. Sherwood tried it and failed.2 Otto punc- tured the tumor in a child also affected with hydrocephalus, and the tumor disappeared, but the child died three weeks afterwards.3 Pliny- Hayes lost a patient in two days after a single puncture.4 In 1819, Dr. Berndt failed in three cases: the first died twelve days after the operation, the second after three weeks, and the third after three punctures. Benedict Trompei performed the operation upon a girl of six years old, with a cataract needle, and she died comatose thirteen days after. I tried the same plan three or four years ago, and the tumor was becoming more solid, so that I began to have some hope of success, when the child was seized with convulsions and died. Still, small as the chance is, it would appear that, of all the methods proposed, the most feasible is compression alone, or combined with acupuncturation. In the New York Journal of Medicine for September, 1843, a case is related by Dr. Stevens of New York, successfully treated by punc- ture alone. The tumor was about three inches and a half broad from side to side, and it was punctured three different times, and more than nine ounces of fluid escaped. After the last operation, the sac in- flamed, and the child became irritable and restless; but these symp- toms soon subsided, and a year after nothing remained of the sac but a small bunch of indurated and corrugated integument. The child was eight months old. CHAPTER II. CEPHALHEMATOMA.--FRACTURES OF THE CRANIUM, ETC. 99. The tumors on the head of the infant which are observable at birth, although congenital, are not of intra-uterine growth, being entirely mechanical in their origin, and produced during the passage of the child into the world. After the liquor amnii has been dis- charged, the head of the child comes into immediate contact with the cervix uteri, occupying or closing the partially dilated os uteri, the edges of which, according to the resistance they offer, press more or less firmly upon the scalp. If this circular pressure be considerable, it necessarily interrupts the cutaneous circulation, and after a time the portion of scalp thus enclosed is observed to swell, and become more 1 Surg. Diet., p. 1173. 2 Med. Repository, 1812, vol. i. 3 Ollivier, Mai. de la Moe'lle Epin., vol. i. p. 206. 4 Braithwaite's Retrospect, vol. ix. p. 240. 6 82 CEPHALHEMATOMA. or less tense; and if the head of the child be examined after its birth, a tumor of varying size and density will be discovered at this part. This is what has been called the caput succedaneum. The size of the tumor is in proportion to the delay and pressure at the orifice through which the head passes, and its situation indicates accurately the part which presented; the primary tumor being formed by the os uteri, and a secondary or supplementary one by the vaginal orifice, if there be much resistance or delay there. If the part presenting, then, be the same as at the os uteri, the tumor will merely be enlarged; but if the position of the head be altered, it will be extended in one direc- tion or the other, according to the part embraced by the external orifice. As the situation of these swellings is sometimes of importance to their right diagnosis, I shall shortly state where we find them in the different positions of the head. In the first position, the head lies across the brim of the pelvis in its left oblique diameter, with the posterior fontanelle towards the left acetabulum; the os uteri embraces part of the right tuber parietale and the bone superior to it up to the suture, and in this situation we find the primary tumor, which, by the pressure of the lower outlet, is generally extended posteriorly, whilst it embraces more of the tuber parietale. In the second position, the tumor is formed in the same situation, but upon the left parietal bone, i. e. on the superior and rather poste- rior part, including more or less of the tuberosity.1 In the third position, I have found the primary tumor more anterior, or nearer to the anterior angle of the left parietal bone, than the pos- terior, but owing to the change from the third to the second position, which the head makes in its transit through the cavity, the secondary tumor is extended posteriorly over the greater part of the tuber and the superior and posterior part of the parietal bone. So in the fourth position, the primary tumor is formed anterior to the tuber, but at the lower outlet extended posteriorly. In the first position of face presentation, viz., with the forehead to- wards the left ilium, " three forms," says Naegele,2 " a swelling, first upon the upper part of the right half of the face, which, in this spe- cies of face presentation, is always situated lowest." "But if the third stage advance slowly, the inferior half of the right side of the face, viz. part of the right cheek, will be remarked after birth as being the principal seat of the swelling." In the second position of the face,—the forehead towards the right ilium, the left side of the face is the seat of the tumor, or of the red mark which indicates it; the upper part of the primary, the lower of the secondary tumor. I should mention that the situation of the tumor in face presentations is indicated rather by a red-coloured mark (the result of pressure) 'than by a defined swelling. 100. We may now turn to the examination of these tumors them- selves, their nature, pathology, and treatment, and it will be seen 1 Rigby's Midwifery, p. 127. * Mechanism of Parturition, Trans., pp. 77, 78. CEPHALHEMATOMA. 83 that they are by no means so simple or so uniform as might be sup- posed. The simpler ones are by far the most frequent; in fact, it is seldom that we meet with the cephalsemata, as they are called: I have myself for some time past taken every opportunity of examining these tumors, and such information as I have been able to obtain, I shall incorporate with that given by the authors whose works I have consulted. i. The simplest and most common tumor, when laid open, will be found to consist of yellowish serum, effused under the scalp, and very rarely also beneath the pericranium. The scalp preserves its usual density, and the bone and pericranium are in a state of perfect integrity. The tumor is formed during the passage of the head of the child, and does not increase after birth. It is limited simply by the pressure of the os uteri and os externum. For this kind of tumor-no treat- ment is necessary, as very shortly after birth it loses its peculiar form, and after twenty-four hours often entirely disappears. If not, a spirit lotion, occasionally applied, will hasten its dispersion. n. Occasionally, instead of simple serum, the tumor consists of sero-sanguineous fluid, owing, probably, to the greater amount of pressure, or the fragility of the blood-vessels, or to both. In such cases we find the scalp unusually vascular, with small ecchymoses on its surfaces, especially the inner. In some cases I have also ob- served small ecchymoses upon the pericranium and the surface of the skull, but the bone is perfectly sound. Most of these cases also subside without special treatment, or after the application of a spirit lotion; but in some rare examples I have known inflammation to attack the tumor, followed by ulceration or abscess. This will be the more likely if violence of any kind have been used. If we find inflammation arising, and the spirit lotion ineffectual, the best application is a soft, warm poultice, frequently repeated. The same treatment will be the best in case of ulceration, at least at first, and afterwards some slightly stimulating ointment or lotion. If an abscess form, of course the best plan is to evacuate the pus by a free incision, followed by poultices. Fortunately, these cases are very rare. m. The third variety of tumor is the sanguineous, or cephalse- mata, as they are called by Naegele and others. The first writer who distinctly described these tumors was Michaelis;1 he was fol- lowed by Naegele,2 Zeller,3 Hcere,4 Schwarz,5 Golis,6 Osiander,7 Che- lius,8 Henke,9 Rau,10 &c, Moscati and Palletta ;u and from the facts 1 Ueber eine eigene Art von Blutgeschwulsten, &c.—Loder's Journal, vol. ii. cah. 4» 1804. - Erfahrungen und Abhandlungen, &c, p. 247. 1812. 3 Thesis, Comment, de Cephalsemate. 1822.- * De Tumore Cranii rec. nator. sang. 1824.—Siebold's Journal, vol. v. 6 Siebold's Journal, vol. vii. part 2, p. 440. 6 Practische Abhandlungen, &c. 7 Handbuch der Entbindungskunst, &c. 8 Manuel de Chirurg. (Trans.) vol. ii. p. 186. 9 Kinderkrankheiten, p. 148. 10 Handbuch der Kinderkrankheiten,.p. 78. " De Abscessu sang, capit. Mediol. 1810. 84 CEPHALHEMATOMA. published by these authors, the Memoirs of MM. Pigne1 and Du- bois2 were written. M. Halmagrand, in his edition of Maygrier,3 and M. Velpeau,4 have also added observations of their own to the results previously before the profession. But by far the best essay I know, and one to which I have been largely indebted, is that of M. Valleix, formerly " interrte" " at the Hopital des Enfans Trouves," in Paris.5 The simplest and most general of these tumors, which are essen- tially of the same nature, is, according as the blood is effused imme- diately under the scalp, under the pericranium, or within the skull. Chelius and Hcere describe cases where the effusion takes place in the diploe of the cranial bones. SUB-APONEUROTIC CEPHALHEMATOMA. 101. This is the simplest, but apparently not the most common form of sanguineous tumor, as, in about 500 new-born children, M. Valleix observed it but twice, and neither Naegele nor Zeller alludes to it. It has been described by Baudelocque,6 Velpeau, Du- bois, &c. The blood is effused immediately underneath the cranial integument. It is probably owing to the violence of the labor, and sometimes to external violence. In most cases, it is promptly dissi- pated. SUB-PERICRANIAL CEPHALHEMATOMA. 102. This appears to be the most common form of the sanguineous tumor, though, after all, it is rare. M. Naegele met seventeen cases in twenty years' practice, and it is the only kind described, by him and Zeller. Hoere thinks it tolerably frequent. Palletta found but a few cases in a great many children. M. Baron estimates its occur- rence at about in 1 in 500 children.7 M. Dubois, during a number of years at La Maternite (where from 2500 to 3000 children are born annually), has seen but six cases. Dr, Doepp, of St. Petersburgh, states, that in the Foundling Hospital it occurred in 262 cases in eleven years, or in one in 190 of the whole number of children in the hospital. M. Velpeau refers to five cases, and M. Valleix8 met with four cases in 1937 children in five months at the Hopital des Enfans Trouves, or about one in 387. According to most writers, the tumor is seated about the posterior and superior angle of the right parietal bone, or nearly in the situa- tion of the tumor in the first position; and when small it is placed 1 Journal Hebdom. Sept. 1838. a Nouv. Diet, de Medecine, vol. vii. p. 88. 3 Page 551. •> Traite des Accouch., p. 510. Ed. de Bruxelles. 6 Mai. des Enfans, p. 495. » Art des Accouch., part i. ch. ii. sect. 11. ' Diet, de Med., Art. Cephalaematome. » Mai. des Enfans, p. 500. CEPHALHEMATOMA. 85 above, and distinct from the tuber parietale. It is occasionally, but rarely, met with on the left parietal bone, and still more rarely in any other situation. Ordinarily, there is but one, but sometimes we may observe one on each parietal bone, separated by the sagittal suture. Naegele has, however, mentioned a case where a greater number were found. Of six cases seen by M. Valleix, three were on the right parietal bone, two on the left, and in one there was a tumor on each bone, but which, he states distinctly, was not the result of the blood passing across the suture. The size of these tumors varies from that of a small nut to a swell- ing occupying the whole parietal bone. In the case of double tumor, related by M. Valleix, they were the size of an apricot kernel; in two others they covered seven-eighths of the parietal bone. There is no proof of these tumors existing before the completion of labor; if we make an examination some hours, or a day, after birth, we find a small tumor, slightly tense, fluctuating, and on pressure from the edge of the tumor inwards we can feel the bone entire. In rare cases, the integuments are of a deep red color, and slightly cede- matous,1 and still more rare is it to find a pulsation in the tumor, although Naegele states that he did so in twTo or three instances. But the most striking peculiarity of this variety is a bony circle— " cercle osseux, bourrelet osseux"—which is formed around the ef- fused blood, and limiting it. Palletta has mistaken this for the edge of an opening through the cranium, and to this cause he attributes the formation of the tumors. However, the bone, as Valleix remarks, can be distinctly felt uninjured within this bony ridge, if we pass the finger from the outer edge inwards to the centre.2 Michaelis states that the bony circle maybe felt from the commencement of the tumor; but in this he is not borne out by the researches of Naegele, Zeller, Hcere, and others, who examined with great care. M. Valleix says, that in two cases which he saw only at an early period, he could not detect it: in one it had just commenced, and in a fourth it had not at first attained its full development, but it did afterwards. Wigand relates two cases in which no circle could be felt until twenty-four hours after birth; and M. Fortin,3 one in which no circle was present immediately after birth, but which was formed within two days. From these facts we may conclude that it is not present at the com- mencement of the formation of the tumor, but that it is a subsequent production. It is very perceptible to the touch when found, sur- rounding the tumor entirely, except when it is over the sutures. The tumor rapidly acquires its full development, sometimes in a few hours, sometimes in a day or two, and at each time we find it of different sizes in different cases, tense, rounded, defined, elastic, and with fluctuation almost always perceptible. Generally speaking, the color of the skin is unchanged, and it is neither ecchymosed nor cedematous, though there are exceptions. No alteration of the vol- 1 Valleix, Mai. des Enfans, p. 502. 1 Valleix, Gaussail.— Presse Med. 1837, No. 54. 3 Cephal. sous-pericran.—Ibid., No. 39. 86 CEPHALHEMATOMA. ume is produced by pressure made upon the tumor, nor does it cause stupor, coma, or convulsions; and, according to Valleix, it is quite consistent with the health and thriving condition of the child. Palletta states that the size of the tumor continues to increase until it is opened, but this is not the case: it may increase until the bony circle is formed, but this appears to determine its extent. Diagnosis.—These sanguineous tumors have been mistaken for hernia cerebri, and perhaps this is the disease with which they are most likely to be confounded. MM. Ledran and Corvin made this mistake, as was subsequently pointed out by M. Ferrand.1 And yet the differential symptoms are sufficiently marked, for in cephalsema- toma there is always fluctuation, which is not present in hernia cere- bri ; in the latter, there is always pulsation, but never in fully-formed cephalsematoma, and very rarely indeed even at the beginning. In hernia cerebri, the perforation in the skull may always be felt, whereas in cephalaematoma, by a little care, we can alw-ays (with only one or two exceptions on record) feel the cranium beneath the tumor. In hernia, compression gives rise to symptoms of cerebral pressure, but not with cephalaematoma; and lastly, cephalaematoma almost never form upon the sutures, whereas this is the most frequent seat of hernia cerebri. In a case related by Fried, hernia cerebri occupied the occiput, and a sanguineous tumor each parietal bone.2 As Dubois observes, there is no danger of confounding cephalae- matoma with hydrocephalus externus, and the osseous circle will dis- tinguish them from the aqueous cysts mentioned by Zeller. Hoere mentions, in his Memoirs, a case of fungus of the dura mater ; but this disease is so rare in infancy (if it ever occur at so early a period) that we run little risk of mistaking the one for the other. Valleix relates a case of abscess of the scalp circumscribed by a thickened condition of the cellular membrane, which had considerable resemblance to the osseous circle, but the previous history differed considerably; for abscess is not formed so soon after birth, makes slower progress, is irritable and painful, and the condensed cellular membrane does not form so hard a boundary as bone. The ordinary caput succedaneum is softer, pitting on pressure, but not fluctuating, not so defined, without the bony circle, and is speed- ily dissipated. The sub-aponeurotic cephalaematoma are more rapidly formed, the skin is discolored, the tumor is sometimes painful, but not circumscribed, and without the bony circle. M. Dubois saw in the same child the sero-sanguineous tumor, the sub-aponeurotic and the sub-pericranial cephalaematoma, the coexistence of which would of course embarrass the diagnosis. 1 Mem. de l'Acad. de Chir., vol. v. p. 47. 2 Extract, de Thes. de Haller, vol. i. p. 110. CEPHALHEMATOMA. 87 SUBCRANIAL CEPHALHEMATOMA. 103. This variety is extremely rare. Hoere was the first to de- scribe it,1 and since then MM. Moreau and Dubois2 have detailed each a case. M. Baron states that he has seen several;3 and M. Padieu showed to M. Valleix the parietal bone of an infant, which had been the seat of one.4 M. Valleix has found the dura mater separated by effused blood, but which was not limited so as to form a tumor. The blood is stated by Chelius and others to be effused into the diploe of the cranial bones; by others, on the external or internal surface of the dura mater. My friend, Dr. West, of London, has lately published a very inte- resting case of external and internal cephalaematoma, with fracture of the frontal bone. The child died twenty-three or twenty-four days after birth, of convulsions. The tumor was about the size of a wal- nut originally, but it extended so as nearly to cover the right parietal bone. On dissection, the tumor was found filled w'ith coagulated blood, underneath which was " a semicircular layer of dense, reddish, fibrinous exudation, about three lines broad, wedge-shaped, with its narrow edge directed inwards." The subjacent surface of the bone was rough and uneven. The right parietal bone was then removed ; but previously a fissure, with clean edges, was noticed in the bone running from the coronal suture obliquely backwards and upwards. "On the inner surface of the bone was an effusion of blood between the cranium and the dura mater, more than half an inch in thickness, and occupying the whole of the fossa of the parietal bone." "Be- tween the two layers of the dura mater by which it was covered were numerous bony deposits, and a ring of newly formed bone surrounded its base."5 Dr. West thinks, and I believe correctly, that the fracture occurred during labor, although it was quite natural and easy. Such occur- rences have been noticed by D'Outrepont, Carus, Hoere, and Danyau. They are still more likely, and more easily explained, when the pelvis is narrowed by undue projection of the sacral promontory, as in Monde's, Adelmann's, and Becher's cases. 104. Pathology.—In describing the appearances in sub-pericranial cephalaematoma, discoverable in dissection, I shall give the substance of M. Valleix's researches, which are by far the most minute and accurate of any. The scalp has generally its natural aspect, although Osiander and others speak of its being red or .livid. Its substance is alwrays unin- jured. The pericranium preserves its transparency, and through it is perceptible the deep color of the effused blood. M. Dieffenbach6 has noticed a thickening of the pericranium, which is confirmed by M. Val- 1 De Tumore Cranii, &c. a Diet, de Med., Art. Cephalaematome. 3 Ibid. 4 Mai des Enfans, p. 512. 5 Transactions of Med.-Chir. Soc, vol. xxviii. 6 Abscessus Capitis Sang. Neonat.—Rust's Magazin, 1830. 88 CEPHALHEMATOMA. leix. At the circumference of the tumor, the pericranium is adherent to the bony circle ; but it is never ossified itself, according to M. Val- leix, although Chelius has found it so. According to M. Valleix, the effused blood is enveloped in a sac formed of a fine membrane, having all the characters of condensed cellular tissue, around which he observed an adventitious tissue, consisting of a cartilaginous plate, varying from a line to half an inch in breadth, and about half a line in thickness, gradually thinning externally. It is placed on the bone, from which it is easily detached, and underneath the pericranium, to which it adheres more firmly, but from which it can be detached, leaving the membrane in its natural state. In the under surface of the cartilaginous plate, points of ossification may be observed. The state of the bone underneath the tumor has been differently described by different authors. Michaelis and Palletta, who attribute the affection to disease of the bones, think that the outer table gf the bone is necrosed, carious, and destroyed, and that the injured vessels of the diploe give rise to the hemorrhage. Naegele, Zeller, Hoere, Valleix, and others, differ from this view, and this opinion is founded upon examinations made after incisions have been practised, and after death. Valleix found part of the surface smooth, but sprinkled with numerous irregular osseous rugosities, very difficult to be detached, but neither carious nor destructive. The bony circle always surrounds the tumor entirely, except when it is seated near to the suture: it consists of a bony ridge placed upon the bone, from which it may easily be detached, exposing the parietal bone unaltered. It appears of different degrees of consistence, ac- cording as the process of ossification is more or less advanced. Its height varies in different cases, and in different parts of the circle, varying from half a line to a line and a half. 105. Terminations.—Velpeau gives the following statement from Naegele as the process of cure:— "i. The detached pericranium becomes ossified on its internal surface. "n. In proportion as the effused blood is absorbed, the ossified pericranium approaches the cranium, and at length is united to it. " m. After six months, or even a year, we may still remark an elevation at the place where the tumor was situated. " iv. In children who died six months or a year after, M. Naegele found, on making a section of the parietal bone, that it was much thicker at the situation of the tumor."1 M. Valleix states, that in one case the bony circle gradually increased internally, until it nearly occupied the whole extent of the tumor, and that the fluid disappeared in the same degree. The tumors, if untouched, are rarely cured within forty days; they may, however, disappear, though not often, without opening, and in the majority of cases there is no danger. 106. Treatment.—I have already stated that, for the simple forms, 1 L'Art des Accouchemens, p. 512. CEPHALHEMATOMA. 89 nothing beyond cold lotions or spirit wash will be necessary, unless ulceration take place, or an abscess form. The same treatment may be tried in the subaponeurotic cephalaematoma, and will generally succeed. Even the sub-pericranial tumors maybe dissipated, accord- ing to Golis, Rau, Halmagrand, and others, when slight. The latter author speaks highly of a lotion of the hydrochlorate of ammonia in red wine. Others recommend the usual cold and spirituous lotions. Henschel recommends pressure. If these means fail, and they will fail if the tumor be large, it will be necessary to make an opening into it. For this purpose, Moscati and Palletta passed a seton through the tumor to provoke suppuration, on the supposition that the bone was diseased. Golis of Vienna estab- lishes a slight issue on the top by means of caustic potash, in hopes of promoting absorption; and he cites thirty-two cases of cure by this means, in from fourteen to eighteen days; but Zeller throws great doubt upon some of these: Krukenberg and Schmitt, however, adopt Golis's plan. Lowenhardt recommends puncture with a trocar, and strapping. By far the simplest mode, however, is to make an incision with a bistoury, sufficiently ample according to the size of the tumor, and by most writers this plan is preferred. The wound maybe dressed with charpie, according to Chelius, or with spermaceti cerate.; or, when the blood is evacuated, a strap of plaster may be passed across it. The simpler the dressing, the better. I may remark, in conclusion, that we should take care not to make the incision near any of the principal arteries of the scalp. 107. I give the following notice by Dr. Scholler, of Berlin, of a case of injury arising from pressure, although it does not properly belong to any of the varieties of swelling on the scalp just described, on account of its rarity and interest. " A healthy young woman was seized with labor of her first child, August 23, 1839. The first stage was very tedious, and the pelvis very small. At the end of three days, and after the use of venesection and opium, she was delivered of a small child. Its head was a quarter of an inch smaller than usual in each diameter; a large caput succedaneum occupied the right parietal bone ; and in the middle of the left parietal, and in the neighborhood of the left temple, the skin was abraded and the bone depressed. The skin about these parts became gangrenous, and a red line of demarcation surrounded the mortified structures. The bone beneath likewise died, and a portion as large as a sixpence of the whole thickness of the parietal bone exfoliated, leaving the dura mater exposed. The destruction of the frontal bone was less con- siderable, and was replaced by granulations, which, on September 13, had likewise advanced so far towards restoring the lost part of the parietal bone that the child was dismissed from hospital."1 A similar case is recorded by Meine, in his thesis "De Osteomalacia et ejus in partum actione." 1 Medicinische Zeitung, September 22, 1841. 90 IRRITATION OF THE NERVOUS SYSTEM. CHAPTER III. IRRITATION OF THE NERVOUS SYSTEM.—TRISMUS NASCENTIUM. NERVOUS IRRITATION. 108. When we consider the delicate structure of the brain'in in- fants, the great vascular action going on therein, the influence re- flected upon it from the different organs, and the stimulation to which it is exposed from external impressions (22), we cannot be surprised that it should be liable to various degrees of disturbance, from simple irritation up to disorganization. Some of these attacks are apparently merely functional, i. e., they entail no permanent disorder, and leave no pathological traces in the structure of the organ, so far as we can ascertain. They do not amount to inflammation, but consist probably in temporary irritation, with probably some degree of congestion or unequal circulation. Without attempting to explain further what we confessedly do not as yet understand, I shall proceed to notice the ordinary forms of nervous irritation occurring in infants and young children. 109. In very mild cases, the principal symptoms are great wake- fulness and a keen sensibility to slight impressions, much restlessness, and rather more animation than usual. In severer cases, these symp- toms are aggravated; the infant sleeps very little, and is awoke by the slightest movement; is painfully sensitive to sound and light; the temper becomes irritable, and it is scarcely possible to please the child; it cries on the slightest occasion, and is only soothed when at t the breast. It is restless, keeping the limbs in constant motion, and requiring the nurse to walk about with it constantly. Its sleep is not the calm rest of a healthy infant; it starts now and then, a frown passes over its forehead, the eyelids are occasionally squeezed to- gether, and the least noise disturbs it. The arms are tossed about, and the lower limbs frequently moved. The bowels in some cases are regular, but more frequently they are deranged, either confined or relaxed, or the motions exhibit an unhealthy character. The pulse is quicker than natural, and the heat of the surface increased. So far, these symptoms resemble very closely those which usher in convulsions; neither can we be sure that any case in which they are present may not thus terminate, although, if promptly and judiciously treated, the attack may generally be ar- rested. 110. But nervous irritation may show itself in another form, and with somewhat opposite characters. The infant is heavy and dull IRRITATION OF THE NERVOUS SYSTEM. 91 yet fretful when disturbed or touched ; it is uneasy except when resting the head on the nurse's arm or on its pillow; it does not sleep, and yet is scarcely awake; there is a great indisposition to move or make any exertion, with an indifference to all objects. The eyes are dull, and frequently rolling or turning upward with an occasional wild stare; the child is restless, tossing its arms, and moving its legs about uneasily; starting in its sleep, and awaking crying, or as if frightened. There is a general pallor with chilliness of the body; the face is of a dull lead color, and darker underneath the eyes. The heat of the head may be natural or slightly increased. If its course be not arrested, this form of irritation of the nervous system may run on into convulsions; for this very reason, it would ap- pear, writers have generally omitted to notice these attacks, regarding them, doubtless, as the first stage of convulsions; but I have seen them so frequently stopping short of that extreme, either sponta- neously, or under the influence of treatment, that I felt it right to allude to them separately. Dr. Whitlock Nicholl has published a monograph1 on the subject, containing much valuable matter, which the reader would do well to consult. 111. The late Dr. Gooch has described,2 with his usual discrimi- nation, a class of cases in which " the symptoms are erroneously attributed to congestion of the brain," and which closely resemble the last form of nervous irritation. " It is chiefly indicated by heavi- ness of head and drowsiness. The age of the little patients whom I have seen in this state has been from a few months to two or three years; they have been rather small of their age, and of delicate health, or they have been exposed to debilitating causes. The phy- sician finds the child lying on its nurse's lap, unable or unwilling to raise its head, half asleep, one moment opening its eyes, and the next closing them again, with a remarkable expression of languor. Its tongue is slightly white, the skin is not hot, at times the nurse re- marks that it is colder than natural; in some cases, there is at times a slight and transient flush; the bowels I have always seen already disturbed by purgatives, so that I can scarcely say what they are when left to themselves: thus the state which I am describing is marked by heaviness of head and drowsiness, without any signs of pain, great languor, and a total absence of all active febrile symp- toms. The cases which I have seen have been invariably attributed to congestion of the brain, and the remedies employed have been leeches and cold lotions to the head, and purgatives, especially calomel. Under this treatment, they have gradually become worse, the languor has increased, the deficiency of heat has become greater and more permanent, the pulse quicker and weaker, and, at the end of a few days or a week, or sometimes longer, the little patients have died with symptoms apparently of exhaustion. In two cases, how- ever, I have seen, during the last few hours, symptoms of oppressed ' Practical Remarks on disordered States of the cerebral 'Structures, occurring in In- fants, p. 10. 1821. 3 Diseases of Woman, p. 357. 92 IRRITATION OF THE NERVOUS SYSTEM. brain, as coma, stertorous breathing, and dilated, motionless pupil." Dr. Marshall Hall has also described a similar form of disease, attri- buting it to the same causes. Dr. Abercrombie remarks: "I have many times seen children lie for a day or two in this kind of stupor, and recover under the use of wine and nourishment. It is scarcely to be distinguished from the coma which accompanies diseases of the brain. It attacks them after some continuance of exhausting dis- eases, such as a tedious and neglected diarrhoea; and the patients lie in a state of insensibility, the pupils dilated, the eyes open and in- sensible, the face pale, and the pulse feeble. It may continue for a day or two, and terminate favorably, or it may be fatal."1 Now, as an organ may be in a state of irritation from a deficient as well as from an excessive supply of blood, either error destroying its healthy equilibrium, I do not know a better term by which to indicate both conditions than nervous irritation; but, whatever nomenclature we use, they are to be observed in practice, and are of considerable importance. 112. Causes.—In the first variety, I think, there will generally be found some disorder of the stomach or bowels, or both. The child may have been eating some indigestible food, or, without any special cause, the mucous membrane of the stomach and bowels has become deranged, and there is occasional vomiting, or purging, not of large but of small and frequent stools, with great flatulence. In some cases, no exciting cause can be detected; but the attack seems to be the commencement of some serious affection of the nerv- ous system, presenting the character and symptoms I have described, and either subsiding spontaneously or from judicious treatment, or really developing itself in a graver form, or lastly, as it were, pro- jecting itself upon some other organ, and giving rise,' e. g., to spasm of the glottis. In the second variety, where torpor is the characteristic symptom, the cause seems to be a feeble state of constitution, and exhaustion from some other disease, as diarrhoea, increased by treatment of the primary affection, or that which has been erroneously directed to the cure of supposed cerebral disease. 113. Treatment.—In the first variety, if the pulse be quick and firm, and there be any heat of the scalp, I have found immediate and great relief from the loss of a small quantity of blood by leeches. And, as this is the first time I have had occasion to mention leeches, let me recommend to my readers that, in all cases where they are applied to infants or children, the bleeding should be arrested at once when they fall off. By so doing, we can estimate exactly the amount of blood lost, and we avoid the great mischief of continued draining. Of course, it will be necessary to apply a greater number of leeches than usual, or to repeat them ; but that is of no consequence compared with the danger of the ordinary method. Each leech will abstract from one to two drachms of blood, and the number must be propor- 1 Diseases of the Brain, p. 310. TRISMUS NASCENTIUM. 93 tioned to the amount we wish to take away; and, in the following pages, when speaking of the number of leeches to be applied, I must request the reader to bear this in mind, and that I do not include any subsequent draining from the leech-bites. After leeching, or at once if that be necessary, sponging the head with cold water, or a cold lotion, and a warm foot-bath at bed-time, will calm and soothe the infant, and perhaps procure for it some refreshing sleep. The state of the stomach and bowels demands immediate attention: if they are too free, as well as disordered in the character of the eva- cuations, it is better first to quiet the excessive action before attempt- ing to correct the secretions, and I have found for this purpose the following simple mixture of great use ; the proportions are, for a child of twelve or fourteen months old :— R. Mucilag. acacise, Syr. zingib., aa :"Jii-; Tinct. opii, gutt. i. to iii.; Aquas carui vel anisi, ^i. M. A teaspoonful may be given every three or four hours, until the bowels are quieter, and then at longer intervals. When the bowels are steady, the mercury with chalk, with the addition, if necessary, of a little compound powder of chalk, may be given, or, instead of the gray powder, minute doses of calomel—say one-sixth of a grain. The diet should consist of milk, thin arrow-root, panada, &c, without stimu- lants; but when the irritation subsides a little broth may be given. In some cases, I have seen great benefit result from a small blister applied for an hour or two behind the ears, across the forehead, or at the nape of the neck. 114. For the second variety, neither depletion nor any exhausting remedies are admissible; on the contrary, it is absolutely necessary to administer good although bland nourishment. Chicken broth or nicely made beef tea must be given frequently, but in small quanti- ties, and after a time a little wine whey, or wine and water. If the bowels are irritable, some soothin'g medicines must be given, and the head may be sponged with cold lotion if it be hot, or a foot-bath used. TRISMUS NASCENTIUM.--NINE-DAY FITS. 115. This disease, which consists in intense cerebro-spinal irrita- tion, seems peculiar to hot climates, certain localities in more tempe- rate climates, and to vitiated atmospheres. It is frequent in Jamaica and the West Indies, according to Drs. Evans and James Clarke,1 in Cayenne, Minorca, and some parts of Germany. Dr. Schneider was called to six cases within fourteen days, in March, 1802, in the town (Fulda) in which he resides; and he states that a midwife of the same place met with more than sixty cases in nine years.2 The town is 1 On the Yellow Fever, 1797. 1 Edinburgh Medical and Surgical Journal, vol. vii. p. 225. 94 TRISMUS NASCENTIUM. situated close to the river, and very damp, so far bearing out the truth of Sauvage's observation, "hie morbus hieme. et cum aura humida advenit quam sicca aestate."1 It only occurred once in the British Lying-in Hospital in many years,2 and Capuron mentions that he once met it in Paris.3 In a letter to the editors of the New Orleans Medi- cal and Surgical Journal for May, 1846, Dr. Wooton states that it is of fearful frequency in the cotton plantations in Alabama. He be- lieves that it destroys more negroes than any other disease, always proving fatal; but he has never seen a white child attacked.4 In private practice, it is rarely met with, even amongst the poor, so that of the waiters who have noticed the disease very few indeed seem to have seen an example of it. No institution, so far as I know, has ever afforded such ample ex- perience of the disease as the Dublin Lying-in Hospital, before the improvements in ventilation and cleanliness introduced by the late Dr. Joseph Clarke, to whom we are indebted for the best description of the attack. 116. He states that those children who were observed to whine and cry very much from their birth, or who started much in their sleep, were more liable to the disease. Twisting of the limbs without cause when awake, a livid circle about the eyes, sudden changes of color, screwing up the lips like a purse, involuntary smiling, with a peculiar kind of screech, were certain and not distant precursors. Previous to, or along with these symptoms, the infants were greedy for the breast or for food, the bowels were easily moved, and the evacuations were sometimes natural, at others greenish, slimy, or knotty. " Generally with one or more of these symptoms preceding, but sometimes without any warning whatever, the infants are seized with violent irregular contractions and relaxations of their muscular frame, but particularly those of the extremities and face. These con- vulsive motions recur at uncertain intervals, and produce various effects. In some, the agitation is very great; the mouth foams, the thumbs are riveted into the palms of the hands; the jaws are locked from the commencement, so as to prevent the action of sucking and swallowing; and any attempts to wet the mouth or fauces, or to ad- minister medicines, seem to aggravate the spasms very much; the face becomes turgid and of a livid hue, as do most other parts of the body. From this circumstance, and from the shorter duration of the disease, when it occurs in this form, the nurses reckon this a different species, and call it the 'black fits.' The conflict in such cases lasts from about eight to thirty hours, and in some very rare cases to about forty hours, when the powers of nature sink, exhausted and overpowered, as it were, with their own exertions."5 There is a milder variety, to which the nurses give the name of 1 Nosolog. Method, vol. i. p. 531. 3 Underwood on Diseases of Children, p. 280. 3 Vol. iii. p. 454. < Transactions of the College of Physicians of Philadelphia, 1847, p. 115! 6 Transactions of the Royal Irish Academy, vol. iii. p. 92. TRISMUS NASCENTIUM. 95 " white fits," in which the convulsive movements of the extremities are less violent, the paroxysms less frequent, and the power of suck- ing and swallowing, although enfeebled, is not lost until near death. The attack is also more prolonged, lasting from three to nine days. The face remains pale, and the body is greatly emaciated. # Both forms of the disease certainly attack the infant within nine days, and generally about the period when the remains of the umbi- lical cord fall off; and both are distinguished from other varieties of convulsions by the permanent difficulty or impossibility of swallow- ing; hence the more appropriate name of Trismus Nascentium (rather than the popular one of nine-day fits); for the attack, as Mr. Colles has truly observed, resembles very closely tetanus in the adult. He and others have also remarked, that plump, healthy-looking children are as liable to the attack as the delicate and weakly. 117. Causes.—M. Bajon attributes the prevalence of Trismus, on the coast of Cayenne, to cold and the sea wind, as it is unknown in the interior; Dr. Evans to costiveness; Dr. Bartram to improper swathing, and the application of scorched linen to the navel; Dr. James Clarke to the smoky, unventilated state of the huts of the ne- groes in Jamaica; and Dr. Underwood to impure air. Dr. Joseph Clarke enumerates three especial exciting causes of the disease : first, impure air ; second, neglect of keeping the infants clean and dry; and third, irregularity of living on the part of the mothers, especially the abuse of spirituous liquors. But it is to the first of these that Dr. Clarke chiefly attributes it, because of its frequency in hospitals, and infrequency among the poor who are delivered at their own homes, where want of cleanliness and irregularity are more remark- able than in any hospital. At the end of the year 1782, of 17,650 infants born alive in the Lying-in Hospital, 2944 had died within the first fortnight, or nearly every sixth child, and that mainly of trismus. After the precautions he adopted, to secure pure air and adequate ventilation in the hospital, out of 8033 born alive, only 419 died in the hospital, or one in 19^. And Dr. Collins states that, out of 131,227 children born alive, only 5500 have died,1 a very striking evidence of the correctness of Dr. Clarke's opinion, and of the value of his preventive treatment. During Dr. Collins's mastership, there only occurred thirty-seven cases of trismus, out of 16,654 infants born. 118. The late Professor Colles attributed trismus to inflammation and ulceration of the umbilicus, without, however, denying that it may be connected with a vitiated state of the atmosphere; and he grounded his opinion upon repeated dissections: "Five years ago," he observes, " I first made a careful dissection of the umbilicus of a child who had died of locked-jaw, and I have every year since dis- sected from three to six subjects who have fallen victims to this dis- ease."2 From fifteen to thirty post mortem examinations constitute evidence very well worthy of attention; I shall, therefore, extract his 1 Practical Treatise on Midwifery, p. 514. 2 Dublin Hospital Reports, vol. i. p. 286. 96 TRISMUS NASCENTIUM. account of the appearances observed: " The skin forming the edges of the umbilical fossa was in some a little more raised than usual. When the borders of this hollow were expanded by introducing a pair of dissecting forceps, we observed the floor of this cavity not flat, but considerably raised in the centre by a knob or large papilla; both the central raised part and the surrounding flat parts of this surface presented all the characters of those new7 membranes which are formed by suppurative inflammation. In some few instances, the fundus of this cavity presented evident marks of superficial ulcera- tion, confined to the vicinity of the umbilical vein. A probe readily passed through the substance of the central tubercle, and entered into the umbilical vein. On cutting into the abdomen, the peritoneum covering the umbilical vein was highly vascular, as if from inflam- mation : this extended sometimes up to the fissure of the liver, often, however, not for a greater length than one inch above the umbilicus. The peritoneum in the course of the umbilical arteries appeared to be still more inflamed, an appearance which extended often as far as the sides of the bladder. Besides the appearance of the peritoneum along their posterior surface, the cellular substance which covered them and the urachus anteriorly was loaded with a yellow watery fluid, even down to the bladder. Leaving the umbilicus untouched, if we cut open the umbilical vein from the liver to the vicinity of the umbilicus, we found only a few small coagula within its canal; the inner surface of the vein was pale, and free from any marks of in- flammation, yet the coats of the vein altogether were very much thickened. The umbilical arteries exhibited evident marks of inflam- mation; first, on slitting them up, a thick, yellow fluid, resembling coagulable lymph, was found within their coats; second, in all cases their coats were much thickened and hardened, even as far as the fundus of the bladder. On cutting into the umbilicus itself, from its posterior or peritoneal surface, we found in the centre a space about half an inch long, occupied by a soft yellow substance, which bore a very strong resemblance to coagulable lymph produced by inflamma- tion ; it was this which formed the prominence observed in the external vein of the fossa. The extent of this middle space varied in different cases; but in every instance the arteries opened into it, or rather were lost upon it." " The extremity of the umbilical vein was affected in different degrees in various instances. In some, it presented a pouch or varix, which extended one-eighth of an inch below the extremity of the opening of the vein, i. e., in a direction towards the opening of the bladder. In some, the extremity of the vein presented an appear- ance of ulceration on its margins; and in all, the edges of the extre- mity of the veins were thickened. In every instance, the ends of all these vessels remained open; their canals were in continuity with the soft substance which occupied the centre of the umbilical space, so that a bristle or small probe passed without opposition from their ves- sels into the soft substance."1 1 Loco citato, p. 286. TRISMUS NASCENTIUM. 97 119. In the year 1819, Dr. Labatt, then Master of the Lying-in Hospital, published a paper1 to refute Mr. Colles's views, in which he gives memoranda of nine dissections of infants, six of whom died of trismus, two of diarrhoea, and one of an affection of the chest. The peculiarities mentioned by Mr. Colles as characteristic of the navel in trismus he states to have been absent in all the cases of locked jaw, and many of them present in the other cases, so that in the former the umbilicus appeared to be perfectly free from disease. Dr. Breen, in a valuable paper published some time afterwards,2 coincides in a great measure with Dr. Labatt; and Dr. Collins observes, that, " from dissection, we have never been able to discover any morbid appearances which would justify us in offering any explanation of the pathology of this disease." It is an old opinion, however, that the disease is in some way con- nected with the condition of the umbilical cord. Moschion thought that stagnation of blood in the funis might give rise to serious disease; with which Levret agreed; and M. Bajon expressly attributes trismus to this cause, and advises that the blood should be carefully emptied out. Alphonse Le Roi fancied that it might be caused, among the negro children, by the use of dirty, rusty scissors for dividing the cord.4 Dr. Wooton made careful investigations on this point, but could come to no definite conclusion. The pathological phenomena he ob- served were, general peritonitis, and the portion surrounding the en- trance of the navel-string in a gangrenous condition; liver engorged; and heavy engorgement of the membranes of the base of the brain, and along the medulla oblongata and cervical portion of the spinal cord. Whatever may be the exciting cause, there can be no doubt that the proximate cause is intense cerebro-spinal irritation, but which leaves no trace of disorganization in the brain or spinal marrow. 120. Treatment.—A more intractable disease does not come within our observation. Dr. Collins remarks: " With respect to the treat- ment, I have nothing to propose, as I have never seen an instance where the child seemed even temporarily relieved by the measures adopted. Calomel has been tried in large quantity, also in small doses often repeated, as well as extensive friction with mercurial ointment. I have tried frequent leeching along the spinal column, also repeated blistering over its entire length. Opium I have ex- hibited in many ways, both in very large and small doses; also tartar emetic in the same manner, and at times both combined. I have tried tobacco extensively, in the form of stupes and injections of various degrees of strength, from one grain to the ounce of fluid, to five or more, besides the frequent use of the warm bath, oil of tur- pentine, tincture of soot, assafetida, and many of the ordinary pur- 1 Edinb. Med. and Surg. Journal, vol. xv. p. 216. a Dublin Journal, vol. viii. p. 548. 3 Practical Midwifery, p. 516. * Gardien, Traite des Accouch., vol. iv. p. 244. 7 98 TRISMUS NASCENTIUM. gatives and stimulants; and all, as far as I could judge, without a shade of relief." 121. In accordance with his view of the cause of this disease, Professor Colles advises that our attention should be directed to the .umbilical cord. He mentions that he had been informed, that, in Jamaica, where this disease was formerly frequent and fatal, it is now rarely to be met with, and that the means used are, to plunge the infant daily into a cold bath, and daily to dress the umbilical cord with spirits of turpentine. He suggests that this might be tried here, and inquires whether tying the cord nearer to the abdomen might not induce a more healthy and active inflammation, by which trismus might be avoided. 122. Dr. Breen seems to be more hopeful of the cure of at least some cases; his panacea is small doses of laudanum, with calomel and castor oil. "When the complaint develops itself, I order one drop of laudanum in an ounce mixture, and of this I direct a tea- spoonful to be taken every second hour, until the patient appears to be affected with the narcotic properties of the opiate, which often happens after the third dose ; then the mixture is given less fre- quently. A grain and a half of calomel is also administered every fifth or sixth hour up to the third time; afterwards, it is not given more frequently than twice or three times in twenty-four hours, with inter- mediate doses of castor oil, in the quantity of a large-sized tea- spoonful, sometimes joined with a third part spirits of turpentine, which appears to me to quicken the action of the former. I also occasionally order three ounces of the assafetida clyster of the Dublin Pharmacopoeia to be thrown up the rectum." Under this treatment, the paroxysms diminish in force and frequency. Nurse's milk must be given, and as the effect of the opium is weakened by use, the dose must be increased; but Dr. Breen has never found it necessary to give more than three drops in a two-ounce mixture. Occasionally at night he found it useful to substitute a grain of pulv. cretae comp. cum opio, with a grain and a half of calomel. He records two cases occurring in one year, that recovered under his own care by this plan of treatment, and one under the care of Dr. Graves. Gardien advises frictions with warm oil and laudanum, opium internally, and counter-irritants. Dr. Schneider recommends a compound tincture of musk and ambergris as having been of great use: The following is the for- mula employed in the hospital at Bamberg:— R. Ambr. gris. Q; ^Ether. vitr. gss. Stet per hor. xii. ssepe agitando, dein adde, Mosch. ^i: Liq. anod. Hoffm. §iii. M.1 Mr. Chalmers mentions that he had succeeded in one case by a combination of rhubarb and musk. Barere and Bajon tried warm 1 Edin. Med. and Surg. Journ., vol. vii. p. 225. CHOREA. 99 douches and cold baths, embrocations, oil of almonds, and syr. dia- cod., but in almost all cases were unsuccessful. 123. With a disease in which such faint hopes of a cure can be entertained, it becomes the more necessary to attend to such methods of prevention as have been found successful. Dr. Joseph Clarke's improved ventilation and attention to cleanliness, we have seen, had. a striking influence in reducing the number of cases and in diminish- ing the fatality, which decrease has continued, under successive masters of the hospital, until the present time, by the adoption of similar precautions. Each ward of a hospital ought to have an ample supply of fresh, pure air, by day and night, with the means of escape for vitiated air. A moderate number of beds in each ward, so as not to overcrowrd it, is also necessary. In the Western Lying-in Hospital, to which I have been many years attached, the disease is almost unknown. In private practice, trismus nascentium is exceedingly rare, because the more obvious and frequent cause is seldom present; however, as it does occur, it will be well to try Dr. Breen's plan of treatment. CHAPTER IV. CHOREA.--ST. VITUS'S DANCE.--DANCE DE ST. GUY, F.--VEITSTANZ, G. 124. The second name (St. Vitus's dance) given to this disease is said to be derived from a chapel at Ulm, built in honor of St. Vitus, who was himself affected with the disease, and which was visited in hopes of a cure by persons similarly afflicted. Without being limited to the period of childhood, it is nevertheless more frequent then than afterwards, occuring chiefly from the second dentition to puberty, or between the ages of seven and fifteen years, although we now and then see it in persons advanced in life: for example, Crampton met with it in a female upwards of forty years of age; Copland in a man upwards of fifty; Powell and Maton in females of seventy; and Bouteille in one of eighty years. It is also three times as frequent in females as in males. "Everything is extraordinary in this disease," M. Bouteille ob- serves in his preface; "its name is ridiculous, its symptoms singu- lar, its character equivocal, its cause unknown, and its treatment problematical." The definition given by Dr. Copland, in the learned article in his Dictionary, to which I have been much indebted, is the following: "Tremulous, irregular, involuntary, and ludicrous motions of the muscles of voluntary motion, more marked on one side than the other, without pain, occurring in both sexes, more frequently in the female, and chiefly between eight and fifteen years of age."1 1 Diet, of Pract. Med., Part i. p.. 327, Art. Chorea. 100 CHOREA. Chorea was known to the ancients, a disease closely resembling it having been described by Galen. It is noticed also in the writings of Plater, Horstius, and Sennert. From its striking peculiarities, it has at different times been attributed to demoniacal possession, or included among feigned diseases, and an affection very like it seems occasionally to have prevailed epidemically in Scotland and Ame- rica. 125. Symptoms.—In some cases, the attack comes on suddenly, without previous illness of any kind; but more frequently, for some days, the stomach and bowels are disordered, the spirits depressed, temper irritable, with frequent sighing. These symptoms are followed by irregular and involuntary motions or twitchings of the muscles of one side of the body, more frequently the left, or of one superior extremity, or of the face; very slight at first, but gradually increasing and extending to one of the lower ex- tremities, so as to impede walking, or render it unequal or jerking. By and by these chronic convulsive movements involve the other side of the body more or less, and at length the tongue, so that the speech is interrupted, unequal, and imperfect. It is very possible that some cases of stammering1 may in fact be a local species of chorea, and also those cases of incessant winking or twitching of the nose or month, which we meet occasionally, and which are so difficult to cure, although they often get well. I have at this moment under my care a little boy, very nervous, but healthy, who ordinarily winks about twice as often as other children, but if it be noticed, or if he be unusually earnest about anything, the eyelids are in incessant mo- tion, and closed with unusual force. The expression of the countenance undergoes a remarkable change; in action it borders upon the ludicrous, but in repose it is almost idiotic. All the voluntary movements are distorted or impeded; con- trol and direction are all but impossible, as Sydenham observes: "Before a child who hath this disorder can get a glass or a cup to wet his mouth, he useth abundance of odd gestures; for he does not bring it in a straight line thereto, but, his hand being drawn side- ways by the spasm, he moves it backwards and forwards, till, at length, the glass accidentally coming nearer his lips, he throws the liquor hastily into his mouth, and swallows it greedily, as if he meant to divert the spectators."2 The movements of the lower extremities are generally less violent than those of the upper, but sufficiently so to render the walk uncer- tain, irregular, and jerking, obliging the child, in some cases, to keep constantly moving in order to avoid falling, and rendering him at all times insecure and liable to fall. There is more agitation of the lower limbs in bed than when up, evidently because the weight of the body steadies them in the latter case. 126. The muscles which support the head are also affected, so that it is sometimes bent forwards or backwards, or jerked towards one .or ' Dr. Marshall Hall on the Diseases and Derangements of the Nervous System, p. 191. 2 Sydenham's Works, by Wallis, vol. ii. p. 430. CHOREA. 101 other shoulder, or agitated with a rotary movement. When the attack is very severe, the muscles of the trunk participate, and the body is jerked hither and thither so violently as to render confinement to bed necessary.1 Rufz mentions a case in which the child threw itself out of bed, and crawled about the room like a worm.2 Mr. Watt has related a case, in the Medico-Chirurgical Transactions, of a little girl who was seized with an irresistible propensity to turn round on her feet like a top, then to lie down and roll rapidly back- wards and forwards; in a more advanced stage of her disease, while lying upon her back, to bend herself up like a bow, by drawing her head and heels together, and then suddenly to separate them, so as to cause the buttocks to fall with considerable force upon the bed, and to repeat this continually for hours: at a still later period, she was seized with a propensity to stand upon her head, with her feet per- pendicularly upwards; as soon as her feet gained the perpendicular, all muscular action ceased, and her body fell as if dead, her knees first striking the bed, and her buttocks striking her heels; this was no sooner done than she instantly mounted up as before, and con- tinued these evolutions, sometimes for fifteen hours successively, at the rate of from twelve to fifteen times in the minute.3 In other cases, the parOxysm consists in hammering the knees with the hands, or of a constant series of bowing. Such cases as these latter, however, have one peculiarity not usual in chorea, i. e., the muscular movements appear independent of the will, neither excited by it nor under its control, and it is almost certain that, in some of these cases, the patient is unconscious. In mild cases of chorea, the irregular movements cease during sleep ;4 but, when the attack is very severe, they do not cease entirely.5 So far, we have seen the convulsive motions affect chiefly the volun- tary muscles, but the muscles of organic life do not altogether escape: the rapid deglutition, the gulping down of fluids, is, doubtless, owing to a spasm of the pharyngeal muscles, and the peculiar cry, which some emit, to spasmodic action of the larynx. 127. The general health may not be so much affected as we might expect, in simple chorea; the stomach seems capable of digesting food ; the appetite, though occasionally capricious, is generally good, and now and then enormous; the bowels are most commonly regular and under control, although Berndt and Frank mention that they are occa- sionally moved involuntarily during a paroxysm. Dr. Copland states that the bowels are always constipated, and the abdomen somewhat hard and tumefied. There is no febrile action when the disease is uncomplicated; the pulse is rarely quickened, the skin is cool, and there is no increase of thirst. Pain is seldom complained of, and but little general distress. Out of twenty cases related by M. Dufosse, eight suffered from slight headache, six from palpitations, and two ' Rilliet and Banhez, vol. ii. p. 297. z Archives Gen. de Med., 1834, vol. iv. p. 239. 3 Condie on Diseases of Children, p. 403, second edition. < Richard, Mai. des Enfans. p. 547. '= Stewart on Diseases of Children, p. 496. 102 CHOREA. from a pain, increased by pressure upon the spinous processes. M. Richard states that most of the girls he has seen affected with chorea presented a lateral curvature of the spine, and he seems inclined to attribute it to an overstretching of the nerves.1 The temper of children laboring under chorea is very unequal; they are apt to be capricious, fretful, and easily frightened; even a slight contradiction will bring on a paroxysm. In the majority of cases, when the attack is not prolonged, the intellect is scarcely affected; but if the disease be permanent, the mental power becomes weakened, or exercised fitfully and fancifully, and at length the patient becomes melancholy and silent. M. Gardien denies that it ever ends in idiocy, but M. Rufz has related two cases in which it did; and certainly the appearance of some chronic cases gives one the impression of their being very little removed from this condition. It is possible that, in these extreme cases, the imbecility may be owing to some organic change in the brain, as we also occasionally find the patient attacked by epilepsy or hemiplegia; and Condie mentions that they are some- times carried off by tubercular meningitis ;2 but this can only be con- sidered as a secondary disease. 128. In the great majority of cases, chorea in children is an acute disease, increasing up to a certain point, then perhaps remaining stationary for a time, and at length gradually subsiding. Its duration varies from two or three weeks to several months. The quickest re- covery Dr. Copland has ever known was eleven days; M. Legendre's patient died in nine days; M. Rufz fixes the mean duration at thirty- one days; M. Dufosse at fifty-seven days; and Rilliet and Barthez state the duration to range from six weeks to two months and a half; the'latter, careful observers saw but two cases that b'ecame chronic. Relapses, however, are very frequent. Dr. Copland saw it occur three times in the same patient; M. Rufz six times; and Rilliet and Barthez once, twice, and thrice in nineteen cases. Chorea most frequently terminates in a return to health; but it may also end in convulsions, epilepsy, palsy, anaemia, dropsy, hydroce- phalus, or idiocy;3 and any of these attacks may prove fatal. Dr. Brown mentions three cases terminating in convulsions, coma, and death ; and Dr. Elliotson one which proved fatal from apoplexy. 129. Complications.—The complications of any disease, or those secondary affections which arise in its course, are always of import- ance, and deserve most careful investigation, particularly in the dis- eases of children, for they are often masked by the primary disease, and yet are occasionally the more fatal. On this account I shall en- deavor to lay before my readers these secondary attacks as accurately as I can, without deciding whether they are mere accidental compli- cations, or, as in many cases I believe, have a positive relation and dependence upon the primary morbid condition. Chorea is not unfrequently combined with hysteria, when it sets in at or soon after the eruption of the catamenia; nay, it may assume ' Mai. des Enfans, p. 547. * Diseases of Children, p. 397. 3 Copland's Dictionary of Medicine, p. 328. CHOREA. 103 very much the appearance of the latter, and there will also generally be found some irregularity in menstruation; it is either scanty, light- colored, irregular, or altogether absent. "The following procession of morbid phenomena is not uncommon," says Dr. Copland; "chorea, with defective action of the digestive, assimilating, and secreting func- tions, and torpor of the liver; at a subsequent term, protracted cata- menia, or scanty and protracted appearance of the secretion, occa- sionally with various hysterical affections, seldom amounting to a complete fit of hysteria; and lastly, when the catamenia become established, the hysterical affection is sometimes more fully pro- .nounced, and with the regular establishment of the uterine functions, the chorea disappears."1 Dr. Copland was the first to demonstrate by post-mortem examina- tion its complication with rheumatism, rheumatic pericarditis, and disease of the membranes of the spine, and his observations have since been confirmed by Drs. Pritchard and Roeser.2 • Congestion of the brain, inflammation of its membranes, with serous effusion, tubercular meningitis, &c, have been detected by Soemmering, Brown, Coxe, Patterson, Serres, Condie, &c. It is not uncommon to have some of the febrile diseases of infancy, as measles or scarlatina, concurrently with chorea; and some difference of opin- ion exists as to their influence upon the original affection. M. Rufz says that "they exercise no influence upon either the duration or in- tensity of the chorea." On the other hand, Rilliet and Barthez state that, out of nineteen cases, nine were attacked by other diseases, and eight were evidently influenced by them ; sometimes the chorea di- minished from the commencement; in others it increased, at first, and afterwards disappeared. They cite four cases from Legendre, Piet, and Rufz, in which measles, scarlatina, and small-pox occurred, and the chorea was cured.3 130. Pathology.—The post-mortem appearances which are record- ed result from the complications or secondary affections, rather than from the primary disease. The body is generally emaciated, the muscles flaccid and pale, and occasionally we meet with some lesion of the stomach and bowels, or slight effusion into the peritoneum. Dr. Hawkins found increased vascularity of the uterus, tubercles in the lungs, and earthy concretions in the mesentery, omentum, and pan- creas ; Drs. Copland, Pritchard, and Roeser, adhesion of the opposite surfaces of the pericardium, with effusion of serum. In one case, Dr. Pritchard observed the surface of the heart covered in parts with coa- gulable lymph, its cavities much enlarged, and their parietes thin, pale, and flabby. Soemmering, Brown, Coxe, Willan, Patterson, Guersent, and others, have detected marks of inflammation of the membranes of the brain, or of the brain itself, and also some foreign deposits in its substance or on its surface. In three cases, M. Serres found inflammation of the tubercula quadrigemina, and in one a tumor resting on this part of 1 Dictionary of Medicine, p. 328. 2 Ibid. 3 Mai. des Enfans, vol. ii. p. 303. 104 CHOREA. the brain. MM. Mo nod and Hatin observed hypertrophy and vascu- larity of the brain and spinal cord, especially of the cortical substance ; Bright, turgescence of the brain and cord, with bony lamellae on the pia mater of the spinal marrow ; and Kein, ecchymoses of the mem- branes, with a pulpy state of the medulla. Dr. Copland remarks: "In a case which occurred to me in 1819, complicated, or rather alternating, with rheumatism, with metastasis of this disease to the heart, and subsequently to the membranes of the spinal cord, inflam- matory appearances, with coagulable lymph and an effusion of turbid serum, were found through nearly the whole extent of their mem- branes ; the patient having died in a state of universal paralysis." " Dr. Aliprandi has also detailed a case, in which morbid appearances similar to those described by myself and Dr. Pritchard were found in the spinal canal."1 MM. Rilliet and Barthez observe that, in the great majority of cases, no lesion of the cerebro-spinal system can be detected, their observa- tions so far agreeing with those of Black, Rufz, Gerhard, and Gen- drin, &c. They mention some cases, however, in which there was great congestion of the membranes of the brain and spinal marrow, and one in which the latter was slightly softened,2 as in twro cases of M. Gendrin, one of M. Courtois, and three or four of M. Rufz.3 Mr. Coley has also reeorded the appearance of medullary meningitis, with softening.4 131. These opinions as to the nature of chorea, founded upon post mortem examinations, are necessarily very various. They who have detected no morbid traces will regard it, with Sydenham and many others, as a nervous affection analogous to convulsions ; those who have observed morbid alterations will determine the seat and nature of the disease accordingly. So Bouteille, Clutterbuck, Lisfranc, &c. consider it to be inflammation of the cerebro-spinal axis; Serres, as an affection of the corpora quadrigemina ; Bouillaud and Magendie, of the cerebellum, &c. But we must carefully guard against the error of mistaking complicated forms of the disease for essential ex- amples of it, and of generalizing from too small a number of cases. There can be no doubt that this, as well as other nervous diseases, may be either idiopathic or symptomatic : in the former, little or no organic changes will be discovered; in the latter, merely those of the exciting cause. Dr. Marshall Hall observes5 that " chorea is distinctly an affection of the true spinal system; it affords an example of the want of har- mony between the cerebral and the true spinal acts; volition is nor- mal ; the true spinal action is abnormal. The action is abnormal or irregular, for want of a precise harmony between the two." Probably the explanation given by Dr. Copland is as correct as any; he states that "the proximate cause of chorea, in its true and simple form, seems to consist of debility, with some degree of irritation of the or- 1 Diet, of Pract. Med., p. 329. a Mai. des Enfans, vol. ii. p. 314. 3 Barriere, Mal.de l'Enfance, vol. ii. p. 434. « Diseases of Children, p. 447. 6 Diseases and Derangements of the Nervous System, p. 195. CHOREA. 105 ganic or ganglial class of nerves, extended more or less to those of volition, and occasioning morbid susceptibility of the nervous system - generally, with diminished power, increased mobility, and irregular actions of the muscular system, particularly of those muscles supplied with the nerves principally affected. Whilst this appears to be the pathological state of the majority of cases of chorea, yet instances not unfrequently occur, in which the disorder evidently commences in the spinal cord or its membranes, disturbing the functions of the nerves issuing from the affected part."1 132. Causes.—Among the predisposing causes, it would appear that sex has much influence, as we find the proportion of those at- tacked to be about three females to one male. In 240 cases, M. Du- fosse found seventy-nine male and 161 female children; and Dr. Stewart states that, in 174 reported cases, there were 122 girls and - fifty-two boys. The age most obnoxious to attacks of chorea is from six to fifteen years, and on this account it has been regarded as essentially con- nected with puberty;2 but this cannot be correct, for M. Constant saw a case of the disease at the age of four months, and M. Dufosse one aged three years. M. Rufz gives a record of 189 cases: of these, ten were six years old, or under, and 179 from six to fifteen years of age. No doubt, as has been observed, this is a loose calculation, based upon hospital registries, which are not proverbial for their ac- curacy. Barthez and Rilliet mention nineteen cases: in three, the first attack occurred at four years of age; in one, at five; in one, at six; in two, at seven; in two, at eight; in four, at nine; in one, at ten; in two, at eleven; in one, at thirteen and a half; and in two, at fourteen years of age. I have already mentioned cases occurring at an advanced period, so that we cannot attribute as exclusive an influence to a certain age as some writers; but, on the other hand, it cannot be denied that pu- berty may, and probably does, exert considerable influence. What effect climate may have, is not very easy to determine; the disease appears to occur less frequently in southern countries, and in the West Indies is altogether unknown.3 Children of a nervous tem- perament, of great sensibility, and precocious intellect and passions, .are generally considered to be more liable to chorea than others; but this is doubted by Elliotson, Rufz, Rilliet and Barthez. It is cer- tainly not confined to delicate children, for many of those attacked by it have previously enjoyed excellent health. Nor are there sufficient grounds for regarding chorea as a hereditary disease, although Coste, Young, and Constant have each met an example. 133. According to some authors, e. g., Mezerai, Cullen, and Heck- er, chorea has occurred epidemically. Albers, cited by Frank, men- tions a school in-which it appeared as an epidemic, and Rilliet and Barthez, a village in the Tyrol, in which it occurred recently. Dr. Copland has given an interesting section on nervous disorders, resem- ' Diet, of Pract. Med., p. 331. a Gardien, Traite des Accouch., vol. iv. p. 269. 3 Stewart on Diseases of Children, p. 495. 106 CHOREA. bling chorea; as, the effect of the bite of the tarantula, the leaping ague of Scotland, and an affection which spread rapidly among a sect of religious enthusiasts in Tennessee and Kentucky, described by Dr. Robertson, &c. &c, which strikingly resemble chorea, and the exten- sive prevalence of which may have originated the idea of an epide- mic. Dr. Wicke1 states that, in a boarding-school at Eisenach, the disease spread by imitation; and it must be remembered that no dis- ease is more likely to be imitated, and no class of persons more likely to become imitators, than those who are the fittest subjects for chorea. Among the exciting causes, are enumerated worms, dentition, fright, falls, or blows, according to Reeves, Bedingfield, Hall, Ecker, Ril- liet and Barthez, &c. Copland, Ploucquet, and Pritchard attribute it to rheumatic metastasis to the membranes of the spinal cord; Darwin, Haygarth, and Richter, to mental exercise, emotions, or pas- * sions. 134. Diagnosis.—The pathognomonic characters of chorea are, permanent, chronic, and, to a certain extent, voluntary movements, irregular in direction and amount; their cessation during sleep; the consciousness and sensibility of the patient; and the age at which, and the mode in which, the disease commences. It is just possible that chorea may be confounded with hysteria, convulsions, paralysis, and delirium tremens. i. From the similarity of the age at which hysteria makes its first appearance, there may be some difficulty in the diagnosis of these dis- eases about the period of puberty, and especially at the commencement of a first attack, but none at an earlier age, for then hysteria is un- known. Moreover, as Dr. Copland has observed, chorea is often combined with hysteria in girls, and then, of course, distinction is impossible. But generally hysteria occurs in more distinct periodic paroxysms, the movements less contorted, less ludicrous, quite invo- luntary, and generally accompanied with globus hystericus, laughing and crying, and pale urine. n. In convulsions, the movements are spasmodic, entirely involun- tary, and much more violent, whereas the movements in chorea, though partly involuntary, are, to a certain extent, under the control of the will, and are in general modifications of voluntary motions. Further, in convulsions, the patient is, for the most part, unconscious and insensible. in. When chorea is confined to one portion of the body—for in- stance, the tongue, on account of the difficulty of articulation, and the irregular protrusion of that organ—we may be led to suspect cerebral disease, but the speedy extension of the chorea will rectify our opin- ion ; and when more of the body is affected, the preservation of sensibility, and, to a considerable extent, of motion, voluntary and involuntary, will preclude the possibility of supposing the case to be paralysis. 1 Analekten der Kinderkrankheiten, Pt. viii. p. 89. CHOREA. 107 iv. The age at which chorea occurs—so far, at least, as concerns my present subject—precludes, of course, the suspicion of delirium tremens. 135. Prognosis.—The prognosis will mainly depend upon whether the chorea be simple or complicated, idiopathic or symptomatic. In the majority of simple cases, it is favorable, although Rufz, and Rilliet and Barthez have recorded two cases which terminated fatally. But when it is complicated with rheumatism, inflammation of the membranes of the brain or spinal marrow, convulsions, dropsical effusions, &c, the prognosis will be much more serious, and will depend, in a great measure, upon the extent and severity of the secondary affections, and upon the constitution of the child. Many fatal cases are upon record, although the majority recover. Accord- ing to Joseph Frank, chorea, neglected, may lead to mania, apoplexy, paralysis, and consumption. 136. Treatment.—The list of remedies which have been tried in this disease is long and varied, as the reader may see by referring to Copland's Dictionary. The indications of treatment must be founded on a careful study of each case, its characters, complications, &c. The first indica- tion in simple chorea will be to remove fecal accumulations, and to correct any morbid condition of the intestinal canal; the second, to relieve the nervous affections ; and the third, to subdue the compli- cations, if there be any. By many authors, purgatives alone are recommended; but, as Dr. Copland observes, a combination of purgatives with antispasmodic or stimulating remedies is much more efficacious. A full dose of calomel maybe given at first, followed, at intervals, by infusion of gentian and senna, or by an occasional dose of castor oil and turpentine. The frequency and continuance of the purgatives will be decided, in a great measure, by the character of the evacuations. But although we have abundant evidence of the success of this plan in this country, I ought not to omit to state that, in France, according to Rilliet and Barthez, little or no confidence is felt in purgatives. Breschet recommends tartar emetic in full doses, but given so as not to excite vomiting. 137. For the relief of the nervous affection, antispasmodics, nar- cotics, and tonics are recommended. Valerian was first employed by Bouteille, and since by Murray, Guersent, and Jadelot, with suc- cess; assafetida has also been found useful. Oxide of zinc, originally given as a quack medicine in this disease, has been employed by Duncan, Fouquet, La Roche, Wright, &c. Should it irritate the stomach, the addition of gr. ii of the cuprum ammoniatum will correct it, as Dr. Odier, of Geneva, has observed. Drs. Copland and Babington consider the sulphate of zinc very useful, beginning with small doses, and increasing up to twelve or fifteen grains, three times a day, according to the latter physician. Frank, Uwins, and Crampton have tried nitrate of silver, after purgatives, with great benefit in obstinate cases. Camphor has been 108 CHOREA. recommended by Worlhoff, Mahon, &c. Other practitioners have given, successfully, Fowler's solution of arsenic, iodine, stramonium, prussic acid, belladonna, opium, &c. As, however, to be of any use, antispasmodics must be continued long, it will be well, after free purgation, to try those first which will admit of continuance, as vale- rian, assafetida, oxide or sulphate of zinc, &c, and in combination with some tonic, as in the following formula, given by Dr. Copland :— R. Pulv. calumbae, gr. x; " Valerianae, gr. xii ad J") i; Carb. ferri, pp. gr. x ; Pulv. cinnam. gr. vi. M. Ft. pulv. vel elect, molle cum. syr. zingib. q. s. Bis vel ter quotidie sumatur. As a tonic, bark or quinine will be found most generally useful, and it may be given in the form of powder or decoction, or as a pill. Marley recommends bark or calumba, with decoction of aloes, after a full dose of calomel and jalap, followed by moderate laxatives. Mead, Elliotson, Bateman, Baudelocque, and Bonneau have ob- tained great success from preparations of iron ; Elliotson and Baude- locque prefer the subcarbonate, and Bonneau iron filings, in combi- nation with quinine and a small portion of opium: and to the efficacy of the latter remedy, Rilliet and Barthez bear ample testimony. Mr. Salter1 has detailed successful cases treated by the liq. ar- senicalis; and Dr. M. Hall has added a similar case of his own, and one of Dr. Heming's.2 Drs. Peltz, Abney, and Baudelocque have lately tried iodine with great advantage.3 "Recently, very decided testimony has been presented by Young of Pennsylvania, Lindsay of Washington, Hilddreth of Ohio, Kirk- bride and Professor Wood of Philadelphia, and Beadle of New York, in favor of the cimicifuga in cases of chorea. It may be given in doses of half a teaspoonful of the powdered root three times a day ; or from one to two drachms of the saturated tincture; or a wine- glassful of the decoction."4 138. When the convulsive movements are violent, incessant, and prevent sleep, there can be no hesitation in administering narcotics ; it is in such cases that opium, stramonium, hyoscyamus, and bella- donna have been recommended ; but it will need great watchfulness and caution if the latter be exhibited, especially with young children. I should myself much prefer opiates, as being more steady and cer- tain in their effects, and less injurious. Cold baths have been much used by Petit, Jadelot, Dupuytren, and Marley, and sea bathing by Hufeland and Himly; but I agree with Biett and Copland that a shower bath, the patient standing in warm w-ater, is more likely to be beneficial. Baudelocque substituted sul- phurous baths for simple water, and with good effects; they were easily prepared by adding sulphuret of potash to the ordinary bath, and were taken every day, the patient remaining in the bath half an 1 Med.-Chir. Trans., vol. x. a Underwood, p. 285. 3 North American Med. Journal, vol. ii. * Condie on Diseases of Children, second edition, p. 407. CHOREA. 109 hour or an hour. Five out of eight patients thus treated were rapidly cured, according to Rilliet and Barthez. Counter-irritants have been recommended; blisters, setons, issues, and moxas have been tried, but the result does not seem very en- couraging. Electricity or electro-magnetism has been advocated by De Haen, Fothergill, Schaeffer, &c, and found useful in some obstinate cases by Meyraux, Addison, Bird, and others. Dr. Bird is said to have cured twenty-nine out of thirty-six, and to have afforded relief in five of the remainder. The electricity was applied in the form of sparks, in the course of the spine, every other day, for about five minutes at a time, until an eruption appeared. When the electric shocks were transmitted through the affected limb, the convulsive movements were increased; and if employed when the patient was convalescent they reproduced the disease. " Trousseau has recently treated thirteen cases of chorea with strychnine, ten of them with complete success. He employs the sul- phate of strychnine dissolved in syrup, one grain to three ounces and a half; of this two drachms and a half are given daily in three doses; and the quantity is every day increased a drachm and a quarter until itching of the scalp and slight muscular stiffness are observed. The cure is generally completed in one month."1 139. Opinions differ very much as to the propriety of blood-letting, and it is not improbable that the difference may have been owing to the presence or absence of complications which would materially affect the result. Sydenham recommends bleeding to eight ounces, then three or four purgatives on alternate days, after which he repeated the bleeding and purging, with an opiate at night and a sufficient in- terval between each evacuation to avoid all danger.2 Cullen says that it is sometimes useful; in other cases, injurious. W^att found it decidedly useful; Armstrong injurious; but Clutterbuck, Bouteille, Serres, and Lisfranc recommend it. Its propriety will depend upon the evidences of congestion or in- f flammation in the brain or spinal marrow, indicated by pain, increased vascular action, heat of the head, coldness of the extremities, &c.; then a few leeches behind the ears or along the spine, or cupping, followed by cold affusion or irritating liniments, and warmth to the lower extremities will be highly proper. Marley3 mentions that twro of his patients, who had resisted the usual remedies, recovered on the occurrence of menstruation, and this will always be a ground of hope with girls affected with chorea. During the progress of treatment, the diet should be light and mo- derate, varying according to the constitution of the patient and the complications it presents. If there be evident inflammatory action, of course low diet will be necessary; if, as is sometimes the case, the patient be nearly in a state of anaemia, full diet will be required. When convalescent, the patient will be greatly benefited by change 1 Condie on Diseases of Children, p. 408, second edition. ' Works, vol. ii. p. 431. 3 On Diseases of Children, p. 111. 110 CONVULSIONS. of air and scene, and by the use of mineral, aperient, or chalybeate waters, according" to circumstances. Sea bathing, with a free admix- ture of amusement, exerts a salutary influence. 140. The complications will necessitate a change in the treatmenf. When rheumatism occurs, Dr. Copland observes, "It has generally been promoted by too lowering a treatment, but prevented by tonic and stimulating medicines, with due attention to the alvine evacua- tions. In cases, therefore, complicated with rheumatism, chlorosis, anaemia, or retention of the menses, the purgatives selected should be of a warm and stomachic kind, or combined with cordial and stimu- lating substances: the ammoniated tincture of guaiacum, camphor, serpentaria, and similar substances, being also employed. In these states of disease, the internal use of the cod or tusk-liver oil will be found most beneficial. Having observed instances in which the sup- pression of rheumatic affections of the joints, by the use of embroca- tions and liniments, was rapidly succeeded by the appearance of in- ternal disease, the application of such remedies to the external seat of the rheumatic disorder should not be resorted to."1 When chorea is complicated with hysteria and menstrual irregu- larity, it will be necessary, after evacuating the bowels, to attempt the regulation of the uterine functions by hip baths, emmenagogues, par- ticularly preparations of iron, and perhaps by leeching the upper part of the thighs. To the treatment of inflammatory complications, I have already- alluded ; for them a certain amount of antiphlogistic treatment is essen- tial. Whatever they be, they must be treated in the manner appro- priate to them as independent diseases, but with more caution and moderation than usual, because of the existence of the chorea. CHAPTER V. CONVULSIONS. 141. There are few diseases of infants and children which are more formidable or more fatal than convulsions. They attack chil- dren of all ages, of different natural constitutions, and under very various circumstances, usous toutes les latitudes, sous la zonebrulante des tropiques, comme sous la zone glacee de Spitzberg."2 The disease has been variously classified, and with different mean- ings attached to the same nomenclature; the essential distinction, however, being between an attack dependent upon disease of the brain or spinal marrow, and those cases where no such disease exists. These constitute the idiopathic and symptomatic convulsions of authors. 1 Dictionary of Medicine, p. 335. 1 Brachet sur les Convulsions. 1824. CONVULSIONS. Ill Dr. Marshall Hall has proposed a more scientific division into centric and eccentric: "The former class would comprise all diseases of the brain and spinal marrow, complicated with convulsions; the latter all those convulsive diseases which arise from teething, indigestion, de- ranged bowels, and w'hich probably act through the fifth pair, the eighth pair, and the spinal nerves respectively, and constitute a part of a more comprehensive class of diseases, embracing affections of a series of nerves of what I have designated the reflex functions."1 I shall, however, adopt the more recent division into: 1, primary or essential convulsions, arising from irritation of various kinds, men- tal emotion, &c.; 2, sympathetic convulsions occurring in the course of fevers, or organic diseases of any kind, excepting those of the brain or spinal marrow; and 3, symptomatic convulsions, connected with diseases of the head or spine. 142. M. Bouchut has given forty-one cases of convulsions: twenty- seven were essential or sympathetic, and fourteen symptomatic. Of the twenty-seven, fifteen were attacked in perfect health, and were cured; but four of them died some months afterwards, of other dis- eases, and no structural alterations were detected in the brain; twelve occurred in the course of other complaints, as pneumonia, erysipelas, &c; seven of these died, and in one only was there any morbid ap- pearance in the brain. He concludes, therefore, that "convulsions may occur, 1, in a state of health; 2, in the course of acute diseases, and in such cases are analogous to delirium; and 3, that there is no relation betwreen these convulsions and lesions of the nervous centres."2 MM. Rilliet and Barthez refer to twenty-five cases of sympathetic, and thirty-five cases of symptomatic convulsions; but this apparent disproportion is explained by their not including in their report infants under a year old, and we know that primary convulsions are greater in infants than in older children. They have given the following table of the ages at which the patients were attacked.3 25 Cases of Sympathetic Convulsions. At 18 months old there occurred 1 case. 2 years 3 4 5 6 4 eases. 7 " 4 " 3 " 5 " 1 case. 35 Cases of Symptomatic Convulsions. At 2 years old there occu ■red 6 cases. 3 " " :< 9 " 4 a " " 2 « 5 n " :. 5 " 6 " ft " 2 « 7 u " " 3 '< 8 " tc u 1 case. 9 a £( " 3 cases 10 u U !( 2 " 11 i: " " 2 « Taken altogether, primary convulsions are by far the most frequent during early infancy, and symptomatic convulsions at a more ad- vanced age. 143. Causes.—It has been stated that female children are more obnoxious to these attacks than males; but this is very doubtful. As 1 Underwood on Diseases of Children, p. 268. a Manuel Prat, des Mai. des Nouv.-nes et des Enfans a la Mammelle, p. 387. 3 Mai. des Enfans, vol. ii. p. 278. 112 CONVULSIONS. far as my own experience goes, I should say the contrary, and this accords with the observations of MM. Rilliet and Barthez. Of their twenty-five cases, fifteen were boys, and ten girls. The opinion, pro- bably, had its origin in the fact that nervous children seem especially predisposed to convulsions, but the distinction of sex as to tempera- ment is not so decided in children as in adults. It is not very clear whether climate exerts much influence upon the disease. Mr. North seems to think that it does, and he quotes Dr. Hillary, who observes that the children of the Island of Barbadoes are so irritable that they are thrown into convulsions by the slightest noise;1 but we find convulsions equally prevalent, I think, in temper- ate, or even in cold climates. It certainly appears that convulsions may be hereditary and conge- nital. Boerhaave mentions that the children of an epileptic man all died of the same disease. Lorry relates the history of a family, of which the father, mother, and children were affected with convulsions from the slightest cause, notwithstanding that the children had been brought up separately, and educated differently. Baumes gives several similar cases. Guersent and Blache mention the case of a woman who was extremely passionate during pregnancy, and who lost three infants successively, from convulsions, soon after birth; and Bouchut states that he knew a family of ten children, all of whom had convulsions during infancy; one of them married, and had ten chil- dren, nine of whom had convulsions, and six died.2 Among Rilliet and Barthez's cases, two were children of an epileptic father, and a third had lost four brothers and sisters of convulsions. Mr. North attributes the congenital predisposition to convulsions, in many cases, to feebleness on the part of the parents; to their marrying at too early or too advanced an age. If the mother, when pregnant, receive a great shock, a severe fright, or be subject to any other strong mental emotion, the child is often attacked by convulsions soon after birth. On the other hand, children born during an attack of puerperal convulsions are not necessarily affected by the disease. I have seen a considerable num- ber of such cases, where the infant was saved, and I am not aware of a single case which was subsequently attacked. The disease has occasionally prevailed as an epidemic; in Paris, as described by Gaultier de Claubry, and in Copenhagen, according to Lange, where it was very fatal. The pressure exercised upon the head of the infant, in its transit into the world, and " the natural state of increased vascular action in the"*brain, and the consequent excess of vitality, during its transmis- sion from the soft mass to its regular organization, also imparts a strong predisposition to irregular nervous action, when an excess of action occurs, or any circumstance comes to interrupt the regular process of gradual development."3 144. The delicate condition of the brain, its transition from quies- i North on Convulsions, p. 15. 2 Mai. des Nouveaux-nes, &c, p. 392. 3 Stewart on Diseases of Children, p. 483. CONVULSIONS. 113 cence to organic activity at birth, and. the concentration of stimula- tion from the senses and other organs, must naturally, one would think, predispose to the disease. The influence of temperament must not be omitted; no doubt, nervous, sensitive, and irritable children are more liable to convul- sions, and perhaps those of a full plethoric habit; but not these alone, for they not unfrequently attack infants in a state of anaemia; those, for instance, who have lost blood from the navel-string; or weak, pale, delicate children, and those exhausted from excessive dis- charges.1 A large-sized head has been regarded as predisposing to convul- sions, by Desessart, Gardien,2and others, and popularly it is considered as a sure sign, especially if the forehead be prominent, and yet nothing can be less generally true. I have noticed many such cases, and have watched them carefully for many years, for the purpose of as- certaining the value of this opinion, and I have found it, as a rule, useless and untrue. " Levret, Baumes, and other writers," says Mr. North, " affirm that it may be established as an axiom, that children born with large heads, or whose heads increase in size disproportion- ably to the other parts of their bodies, will have convulsions. In my own practice, I have seen convulsions occur very frequently in chil- dren with small heads. In rickety children, the size of the head is disproportionately large; and from the general symptoms of rachitis, it is evident that the head and spinal marrow are considerably affected: the brain increases rapidly in size, the senses are usually very acute, and convulsions are very frequent attendants of this distressing malady. It not unfrequently happens, that when some children of the same parents are affected with rachitis, others, who are exempted from this disease, are at a very early age destroyed by convulsions."3 145. The exciting or occasional causes are very various. Shame, anger, and fright have been known to induce an attack. North re- lates a case of a child thrown into fatal convulsions by the nurse threatening to throw him out of the window if he did not cease cry- ing. It has been attributed to tight bandaging, a pin piercing the child,4 excessive mental emotion, a loud noise, sudden exposure to a bright light, hot, impure air, or severe cold. Guersent and Blache mention their occurrence in children confined in a hot cham- ber, or in a crowded and hot theatre, for some hours; and Brachet states that a little girl being exposed to severe cold for eight or ten minutes, was seized with difficulty of breathing threatening suffoca- tion, followed by convulsions. During the first year of life, convulsions may not unfrequently be traced to the milk of the mother or nurse disagreeing with the infant, or having been disordered temporarily by fright, passion, or suffering. Soemmering mentions a curious case of a woman whose milk agreed with her own child, but caused convulsions in all others. M. Guer- 1 Barrier, Mai. de l'Enfance, vol. ii. p. 380. a Traite des Accouchemens, &c, vol. iv. p. 250. 3 On Convulsions, p. 11. 4 Richard, Mai. des Enfans, p. 541. 8 114 CONVULSIONS. sent relates an instance of a woman deserted by her husband, and in her distress her infant had an attack each time it took the breast. Dr. Underwood mentions a mother who nursed her child immediately after witnessing a sudden death; the child was attacked by convul- sions, after which it remained comatose for thirty-six hours, but ulti- mately recovered.1 Numerous cases are on record of convulsions supervening upon violent passion in the nurse. I have witnessed more than one case resulting from the mother suckling her child dur- ing a time of severe affliction and distress. It is said that the exhibition of soothing medicines by the nurse, such as Godfrey's cordial, syrup of poppies, &c, may bring on an attack. 146. At a later period, dentition is certainly a very frequent cause ; the distension of the gums, the pressure, the intense congestion, occa- sion so much irritation, that an attack of convulsions is a common result. This is the case particularly with lively, sensitive, nervous children, although the more quiet and phlegmatic do not always es- cape. I have repeatedly observed in these cases a sort of gradation from simple irritation and restlessness to starting, surprise, wildness of look, partial or local convulsive movements, and lastly, general convulsions. Or the attack may be caused by derangement of the stomach and bowels, from retention of the meconium or urine, from too much or too thick food, from eating indigestible matters, the improper use of stimulants, &c.; or it may result from the diarrhoea consequent upon these errors of diet. One of my own children was attacked by severe diarrhoea, followed by reaction, high fever, and convulsions. It was remarked to me by Dr. Johnson, one of the most accurate observers and judicious practitioners I have ever known, that such cases are generally more manageable than others, and so I have found it. By many authors an attack has been attributed to worms, and Brachet relates a case of convulsions which was owing to a worm in the meatus auditorius. Cerise and Barrier admit the influence of suppressed normal or morbid secretions or eruptions in the production of convulsions, although the latter thinks that it has been exaggerated. Certain it is that an eruption of crusta lactea on the head has been repeatedly found to cure the disease. Too long continued or too long suspended exercise of the senses may equally give rise to convulsions in infants, and too much mental excitement and exertion in children of more advanced age. The attempt to press forward the education of children is, in fact, an excess of stimulation to the brain, and is attended with the greatest risk. 147. So much for the causes of primary convulsions. Sympathetic convulsions frequently usher in organic diseases, or eruptive fevers, as scarlatina, measles, &c.; and Sydenham and Bouchut are rather disposed to regard it as a favorable occurrence. Barrier mentions three cases of pneumonia, commencing in this manner, and the fact is noticed by many writers. 1 On Diseases of Children, p. 258. CONVULSIONS. 115 Or they may occur in the course of organic diseases of the chest or abdomen, particularly towards their termination, from their amount of irritation, or from exhaustion. The latter attacks are analogous to the convulsions from anaemia.1 Mauthner remarks, "I have often observed, in cases of extensive hepatization or tuberculization of the lungs, during the course of which the brain was perfectly unaffected, that the children, a few days before death, lost all chest symptoms; that the cough and orthopnoea seemed to have entirely vanished, their appetite returned, and they seemed cheerful; when convulsions suddenly came on, followed, in a few hours, by death."2 From the mechanical interruption to the regular central circulation, it is not uncommon to have convulsions in the course of croup or hooping-cough, nor do I know a more unfavorable complication; the child is generally not in a condition to bear active treatment, and even if we succeed in allaying the convulsive attack for the time, it is almost certain to return if the cough continue. Convulsions may occur at the termination of any of the organic diseases, and in such cases the result is generally unfavorable, whether the sympathetic irritation be of an active kind or result from exhaus- tion—"a repletione aut ab evacuatione"—according to Hippocrates. 148. Symptomatic convulsions may result from various cerebro- spinal diseases; congestion and inflammation of the membranes; effusion of fluid; inflammation and softening of the brain or cord; abscesses, tumors, or spiculae of bone making undue pressure upon any part, &c. &c. We shall enter more fully upon this question by and by, when treating of these diseases. 149. As to the proximate cause or pathological condition of the nervous system in convulsions, some confusion has arisen from the distinction between primary or sympathetic and symptomatic convul- sions not having been always observed. In the former classes very little information is obtained by a post-mortem examination, the knife of the anatomist being inadequate to the detection of functional de- rangements, or of disturbances, however serious, which result from irritation only.3 In the majority of cases of primary or sympathetic convulsions, no change can be discovered in the brain or spinal marrow, or in their membranes; in others, there may be a degree of congestion or vascularity, but whether this precedes or follows the attack of convulsion is not quite clear. In some cases, the brain exhibits an anaemic condition.4 In symptomatic convulsions, we shall find the traces of the primary disease of the nervous centres: "Inflammation of the membranes of the brain, sharp spiculae of bony matter formed in the dura mater, abscesses in the brain, or effusion of blood into its substance from external violence, are the appearances recorded by some of the older 1 Denis, Recherches sur plusieurs Mai. des Enfans, p. 325. z British and Foreign Review, No. 42, ap. 1846, p. 39,'. 3 North on Convulsions, p. 41. « Rilliet and Barthez, Mai. des Enfans, vol. ii. p. 281. 116 CONVULSIONS. physicians. Effusions of serum, vascular turgescence, tumors attached to the membranes, or imbedded within the substance of the brain, are noliced by more recent writers. Turgescence of the vessels, a deep red color of the dura and pia mater, and effusion of blood beneath the cranium, are the appearances described by De Claubry. Vascular turgescence at the origin of the nerves distributed to the muscles that had been affected with convulsive movements, has been noticed by Moulson. Effusion of serum, or of a gelatinous matter, engorgement of the blood-vessels, extravasation of blood, abscesses, tumors, and inflammation of the meninges of the brain, are the lesions described by others. Effusion of blood within the spinal canal, engorgement of the vessels of the brain, and extreme venous congestion of the entire substance of the brain, with serous effusion, were met with by Horner in one case, and the same appearances, with extreme mollescence of the brain, in another. Turgescence of the vessels of the brain, its substance of a pink color, with serous effusion into the ventricles at the base of the cranium and within the theca of the spine, are noticed by Kennedy."1 Dr. Condie states, "that in every instance in which we have examined the brain, after death from convulsions, more or less disease of that organ, or of the medulla oblongata or spinalis, was present. In most cases this amounted to simple but very extensive hyperaemia, with slight effusion of serum beneath the membranes, or within the ventricles; in other cases partial softening of the brain was very evident; tubercles were frequently detected, either meningeal or within the substance of the brain; and in a few cases of effusion of blood upon the surface of the brain, at its basis, or within the theca of the spinal marrow." 150. Symptoms.—The mode of invasion varies a good deal in pri- mary convulsions. In the majority of cases the infant is dull, heavy, and feverish for a day or two previously, or it may be restless and irritable, with an uncertain oscillation of its eyes, or an occasional wide stare; grinding its teeth, starting in its sleep, or awaking in a fright; disordered and irregular respiration ;2 loss of appetite; thirst, and spasmodic turning in of the thumbs, and bending of the wrists or ankle-joints, as described by Dr. Kellie. In other cases there are no precursory symptoms; the child is at- tacked when perfectly well, occasionally in his sleep; or suddenly in the course of other diseases, with no circumstances which would lead us to anticipate convulsions. WThen first seized, the child has a bewildered, surprised, frightened look; its eye expresses terror; the globe is agitated with irregular, jerking movements. Sometimes the pupil is turned upwards, some- times downwards; then, perhaps, it is for a moment steady, until drawn to one side or the other; the parallelism of the two eyes is lost, arid the child squints horribly; sometimes the pupil is contracted, in other cases it is dilated; and frequently, from the turning upward ' Condie on Diseases of Children, p. 360. a Capuron, Des Accouchemens, vol. iii. p. 440. CONVULSIONS. 117 being excessive, the iris is invisible, giving a frightful expression to the face. "The effect of light upon both pupils is not always similar; one may remain fully dilated, while the other contracts; or one pupil may remain stationary, the other being alternately contracted and dilated. I am not awTare that the remark has been made before, but I believe, from frequent observation, that when a light is applied close to the eyes, and the same effect is not produced upon both pupils, that we have much reason to fear some serious affection of the head."1 The muscles of the face are thrown into irregular and distorted action; the mouth, cheeks, &c. are twitching or jerking in different directions; sometimes the jaws are forcibly closed, or only moved laterally, so as to grind the teeth. The child froths at the mouth, and the respiration has a short, broken, and hissing sound. 151. If the attack be very slight, the convulsive movements may be limited, or nearly so, to the face, but in general the trunk and ex- tremities speedily become involved. The head is thrown strongly backwards, or to one side, or it is rapidly rotated from side to side; the muscles of the back are rigid, or act with sudden and irregular jerks; the arms are demiflexed, and thrown about irregularly; the hands are clenched, with the thumbs turned into the palm, and twisted or forcibly flexed or rotated. The lower extremities are simi- larly affected, but more slightly, and the feet are generally flexed up- wards and inwards. I have already stated that the respiration is quick, broken, and sibilant, from the quantity of mucus in the mouth. Occasionally it is very irregular, a series of rapid breathings being followed by a long rest, then a deep inspiration, and immediately after the rapid respira- tion. This may be partly owing to disordered innervation, and partly to muscular disturbance. The pulse is accelerated, ranging from 110 to 140 or 160, gene- rally small and hard, and often irregular. The action of the heart is disturbed, the rhythm and force of its contractions being frequently modified. The face becomes florid, sometimes violent; the head is hot, the feet cold, and a clammy moisture soon breaks out over the body, but par- ticularly upon the head and face. Intelligence is wholly and sensation partially suspended; the child recognizes no one ; in most cases it does not see at all; a loud noise or a brilliant light produces no effect; but the sense of touch, though impaired, is not lost. If the attack be violent, the internal muscles share in the disorder, and the urine and faeces are evacuated unconsciously. The duration of the fit varies very much, lasting but a few seconds in some cases, in others from five minutes to ten or twelve .hours.2 At length the convulsive movements relax, and ultimately cease, 1 North on Convulsions, p. 70. 2 Rilliet and Barthez, vol. ii. p. 269. 118 CONVULSIONS. and the child falls into a state of general relaxation; the face becomes pale, the eyelids closed, the limbs flaccid, the respiration quiet and regular, the pulse slower and weak, and sleep supervenes. From this sleep the infant awakes feeble and exhausted, but generally con- scious and intelligent. 152. The above is an imperfect sketch of an ordinary convulsion; it would be almost impossible to describe the multiplicity of combina- tions, and the endless variations we meet with in practice. Some of the more ordinary deviations, however, I must notice. I have already mentioned that in many cases there are no premonitory symptoms; this is the case with primary convulsions, and also with sympathetic; in the latter, there will be present the symptoms of the organic disease, but the fit may supervene quite unexpectedly, whether at the begin- ning or the end. When it ushers in the eruptive fevers, the child will show more or less evidences of fever, and perhaps, but not always, some evidence of the head being involved. In symptomatic convul- sions, there will generally be ground for anticipating a fit, although it may occur suddenly. Again, the convulsion may be much slighter than the one I have described, consisting of momentary unconsciousness, with sudden in- voluntary movements, something like a violent rigor; or even less marked, the body becoming rigid, the eyes fixed and staring, the hands clenched, and almost immediately a return to the natural state. I remember a case in which measles was ushered in by a fit as slight as this, but was accompanied or followed by an optical delusion, the child fancying that he saw dogs jumping on the bed: the fit did not return, but the vision of dogs recurred occasionally for some time. In other cases the convulsion is partial; one part of the body only being affected, sometimes one-half; in other cases the face only, or the eye, or a more distant set of muscles; and these local or partial attacks are apt to lead the young practitioner to undervalue the dis- order, and to treat the case feebly and inefficiently. Ordinarily the fit terminates in sleep, and on waking the child is heavy and exhausted ; occasionally there remains some weakness of one or both limbs, with a peculiar expression about the eyes. In some cases it is cut short by what appears to be a critical evacua- tion, as in the cases related by Planque,1 Condie,2 and others, in which hemorrhage occurred from the mouth, nose, and ears; by diarrhoea, according to Whytt,3 Jacques,4 &c.; or by vomiting or epistaxis, ac- cording to MM. Brachet and Bouchut. In primary and sympathetic convulsions, the first attack is some- times, though not always, the only one, but in symptomatic convul- sions there are generally several. The interval between them varies from half an hour to a day or two; the symptoms of each fit are the same, and the termination similar, unless they prove fatal. Rilliet and Barthez remark, that the duration of each fit is longer, and the ' Bibliotheq. Med., vol. iii. p. 504. * Diseases of Children, p. 359. 3 On Nervous Diseases. 4 Journ. Gen. de Med., vol. xxix. p. 280. CONVULSIONS. 119 severity greater, in symptomatic than in sympathetic convulsions, and that they occur more frequently in the night. 153. Under proper treatment a good proportion of cases of primary convulsions recover; the fits either do not return, or they become weaker, the intervals longer, and then cease altogether, and the child gradually recovers its health. In some of the most successful of such cases, I have seen, howrever, two consequences of the attack, which remain for a considerable time; one is an obliquity of vision, not, perhaps, amounting to a squint; and the other a degree of insecurity in walking or running, so that a very slight obstruction will occasion the child to fall. More serious effects, however, are not uncommon. Brachet mentions, as a consequence of convulsions, pains in the limbs, ecchymoses, rupture of the tendons, luxations, fractures, and curva- ture of the bones.1 Bouchut states that he has seen wry neck, drooping eyelid squint- ing, distortion of the mouth, and contraction of some of the limbs ;2 but in sixty cases, Rilliet and Barthez did not find a single case of this kind. Dr. John Clarke mentions the occurrence of paralysis after one or two convulsions,3 from which, after some time, the child may partially or wholly recover; and Dr. Hamilton, chronic epilepsy, chorea, idiocy, or imbecility.4 Or an attack of convulsions may localize itself, as it were, and become partial: thus I have seen spasm of the glottis supersede gene- ral convulsions, by which it was preceded and complicated. Mr. Thompson, of Whitehaven, has recorded a case in which loss of hearing and speech occurred after a fit of convulsions, and were not recovered for many years. Children who recover from convulsions are very liable to a relapse from even a slighter degree of the same causes, or from others of less severity, but this susceptibility ceases in a few years. When convulsions occur at the commencement of eruptive or ordi- nary infantile fever, the child may run through them very safely, not- withstanding. Hippocrates observes, that convulsions followed by fever terminate happily. 154. Sympathetic convulsions, occurring in the course or towards the end of other organic diseases, are a serious addition to the danger; the former may subside, but the latter generally terminate the disease fatally. The frequency of this occurrence will explain the dispro- portionate amount of cases of convulsions in the list of mortality. In some cases, the attack has terminated in a state (probably of partial asphyxia) which has been mistaken for death. Brachet mentions a child which recovered after having been abandoned as dead. Mr. North relates a similar case, which occurred to Dr. John- son; and Bouchut refers to one in Paris; the child was put into its coffin, and placed in a "chapelle," but the next morning it was found 1 Traite des Convulsions, p. 46. 2 Mai. des Enfans, p. 400. 3 Comment, on Diseases of Children, p. 83. * Hamilton on Diseases of Children, p. 88. 120 CONVULSIONS. sitting up and playing with the ornaments by which it was surrounded. I need hardly say that the stethoscope will enable us to settle this question correctly. Lastly, the intensity and frequency of the fits may augment instead of diminishing, and so terminate fatally. This, according to Brachet, " may occur in two ways, either primarily through the brain, which, being over-excited, ceases to act upon the other organs, haematosis does not take place, and death is certain ; or primarily in the lungs, in which case respiration, impeded by the irregular and violent con- tractions of the respiratory muscles, is imperfectly performed; the lungs become congested, the blood only circulates partially through them, suffocation is threatened, and does take place if more regular efforts do not restore the respiration and circulation. Lastly, syncope may occur, and be so prolonged as to prohibit a return to life." 155. Diagnosis.—i. From Epilepsy. A single convulsion and a single epileptic fit resemble each other so closely, that it would be difficult to point out any marked distinction ; there may be a differ- ence in the intensity and extent of the convulsive movements; in the sudden onset and frequency of the fits; in the history of the case and its termination; but time is, after all, the principal test, the course of the two diseases being very different. n. From Chorea the distinction is easy, for in it the motions are slighter, not altogether involuntary, nor accompanied by insensibility. Even at the commencement of an attack of chorea there is but little resemblance to the involuntary violent motions, partial or general, of convulsions, and there is no loss of consciousness. 156. But the diagnosis of the cause of the convulsions is of far greater importance, as Rilliet and Barthez have observed, than the differential diagnosis. Suppose we are called to a child from one to six years old, strong and hitherto healthy, who has had a convulsion following a fright, blow, fall, indigestion, &c. The convulsion may of course be pri- mary, sympathetic, or symptomatic; but, upon further inquiry, we find that the child was perfectly well up to the moment of the attack; that the exciting cause is plain, the constitution sound, the access not very violent, and that there are no other head symptoms. So far, then, the case is one of primary or sympathetic convulsions ; but further investigation proves that there is no disease of the chest, abdomen, &c, and we conclude that the convulsions are primary or essential. But if, on examination, we discover evidences of pectoral or abdo- minal disease, acute or of long standing, we must then infer that the convulsions are sympathetic, and we cannot be too minute in our examinations of all the organs in every case, as the treatment as well as the diagnosis will depend upon it. In these primary and sympa- thetic attacks, the brain and nervous system are in a state of sympa- thetic irritation only in most cases, but we cannot be quite sure of this when the fit comes on in the course of some chronic disease; as, for instance, in tuberculous affections, in which it is quite probable CONVULSIONS. 121 that the brain may be the seat of a similar deposit. Such cases render the diagnosis very difficult. After six or eight years of age, it is rather rare to find a child attacked with either primary or sympathetic convulsions ; they are almost always symptomatic of disease of the nervous system. MM. Rilliet and Barthez state that, with one exception, all the twenty-five cases of sympathetic convulsions observed by them were under seven years of age.1 Moreover, the absence of adequate exciting causes, the freedom from organic disease of the chest and abdomen, will exclude the primary and sympathetic forms, and we shall generally be able to detect other symptoms of head disease existing at the time, and previously, in addition to the convulsions. 157. Prognosis.—The prognosis in primary convulsions will de- pend upon their intensity and frequency, upon the age and strength of the patient, and in some degree upon the cause ; for instance, when they arise from indigestion, cold, &c, they are less dangerous than when they are caused by a fright or wound, or any mechanical cause. If the attacks be partial or slight, with long intervals, without much acceleration of the pulse or congestion about the face and head, the child will almost certainly recover; but if they be general, with a quick pulse, great congestion, and a frequent repetition of the fit, the danger is very great. I have no doubt that Bouchut is right, in stating that primary convulsions are the least fatal. Sympathetic convulsions have a more serious character because of the complication ; the child has to contend not merely against the affection of the nervous system, but against the organic disease giving rise to it, and the danger is more than doubled. Moreover, in some complications, as in hooping-cough, for example, the original disease is a perpetually recurring cause; each fit of coughing throws so much stress upon the brain, that the convulsions are reproduced at the very moment when they seem to have been relieved.2 The convulsions which occur in the course of fever, and which as- sume, as it were, the place of delirium, are rather favorable according to Sydenham ; and certainly those which are preceded, and perhaps caused by diarrhoea, are more manageable than the other varieties of sympathetic convulsions. In symptomatic convulsions, the prognosis is always serious, and * Rilliet and Barthez, Mai. des Enfans, &c, vol. ii. pp. 274, 275. 3 "Inasmuch as convulsions are a frequent attendant on diseases of the brain, it is cer- tainly very natural to turn our attention" first to the nervous centre. It often happens, however, if much care be not taken to investigate a case thoroughly, that leeches and cold applications to the head are hastily ordered, and calomel given, when the presence of pneumonia is afterwards detected, or some cause of gastric disturbance found to exist, without due attention to which no permanent amendment can result from any treatment. Inflammations of the chest are peculiarly liable to lead into this kind of error. Their real symptoms are marked by convulsive seizures; the medical attendant fancies on the first day that the case is one of inflammation of the brain, on the next day he thinks it must be pneumonia, and thus the uncertain diagnosis leads to vaccilating treatment, and much mischief is the result."—Maulhneron Diseases of the Brain, 8$c.,in Children, British and Foreign Review, April, 1846, p. 392. 122 CONVULSIONS. generally unfavorable when they occur in the course of the disease of the nervous system ; less so, when at the commencement.1 Mr. North remarks, that the younger and the more susceptible the child the less is the danger, and also that they are less serious in girls than in boys. 158. Treatment.—In proceeding to treat a case of convulsions, we should first ascertain to which of the varieties it belongs, whether it is primary, sympathetic, or symptomatic ; we must bear in mind also the constitution of the child, its previous state of health, previous attacks, &c. &c. The treatment also will vary in some degree ac- cording as we are called during the fit, or during an interval. If we see the child during a fit of partial convulsions, our first duty is to remove any exciting cause which may be present. Thus all tight bandages should be loosened, all pins removed, the dress made quite easy, and the child placed in a recumbent position, ex- posed to plenty of fresh air. If the gums be swollen or congested, they must be freely lanced down to the teeth, and beyond those teeth which are pressing forward. If we do not cut deeply or extensively enough, very little relief will be afforded. After this, the child should have a warm bath for a few minutes, and then be carefully dried and wrapped in a warm blanket. 159. It may be that these measures will relieve the paroxysm; but whether or not, the next question is as to the propriety of abstracting blood. Almost all writers are in favor of it, and whatever experi- ence I have had only confirms their opinions, with very few excep- tions. If the convulsion be very slight or partial, if there be no flushing of the face, no quickening of the pulse, it is probable that lancing the gums, a warm bath, and a smart purgative, may be sufficient. Again, in some cases of sympathetic convulsions, in the course of or at the termination of other organic diseases, when the infant is much reduced, it may not be able to bear the additional loss of blood; in such cases we must have recourse to counter-irritation. Lastly, in symptomatic convulsions, the propriety of blood-letting must be in a great measure determined by the nature and extent of the original disease. But in severe cases of primary convulsions, when the pulse is quick, the face and head flushed, and the paroxysm well marked— in sympathetic convulsions, at the commencement of diseases of the lungs or abdomen—in the febrile diseases of children, or during their course, if the child be strong—and in symptomatic convulsions, at the outset of cerebral disease—there is no doubt in my mind that a liberal application of leeches is of the greatest service. It is not enough to apply one or two leeches, but, e. g., to a child of a year old, six at least ought to be applied, and the bleeding stopped when the leeches detach themselves. I must strongly protest against the ordinary- plan of allowing the leech-bites to bleed indefinitely; more blood is 1 Rilliet and Barthez, Mai. des Enfans, vol. ii. p. 277. CONVULSIONS. 123 thus often lost than was intended, and it is quite impossible to form any precise estimate of the quantity desired or actually taken, unless by arresting the hemorrhage at a given time. If the convulsions return, the leeching must be repeated, nor need we fear for the chil/1 if it be strong and healthy; there is more danger of our not bleeding sufficiently than of the other extreme in these cases, especially in cases of threatened meningitis. My friend Dr. M'Donnell's child, of four months old, was attacked by meningitis ushered in by violent and almost incessant convulsions. I applied eighteen leeches in the course of twelve hours with perfect success; the convulsions alto- gether ceased after the last application, and the child recovered. As to the best situation for applying the leeches, some advise the forehead or behind the ears, others the back of the hand or foot, the ankles, or the anus. I prefer the forehead, as being nearer the seat of the disease, and requiring fewer leeches to produce an equal im- pression, and because it is easy to stop the bleeding. North advises that "blood should be drawn from the jugular vein, or from the temples, by cupping." 160. At the same time we may diminish the vascular action of the brain by the application of cold lotions or ice in a bladder. Dashing cold water upon the face will- sometimes terminate the fit; and next in efficacy to this, according to Dr. John Clarke, is the effluvia of volatile alkali, plentifully inhaled.1 For the purpose of preventing or diminishing cerebral congestion, MM. Dezeimeris and Trousseau have proposed compression of the carotids, and, it is said, with success. Drs. Bland and Stroehlin have published some favorable cases,2 and Mr. North thinks favorably of it in cases of great weakness and exhaustion. Barrier, however, states that it rarely succeeds. 161. So far, the remedies I have mentioned may be employed during the paroxysm; our treatment, however, must be continued during the interval of quiet which succeeds. The repetition of leech- ing must be decided by the repetition of the convulsion, or the occur- rence of slight convulsive twitchings or of much starting in sleep. If these are absent, and if the infant sleep calmly, no further leech- ing will be necessary; but measures must be taken to act briskly upon the bowels by means of calomel and jalap, or rhubarb, castor oil, infusion of senna, &c. Or a purgative enema may be given in order to produce the effect more quickly, or whilst the child is unable to swallow. The advantage of evacuating the bowels is twofold; any indigestible or irritating matter is removed, and we establish a derivation from the brain. Dr. Condie speaks highly of the effects of spirits of turpentine in' cases dependent upon derangement of the alimentary canal, and my own experience amply confirms his ob- servation; combined with castor oil it acts promptly and beneficially. M. Brachet recommends calomel pretty largely; two grains every two hours. Mr. North objects to this; but although I have not given 1 Commentaries on Diseases of Children, p. 109. a Med.-Chir. Journal, April, 1839. 124 CONVULSIONS. it in the full doses recommended by M. Brachet, I have certainly found benefit from smaller ones, say half a grain three times a day, in combination with as much Dover's powder, and a grain of James's ppwder. Next to intestinal derivations, those applied to the surface are the most effectual. Fomentations of hot water, with mustard to the feet and legs, and blisters to the neck, upon the head, or behind the ears, will be advisable. Mr. North recommends mustard sinapisms to the feet; Sydenham a blister between the shoulders; Dr. John Clarke one to the calves of the legs, or between the shoulders. The blister should not be applied too soon; it will be quite time enough after the baths, leeching, and the free evacuation of the bowels; I think also that a succession of small blisters is much preferable to one large one: a narrow strip may be applied across the forehead, then one behind each ear, or, if necessary, the upper part of the head may be shaved, and then blistered. With children of delicate constitution, or who have been much ex- hausted by any cause, leeching is sometimes impossible, and then our principal reliance must be upon a succession of blisters. When the attacks are often repeated, so that the disorder becomes chronic, I have seen great benefit result from a seton of three or four silk threads in the arm, and continued for some time, particularly in the convulsions arising from dentition. An argument for the use of counter-irritation to the scalp has been derived from the fact, more than once observed, that convulsions have ceased, on the appearance of an eruption of crusta lactea. Professor CEttinger has recommended that the eruption should be produced by inoculation, but a blister will act just as effectively. M. Husson states that he has relieved convulsions by vaccination. Dr. Grantham considers non-ossification of the fontanelles as one cause of convulsions, which he proposes to remedy by compression of the head generally, with a calico bandage applied moderately tight; and he quotes one case in which he succeeded. 162. Antispasmodics of various kinds have been strongly recom- mended ; by German writers camphor and valerian are especially praised ; by others ether, assafetida, musk, bismuth, ammonia, &c. Drs. Underwood1 and Stewart2 speak very highly of musk given freely, that is, from half a grain to two grains every two hours. Dr. John Clarke, howrever, states that he has seen no good effects from any, with the exception of ether and ammonia : " It does not appear to him that they derive any additional good quality from mixing them with assafetida, valerian, castor, musk, tinctura fuliginis, amber, and other fetid substances."3 How far the inhalation of ether in certain cases may be advantageous, is as yet unknown; I am inclined to think, however, that it might be beneficial after the removal of the exciting cause, and when the fits are not accompanied by high vascu- ' On Diseases of Children, p. 264. a On Diseases of Children, p. 493. 8 Comment on Diseases of Children, p. 108. CONVULSIONS. 125 lar action. I am using it at this moment, in a case of convulsion, complicating hooping-cough. Dr. Locock speaks highly of the subcarbonate of iron in cases where the child has been much exhausted by other diseases. The oxide of zinc has been much relied upon by M. Zangerl, who gives one and a half to three centigrammes every two hours; by M. Brachet, who combines it with the extract of hyoscyamus, ten centi- grammes of the former, and twenty of the latter, in the twenty-four hours; and by MM. Guersent, Blache, and Barrier. 163. Narcotics have been sometimes advised, but they are rarely necessary, and when given, require great watchfulness in their admi- nistration ; perhaps the best mode is to combine a little Dover's pow- der, with calomel, or James's powder. Mr. North recommends Dover's powder when the infant is restless, with startings and twitchings. Brachet, Blundell, Condie, and others, prefer hyoscyamus, either alone or in combination. The external application of opium has also been advised. If used at all, we should begin with very small doses, watching their effects, and only increasing them very gradually. They should never be given when the pulse is full, when there is much fever, general plethora, or determination to the head. When diarrhoea is present, I have seen them very useful. Dr. John Clarke remarks: "It requires the greatest consideration, and the exercise of great circumspection, to determine when, and in what quantity, opium may with propriety be exhibited in convulsions. It may fairly, however, be laid down as an axiom, that it should never be employed on any account, until it is clearly ascertained that no danger is likely to arise from pressure on the brain ; that there is not any existing inflammation of that organ; and never until the bowels have been completely unloaded, lest the stupor arising from a compressed brain should be attributed to opium; and the time when alone relief could have been given in inflammation of the brain should be allowed to pass by, never to be recalled. When the medical at- tendant has reason to believe that no danger is to be apprehended from any of those circumstances, opium in small doses, cautiously re- peated, may be administered with advantage, and it will sometimes diminish pain, by lessening the sensibility and irritability of the pa- tient. Great care, must, however, be taken, during the use of it, to keep the intestinal canal free."1 Alkaline medicines will be of service, when we afe satisfied of the presence of acid in the stomach* 164. Thus we find that primary convulsions may be arrested and relieved by cold affusion, warm baths, bleeding, &c, after removing all apparent causes; that during an interval the principal remedies are, perhaps, a repetition of the bleeding, purgatives, counter-irrita- tion, antispasmodics, and narcotics; and that in a chronic state of the disease, when the fits are repeated, great benefit is derived from a permanent drain upon the constitution. 1 Comment, on Diseases of Children, p. 108. 126 CONVULSIONS. But a little deviation from the ordinary treatment is often advisable. When the patient is delicate and weakly, or run down from other dis- eases, it may be necessary to give tonics and stimulants ; Barrier and others speak highly of ammonia. In some cases we are obliged to give wine, with great caution however, and nourishing diet; in other cases a change of air is highly beneficial; or, if the infant be suck- ling, a change of nurse : this is strikingly the case when hooping- cough is complicated with convulsions. In sympathetic convulsions, the treatment of the secondary affection must necessarily in a great measure depend upon the state of the pri- mary disease and the condition of the child. In the majority of cases we shall have to content ourselves with measures of less activity, such as counter-irritation, cold to the head, antispasmodics, &c.; leeches or cupping will only be admissible in few cases. But as a compensation, we shall generally find that the remedies which benefit the original disease will relieve the convulsions. In febrile diseases ushered in by fits, however, the local treatment maybe pretty active. The same observation will apply to symptomatic convulsions, ex- cept those cases where the convulsion ushers in the disease, or occurs at a very early period in an inflammatory affection ; then, indeed, so far from diminishing the activity of our treatment, we must rather increase it. The convulsions which accompany the chronic organic diseases of the brain require delicate management, and a nice adjust- ment of remedies, but of these I shall speak at length when I treat of those diseases. 165. The diet of children attacked by convulsions should in ge- neral be simple and bland ; milk in any form,.rice, arrowroot, &c, will be suitable and sufficient until the severity of the disease is sub- dued. Animal food and wine should in general be prohibited, except, as I have already said, where there is great exhaustion, or in some cases of sympathetic convulsions. In them, it may be necessary to allow a little broth. Cool, fresh air in a large room is very desirable, and in many cases assuming a chronic character a complete change of air is most bene- ficial. I need not dwell upon the necessity of a warm, loose dress, and the removal of everything which can irritate. But perhaps the most important and most neglected hygienic ar- rangement is perfect quietness; the nervous system has been so shat- tered that quietness is essential to its recovery; and yet, if there be any improvement, the nurse and parents are so delighted, that they inva- riably set about amusing and exciting the child, to obtain renewed evidence of its restoration. The room should be darkened, and no- thing done to excite the child ; the longer it sleeps the better. 166. As to the consequences of convulsions, little direct treatment is necessary; the weakness of the limbs, or of one side will in most cases gradually diminish; gentle frictions or salt water baths may be employed, and, with country air and exercise, will generally succeed. In like manner, the squinting gradually diminishes in many cases: for the more marked cases various contrivances have been proposed. ACUTE HYDROCEPHALUS. 127 Mr. North relieved it by an ivory instrument, covering each eye, and pierced with a minute aperture; or we may sometimes succeed by tying up the sound eye, and using the distorted one. Dr. Junn pre- fers the following method: "Place the child before you, and let him close the undistorted eye and look at you with the other. When you find the axis of this eye fixed directly upon you, bid him endeavor to keep it in that situation, and open his other eye. You will imme- diately see the distorted eye turn away from you towards his nose, and the axis of the other will be pointed at you; but with patience and repeated trials he will by degrees be able to keep his distorted eye fixed upon you, at least for some little time, after the other is opened; and when you have brought him to continue the axis of both eyes fixed upon you as you stand directly before him, change his posture; put him first-to one side of you, and then to the other. When, in these different situations, he can perfectly and readily turn the axes of both eyes towards you, the cure is effected."1 CHAPTER VI. ACUTE MENINGITIS.--ACUTE ARACHNITIS.--ACUTE HYDROCEPHALUS. 167. The disease I purpose describing in this chapter, has been termed by some dropsy of the brain, water in the head, internal hy- drocephalus; by Cullen, hydrocephalic apoplexy; by Macbride, hy- drocephalic fever; by Bricheteau, hydrocephale aigue; by Gardien, Capuron, and others, fievre cerebrale; by Brachet, hydrocephalite; by Rufz, Piet, Guersent, Green, Barrier, Rilliet and Barthez, &c, meningite tuberculeuse; by the Germans, hitzige gehirnhdhlenwas- sersucht. By whatsoever name described, and however various the theories as to the nature of the disease, it appears to me that both the symp- toms and the post-mortem appearances indicate an affection of the membranes of the brain as the essential character of the disease, whether primary or secondary; and as that affection exhibits evi- dences of inflammation or of its results, I prefer using the simple terms prefixed to this chapter. Modern writers, indeed, particularly the French, have drawn a marked distinction between acute menin- gitis and tubercular meningitis ; but as the most intelligent of them confess that they differ only in the pathological condition of the mem- branes, and not essentially in the symptoms or course of the disease, I have thought it better to include both under the one name, and to describe them as two (out of many) phases of the same disease. 168. The earliest record of the disease is by M. Duvernay, in 1701, 1 North on Convulsions, p. 215. 128 ACUTE HYDROCEPHALUS. and by Messrs. St. Clair and Paisley in 1732-3, in the Edinburgh Medical Essays. In 1768, Dr. WThyte's essay "On the Dropsy of the Brain" was published, and as a minute and accurate description of the disease, it is admirable, but his pathological reasoning is incorrect. In the same year, Dr. Fothergill and Dr. Watson read their papers on the subject to a society in London, and afterwards published them in the fourth volume of the Medical Observations and Inquiries. The former physician regarded the disease as incurable, and so would Dr. Watson, but for one case of recovery, which hardly appears to have been owing to the treatment. A case of hydrocephalus internus, published by Dr. Dobson in 1775, was the first in which mercury was used; and as it was successful, it made a considerable impression, and led to the general use of this remedy in the disease. As yet, the theory of Whytt and others, that the effusion of fluid into the ventricles depended upon debility of the vessels, or an attenuated state of the blood, prevailed. In 1779, however, Dr. Charles Quin published an inaugural essay, founded upon information derived from his father, Dr. Henry Quin, an eminent physician of this city, in which he at- tributed the disease to determination of blood to the brain, to increased arterial action, and effusion of fluid as a consequence. The practical result of this theory was the employment of antiphlogistic remedies, as venesection and cold applications to the head. In a more ad- vanced stage of the disease, he recommended mercury, on the prin- ciple laid down by Dobson, for the purpose of stimulating the absorb- ents of the brain. This essay was afterwards enlarged into a treatise. Dr. Withering, in his "Account of the Foxglove," published in 1785, agrees with Dr. Quin in regarding the disease as inflammatory, and the effusion as the consequence, not the cause, of the illness. Dr. Rush, in the Medical Observations and Inquiries for 1789, added some important information to the previous knowledge of the disease. Admitting the occurrence of primary hydrocephalus, he showed that it may be caused by other diseases; and he carried blood-letting to a greater extent than his predecessors, even affirming that hydrocephalus may be cured by the lancet. In 1791, Dr. Perce- val, of Manchester, published a valuable paper in the first volume of the Medical Tracts and Observations, containing a post-mortem, ex- amination of a case in which death took place before effusion, and recommending the combination of opium with calomel. Dr. Garnett, in 1801, maintained that the disease consists in a plethoric state of the vessels of the brain, occasioning a considerable degree of inflam- mation, and generally, though not always, giving rise to effusion. In 1808, Dr. Cheyne's first essay was published, confirming the value of mercury in the disease, and clearly establishing the secondary charac- ter of some varieties of hydrocephalus. To this work, confessedly of very high value, I shall refer more particularly by and by. Although at this time it was pretty well agreed that the disease was inflamma- tion, there continued to be some dispute as to its exact locality, al- though Bricheteau and others regarded the effusion as the principal phenomenon. Golis (1815), Piorry (1822), placed the seat in the ACUTE HYDROCEPHALUS. 129 arachnoid ; Coindet in the cerebral ventricles; Brachet in the lymph- atics ; Abercrombie in the brain; M. Senn (1825) in the pia mater, and he first applied to it the term meningitis; M. Piorry (1823) and MM. Parent-Duchatelet and Martinet (1825) in the arachnoid. In this country and America, we have had valuable essays and monographs by J. Clarke, Monro, Duncan, Yates, Mills, D. Davis, Burnett, Griffiths, H. Smith, &c. &c.; and more or less space devoted to its consideration in the works of Underwood (late editions), Dewees, Burns, Maunsell and Evanson, Eberle, Stewart, Condie, Coley, and Hood. The recent communications to the different periodicals will be found in Braith- waite's or Ranking's Retrospect, and to which I shall hereafter refer. More recently, great light has been throwTn upon the pathology of the disease by the valuable essays of Guersent,1 Papavoine,2 Fabre and Constant, Gerhard,3 Rufz,4 Piet,5 Green,6 Schweninger,7 &c, who have demonstrated the existence of tuberculous meningitis. 169. After this brief historical notice, I shall endeavor to sketch some of the various phases or forms of the disease sufficiently distinct to merit especial mention, and having corresponding pathological conditions. The first corresponds to the acute hydrocephalus of Golis and others, and to the "meningite simple aigue" of Barrier, and Ril- liet and Barthez. It is not the most common, but very far from being rare. The different stages into which authors have divided hydrocephalus are not always to be clearly distinguished in this form. Conradi and Rush made two stages; Whytt, Cheyne, Tissot, Vanhoven, Baader, Plenck, Sprengel, &c, three; Golis four stages: but most frequently but two stages will be remarked, that of excitement and effusion. 170. In some cases, a formative period may be observed, during which the child loses his spirits and cheerfulness, exhibits a distaste for his usual amusements and toys, the eye has lost some of its lustre, the face is somewhat collapsed and pale, and there is a kind of creep- ing or chilliness over the body. The pulse is uncertain—sometimes quick, perhaps irregular, in other cases but little altered from its na- tural state. In most cases, however, the developmenfof the disease is sudden, and marked by high fever, thirst, heat of skin generally, and parti- cularly of the head, sometimes, as I have seen more than once, by a convulsion.8 The child complains of severe pain in the head, if old enough to express its sensations; and if too young, we find it clasping its head, or constantly raising its hand to that part; unable to sup- port the weight and suffering, it seeks to rest it upon something, rolling it about incessantly; or lying still, heavy, and dull, with an occasional cry of pain. In some cases, the eyes have a heavy, muddy expression; more fre- • Diet, de Med., p. 392. 2 Journ. Hebdom., vol. vi. p. 113, 1830. 3 American Journal of Medical Sciences, April, 1834. < Thesis, 1835. 5 Thesis, 1836. e Lancet. 7 Uber Tuberculose als die gewohnlichste Ursache der Hydrocephalus acutus. 8 Dr. John Clarke's Comment, on Diseases of Children, p. 130, 1830. 9 130 ACUTE HYDROCEPHALUS. quently, they are bright and restless, moving quickly from one object to another, and the conjunctiva more or less injected. There is a peculiar stare, a wide opening of the eyes, so that the white is visible all round the iris, which I have found very characteristic of the com- mencement of meningitis. The infant is generally very wakeful, or sleeping restlessly, drowsy, but waking up suddenly, crying or screaming as if from fright; if it sleep continuously, we may observe frequent startings and twitchings of the limbs. . When awake, it is evidently oppressed, sighing, agitated, and utter- ing a cross, whining cry; complaining, if old enough, of pains in different parts of the body, about the neck, shoulders, or stomach: Dr. Mills mentions an irritative cough in the first stage.1 Alibert adds to this an extreme difficulty of respiration, which he considers to indicate the commencement of compression. Dr. H. Smith notices this cough as occurring in all the stages;2 and I saw this difficulty of respiration precede every other symptom in one of my own children attacked by the disease. It was remarkable, too, that the dyspnoea was in expiration, not in inspiration. The stomach almost immediately sympathizes with the cerebral disturbance; there is complete loss of appetite, and in almost every case vomiting, sometimes concurrently, in others alternating with the headache. The tongue is white and loaded, the bowels generally con- stipated, and occasionally most obstinate; when they are free, the stools are peculiar, greenish, tenacious, glairy, and fetid. The urine is frequently scanty and high-colored or cloudy. 171. If not at the beginning, yet before the disease has lasted long, a convulsion occurs, complete or partial, with only a temporary loss of consciousness. Generally speaking, it is not repeated until a later - period of the disease, but in some severe cases I have known them to recur at short intervals. _ . Thus far, the disease advances with different degrees of rapidity in different individuals, nay, in some cases, as Golis has remarked, there is an occasional remission, as if the child were about to recover, after which the symptoms return with greater violence. ^ The fever rapidly becomes intense, with occasional intermissions, the heat of head is great, the headache is severe, with delirium, gene- rally moderate, but in many cases with loud outcries, especially, as Parent-Duchatelet and Martinet have remarked, when the convexity of the arachnoid is principally affected ;3 the head is declared to be the seat of the suffering, either by words or gestures; and the face is pale and livid, or with a circumscribed hectic flush on one or both cheeks. The eyes are generally bright but sunk, the pupils contracted, and painfully sensitive to light, as the ears are to sound, and the whole expression of the countenance is not to be mistaken. The pulse is quick at first, then occasionally irregular, and at last intermitting; 1 Transactions of the Association of the College of Physicians in Ireland, vol. v. p. 438. 9 On Hydrocephalus, p. 12. s De l'Arachnite, p. 207. ACUTE HYDROCEPHALUS. 131 but these changes are by no means so regular as in some of the other varieties. The respiration is at first hurried, then unequal, sometimes slow and oppressed, and ultimately irregular, a few rapid respirations being followed by an interval of rest; the accordance between the pulse and the respiration is no longer observed. The vomiting in most cases continues, and generally the constipa- tion increases. The child is restless and uneasy, seldom lying still, and awaking from sleep with loud cries, or when asleep disturbed by startings and twitchings. 172. There is a sign which has been recorded by some American physicians, which I ought to mention here, although I can give no opinion as to its precise value. I allude to the information derived from cerebral auscultation. Dr. Fisher, of Boston, was the first to apply auscultation to the brain, and he published a valuable paper in the American Medical Journal.1 He has since been followed by Dr. Whitney,2 who certainly deserves great credit for the care and labor he has bestow-ed upon the subject. He describes four sounds heard in the brain in certain diseases: 1, the cephalic bellows sound; 2, cerebral cegophony; 3, fremissement cataire; and 4, the cooing sound. The first, or bellowTs sound, is heard in "cerebral congestion, acute cerebral inflammation, hydrocephalus, compression of the brain, scirrhous induration with softening, ossification of the arteries of the brain, and the hydrocephaloid disease." This is the only sound with which we have to do, and its value is of course diminished by the extremely different diseases in which it is heard, and occasion- ally by the difficulty of detecting it. Still, it is a subject worthy of minute attention, and may ultimately lend important aid to the diag- nosis. 173. As the disease advances, the symptoms gradually change from those of excitement to those consequent upon effusion or pres- sure, and earlier in those cases where the sutures and fontanelles are closed than in those where they are incomplete.3 The headache is less complained of, although the head is still rolled about uneasily, or retracted; the delirium subsides, or occurs occasionally; the sensi- bility of the eye is gradually lost, and the pupil is generally dilated, and it is evident the child can no longer see; the eye is rolled about, turned upward, or squinting takes place; the hearing may for a time appear acute, but at length it diminishes, and the infant appears un- conscious of sound; the sense of touch remains longer than any other, and at a period of apparent insensibility I have noticed the child uneasy at being touched or moved. Dr. Hennis Green has noticed a temporary but firm contraction of the eyelid, which for a time pre- vents our exposing the eyeball. The convulsions increase in frequency and sometimes in strength, or perhaps there may be convulsions of one side of the body and pa- ralysis of the other. And a new symptom is developed about this 1 March, 1838. 3 American Medical Journal, October, 1843, p. 282. 3 Dr. John Clarke, Commentaries on Diseases of Children, p. 130. 132 ACUTE HYDROCEPHALUS. time, which adds much to the distress of the mother ; I allude to the sharp, piercing scream of agony which the child utters from time to time, and which I am sure is the result of pressure upon some par- ticular portion of the brain, and not of pain, as the face at the time is not expressive of suffering. This peculiar hydrocephalic scream, which occurs in no other disease, and not in every case of this, has been noticed by almost all writers, but they differ as to the time when it appears. Some, as Stewart and Condie, place it during the inflam- matory stage; others at a more advanced period, at the commence- ment, or after the occurrence, of effusion. My own experience confirms the latter view. 174. During the intervals of the convulsions, consciousness and sensibility diminish until they are finally lost. Sometimes local spasms occur; I have seen well-marked spasm of the glottis and crowing inspiration. The child now lies quiet, occasionally moving the head, or throwing about an arm or leg unconsciously; the eyes are open or only half closed, and acquire a glazed appearance, with mucus at the corners of the eyelids; the face is pallid, sometimes waxlike, without expression; sometimes sunken and anxious, as representing the last conscious feeling. The vomiting rarely con- tinues; the bowels are sometimes evacuated unconsciously, generally confined; the urine may accumulate or be passed at long intervals, and the belly is sunk, concave. The attack terminates by a convul- sion or in coma. The duration of this form of the disease varies from thirty-six hours to ten or twelve days, rarely so much as the latter; it is much more rapid than most of the other varieties of meningitis. 175. Dr. Monro has described a variety of the disease, which he calls "the most acute species of hydrocephalus," and which differs from the foregoing, especially in its commencement: "It begins," says the Professor, "like the croup. The child awakes in the night, in a state of extreme agitation, and much flushed, and with a" quick pulse; he is hoarse, and the sound of his voice, when he inspires, is similar to that in croup; the sound seems to come from a brazen tube which is contracted at a certain part."1 This croupy breathing, in a case he relates, was changed for asthmatic respiration, and the little patient gradually gave evidence of cerebral disease—high fever, quick pulse, partial convulsions, dyspnoea, squinting, and insensibility. On dissection, besides serum in the ventricles and spinal canal, and gelatinous effusion on the upper surface of the brain, " the eighth pair of nerves was of a deep, uniform, red color, along its whole tract, as far as its branches going to the lungs."2 Dr. Monro believes that the peculiarity of this case depended upon the state of the eighth pair, as he has found an analogous condition in patients affected in the same way. Professor Burns has noticed a similar deviation from the ordi- nary form of hydrocephalus, and attributes it to the same cause. It is very rapid in its progress, and proves fatal in three, four, or five days. 1 On the Morbid Anatomy of the Brain, p. 70. 2 Ibid. ACUTE HYDROCEPHALUS. 133 176. The next phase ox form of the disease is much more frequent than the first; it is more deliberate in its commencement and progress, though probably not less fatal. The stages, too, are much more marked, although I agree with my friend, Dr. West, who, in his ad- mirable lectures on the Diseases of Children,1 observes, that "there are too many exceptions, however, to the order of these changes (of the pulse) for it to be right to make them the foundation of any divi- sion of the disease into different stages; and the same remark may be made with reference to any arrangement founded on the variations in the sensibility of the patient." The child in this case usually exhibits evidences of deranged health some time before the characteristic symptoms appear. The appetite may have been lost, the bowels relaxed or constipated, with erratic pains in different regions. Occasionally, there is some complaint of headache, a crick in the neck, or the child in walking is observed to be more feeble on one leg than the other, or to drag one leg. These symptoms may excite little attention at first, but they will be found to be accompanied with disturbed temper, indifference or irritability, languor, pale countenance, occasional chills, and other indications of ill health. In cases where hydrocephalus is secondary to organic diseases of the lungs or intestinal canal, the symptoms of these diseases will mask those of the beginning of the former, until their full development. 177. In ordinary cases, Dr. Golis thus states the symptoms of turgescence, or of the first stage: "Indifference succeeding to in- creased sensibility and irritability; a constipated state after habitual looseness or diarrhoea; a scanty, unusually yellow urine, with or without sediment; dryness of the skin, which previously, on the slightest exercise, even on eating and drinking, and particularly dur- ing sleep, perspired profusely; sleep without medicine often suddenly occurring in restless children; remarkable gravity and earnestness, which had never been previously noticed: these, taken together with the symptoms, are the signs by which the turgescence of hydrocephalus may with great justice be suspected."2 In the majority of cases, the child complains of headache, or, if an infant, gives signs of it by putting his hands to his head, rolling it uneasily about, and being unable or unwilling to support it. To this succeeds vomiting of ingesta and of bilious or greenish matter; the child becomes dull and heavy, complaining of weariness, disliking the light, and sensitive to noise; often in the dark seeing flashes of light, and having the pupils contracted, giving a sharp expression to the eye. The tongue is white and loaded, the bowrels sometimes free, but often confined; the stools are clay-colored at first, but afterwTards of a green color, like chopped spinach, and of a gelatinous consistence, or in some cases resembling tar, and with a peculiar smell, compared by Dr. Cheyne to the " smell of the breath in the beginning of some 1 Medical Gazette, July 16, 1847, p. 93. a On Water in the Head, p. 15. 134 ACUTE HYDROCEPHALUS. of the exanthemata." The child sometimes complains of pain in the bowels. The pulse varies a good deal; in some cases, it remains long unal- tered ; in others, it is permanently quick; in others, sometimes slow and sometimes quick. Dr. Whytt states, as I have already mentioned, that it is quick in the first stage, irregular and quick in the second, and intermitting in the third; but Dr. Cheyne seldom observed this regular division. In some cases, no doubt, it exists; in many, it is certainly absent. 178. Thus the disease may go on for some days, without any very marked change; but by degrees we may perceive the child getting worse. Febrile paroxysms are observed, with heat of skin, thirst, quicker pulse, rapid respiration, and a bad smell from the breath. The countenance becomes altered, thin, and pale, with a peculiar expression, as Sprengel has observed; in some cases, it is cedematous. Portenschlag remarks, that "the glance, the features, and complexion, the voice, the movements, the actions and sentiments of patients in acute hydrocephalus, if they have been know7n to the physician before the commencement of the disease, are very different from what he remembers in health." 179. The headache and heat of head may continue or diminish, and there may, perhaps, be some delirium, but it is not so loud or violent as in the first species; the vomiting continues, especially in the upright position;1 the bowels are generally torpid, although we see occasion- ally an attack of bilious purging; the region of the stomach and liver is often tender on pressure; and the belly is concave and not tumid. The urine is scanty, and frequently voided, generally with sediment; sometimes, as Coindet observed, with a white micaceous sediment. The senses, which wrere morbidly sensitive, and the intellect, which may have at first been unusually active, gradually lose their power, and the child becomes dull and stupid. He lies more quietly in bed, throwing his head back, and moving about the legs, and picking his nose and ears, or rather thrusting his fingers into his nostrils or ears. He becomes greatly emaciated, the skin hangs about his arms and legs, the pulse increases in quickness and irregularity, the respiration is more interrupted by sighing, and very decided symptoms of pressure show themselves in the form of twitchings, starting, screaming, and partial or complete convulsions, with insensibility, glazed eye, squint- ing, &c. Drs. Cheyne and Golis remarked, in several instances, a temporary restoration of intellect before death. This condition may continue for some days, with but little varia- tion, until at length it is terminated by a convulsion or coma. 180. The duration of this form of disease is greater than the former. Perceval, Fothergill, and Vanhoven say from fourteen to twenty-one days; Golis from thirteen to twenty-four days; Dr. Cheyne, that it is almost always over in three weeks; Dr. Whytt, that it lasts four, five, or six weeks; Peter Frank saw a case last six weeks; Drs. Letl and Adelt, more than two months. 1 Eberle on Diseases of Children, p. 371. ACUTE HYDROCEPHALUS. 135 This form of meningitis, which corresponds with Dr. Cheyne's first species,1 will, with some little modification, apply to those cases in which the meningitis occurs in the course of measles, scarlatina, or infantile remittent, or when it is secondary to disease of the bowels or liver. In most cases, it terminates fatally; but, in cases of recovery Dr. Cheyne remarked the occurrence of large bilious stools, an increased flow of urine, or an abundant perspiration.2 • 181. Dr. Brockman has described, under the term meningitis en- cephalica, a species of local meningitis in which the membranes of the pons Varolii and medulla oblongata are chiefly affected. I quote the following description from Dr. Condie's excellent work: "It is sometimes associated with general disease of the brain; at others it is uncomplicated. Notwithstanding in its earlier stages it is unat- tended by any serious symptoms, it is an affection fully as dangerous as cerebral meningitis. The first stage, or that of simple hyperaemia, generally continues for one or two days. The child is dull and heavy, and the occiput is often hot; the bowels, however, are regular; there is no vomiting, no intolerance of light, nor any disturbance of sleep. The general dulness of the patient, and vague complaints of some uneasy sensation in the head, increase as the inflammatory stage sets in; the heat of the occiput is augmented; the head becomes retracted, as in the ordinary cases of acute meningitis; and convulsive twitch- ings of the limbs occur, similar to the effects of slight electric shocks, which recur every few minutes while the patient is awake, but cease during sleep. The general febrile symptoms continue during the third stage; the pulse, however, diminishes in frequency and fulness, but does not become either irregular or intermittent. The general disquietude of the child subsides by degrees into a comatose condition, in which the head becomes still more retracted, but unattended with strabismus or any morbid condition of the pupil: the peculiar air of stupidity w'hich characterizes hydrocephalic patients is wanting. Two pathognomonic symptoms, however, indicate the occurrence of the stage of effusion. One of these is deafness, the other is difficult articulation and difficulty in moving the tongue, both of which occur at the same time, probably from paralysis of the motor nerves of the tongue. The deafness and affection of the tongue usually occur suddenly; sometimes they are first observed upon the child awTaking from a quiet sleep. They are, according to Dr. Brockman, the earliest and most certain indications of the occurrence of effusion. This stage continues sometimes for three, sometimes for fourteen days. Its termination is in fatal paralysis, the occurrence of which is often preceded by various singular nervous phenomena, as sudden pauses in the respiration, or equally sudden syncope. In some cases, howT- ever, the paralysis does not follow, but the anomalous symptoms sub- side, and the patients gradually recover. Until, indeed, the paralytic stage is fully established, the recovery of the patient is still possible. "In the uncomplicated cases of the disease, upon examination after ' On Acute Hydrocephalus, p. 2. 2 Ibid., p. 9. 136 ACUTE HYDROCEPHALUS. death, the cerebrum in general presents an extremely pallid and anaemic condition, in striking contrast wTith the cerebellum, the vessels of which are turgid with blood, while its substance also is often in a state of marked hypersemia. The hypercemia also increases in in- tensity towards the central portions of the encephalon ; and the mem- branes covering the pons Varolii and medulla oblongata are found in a most decided state of inflammation; the portion of inflamed membrane is perfectly isolated, and not more, usually, than a square inch in extent; the membrane of the cerebellum being entirely free from any indications of inflammation. There is ordinarily an effu- sion of a serous fluid into the subarachnoid tissue, sometimes to the extent of several ounces; occasionally, a gelatinous matter is effused, and in some instances the effusion is of a purulent character. " This form of the disease is most frequently observed in children from three to ten years of age, and who had previously enjoyed good health. "The treatment recommended by Dr. Brockman, in its first two stages, is depletion by leeches to the posterior part of the head, cold applications to the scalp, and the free administration of calomel, which latter may be continued during the stage of effusion. Here, however, it becomes necessary to support the strength of the patient; for this purpose, ammonia is directed by Dr. Brockman; but he re- marks that in some cases the administration of wine may be required. According to his experience, powerful counter-irritants, as a large blister, or the actual cautery, prove also sometimes beneficial."1 182. The next form I shall describe is the tubercular meningitis of the French authors, upon which so much light has recently been thrown. According,to Rilliet and Barthez, the progress of the dis- ease corresponds pretty accurately with the three stages of Dr. Whytt: the first characterized by loss of appetite, paleness, quick pulse, vomit- ing, and headache; the second, by a slower but irregular pulse, sleep, delirium, and outcries; the third, by acceleration of pulse, paralysis of eyelids, dilated pupils, convulsions, subsultus, &c. Senn and Guersent adopt these three periods; Rufz makes only two, including the two first of Whytt in one; and Piet makes none. From the researches of late years, it would appear that this form of the disease is much more frequent (at least on the Continent) than any other. Rufz, Piet, and Gerhard scarcely met with two cases of simple meningitis to twenty of tubercular; M. Becquerel found one case of simple meningitis in six of hydrocephalus; Barrier four in thirty. M. Guersent observes: "Fromthe observations I have made at the hospital for many successive years, it appears that in children from two to fifteen years the proportion of simple meningitis to tuber- cular is as two to twelve; after puberty, simple meningitis becomes more frequent."2 183. The disease very generally attacks a child in good health ; but it may supervene in the course of some other affection, especially those of a tubercular or scrofulous character. The most common * Condie on Diseases of Children, p. 383. 2 Diet, de Med., vol. xix. p. 411. ACUTE HYDROCEPHALUS. 137 symptoms are headache, attended with vomiting and constipation, and these may be the first to attract attention; but in some cases a series of slighter disturbances have been noticed, especially by German writ- ers, as fantastic desires, caprices, uneasiness, sleepiness, giddiness, uncertain walk, quick pulse. Formey speaks of a fine dry eruption of the color of the skin, milky urine, crossness, irregular walk, nau- sea, vomiting, &c. I saw one case in which, before cerebral symp- toms were very marked, the child was greatly distressed by optical delusions, visions of animals walking before him or around his bed. Restlessness, staring eyes, or semi-rotation of the head are also com- mon, with heat of scalp. The appetite is not always immediately lost, nor is the thirst great until after the eighth day, although the tongue may be dry at an earlier period. The vomiting is sometimes very slight or not persistent, and the headache in some few cases is less remarkable. The pulse is generally quickened, and the child preserves its intelligence. The strength is but slightly depressed. As the disease advances, the vomiting continues, or perhaps in- creases, at first of bilious matter or of the food taken; the pulse be- comes irregular, whether quick or slow ; the child is cross, dull, grinds its teeth, and has a frightened, staring look, evidently distressed by the light. Then the respiration becomes unequal and irregular, with sighing or yawning. The face is sometimes flushed, at others pale, the eye oscillating or turning upwards, the expression of the face that of surprise, or wonder, or indifference, sometimes utterly smooth and without expression, like a wax face. 184. Now these symptoms may last some time before the more decided symptoms of cerebral disease develop themselves. At length, however, a degree of agitation is observed, with some incoherence, either persistent or alternating with intervals of perfect intelligence; an increase of somnolence, or starting, clenching the hands, the thumbs being firmly flexed inwards, and the ankles bent, and con- vulsions or coma. The convulsion may be general or confined to one side, the other being paralyzed. In some cases, the coma comes on very gradually; in others, suddenly; the eyes become dull and glazed, the corners of the eyelids encrusted, and the nares dry. The bowels, at first constipated, are afterwards much relaxed, and the stools green and glairy. Occasionally, the jaws are firmly closed, the trunk rigid, the pupils dilated, or one dilated and the other contracted ; sharp cries are occasionally uttered ; the eyes squint, either divergent or converg- ent; the pulse is small, quick, and irregular; the respiration irregu- lar; the skin is covered with cold sweat, the stools and urine are passed involuntarily, and the coma is persistent and constant. Shortly before death, the face becomes red or violet, covered with sweat; the eyes hollow and filmy; nares dry and crusted ; respiration loud, almost stertorous; pulse smaller and weaker, with occasional convulsions, until death closes the scene. 185. The duration of this form of disease is pretty much as the last. Rilliet and Barthez have never seen death before the seventh day, but 138 ACUTE HYDROCEPHALUS. most commonly from the eleventh to the twentieth day; in some cases, the patients lived sixty and sixty-seven days. Of 117 cases collected by Dr. Green, thirty-one died before the seventh day; forty-nine before the fourteenth; thirty-one before the twentieth; and six after the twentieth. Of thirty cases noted by Dr. West, the average duration was twenty days and a half; in one, death took place in five days; in ten, before the fourteenth day; in eleven, during the third week; and in three, during the fourth week.1 186. Although I have given this description of the disease with ap- parent precision, I should wish to caution my readers against supposing that they will always find the exact series of symptoms here laid down ; nothing can be more variable than they are: but, on the other hand, there are always sufficient to show that the brain is the part affected, even in those cases related by Rush, Mills, and others, in which there was neither pain in the head, nausea, dilated pupil, nor strabismus.2 Moreover, it must strike every one that, between several of the forms here described, there is very little difference of symptoms, nor do I think that they will be found more unlike in practice. Every one who has seen much of this fearful disease must have been struck with the general resemblance of all cases, and yet with the infinite variations in minute points, so that it is almost impossible, in a general descrip- tion, to include even the majority of cases. This must be my apology, if one be needed, for apparently multiplying the forms of the disease. I have written partly from my own experience, and partly from the works of others, most of which I have carefully consulted. 187. The last form of the disease which I shall notice has been called the water-stroke; wasserschlag by the Germans; apoplexia hydrocephalica by Cullen and others; and is described by Golis,3 but omitted by most writers. It consists in a sudden, almost instantane- ous effusion of fluid within the brain, and may occur either idiopathi- cally or as the result of obstructed secretion from some other organ, or as a secondary affection in the course of some other disease, as small-pox, measles, or other febrile eruptions, or on the sudden stop- page of diarrhoea, dysentery, or profuse perspiration. Though there are evidences of inflammation occasionally found on a post-mortem examination, the suddenness and rapidity of the dis- ease prevent the development of the usual symptoms. Those which are to be observed rather correspond to the latter stages of hydroce- phalus. The child may go to bed in its ordinary state of health, or suffering from some other disease, and in the morning it may be found dead from a cause which is only detected by a post-mortem examina- tion. Or it may suddenly be attacked by a convulsion, followed by paralysis or apparent apoplexy, with insensibility, stertorous breath- ing, dilated or contracted pupils, and subsultus, terminating in death after a few hours. ' Lectures in Medical Gazette, August 16,1847, p. 92. 2 Stewart on Diseases of Children, p. 510. 3 A Treatise on the Hydrocephalus Acutus, &c, by R. A. Golis, translated by R. Gooch, M. D., p. 5. ACUTE HYDROCEPHALUS. 139 Almost all, if not all, the patients die, and die too quickly for the employment of remedies. 188. Pathology.—It is very rarely that any pathological change is discovered in the bones of the cranium; in one case, Rilliet and Bar- thez found some infiltration beneath the pericranium, and the coronal suture contained a small quantity of blood. The head being enlarged, the bones are more or less separated, and the sutures more widely apart than usual. The dura mater is generally injected; sometimes the sinus is filled with dark blood or gelatinous clots. The cerebral veins contain dark, solid clots. 189. The arachnoid membrane is frequently injected, either gene- rally or partially,1 and in some parts rendered opaque; in other cases, it is smooth and polished,2 but with the products of inflammation in its cavity. Occasionally, thick, abundant, and inodorous pus is found, as described by Golis,3 Rilliet and Barthez; or, the more fluid portion being absorbed, it may lie close upon the serous tissue, and resemble false membrane very much, but it is not smooth, and it breaks up under the finger. This disposition may be either general or partial. The most common result, however, is effusion of serum. The pia mater exhibits similar appearances; purulent matter, more or less fluid, occasionally concrete, and more frequently on its convex surface, in five out of six cases at the base, and varying in quantity in different places. M. Legendre has observed with the microscope that the pus globules are large, round, and transparent, without central nucleus. The ventricles also often exhibit marks of inflammation; the lining membrane may be vascular and softened, and the fluid contained maybe discolored or muddy; occasionally, pus, more or less fluid, is found. But more frequently, the ventricles are distended with a limpid fluid resembling serum, but which differs from serum in the proportion of its constituents. Dr. Davis says that it is " a fluid sui generis, and is the product exclusively of inflammation of the serous membranes, investing the brain, and of the vascular tissues concerned in supplying the encephalon with blood. This is not blood, nor serum, nor purulent matter, nor fibrine, but a fluid already stated, sui generis."4 Berzelius gives the following analysis:— Albumen.......1.66 Matter soluble in alcohol with lactate of soda 2.32 Chlorides of potassium and sodium . . 7.09 Soda Animal matter, insoluble in alcohol Earthy phosphates Water..... 0.28 0.26 0.09 988.30 1000.00 1 Piorry, de Tlrritation Encephalique, p. 28. Eberle on Diseases of Children, p. 379. 2 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 628. 3 On Water in the Head, p. 9. 4 On Hydrocephalus, Preface, p. 10. 140 ACUTE HYDROCEPHALUS. That is, the serum of the blood, diluted with about seven times its volume of pure water.1 The quantity of this fluid varies. Whytt and Golis state it to be from two to three ounces; Coindet, Bright, and Nasse from one to four or six ounces; Brachet as much as twenty-four ounces; Dr. Copland not more than eight ounces. Sometimes, however, the fluid is nearly absent. Parent-Ducha- telet and Martinet state that in eight cases out of twenty-six there was scarcely a trace. Ford and Underwood make a similar obser- vation. 190. Occasionally, the central portions of the brain are diseased, softened, and reduced to a mere pulp; when the effusion is considera- ble, the brain has a compressed appearance, and the convolutions are flattened. The vessels of the brain are considerably congested. According to Laennec, Jadelot, Bricheteau, &c, the substance of the brtain is very firm, and, as it were, hypertrophied, and in these cases the effusion is slight. It is very probable that in many cases the membranes of the spinal marrow may participate in the inflammatory action. In one of M. Legendre's cases, there was serum containing pus globules underneath the arachnoid, and yellow purulent matter in the meshes of the pia mater ; and in six out of thirty cases of convulsions, M. Billard found inflammation of the membranes of both brain and spinal marrow.2 191. These post-mortem appearances are more or less common to all the forms or varieties of hydrocephalus I have noticed, but others are superadded in tubercular meningitis; there we find a peculiar sticky condition of the arachnoid; and in the laminae of the pia mater a deposition of tubercular matter at different points of the hemispheres, or at the base of the brain. These granulations vary in size, although they are generally small, and sometimes opaline or white, and semi- transparent; in other cases, gray and opaque. In most cases, we find also secretion of concrete pus, or what appears to be false membrane, on some portion (generally the base) of the pia mater, which is thick- ened and greenish or yellowish, friable, and sometimes adherent to the brain. The central portions of the brain, the septum lucidum, &c, are also generally softened, and occasionally there is tubercular de- position in the substance of the brain and in other organs. "I found in the water-stroke," says Golis, "the brain commonly firmer than in the acute hydrocephalus ; also the blood-vessels of the brain and its membranes less enlarged and less turgid than in the latter," and "from twTo to four or six ounces of turbid fluid." 192. Morbid changes in other organs are rare in any of the vari- eties, except when the meningeal affection is secondary. In such cases, we may find inflammation or ulceration of the mucous mem- brane of the stomach and bowels,3 evidences of follicular enteritis, &c. Dr. Cheyne mentions that he found in many cases proofs of increased ' Traite de Chimie, vol. vii. p. 141. a Mai. des Enfans, p. 604. 3 On Hydrocephalus, p. 20. ACUTE HYDROCEPHALUS. 141 arterial action on the surface of the liver, that it was adherent to the peritoneum, enlarged, and studded with tubercles. In tubercular meningitis, we not unfrequently meet with tubercles in the lungs or other parts.1 From this statement of the morbid appearances discovered on a post-mortem examination, there appears but little difficulty in deciding upon the nature of the disease. In each form, we find traces of in- flammation in the membranes of the brain, with the results in the form of serum or pus; in some, we find a deposition of tubercular matter, but whether that be the result of inflammation, or not, is not as yet decided. M. Trousseau believes that they are so; but Rilliet and Barthez incline to the opposite view. M. Bouchut considers them a constitutional disease.2 In addition, we find the substance of the brain occasionally partaking of the inflammatory action. 193. Causes.—Age appears to have considerable influence in pre- disposing to the disease, and this we should expect from the suscep- tibility of the brain during its growth.3 Certainly in these countries it is much more frequent during the first six years of life than after- wards. During infancy, the first or second forms I have described are the more common, and afterwards, up to ten years, tubercular meningitis. Drs. Perceval and Coindet found it most frequent between the ages of two and seven years; and Dr. Emerson, of Philadelphia, found that, out of 1602 cases, 1395 occurred before the fifth year, or between the ages of five and ten. Dr. Green found it more frequent between the ages of five and seven. There appears but little difference in the liability of the two sexes; rather more males than females being attacked during the first six years, and fully as many females, or perhaps more, for some years subsequently. Afterwards, three times as many men as women are attacked, according to Parent-Duchatelet. The disease is more frequent in some countries than in others. Dr. Cheyne considers it more frequent in Scotland than in Ireland, and in summer than winter. I cannot, of course, say how frequent it may be in Scotland; but I have reason to believe it very frequent in this city. Dr. Stewart mentions that it is a frequent disease in America; Camper and Tissot that it is rare in Holland and Switzerland. Guersent states that tubercular meningitis is more common in summer or autumn; Piet that it occurs more frequently in March and July. Rilliet and Barthez are doubtful whether the season makes any difference. 194. There can be little doubt that the disease is hereditary, espe- cially tubercular meningitis, and we frequently see several children of the same family successively cut off by it: this has been noted by almost all writers, Sauvage, Ludwig, Cheyne, Odier, Formey, Golis, Bouchut, &c. Dr. West mentions that, "in sixteen out of twenty cases in which the health of the relatives was made the subject of ' Eberle on Diseases of Children, p. 380. a Mai. des Enfans, p. 416. 3 Stewart on Diseases of Children, p. 502. 142 ACUTE HYDROCEPHALUS. special inquiry, it was ascertained that either the father, mother, aunt, or uncle had died of phthisis."1 Something also may be attributed to the constitution of the child. No doubt children of good constitutions, and in perfect health, may be attacked by any form of the disease; but certainly those of leuco- phlegmatic habit, or tainted with scrofula, are especially liable ; and where there is any disposition to scrofulous tubercle, it will favor the production of tubercular meningitis. In a large proportion of cases, Dr. Mills found unequivocal appearances of scrofula; and eleven out of twenty-two cases observed by Dr. Perceval were " decidedly scrofulous." It is a common opinion that a certain form of the head predisposes to this disease; but I have carefully watched children with large heads and prominent foreheads without finding sufficient grounds for the belief. 195. An attack, described as acute hydrocephalus by Dr. Albert,2 is said to have prevailed as an epidemic from March to May, 1825. During this period, more than 150 infants were attacked, and twenty- eight of them treated by Dr. Albert. The disease commenced by shivering, followed by heat, intense headache, vomiting, constipation, scanty urine, epigastric tenderness, &c. The child was constantly rolling the head about, the sleep was broken by starting and cries, there was delirium, oscillation of the eyeballs, and automatic move- ments of the extremities. The face was pale, the tongue white or brown, the mouth and nares dry, the conjunctiva injected, and the eyes intolerant of light. Afterwards, the child lay still, unable to support the head, the face changed, the eyes sunk and turned upwards, the hand raised to the head, respiration labored, with deep sighs, sordes on the tongue and mouth, emaciation increasing, and the pulse small and quick gene- rally, but occasionally slow. From this state very few recovered. I may add, that it occurred as an epidemic in 1840, 1841, and 1842, among the conscripts at Versailles, Lyons, Metz, Strasburg, Avignon, Nantz, and Poitiers. More recently, it has appeared epidemically in this country, at first at Bray, Co. Wicklow, in January, 1846 ; in the South Dublin Work- house in the following months; and in April and May in the Belfast Workhouse (as we find from a valuable paper by Dr. Mayne); attack- ing chiefly boys under tw-elve years of age, and proving rapidly fatal, in some cases in fifteen hours, in others in forty-eight hours, in the greater number in four days, whilst in some it was prolonged a fortnight or three weeks. There were no premonitory symptoms: it sometimes commenced by pain in the abdomen, followed by vomiting, and subsequently by purging; at this time, the patients had all the appearance of collapse; then followed reaction, fever, quick pulse, rigidity of the muscles, those of the neck in particular, with a tetanic expression of face. Soon after, severe general convulsions occurred, or a semi-comatose condition supervened, with grinding of the teeth, 1 Lectures in Medical Gazette, July 16, 1847, p. 93. 2 Hufeland's Journal der Pract. Heilkunde, Aug. 1830. ACUTE HYDROCEPHALUS. 143 and crying incessantly. Towards the close, this state merged into coma, with the pulse slow and labored, failure of power of speech and deglutition, and involuntary evacuations.1 196. Among the exciting causes, may be enumerated milk that disagrees with the child, mental distress in the mother or nurse, of which I have seen several examples, prolonged lactation,2 indigestible food, the sudden suppression of an eruption on the head, retrocession of febrile eruptions, dentition, exposure to the heat of the sun, fright, anger, cold, blows or falls on the head. Golis mentions that children born immediately after the bombard- ment of Vienna, in 1809, were shortly seized with convulsions, and died; within the cranium were found traces of inflammation, and effusion of lymph and serum in the ventricles. Sir H. Halford and Dr. Abercrombie mention suppressed secretion of the kidneys as one cause. 197. Lastly, either variety may occur as a secondary disease to some other affection. Thus, we may observe meningitis in the course of infantile remittent fever, towards the termination of measles, or scarlatina, or hooping-cough; after a severe bowel complaint (gastro- enteritis, follicular enteritis, cholera infantum), or diseases of the liver, as stated by Harris, Curry, Yates, Thompson, Cheyne, &c.3 It is occasionally, but rarely, connected with bronchitis,4 pneumonia, and phthisis. I ought to observe that in these secondary attacks there is some little difference in the symptoms: there is generally less headache with fewer premonitory symptoms; the attack seems to come on more suddenly, often by convulsions, and the duration is less prolonged. 198. Diagnosis.—The most characteristic symptoms of the first stage, according to Dr. Mills, are, "the peculiar expression of coun- tenance, indicative of oppression, pain, and despondency; frequent sighing; a disposition to retirement; a heat, weight, pain, or heavi- ness of the head, or all these combined; waywardness and fretful- ness: a lowT, irregular fever; frequent nausea or retching; an irregular state of the appetite and bowrels, and the continuance of the diarrhoea," notwithstanding the remedies. The second stage is marked by "the heavy sigh, the deep moan, the wild scream, the preternatural dilata- tion or contraction of the pupils, imperfect or lost vision, delirium, difficult deglutition, paralysis of one hand, arm, or leg, and of the sphincters; the head permanently bent back; a slow, intermitting, or rapid pulse; frequent vomiting, or convulsions."5 There are not many diseases likely to be mistaken for meningitis, nor can we easily confound a well-marked case of the latter with another disease ; but 1 Dublin Quarterly Journal of Medical Science for August, 1846, p. 95. 2 Observations on the Healthy and Diseased Condition of the Breast, Milk, &c, by Ed. Morton, M. D., p. 24. 3 Cheyne on Hydrocephalus, p. 49. Piorry de l'lrritation Encephal., p. 52. Golis, p. 71. Eberle on Diseases of Children, p. 382. 4 Mills, Trans, of Association, vol. v. p. 361. 6 Transactions of Association of College of Physicians in Ireland, vol. v. p. 446. 144 ACUTE HYDROCEPHALUS. in their commencement some diseases do exhibit somewhat similar symptoms, and some cases of meningitis terminate like other diseases 199 i In cerebral congestion, we have a marked series ot head symptoms not unlike the commencement of hydrocephalus; there are sleep, stupor, even coma, with agitation of the limbs, or rigidity, sometimes partial paralysis; the face sometimes flushed, or unaltered, or spasmodically twisted; the pupils, perhaps, dilated; pulse quick, &c. Now as meningitis may be accompanied with cerebral congestion, it is not always easy or possible to draw an accurate distinction at first; but, as the disease advances, especially if it be prolonged, we shall find considerable difference: there is less stupor, coma does not come on until late ; convulsions generally occur; the respiration and pulse, are more irregular; the face has a sunk look; and the disease is more prolonged. . ii. Eruptive Fevers.—As these sometimes commence by convulsions and headache, with quick pulse, we may for a while be in doubt, but in a short time the occurrence of the eruption will decide the ques- tion, and the delay is of no consequence, as the treatment, so far as the head symptoms are concerned, must be similar. m. Infantile remittent or gastric fever seldom presents sufficiently marked head symptoms to be mistaken for hydrocephalus, until to- wards its termination, but then certainly, especially when there is follicular ulceration, the aspect of the case is very similar Ihe stupor and insensibility, however, are never so complete; remissions almost always occur; the head is often cool; the headache is not so acute; there is great emaciation, but not that drawn look about the face, or its peculiar expression, or the concave condition of the belly, which is generally tumid; and we rarely have convulsions or para- lysis, or even the twitchings, startings, and screams; moreover, it is rare 'in children under four or five years of age. Of course, these observations do not apply to those cases of infantile remittent which run on into hydrocephalus. iv. Golis considers the difference between hydrocephalus and typhus fever to be marked by the shorter duration of the period of turgescence in the former, the less frequent pulse in the early period, and its irregularity in the latter, the marked stages, the greater sensibility of the eye and ear, the interrupted respiration, the emaciation, and the fallen state of the belly, &c. . v. The fourth variety, or water-stroke, may very likely be mistaken for apoplexy; but the history of the disease, the age of the patient, &c. will correct this opinion, unless we choose to regard it as a variety of the serous apoplexy of authors, the symptoms being very similar. vi. An attempt has been made to distinguish between simple acute meningitis and tubercular meningitis, but I think without success, except in extreme cases. Certainly those cases of the former which commence with high fever, delirium, convulsions, and terminate fa- tally in two or three days, do differ from the gradual development and slower progress of the latter; but, in the majority of cases, the course and symptoms are so similar, that, unless we have some colla- ACUTE HYDROCEPHALUS. 145 teral circumstances to guide us (as, for instance, a disposition to tu- berculization in other localities, or a strongly-marked scrofulous diathesis), 1 do not think any positive diagnosis possible. 200. Prognosis.—Every form of the disease is extremely fatal; very little chance remains for the patient if the first stage, as we may call it, be neglected. Rilliet and Barthez state that they have never seen a single case of tubercular meningitis cured, and in this they only confirm the testimony of Rufz, Piet, Gerhard, &c. 201. On the other hand, Henri states that he cured thirty cases; Odier four out of six; Golis forty-one; and Formey nearly all to whom he was called at an early period of the disease. Guersent admits that tubercular meningitis may be cured during the first pe- riod, but not one per cent, at a more advanced stage j1 nor is Dr. West's opinion more favorable.2 Drs. Perceval and Whytt give one case of cure. Dr. Cheyne men- tions three cases of cure. M. Piorry relates fourteen cases, nine of which recovered. Various cases of recovery may be found scattered through the pe- riodicals, such as those by Thompson,3 Uwins,4 Watson,5 Heineken,6 in the older journals, and more recently in the pages of the Edinburgh Journal, Lancet, Medical Gazette, &c. &c. I have no doubt that all, or nearly all, must have been in the early stage. The fourth variety, or water-stroke, always ends fatally. I have seen a considerable number of cases; and although when symptoms of effusion are present the case is hopeless, yet at an earlier period I have succeeded in curing as large a proportion as in other diseases of equal importance and severity. 202. Terminations. — Some German writers have related cases where acute hydrocephalus terminated by a critical discharge. Meissner mentions one case in which epistaxis occurred, and another in which there was a copious serous discharge from the eyes, with considerable mitigation of the symptoms, and a third who recovered after a similar evacuation. Tortual observed the discharge of serum from the nose, and Riecke from the right ear. Jahn mentions the case of an infant in whom effusion had taken place, but who was cured after a discharge from the ears and eyes. Nasse, Cheyne, &c, enumerate other critical evacuations, such as profuse sweating, exces- sive secretion of urine, eruptions on the face, &c. 203. The favorable signs which give hope of recovery after judi- cious treatment are, the occurrence of tranquil sleep, the diminution of the startings, the pulse becoming slower, the eyes more steady and less sensitive to light, and the expression of the face more natural and calm. On the other hand, the rapid, small pulse, quick, irregular respi- ration, dry, furred tongue, livid face, the increase of the startings ' Diet, de Med., vol. xix. p. 403. 2 Lectures, Med. Gazette, July 16, 1847. 3 Lond. Med. Repos., Jan. 1814. * Med. and Phys. Journal, Aug. 1816. 5 Lond. Med. Repository, Feb. 1816. 6 Ibid., Sept. 1819. 10 146 ACUTE HYDROCEPHALUS. and twitchings, disturbed sleep, wakefulness, or coma, all announce a fatal termination. In some cases, not very frequent, the severe symptoms are miti- gated, and the disease subsides down into chronic hydrocephalus, as in a case of Dr. Monro's; and probably this may be favored in infants by the distensibility of the cranium, for certainly symptoms of com- pression are more marked in children whose sutures are ossified than in very young infants. 204. Treatment.—Believing as I do that hydrocephalus consists essentially in inflammation of the membranes of the brain, occa- sionally accompanied by a deposition of tubercular matter, and agreeing with Dr. Davis, that, when attacked early, a considerable proportion of cases may be cured, I cannot too strongly express my sense of the importance of early and vigorous treatment. I am con- vinced that many children are lost by the usual moderate remedies, who might be saved if more active measures were adopted. Let me illustrate what I mean by a case. My friend, Dr. M'Donnell's child, aged four months, strong and healthy, was suddenly attacked by acute meningitis of the most severe character. Six leeches were ap- plied immediately to the forehead, and the bleeding stopped; the convulsions became less frequent, and the fever diminished ; in about eight hours six leeches were again applied, and we found that the convulsions did not return, but the starting, and crying, and restless- ness continued ; and consequently after the lapse of six or eight hours we repeated the six leeches, i. e., eighteen in twenty-four hours, stop- ping the bleeding as soon as the leeches fell, and from that moment all the symptoms rapidly subsided, and the child recovered his health in two or three weeks. But of course one rule will not apply to all cases; many things must be taken into consideration: first, the constitution of the child; sec- ondly, the cause of the disease; thirdly, whether the disease be primary or secondary; and lastly, the period of the attack at which we are called to the child. These circumstances will necessarily modify the treatment. You cannot bleed a child of a weak constitution so exten- sively as one who is strong and healthy; nor does the disease, when secondary, or in an advanced stage, admit of such active treatment. Let us examine the principal remedial agents in use. 205. Blood-letting.—In all forms of the disease, whatever be the constitution of the child, whether the disease be primary or secondary, if the attack be recent, I believe blood-letting to be necessary, either by opening the jugular vein or the vein in the arm, by cupping, or by leeching. And the quantity taken should be in most cases larger than in other diseases, or even large in proportion to the age of the child. Moreover, if the good effect be not produced, and the child be able to bear it, it should be repeated three or four times, but if leeches are used, the wounds should not be allowed to bleed after the leeches have fallen. M. Piorry says: "I believe, then, that we ought to bleed, especially during the period of congestion; that twenty, thirty, forty leeches, or ACUTE HYDROCEPHALUS. 147 even more, should be applied, or that one or more venesections should be practised; in a word, that we ought to act promptly and energeti- cally."1 Dr. Mills recommends venesection first, and then leeching. Dr. Davis recommends that the first bleeding, if we are called early, should be carried to actual fainting; "not to faintishness, but full fainting."2 It is only right to state that Dr. Rush, of Philadelphia, was one of the first, if not the first, to recommend large bleeding in this disease. But if the child be weak, or if the disease be secondary, the amount of bleeding must be less,3 and I think it better to produce an effect at once, than to repeat small bleedings; after which we must depend upon remedies to be noticed presently. Dr. Cheyne remarks of such cases as those he has described: "In most cases, local bleeding by leeches or cupping, or general blood-letting from the external jugular vein or temporal artery, according to the state of the pulse and strength of the patient, must be practised." "But I am convinced that blood- letting, unless in very robust constitutions, is not always to be repeated without danger." These cases answer to those I have made the second variety (176) of the disease; in the first variety, Dr. Cheyne approves of ample and repeated blood-letting. In tubercular meningitis blood-letting is also necessary, according to the age and strength of the patient and the intensity of the disease; but Rilliet and Barthez do not think it should be carried to so great an extent as in simple acute meningitis. In the more advanced stage of either variety it is rarely of any use, and may perhaps do injury, by reducing the strength of the child. 206. Cold applications may be employed by means of lint dipped in cold lotion, or the head being wet with an evaporating lotion, a current of air may be directed upon the head; this I have found of great value, and a great comfort to the patient. Or*a bladder or a water-fight water-cushion may be partially filled with powdered ice, and allowed, when spread out, to rest lightly upon the head. The hair should be removed as completely as possible before applying the cold. All writers are agreed as to the value of this remedy, which should be employed as early as possible, and continued until the symptoms have subsided, or nearly so. Heine, Formey, Foville, and Piorry recommend affusion with iced water, but to this Piet, Senn, and Charpentier are opposed. 207. Counter-irritation by means of sinapisms or mustard baths to the legs, blisters behind the ears or upon the head, is of great value, and ought in all cases to follow the bleeding. In those cases in which the bleeding or its repetition is inadmissible, our main dependence must be upon counter-irritation and mercury. I think that a repetition of smaller blisters has more effect than one large one. I generally commence by blistering the forehead, and when that begins to heal, apply another over part of the top of the 1 Piorry, de l'lrritation Encephalique, p. 58. a On Acute Hydrocephalus, p. 241. 3 Golis on Water in the Head, p. 129. 148 ACUTE HYDROCEPHALUS. head, and so by degrees irritate the whole of the scalp. This appears preferable to keeping a blister open for any length of time. Frictions to the head with tartar emetic are spoken well of by Golis. Dr. Cheyne recommends that they should be dressed with mercurial ointment, so as to aid in bringing on mercurial action. If when the child is recovering the head symptoms do not disappear completely and satisfactorily, great benefit will be derived from a seton of three or four silk threads in the arm, which may be removed when the child is perfectly well. 208. Mercury, we have seen, wras successful in one of the first cases of cure on record, that published by Dr. Dobson in 1775, and since his time it has steadily maintained its ground as one of the most important remedies we possess.1 In every form of the disease its use may be commenced imme- diately, except in the cases preceded or accompanied by diarrhoea. The bowels must be quieted, at least before we can give it internally; but should the intestinal irritation persist, we may still use mercurial inunction. It is better to give calomel, or hyd. c. creta, in small doses, pretty frequently, than in large ones, as being less likely to disorder the bowels, and it may be continued until the mouth is tender; but it must be remembered that it is not easy to salivate a child, and I have found that mercurial diarrhoea is a tolerable proof of the constitution being affected. Whytt, Odier, Quin, Wilmer, and others, gave it in doses of two, three, or more grains at a time, and continued it for many days, notwithstanding any effects on the intestinal canal; but I quite agree with the following observations of Golis: "In little children, of from one to four or five months, a quarter of a grain—in larger, of from six months to one or two years, half a grain of calomel—given inter- nally every second hour, will be sufficient, until it has produced green, slimy stools four or six times, but not purging stools, against which Perceval has already warned us; or until there occur sharp pains in the belly, which infants express by drawing up their legs, and whining, but larger children describe with words."2 209. I have already mentioned, that if diarrhoea be present it will require attention, and not merely on account of the impossibility of giving mercury internally whilst it continues, but because of the con- stitutional and cerebral irritation which it occasions. And in those cases where the bowels are torpid, we must have recourse to purgative medicines, which benefit by emptying the bowels, and act as deriva- tives also. A brisk mercurial purgative in such cases should be given at once, and repeated if necessary. Neither are we to conclude, in all cases of diarrhoea, that purgatives are unnecessary; in many instances there are accumulations in the bowels which must be removed before relief can be obtained, but in such cases I think it better to quiet the irritation first, and then give purgatives. 1 Cheyne on Hydrocephalus, p. 41. 9 On Hydrocephalus, p. 111. ACUTE HYDROCEPHALUS. 149 So long as the stomach is irritable, enemata must supply the place of ordinary purgatives, but they do not sufficiently clear out the bowels. 210. Dr. Davis strongly recommends the administration of an eme- tic after blood-letting, for the purpose of controlling the action of the heart and arteries; he prescribes one-fourth or one-fifth of a grain of tartar emetic with five grains of powdered ipecacuanha. Laennec had previously found great benefit from tartar emetic, but I am not aware that he gave it so as to produce more than nausea. I have never tried this, nor do I think it would be a wise remedy. Vomiting for the time increases cerebral congestion, which would be injurious; and in many cases an emetic would be unnecessary, be- cause vomiting is already present, and yet we never find that it does good. 211. Drs. Cheyne and Stoker think very highly of James's powder in full doses at the commencement of the disease, and the former men- tions a case apparently cured by it. Certainly, in combination with calomel, it seems to act beneficially, but I should be very sorry to depend upon it alone. 212. Digitalis, alone or in combination with calomel, has been re- commended by many writers, particularly by Weaver and Formey. Dr. Cheyne found it of great use in two cases; others with whom he had tried it were too far advanced in the disease. Golis says that he has used it for sixteen years, and in several hundred cases, but with- out any great advantage; the dose he recommends is one-eighth of a grain of the powder with half a grain of calomel every two hours. 213. Very great difference of opinion exists as to wrhether opium is at all admissible in this disease. Cheyne thinks it useful, joined with an aromatic, in correcting bilious vomiting and purging. Golis is entirely opposed to it. Mills speaks favorably of it combined with the calomel. Hood strongly recommends it.1 No doubt it requires great caution because of its effect upon the brain, but I have used it with great benefit in the cases commencing with severe diarrhoea, and without any injurious consequences. 214. Iodine has been used, and it is said with benefit. Dr. Evanson is favorable to its employment, but its use has not become so general as to lead to a belief in its great efficacy. 215. Phosphorus has been strongly recommended by M. Coindet, in combination with three parts of oil of almonds. It is a very un- certain medicine, and one which may do mischief, and will require great care. Various antispasmodics, such as valerian, arnica, camphor, musk, and castor, have been employed, but very little reliance can be placed upon them. 216. When the symptoms are somewhat mitigated, or the disease is prolonged, and assumes a remittent character, Piorry and H. Clo- quet recommend quinine as having been successful in saving several cases. During convalescence it is undoubtedly of great value. 1 On the fatal Diseases of Children, p. 192. 150 ACUTE HYDROCEPHALUS. 217. I need hardly add, that all possible sources of irritation must be removed as speedily as possible; if the child be teething, the gums must be completely divided all round and across; and if the attack be secondary, our most vigilant efforts must be directed to the mitiga- tion or removal of the primary disease. If there be the slightest suspicion that the mother's or nurse's milk does not agree with the child (when at the breast), we should instantly change it, and choose a new and healthy nurse, whose milk is a little older than the patient, if diarrhoea be present. The mother may be unhealthy, or, if healthy, she may be suffering from distress, which is quite sufficient, as I can testify, to cause hydrocephalus. 218. The diet of the child must be restricted during: the first two periods, and should consist of little more than milk and water, with panada; as the disease advances, we must gradually endeavor to sup- port the strength, and if the termination be favorable, it will need care and caution to give sufficient food without excess. A spoonful of chicken broth may then be given two, three, or four times a day, and increased as the child can bear it. Wine whey will also be found very useful, and ultimately solid food and wine and water, if the child be old enough. 219. But far more important than the diet is it to take measures to insure absolute quiet and soothing rest for the excited brain. The room should be darkened, the air kept fresh and cool, only the neces- sary attendants admitted, and absolute silence enjoined as far as pos- sible. When taken out of the cradle or bed, the infant must lie on the lap or in the arms, and when moving him or walking about with him, the movements should be as gentle and equable as possible. Even when recovering, all excitement, noise, and merriment should be avoided as much as sharp air after pneumonia. Thus,in the first and second stages of meningitis, our remedies are: blood-letting in proportion to the age, strength, and constitution of the child, and the intensity of the attack, but in greater proportion than in other diseases; cold applications, counter-irritation, purgatives, if the bowels are confined; soothing and astringent medicines, if there be diarrhoea; calomel and James's powder; digitalis. In the third stage, a continuance of the calomel, and repeated blis- tering of the head, are nearly all that we can do with any prospect of benefit. 220. Lastly, most anxious inquiries are made of us by parents who have lost one child from hydrocephalus, as to the best mode of pre- venting the disease in others. We have no medicine which will do this; but, nevertheless, much may be done by good care and judicious management. If the child be very young, the mother had better not nurse the child; a change of milk will do much towards changing the constitution; the bowels should be carefully watched, and any devia- tions from health corrected; the gums should be lanced freely, the moment there are any signs of irritation; and the child should neither be exposed to heat nor cold. As the child grows older, he should be kept much in the country, CHRONIC HYDROCEPHALUS. 151 and in the open air; be encouraged in running and jumping, and the ordinary out-door amusements of children; but climbing, and many of the exercises of the gymnasium, particularly those which require the head to be held down, should be avoided. A good showTer-bath, or general sponging with cold water, every morning, is an excellent thing; the more healthy the skin, and the more developed the muscles, the less fear there need be for the brain. Again, in children with the least predisposition to the disease, the education should be carried on very cautiously; the attention should only be occupied for a short time together, the memory not overbur- dened, and every species of intellectual excitement avoided. Let the brain acquire strength before any burden be laid upon it. The sensibility should also be moderated, and passion controlled, not by indulgence, but by a mixture of reason and authority. The diet should'be nutritous, but unstimulating, and the bowels should be kept in order. Should the slightest symptoms show themselves, notwithstanding our care, Odier, Quin, and Matthey recommend the application of a blister; and Dr. Sachse succeeded by means of an issue in preserving a child whose brothers and sisters had died of the disease. I have great faith in the benefit to be derived from an issue (three threads are enough), from having witnessed the good effects in several cases. CHAPTER VII. CHRONIC HYDROCEPHALUS.--CHRONIC MENINGITIS. 221. The chronic form of hydrocephalus is much more rare than the acute; still, cases are met occasionally in children of different ages, from birth up to puberty or afterwards. I have already (83) spoken of hydrocephalus as an intra-uterine disease, and we shall see presently that there is reason to believe that some of the cases which show themselves during infancy, really commenced before birth; and these, probably, are the most common. Dr. Monro observes: "In the course of my practice, I have seen fourteen examples of the disease, and the victims of it were of differ- ent ages. All of them were born with large heads, and at the period of birth the head had evidently undergone considerable pressure in passing through the pelvis of the mother, and the skin of it was of a deep purple color."1 In other cases, however, we have no evidences at birth of any en- largement of the head, but as this commences very soon after, it has been inferred that the disease really began during intra-uterine life.2 1 Morbid Anatomy of the Brain, p. 135. ' Underwood on Diseases of Children, p. 372. Bouchut, Mai. des Nouveaux-nes, p. 450. 152 CHRONIC HYDROCEPHALUS. Barrier remarks that, although at birth the head is not unusually large, yet, as the functions of innervation are too slightly developed to suffer much disturbance from a slight cause, there may be more fluid than usual within the cranium without our being able to detect it.1 222. Chronic inflammation of the membranes, however, may arise at a period long subsequent to birth, even after the sutures have be- come ossified, as in Dr. Mills' cases;2 and in such, the disease com- mences in a slow, insidious manner, with some derangement of the general health, drowsiness, slight and occasional headache, irritability, &c.; and it is not for some time that, either from an increase of head symptoms, or a positive enlargement of the head, the suspicion is ex- cited that a serious disease exists in the head. 223. This chronic hydrocephalus may also be symptomatic of some other disease in the brain, or of some congenital malformation, as Billard supposes. Dr. Whytt relates a case in which a scirrhous tumor occupied the situation of the pituitary gland, and, by compress- ing the neighboring veins, gave rise to effusion. Tubercles of the brain, acephalocysts, or other morbid growths, may produce similar effects, either by mechanical pressure, or by the irritation they excite.3 M. Barrier considers that chronic meningitis is more frequently ex- cited by tubercular deposition in the membranes, such as was described in the last chapter. Here, however, there appears to be no doubt that it is not the inflammation which gives rise to the tubercles, but the tubercles which excite irritation, and at length inflammation, of the membranes, and effusion.4 And further, that the extent and amount of inflammation are in exact proportion to the tubercular granulations. MM. Barthez and Rilliet agree with M. Barrier, but add that they re- gard the compression of the vense galenae, or the straight sinus, as perhaps the most frequent cause of the effusion, whether by a tumor in the neighborhood, or by an obstruction in the cavity of the sinus, or by its obliteration, as related by M. Tonnelle.5 224. Lastly, chronic meningitis may be the sequence of the acute form already described.6 In such a case the symptoms subside in a great degree, but do not disappear; the fever diminishes, the headache is less acute and only occasional; the pulse may become less frequent, but the symptoms of cerebral disturbance and oppression continue, although in a modified form. In a late number of the Archives Generates de Medicine,7 M. Ril- liet has published an interesting case of arachnitis of the ventricles, without any inflammation of the peripheral arachnoid or pia mater; the symptoms to which it gave rise were headache, vomiting, constipa- tion, fever, and convulsion, but without intellectual disturbance at first. Afterwards, the disease subsided into chronic hydrocephalus, with di- minution of intelligence, and ultimately idiocy. 'Mai. de l'Enfance, vol. ii.p. 585. "Transactions of Association, vol. v. p. 398, et seq. 3 Bouchut, Mai. des Nouveaux-nes, p. 451. 4 Mai. de l'Enfance, vol. ii. p. 584. 6 Mai. des Enfans, vol. i. p. 808. 6 Copland's Diet, of Med., Part i. p. 230. • For December, 1847, p. 433. CHRONIC HYDROCEPHALUS. 153 225. Symptoms.—When chronic meningitis occurs after birth, the symptoms to which it gives rise are headache, drowsiness, disinclina- tion for amusement, inequality of temper, vertigo, pallid countenance,1 &c. The intellect is generally clouded, confused, and the face has a bewildered look; there is comparatively little heat of skin, the pulse is quick, and occasionally convulsions occur. In a more advanced stage, the symptoms are common to all the va- rieties of the disease, wTith some modification. The organs of sense are all more or less affected; the eyes are turned upwards or down- wards, or to one side, and unequally, so that the patient squints; the pupils are dilated, and the dilatation increases according to the com- pression ; the sight is generally weakened by degrees, until it is finally lost, although some few preserve it to the end. The nares become dry, and insensible to odor; the hearing, which was delicate at first, is lost by degrees. The taste is preserved longer generally, and in some few it is perfect to the last. The touch is unaltered for some time, but at length is a good deal blunted. 226. After effusion has taken place to any extent, we generally find the intelligence more or less affected, excepting in those cases where the head rapidly enlarges, then for a time the intellect may be as clear or even brighter than usual. After a time, it is evident that the child has not the mind of his age; it has been stationary, and then it retrogrades, until he has the look of an idiot, forgetful, scarce under- standing what is said to him, babbling words without meaning, or at cross purposes, neither able to explain his sensations nor his wants, until at last he seems sunk in indifference, stupor, or coma. This is not always the case, however. Michaelis mentions the case of a man, aged 29, whose intellect was not in the least impaired, although he had the disease from his birth.2 Dr. Monro, the case of a child whose head at eight years old measured two feet four inches in circumference, but whose memory was strong and retentive, and who was as lively as children usually are. Dr. Spurzheim has de- scribed several cases in which the mental powers were not impaired; one in particular, a learned man, "whose head is extraordinarily high on the anterior superior part of the forehead, and which, according to its size, must contain from three to four pounds of water; yet this man has extensive knowledge. The only inconvenience which re- sults from his peculiar state is, that he often falls suddenly asleep in the midst of the most interesting conversation, at table, at the theatre, and elsewhere."3 227. The most striking feature of the disease is the enlargement of the head. In infants, it commences soon, and proceeds rapidly, owing to the separation of the sutures; but even in cases where the sutures are ossified the enlargement has taken place. The amplification is of the vault of the cranium only, the base remaining unchanged, and it may be carried to an enormous extent. There was a case in Cruik- 1 Copland's Diet, of Med., Part i. p. 230. 11 Medical Transactions, vol. ii. p. 359. 3 Monro, Morbid Anatomy of the Brain, p. 138. 154 CHRONIC HYDROCEPHALUS. shank's museum, mentioned by J. Frank, which measured fifty-two inches in circumference. On the other hand, there are cases on record by Golis, Baron, Breschet, and others, in which the skull was full of serum, and the brain compressed, without enlargement, or even any suspicion that the disease existed. The face remains unaltered in size for a considerable time, nay, if anything it seems to shrink, and the aspect of the enormous head with the small face gives a very peculiar expression to the child—the fades hydrocephalica, as it has been termed—an old, withered, idiotic look. Dr. Monro states that at length the bones of the face are en- larged, and the angles, of the eyes more distant from each other.1 When the enlargement is great, the weight is inconvenient, so that the child has much difficulty in supporting the head upright; and in extreme cases, as the muscles of the neck are weakened, it is quite unable to do so, and either rests it on one shoulder, or on some artifi- cial support. 228. The power of locomotion is enfeebled at an early period, and ultimately lost. The limbs are feeble and the walk uncertain and trembling, requiring assistance and support, until, from the atrophy of the muscles, the child is unable to walk at all, and remains in the recumbent position. Very often he is attacked by general or partial convulsions, followed by paralysis, which may extend from the limbs to the muscles of organic life, giving rise to difficult deglutition, re- tention of urine, and constipation, or involuntary evacuations. 229. The respiration, circulation, and digestion are apparently un- affected for a considerable time. Many patients have a good appetite, and digest well, although without any increase of flesh. Vomiting, however, is observed occasionally. The pulse, which was natural, or rather quicker than natural at first, becomes weak and small after a time; the heat and moisture of the skin diminish: the respiration becomes at length labored, with an occasional access of dyspnoea. The appetite also at length diminishes, there is no relish for the food taken, and emaciation advances rapidly. In short, as M. Barrier has well observed, "the patient, deprived of the exercise of the functions of volition, is reduced to a vegetative life, which in its turn is gradually extinguished."2 I am not aware whether or not the cephalic bruit can be heard in the chronic as well as in the acute meningitis. Dr. M. Barth and Roger could not detect it; MM. Rilliet and Barthez heard it in one case resembling chronic hydrocephalus, but the brain was found, on dissection, to be healthy. 230. Pathology.—As I have already stated, the cranium is in most cases (with fewr exceptions) considerably increased in size, and that this is the result of the expansion of the cranial vault, the base re- maining unaltered. The outward shape is a good deal changed like- wise, the enlargement being more marked anteriorly and laterally than ' Morbid Anatomy of the Brain, p. 28. 9 Mai. de l'Enfance, vol. ii. p. 607. CHRONIC HYDROCEPHALUS. 155 posteriorly. The bones feel as if loose, attached only to the skin, the sutures being widely separated, and in some extreme cases, from over-distension, the skin has yielded, and a secondary tumor been formed.1 The bones of the cranium are sometimes of their natural thickness, but more frequently they are thin, weak, and semitransparent, resem- bling parchment rather than bone. They are very porous, and the radiating fibres around each point of ossification are very visible. 231. The cavity of the cranium is chiefly occupied by serum, which varies in quantity from a few ounces to many pounds. Bonetus, Acorivill, Buttner, and Cruikshank, relate cases in which they found eighteen, twenty, or twenty-seven pounds; Dr. Duncan one in which there were 136 ounces: but such cases are, of course, rare. Breschet's analysis of the serum is as follows:— Water...........9.900 Albumen..........0.015 Osmazome .........0.005 Muriate of soda........0.005 Phosphate of soda.......0.005 Carbonate of soda.......0.00102 Other analyses by Marcet, Bostock, and Berzelius give nearly the same results. According to M. Breschet, who has published an ex- cellent article upon the subject,3 the fluid may be contained, (a) be- tween the dura mater and the cranium; (6) between the dura mater and the arachnoid; (c) in the cavity of the arachnoid; (d) in the ven- tricles; (e) or in the laminae of the pia mater. I may add that fluid will generally, in all these cases, be found in the spinal canal. 232. A recollection of these different localities will in a great mea- sure enable us to understand the various conditions in which the brain has been found by different observers. Thus the brain is said to have been found in a rudimentary state, resembling a gland, and of small size, by Gall, Breschet, Baron, Billard, and others, which would natu- rally result from compression exercised upon it by fluid on its outer surface; or, by the combined influence of distension and absorption, reduced to a sort of membranous bag. Recent researches have dis- carded the agency of absorption, and this change, this deploying of the convolutions, is regarded merely as the result of distension by the fluid accumulated in the ventricles. According to the amount of dis- tension will be the thinness of the walls of this pouch, and in extreme cases it may hardly be possible to distinguish between the gray and white matter of the brain, or to recognize the central portions of the brain at all. Occasionally, we find the corpus callosum is raised nearly to the skull, the septum lucidum torn, the corpora striata flattened, the nerves atrophied and softened,4 or there may be no traces of these parts at all.5 1 Stewart, Diseases of Children, p. 525. a Bouchut, Mai. des Nouv.-nes, p. 454. 3 Diet, des Sciences Med., Art. Hydrocephaly 4 Bouchut, Mai. des Nouv.:nes, p. 453. 5 Monro, Morbid Anatomy of the Brain, p. 31. 156 CHRONIC HYDROCEPHALUS. The substance of the brain has also been found in a state of ramol- lissement, and more or less disorganized,1 although it is generally neither harder nor softer than usual. The cerebellum in most cases escapes material injury. 233. The membranes occasionally exhibit but few morbid changes. The dura mater is seldom altered, but M. Breschet mentions the ab- sence of the falx cerebri. The arachnoid is sometimes whiter than usual, and infiltrated with serum. The pia mater is excessively thin, but not destroyed. In other cases, there is abundant evidence of inflammation; the serous membrane may be thickened and rough, with well-marked granulations,2 or covered with a layer of false membrane, both at the base of the brain and in the ventricles. 234. The duration of the disease varies in different cases so much that no general rule can be laid down. Certainly those whom the disease attacks after the sutures are ossified, are carried off much more rapidly than others, because of the greater pressure upon the brain; so that, perhaps, we might say that life will be prolonged in proportion to the distensibility of the cranium, if the intensity of the disease do not anticipate its usual chronic course. Sooner or later, almost all the cases terminate fatally,3 either by the immediate results of pressure, or by the absence of due nervous in- fluence upon the organs necessary to life, and the consequent failure of their functions. 235. Causes.—Congenital hydrocephalus has been attributed to some malformation, or "vice de conformation," during foetal life; to the condition of the mother, moral or physical, during gestation: or to some peculiarity of constitution inherited from either parent. After birth, many of the causes of acute hydrocephalus, acting in a minor degree, or upon a different constitution, may give rise to chronic meningitis, such as cold, blows or falls, dentition, disordered stomach and bowels, &c. &c. I have already mentioned that the disease maybe excited by tumors of the brain, tubercles of the arachnoid, &c, and I may add another cause which I have only found mentioned by recent French writers, viz. hemorrhage into the cavity of the arachnoid, the fibrine and coloring matter being absorbed, and the serum remaining.4 In a large number of cases, the effusion is the simple result of chronic inflamma- tion of the membranes. 236. Diagnosis.—The only difficulty in diagnosis which can arise, is previous to the enlargement of the head, and our judgment must be formed by a careful analysis of the functional disturbances already noticed, among which M. Breschet regards as most important, the vacillation of the voluntary muscles, the difficulty of equilibrium, and the inclination of the head. ' Stewart, Diseases of Children, p. 525. 3 West's Lectures, Med. Gazette, August 13,1847, p. 268. 3 Barrier, Mai. de l'Enfance, vol. ii. p. 612. * Bouchut, Mai. des Nouv.-nes, p. 460. Rilliet and Barthez, vol. i. p. 789. CHRONIC HYDROCEPHALUS. 157 If there be any fever, the case might at first present some resem- blance to infantile remittent, but the absence of remissions, and the gradual increase of cerebral symptoms, will clear up the doubt. The very rare cases of chronic hydrocephalus, where no cranial enlargement takes place, will be with great difficulty distinguished from cases of tubercles of the brain, inasmuch as the muscular weak- ness, want of equilibrium, headache, and, in some cases, vomiting, are common to both.1 Probably the duration of the disease, and the con- stitution of the child, may throw some light upon the matter, as, for example, in a child exhibiting scrofulous tubercles in other situations, one might suspect that the head symptoms proceeded from a similar morbid cause. After the enlargement takes place, there is little danger of a mistake, and every day will elucidate more cjearly the nature of the disease. 237. Treatment.—The principal internal remedies employed are sudorifics, diuretics, and purgatives, with the occasional abstraction of small quantities of blood from the head, when there is a quick pulse, heat of scalp, or turgescence. "Dr. Watson speaks in favorable terms of Dr. Gower's plan in two cases. Ten grains of crude mercury, one scruple of manna, and five grains of fresh squill, are to be rubbed down for one dose, to be given every eight hours. The first patient, a lad who had been ill two or three years, took the above dose three times a day for nearly three weeks, without ptyalism being produced. Its effects were great prostration of strength and loss of flesh, with gradual relief of all his sufferings. It operated profusely by the kidneys. The medicine was continued twice a day, and at length once a day, for another fortnight, when all the symptoms of the disease had disappeared. The boy was greatly emaciated. He was then ordered an ounce and a half of Grif- fith's Mixture thrice daily, and soon regained his health and strength, and got quite well. The second case, a youth of twelve years old, after resisting all other remedies, was treated in the same way. The cure was permanent.2" The strength of the dose administered will of course vary with the age and strength of the child. Mercury in some form, from its power of stimulating the absorbents, and in combination with squills or digitalis, or both, from its diuretic effects, is our sheet anchor in almost all cases. Dr. Reid Clanny and others recommend that mercury should be given in large doses, and state that it is extremely useful. Inunction of mercurial ointment, or the blue ointment used to dress the blister, will assist in bringing the system under its influence. Mr. Wilson speaks strongly in favor of mercurial inunction as a means of reducing the size of the skull.3 Golis recommends calomel internally, mercurial frictions to the head, and slightly irritating baths, generous but not stimulating diet, ' Barrier, Mai. de l'Enfance, p. 611. 2 Underwood on Diseases of Children, p. 374. 3 Monro, Morbid Anatomy of the Brain, p. 144. 158 CHRONIC HYDROCEPHALUS. and fresh air when the weather is suitable; by these means he seems to have been very successful. M. Barrier mentions that iodine has succeeded in a few cases,1 and from its benefit in scrofulous cases, it seems deserving of a trial. Drs. Maunsell and Evanson speak favorably of it. 238. Counter-irritation, by blisters or issues, is doubtless of great use, and, when bleeding is inadmissible, it is the best means of re- ducing the chronic inflammation. Almost all writers are agreed upon the employment of blisters to the head (after having shaved the scalp), or along the spine. Dr. Mills recommends the ung. ant. tartar to the scalp, and that by some means a permanent drain should be established on the vertex or in its neighborhood.2 239. Two other external modes of treatment have been proposed, and to. a certain degree have been successful. i. From an opinion that effusion might be the result of want of firm resistance by the unossified cranium, compression has been tried. Riverius mentions the case of a boy who was thus cured.3 Sir Gilbert Blane used bandages around the head ;4 Mr. Barnard straps of ad- hesive plaster;5 and M. Engelmann, of Kreusnach, both bandages and plaster. Sir G. Blane's case was cured in less than three months. In Mr. Barnard's cases, considerable benefit was derived, and in Engelmann's cases, ten in number, the fluid was absorbed, and the patient recovered.6 Other successful cases are on record.7 M. Jadioux, however, regards it as insufficient and injurious. Mr. Hood, of Ayton, tried it, but without success; the pressure brought on convulsions. * Of course, to produce any good effect, the compression must be gradually increased, and continued for a considerable time. M. Trousseau uses strips of diachylon plaster, about one-third of an inch broad, and applies them, " 1, from each mastoid process to the outer part of the orbit of the opposite side; 2, from the hair at the back of the neck, along the longitudinal suture, to the root of the nose; 3, across the whole head in such a manner that the different strips shall cross each other at the vertex; 4, a strip is cut long enough to go thrice round the head, so as to make a firm and equable pressure."8 If symptoms of compression appear, they must be loosened, or if the skin be irritated, they must be removed. Drs. Watson and West re- commend the trial of Dr. Arnott's air press, as probably superior, for the purpose of compression, to any other means. 240. ii. Puncture of the cranium and evacuation of the fluid were proposed by some of the older surgeons (Severinus and Le Cat, &c), 1 Mai. de l'Enfance, vol. ii. p. 614. 2 Trans, of Association, vol. v. p. 457. * Obs. Commun., 6. * Lectures on the Structure and Physiology of the Bones, p. 269. 6 Lancet, No. 137, p. 52. 6 Archives Gen. de Med., June, 1838. i Lancet, No. 841, p. 82. s West's Lectures, Medical Gazette, August 16, 1847, p. 270. CHRONIC HYDROCEPHALUS. 159 but first practised in this disease, according to Dr. Stewart, by Dr. Vose of New York. It may have been suggested by those cases in which an accidental wound has afforded relief, of which there are several on record.1 The operation has been performed many times by different surgeons, and with varying results. Rossi, of Turin, was successful in one case. Dr. Conquest has related nineteen cases, of which ten were successful. Dr. Lee succeeded in one case in affording great relief, but the child was carried off by cholera.2 Mr. Cooper and others failed. M. Bedor, of Troyes, succeeded in one case;3 M. Malgaigne has not been altogether unsuccessful, and he thinks the operation may be attempted under three months old, when the hy- drocephalus is stationary, and above that age, if the cranium be not ossified, and if the danger be imminent from the increase of the effusion.4 Mr. West has collected sixty-three cases, in which the operation was performed by different persons, and has found that eighteen, or two in seven, terminated favorably.5 On the other hand, M. Boyer altogether rejects it. Golis, Heister, Hecker, and Portenschlag pronounce it cruel and useless. Dupuytren and Breschet tried it, and failed.6 241. Nevertheless, in so hopeless a disease, when other remedies have failed, even such moderate success may justify our having re- course to the operation. It is performed by passing a fine, lancet- shaped trocar, perpendicularly to the surface, through the scalp and membranes, below the edge of the anterior fontanelle, so as to avoid the sinus, if possible, and the great veins. The fluid should be allowed to escape very slowdy, the head being gently compressed in proportion, and the whole fluid should not be evacuated at once. The canula should be withdrawn if the pulse become weak, the pupils con- tract, or the child become faint. In the latter case, a stimulant may be necessary. If any inflammation arise, antiphlogistic treatment will be necessary. The repetition of the operation will be indicated by the increase of the effusion. Dr. Conquest operated five times on one patient, at intervals of from two to six weeks, and removed from fifty-seven to fifty-eight ounces of water. The diet of the patient should be nutritious, but unstimulating; milk in any form, broth occasionally, and in some cases, but rarely, it may be advisable to allow wine. 'Lancet, May 15, 1824, p. 238. Caspar's Wochenschrift, No. 40. * New York Medical and Physical Journal, vol. vi. p. 49. 3 Diet, de Med. de Fabre, vol. v. p. 61. ♦Bull, de Therap., 1840, vol. xix.p.226. s Lectures, Medical Gazette, August 13, 1847, p. 270. 6 Barrier, Mai. de l'Enfance, vol. ii. p. 616. 160 INFLAMMATION OF THE BRAIN. CHAPTER VIII. INFLAMMATION OF THE BRAIN.—ENCEPHALITIS.--INDURATION AND HYPERTROPHY.--SOFTENING.--ABSCESS. 242. Inflammation of the substance of the brain, as distinguished from meningitis, with which it is often partially complicated, is a very rare disease of infancy and childhood, and indeed its existence is chiefly proved by some of its terminations. And it is consequently difficult to separate the symptoms which characterize the period of inflammation from those, for example, which mark the occurrence of softening or of abscess. On this account, the present description should be read in connection with the notice I shall presently give of ramollissement, &c. It does not appear peculiar to any exact age, but certainly is less frequent during infancy than childhood; nevertheless, I saw one case of a very young infant, the substance of whose brain exhibited traces of inflammation, and was extensively softened. 243. Symptoms.—The characteristics of encephalitis are much less vividly marked than those of meningitis: it is sometimes preceded by disordered health for some time, loss of appetite, deranged bowels, occasional headache; or it may attack a child suddenly awaking out of sleep, trembling and frightened; or in the daytime by headache, vomiting, confusion, and more or less of stupor; or it may commence by a violent convulsion; or, lastly, some defect of movement, or dif- ficulty of speech, increasing to absolute loss of the power of articula- tion, as in M. Durand's case,1 may be the earliest intimation of serious disease of the brain. The sensibility, in some few cases, is increased at the commence- ment, but soon diminished; the eyes are heavy and the pupils dilated. The intellect is generally confused, and in some cases the patient is for a time delirious. More commonly, however, there is a degree of stupor, ending often in insensibility. How far inflammation of one hemisphere, or of a portion of one hemisphere, may interfere with the phrenological functions of the organs there situated, and so with the mental manifestations, I am not prepared to say. 244. The convulsion may be repeated, or paralysis of one side (he- miplegia) may supervene, even during the early stage; or the paralysis may be partial, and combined with involuntary movements, twitch- ings, or convulsions of other limbs. In some cases, the limbs become powerless, and without muscular tone, so that, when raised and allowed to fall, they do so like the limbs of a dead person. 1 Rilliet and Barthez, vol. i. p. 656. INFLAMMATION OF THE BRAIN. 161 However slight the effect upon the muscular system may be, the powers of locomotion are affected; irregularity and difficulty of walk- ing, want of equilibrium, the impossibility of standing, or sometimes of sitting, are symptoms commonly observed. Dr. Copland has re- marked: "When cerebritis is general, these symptoms affect all the limbs simultaneously ;wThen local, only some of them, according to the seat of the inflammation."1 Occasionally, but much more rarely, the limbs, or some of them, become rigid, and much pain is experienced in attempting to straighten them. 245. The expression of the countenance is different from that in meningitis, seldom so acute or excited, generally pallid and anxious, or calm and pale, unless the muscles of the face be spasmodically affected. There is rarely much fever, the pulse is pretty quick, and small, and in some cases is but little changed. Respiration is at first rapid and regular, but afterwards irregular and interrupted. The stomach is very frequently disordered, and vomiting, at least occasionally, is present. The bowels may be free or constipated. All these symptoms may be present when there is nothing but simple inflammation of the brain; nay, the disease running on into stupor and coma may end fatally, leaving no other traces in the brain than those of inflammation; but in the majority of cases the disease is not thus arrested; it continues longer, new symptoms are developed, indicating further disorganization, and the disease terminates either in, 1, induration and hypertrophy; 2, softening; or, 3, abscess. 246. A post-mortem examination reveals considerable congestion of all the vessels of the brain, especially of the pia mater, and a minute vascular condition of the brain generally, or of some part of it. In almost all cases, moreover, we find evidences of a more ad- vanced state of disease, to which I shall refer by and by. 247. Causes.—All the causes which act upon the nervous system, as enumerated among the causes of meningitis, appear capable of producing encephalitis. There are some local affections which have been followed by the latter disease, and which I must not omit to notice. In a case quoted in Rilliet and Barthez, the child, aged nine years and a half, had shortly before suffered from purulent ophthalmia, by which she lost an eye, and it seems probable that this may have had some share in the subsequent cerebral attack.2 Other cases are on record, in which inflammation of the brain has followed disease of the ear.3 Dr. Abercrombie mentions a case of inflammation and abscess, which came on in a boy who had been two months affected with headache and discharge from the ear; and others have recorded similar cases. 248. Diagnosis.—I do not know of any symptoms sufficiently pa- thognomonic to enable us to pronounce, with certainty, that the sub- 1 Diet, of Med., Part i. p. 231. 2 Vol. i. p. 656. 3 West, Lectures on Diseases of Children, Medical Gazette for July 30, 1847. 11 162 HYPERTROPHY AND INDURATION OF THE BRAIN. stance of the brain alone is affected by simple- inflammation. The more rapid loss of voluntary power, the earlier occurrence of paralysis and stupor, and the inferior amount of excitement, mark certainly a difference between the present disease and meningitis; but, although the history of the two diseases varies a good deal, the differences are not very characteristic. 249. Treatment.—However difficult it may be to distinguish be- tween this and other cerebral diseases, there can be no doubt in any case that the brain is affected, and by an inflammatory disease, so that our plan of treatment is pretty clear. Abstraction of blood by leeches or venesection is essential at an early period of the disease, and the quantity must be regulated by the constitution and strength of the patient, and the intensity of the disease. Cceteris paribus, however, I do not think that excessive blood-letting is so necessary in this disease as in meningitis; but, if the symptoms continue unmitigated, the leeching should be repeated. Counter-irritation, by blisters to the head, neck, or behind the ears, will also be necessary, and it will be well to dress the blister with mercurial ointment, for our great object should also be to bring the system under the influence of mercury. Calomel, or the hyd. c. creta, may be given in moderate doses frequently, combined with the pulv. cretae c. opio, if the bowels are too freely affected, and con- tinued until either the gums are tender or mercurial stools produced. If the bowels are constipated, purgatives will be necessary. The diet should be mild and unstimulating during the period of in- flammation; it may be increased when other symptoms set in, if the child can swallow. We shall now proceed to treat of the terminations of encephalitis, and first of I. HYPERTROPHY AND INDURATION OF THE BRAIN. 250. I must candidly inform my readers that there appears con- siderable doubt, in the minds of pathologists, as to whether hyper- trophy and induration are the result of inflammation; the disease is rare, and generally obscure, and it is not easy to tra'ce its origin; but, judging from analogy of other organs, I am inclined to regard it as the result of inflammatory action. Hufeland remarks, that any cause which gives rise to congestion of the brain may also cause hyper- trophy; and Laennec, who was one of the first to describe the disease, remarks: "It has happened to me to see several cases, which I con- sidered internal hydrocephalus, but which, on a post-mortem exami- nation, presented but a small quantity of water in the ventricles, although the flattened convolutions of the brain proved that this viscera had undergone a degree of compression which could only be attributed to excessive size, and consequently to too active nutrition of the cere- bral substance."1 1 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 654. HYPERTROPHY AND INDURATION OF THE BRAIN. 163 The disease has not been long known, and we are indebted for our information chiefly to the researches of Scoutetten, Jadelot, Laennec, Bouillaud, Andral, Miinchmayer, Papavoine, Sims, Green, Lees, Mauthner, &c. 251. Mauthner has taken 'the trouble to weigh the brains of 216 children, of all ages, from birth up to the eighth year, so as to show the gradual and healthy increase of the organ. "During this time," says he, "we find a minimum of ten ounces six drachms rise to a maximum of forty-four ounces and a half. The average weight begins with thirteen ounces and a half, and rises to thirty-five ounces and a half. During the first year, it grows from thirteen ounces and a half to twenty ounces and a half, or seven ounces; in the second, from twrenty ounces and a half to twenty-five ounces and a half, or five ounces; in the third, from twenty-five ounces and a half to thirty- two ounces, or three ounces and a half. Hence, it appears that the brain grows most rapidly in the first year of life, that in the second and third years its increase is still considerable, but that its growth is slower after the fourth year. In conclusion, it may be observed, as a remarkable fact, that the minimum weight usually occurs in cases of atrophy or phthisis, and the maximum in pneumonia, scarlet fever, apoplexy, and cerebral tubercle."1 It also appears that the weight is to a great degree dependent upon the amount of blood contained in the brain. 252. Symptoms.—The early period of the disease is marked by dulness, drowsiness, or apathy, with an apparently excessive size of the head. There are generally irritability of temper, giddiness, and habitual headache, with severe exacerbations.2 In passive hypertrophy, M. Mauthner remarks that the shape of the cranium is much changed, and the occiput occasionally promi- nent and globular; the parietal protuberances subsequently project; the coronal and sagittal sutures continue unossified up to the ninth or twelfth month, and the fontanelles much longer; the growth of hair is scanty, and the veins of the scalp swollen. The child sleeps much, though easily startled; the head perspires a good deal, and droops forward by its weight. Attacks of crowing inspiration occur when the child cries, and not unfrequently end in convulsions, especially during the period of dentition. The digestion is impaired, and vo- miting and diarrhoea are frequent. Gradually, we find symptoms of compression developed, or they may suddenly appear as the result of the child being attacked by some other disease. " When hypertrophy of the brain has reached this stage, the skull deviates still more from its natural shape, the forehead sometimes be- comes prominent and globose, like the occiput, and while the skull goes on acquiring an increased curvature, the region of the temples continues flat, and thus contributes to give to the head the appearance of being formed by the union of the segments of four spheres. During this stage of the affection, the preternatural softening and thinning of 1 British and Foreign Review, No. 42, p. 387. 1 Condie, Diseases of Children, p. 343. 164 HYPERTROPHY AND INDURATION OF THE BRAIN. the cranial bones corresponding to the prominences of the convolu- tions are distinctly perceptible, especially at the occiput. The func- tions of the brain become now much disturbed; headache, giddiness, impairment of muscular power, and loss of memory occur; the child grows sullen, peevish, sleepless, whimpers continually, and rolls the head constantly from side to side. At the same time, it seems choked with phlegm, while the skin becomes every day more flabby, the muscles shrink, the bones grow soft, and the muscular power rapidly diminishes. Hence, these children usually lie on the back, breathing with habitual wheezing, and suffering from constant dyspnoea, with occasional asthmatic seizures, such as have been already described. When in this condition, slight causes suffice to produce a general ex- citement of the vascular system, and to excite diseased action in other parts, which render still more obvious the influence of hypertrophy on the nervous system generally. If the child happen to catch a slight cold, attacks of convulsion, cough, or of asthma occur in con- sequence, or convulsions come on, which terminate life in a few days."1 253. When the disease is active (according to Mauthner), i. e. when the walls of the skull do not yield in proportion to the increase of the brain, the symptoms are those of more acute cerebral disease, the result of compression. There is also some modification of the symptoms, where the hyper- trophy and induration are partial, according to the peculiar locality. Further, symptoms resembling those of hypertrophy, but very severe, have been noticed, where the skull is ossified and unusually thick, and does not yield to the increasing size of the brain. The intellectual faculties are generally enfeebled; but Dr. Elliotson relates a case in which they were rather increased in activity and power. The extent of enlargement of the head varies of course. Dr. Con- die mentions a child of five or six years old, whose head was as large as an adult's, and whose intellects were clear and acute.2 This may be expected, if at all, in cases of such enlargement; as the intellectual disturbance, and many of the symptoms, are the result of compression rather than of hypertrophy. 254. Drs. Sims and Green have noticed a sensation of firmness communicated to the finger when pressure is made upon the fonta- nelles, and regard this as a valuable diagnostic sign. Andral observed mania to occur in one case ; others have noticed delirium, and some idiocy, with a repetition of fits like epilepsy. The duration of life in children thus affected is subject to great variation. Some arrive at puberty with but little inconvenience ; but many die during childhood from the consequences of the hypertrophy, such as convulsions, &c, or from states of the brain superinduced by other diseases. 1 Mauthner, p. 174. British and Foreign Review, No. 42, p. 388. 1 Diseases of Children, p. 343. HYPERTROPHY AND INDURATION OF THE BRAIN. 165 255. Pathology.—The change in the brain, which strikes the eye at once, is its increased size in most cases, and the evident flattening of the convolutions, diminished vascularity, and the absence of serum in the ventricles, or at the base of the brain. When the head is much enlarged, the alteration in the consistence of the brain may not be very remarkable, although in general it will be found more dense than usual. But, when the cranium has been ossified, or has not yielded to the pressure of the brain, the cerebral tissue will be found firm and elastic to the touch, and cutting clear by the knife in thin slices, the gray matter paler than usual, and the white matter more brilliant. Or it may be still more firm, and offer some resistance to the knife, or to pressure. Its weight is greatly increased, sometimes even doubled. "Professor Rokitansky states, as the result of many microscopic examinations, that its augmented bulk is not produced either by the development of new nervous fibrils, or by the enlargement of those already existing, but by an increase in the intermediate granular matter."1 According to Sims, and Rilliet and Barthez,2 the hypertrophy and induration may be limited to the corpora striata, or optic thalami, or to one lobe of the brain, which, of course, will condense the parts in its neighborhood more or less. The membranes of the brain are sometimes pale, sometimes injected, and distended so tightly by the brain that, when an incision is made, the brain protrudes. M. Mauthner has remarked a frequent coincidence of enlargement of the thymus gland, the left side of the heart, and the liver, thus affording some support to Munchmayer's theory of the connection of thymic asthma with hypertrophy of the brain. 256. Causes.—Hypertrophy of the brain, or at least a condition of that organ strongly predisposing it to undue and more or less rapid augmentation of bulk, is very frequently congenital. All causes which give rise to cerebral congestion may, according to Hufeland, determine hypertrophy of the brain. Laennec, Papavoine, Rilliet and Barthez mention an extraordinary and inexplicable effect of the preparations of lead in producing this disease; but I do not find it mentioned by other authors.3 257. Diagnosis.—It is not very difficult, in most cases, to distin- guish hypertrophy from acute hydrocephalus, not because the symp- toms of the former are so very clear, but because those of the latter are generally sufficiently marked. Their acute inflammatory charac- ter, the high fever, quick pulse, and the sequence of symptoms, are very unlike hypertrophy. Chronic hydrocephalus has more resemblance to it, and especially in the most obvious characteristic, enlargement of the head. Mauth- ner has thus marked the points of difference: "In hypertrophy, the posterior part of the skull first presents an unnatural prominence. In ' West's Lectures, Medical Gazette, August 27, 1S47, p. 354. 3 Condie, Diseases of Children, p. 343. 3 Mai. des Enfans, vol. i. p. 665. 166 HYPERTROPHY AND INDURATION OF THE BRAIN. chronic hydrocephalus, the forehead is the first part to present un- natural prominence ; the altered direction of the eyes, and the very great width of the sutures and fontanelles, are likewise characteristic. In hypertrophy, children lie horizontally, or throw the head back. In chronic hydrocephalus, children lie on the belly, with the head lower than the rest of the body, burying the face in the pillow. In hypertrophy, the face is puffy, the eyes inexpressive and staring, mouth half open. In chronic hydrocephalus, the countenance is withered, having the expression of premature old age. In hyper- trophy, functional disturbance comes on very gradually, not before the period of dentition or weaning, and consists at first in affection of the respiratory apparatus, difficulty of breathing, and attacks of apnoea. In chronic hydrocephalus, functional disturbance occurs early, and involves the cerebrum from the very beginning. In hypertrophy, the patient is fat and leucophlegmatic. In chronic hydrocephalus, the patient is ill-nourished, subject to rickets and tabes mesenterica."1 258. Prognosis.—The prognosis is in all cases serious, not so much from the dangerous character of the disease as from the effect pro- duced upon the brain by other causes, and its increased susceptibility to disease. There is more hope, when it occurs before the sutures are ossified, and when the cranium yields readily to the increasing mass of the brain. When the skull is resisting, the result of compression may be fatal. 259. Treatment.—When the disease is fully confirmed, there ap- pears to be no means capable of reducing the volume of the brain, and our principal efforts must be directed to guard against any attacks of congestion or inflammation ; by means of leeches, cold lotions, pur- gatives, and counter-irritants. But, when the disease is commencing, we ought to prohibit every- thing which tends to produce excitement, or determination to the brain.. Quiet, rest, and tranquillity of temper should be observed, cold sponging of the scalp, and occasional purgatives. The hair should be cut short, and the head kept uncovered in the house. The appetite, which is generally too good, should be restrained as to the quantity of food, and that not too nutritious in quality. The moment the gums become irritable, they should be lanced, and the child should take plenty of exercise in the open air. Education must be carried on at a moderate rate, so as not to stimulate the intellect too highly, and it may be necessary to sus- pend it entirely at times. When the affection results from saturnine poisons, we are recom- mended to employ blood-letting, opium in large doses, cold applica- tions, and evacuants, &c. ' British and Foreign Medical Review, No. 42, p. 389. RAMOLLISSEMENT OF THE BRAIN. 167 II. RAMOLLISSEMENT, OR SOFTENING. 260. There can be no doubt that encephalitis frequently terminates in softening,1 even if we admit that the latter may occur independ- ently of the former, as in some cases of hydrocephalus already no- ticed, and in other cases of old standing disease of the brain (tuber- cles, for instance), when the neighboring tissue is softened and pulpy. These are instances of secondary ramollissement. 261. It does not appear that there is any symptom which positively indicates the occurrence of this lesion. Some French writers have regarded tonic contraction of one or more limbs as pathognomonic, and no doubt it frequently occurs ; but it is frequently absent, and it is also met with in other affections of the brain. In most cases, we have convulsions, paralysis, and coma as the principal symptoms ; sometimes, a single convulsion, followed by coma ; in other cases, the convulsion is repeated. Occasionally, the loss of power is the most remarkable symptom succeeding the evidences of encephalitis just noticed ; sometimes the rigid contraction, already mentioned, followed by relaxation and paralysis. Or there may be convulsion of one side of the body, and paralysis of the other. In a case of M. Deslande's, quoted by Barthez and Rilliet, the child exhibited a slight, but continual stupor, was very easily disturbed, and died without an additional symptom. In other cases, the coma is deep and permanent until death. In a few examples, not remarkable for any evidences of disease, the child has died suddenly during the night. We generally find complete loss of intelligence, as of voluntary motion; the pulse is sometimes nearly natural; in other cases, quick or irregular ; and'there is occasional vomiting. In one case, already quoted, the speech was impeded from the be- ginning, and ultimately rendered impossible ; a fact which Dr. Aber- crombie has noticed in adults. In some cases, there is squinting with retraction of the head. It is probable that softening of particular portions of the brain is attended by appropriate symptoms, but it is excessively difficult to determine this point. 262. Pathology.—Ramollissement, as Dr. Abercrombie observes, " consists in a part of the brain being broken down into a soft pulpy mass, retaining the natural color of the part, without any appearance of suppuration, and without fetor. This condition we often find as the only morbid appearance ; but we frequently find it combined with the former (evidences of inflammation), one portion of the diseased mass presenting the deep red color, while another is in the state of ramollissement."2 The color of the softened mass is sometimes yellow; all such cases, 'Abercrombie on Diseases of the Brain, p. 128. 1 Ibid., p. 72. 168 ABSCESS OF THE BRAIN. Rilliet and Barthez think, are the result of secondary inflammation or softening. The consistence and extent of the softened portion vary much ; it may be reduced to a kind of jelly or pulp, but without destroying the form of that part of the brain ; or it may be utterly disorganized, and fluid or semifluid, like cream. So we may find it of small ex- tent, limited to a portion of the brain, or occupying the greater por- tion of a hemisphere. Mauthner has observed that the white sub- stance is almost always the seat of the disease in children, the gray matter being seldom affected. The disease is almost uniformly fatal, and of very short duration. 263. The diagnosis is necessarily obscure ; we may know that in- flammation of the brain exists, and we may suspect that softening is taking place, but that is nearly the only conclusion to which we can attain. The sudden paralysis, especially when combined with con- vulsion, the loss of the power of articulation, or the complete resolu- tion of muscular force, appear to be more characteristic than any other symptoms. 264. The fact that we cannot recognize, with any certainty, the disease during life, that all the cases on record died, will at once ex- plain our ignorance of any efficient mode of treatment. I have laid down the best mode of management for encephalitis, but I have no additional information to give as to any change of remedies required by this termination. If the leeching, counter-irritation, and mercury have not secured the patient against this consequence of inflamma- tion, we know not how to afford relief. III. ABSCESS OF THE BRAIN. 265. In this affection, we find, according to Dr. Abercrombie, " a well-defined, regular cavity, filled with purulent matter, generally lined by a soft cyst, and surrounded by cerebral matter in a healthy state."1 So few cases are on record, that it is impossible to give a general description of the disease, without calling in the aid of imagination. I think it better, therefore, to quote two cases from Dr. Abercrombie's excellent work, than to attempt any more formal statement. The first occurred in a girl set. 5, and the case is described by Dr. Bateman.2 "An abscess was found in the posterior part of the right hemisphere, enclosed in a fine vascular sac, and containing four ounces of pus. She was first affected with convulsion of the whole body, which continued for nearly two days ; during this time, the left side was in a state of rigid extension, and the right was in constant mo- tion; and when the attack subsided, the left side remained paralytic. She then had headache, squinting, blindness, and repeated convul- sions; and died after an illness of eleven weeks, having been coma- * Diseases of the Brain, p. 72. 2 Edinburgh Medical and Surgical Journal, vol. i. p. 150. ABSCESS OF THE BRAIN. 169 tose for only one day before her death. In some cases of this kind, paralysis has occurred without convulsion, and in others convulsion without paralysis ; but one or other of these affections appears to be a common attendant on the encysted abscess."1 266. The next case I shall quote is that of a " girl, set. 11, thin, and delicate, who, after having complained for some days of headache, was seized on the 11th of January, 1817, with convulsion, which continued for about half an hour. I saw her on the 12th, and found her affected with severe headache, and paralysis of the right arm, which had taken place immediately after the convulsion. The pulse was 100, the tongue foul, the face rather pale, and the eyes languid. Being bled from the arm and purged, she was much relieved. On the 13th, the pulse was natural, the headache was much abated, and she had recovered considerable motion of the arm. On the 15th, the headache being increased, and the arm more paralytic, she was bled again; and, on the 16th and 17th, she was much relieved, the pulse natural, and. the motion of the arm much improved. On the 18th, after being affected with increase of headache, and some vomiting, she became convulsed, the convulsion being confined entirely to the head and the right arm. The head was drawn towards the right side, with a rolling motion of the eyes; the arm was in constant and violent motion; she was sensible, and complained of headache; pulse 100. Being bled to Iviii, the convulsion ceased instantly, and the headache was relieved ; but the right arm continued in a state of complete pa- ralysis. 19th and 20th, the arm had recovered a little motion ; some headache continued, with occasional vomiting; pulse 60. On the three followring days, the convulsive attacks returned several times; they did not now affect the head or face, but were entirely confined to the right arm, which, after the 23d, was left in a state of perma- nent paralysis. Hitherto, no other part of the body had been affected by the convulsion, but on the 24th it attacked the right thigh and leg, and left them in a state of paralysis; pulse 60. The former re- medies were again employed with activity, without any effect in arrest- ing the progress of the disease. The thigh and leg now went through a course precisely similar to that described in regard to the arm, and on the 29th remained in a state of permanent paralysis. When the convulsion first began to affect the leg, the arm was affected at the same time; but afterwards it was confined to the thigh and leg, the arm remaining motionless. February 4.—Complete paralysis of the whole right side ; no return of convulsion ; she continued quite sen- sible, and made little complaint; pulse from 50 to 60. She now continued for several days without any change, and, except the palsy of the right side, every function was natural. She was quite sensible, appetite good, pulse and vision natural, and she made little complaint of any uneasiness. She was, however, inclined to lie without being disturbed, and gradually became more oppressed. On the 11th, this had increased to perfect coma, in which she continued for three days, and died on the 14th. ' Abercrombie on Diseases of the Brain, p. ill. 170 TUMORS OR TUBERCLES OF THE " Inspection.—In the upper part of the left hemisphere of the brain, there were two distinct, defined abscesses, containing together from six to eight ounces of very fetid pus. They were lined by a firm, white membrane, and a thin septum of firm, white matter separated them from each other; the one was in the anterior part of the hemi- sphere, very near the surface, and the other immediately behind it. They had no communication with each other or with the ventricle. In the posterior part of the right hemisphere, there was a small abscess containing about half an ounce of pus. There was no serous effusion in any part of the brain, and no other morbid appearance."1 CHAPTER IX. TUMORS OR TUBERCLES OF THE BRAIN AND SPINAL MARROW. 267. Besides the tubercular disease of the membranes of the brain already described (182), we find larger and more isolated deposits of the same matter, or tumors of a different kind, growing from the mem- branes or imbedded in the substance of the cerebrum, cerebellum, and spinal marrow, attended by symptoms which indicate their presence but very obscurely, and having almost always a fatal termination. This form of disease is not very common, though more frequent than was suspected until the more accurate researches of late years by Green, Barrier, Rilliet and Barthez, West, &c. It occurs, too, at an earlier age; for, of thirty-four cases mentioned by Barrier, sixteen were under five years; thirteen from five to ten; and five only from ten to fifteen years. Of Dr. Green's thirty cases, in thirteen it oc- curred between two and four years; and in seventy-five cases he states that it occurred most frequently in children from three to seven years. Of Rilliet and Barthez's twelve cases, six were from three to five years; four from six to ten and a half; and two from eleven to fifteen years; and eight were boys. Dr. Condie considers it very rare before the first year. Dr. Mauthner found, in seventeen out of thirty-two, that the age did not exceed six years, which was the case in seven out of eight cases observed by Dr. West. On the other hand, it is very rare in adults, according to Cruveilhier, Louis, and Lugol. The sex of the child does not appear to have any influence in the production of the disease; the majority of Dr. Green's cases were females; the majority of Rilliet and Barthez's cases males. 268. Symptoms.—Dr. Abercrombie has observed, with great truth, that "the symptoms accompanying tubercular disease of the brain in its early stages, are often exceedingly obscure and variable; perhaps ' Abercrombie on Diseases of the Brain, p. 93. BRAIN AND SPINAL MARROW. 171 little more than a tendency to headache, which assumes no formidable character, or sometimes assumes the appearance of what has been called the periodical headache, or the sick headache. The symptoms may go on for a long time in this manner without exciting any alarm, until the disease suddenly assumes a more active character, and is speedily fatal."1 In five of Dr. Green's thirty cases, there was no symptom at all of cerebral disorder; in three, headache wTas the only symptom; in one, deafness; and in one, a purulent discharge from the ear. Moreover, we find it extremely difficult to draw the line between the symptoms which arise from the tumor simply, and those which are the result of the morbid action which it provokes in the neighboring tissues. Headache is, perhaps, the most universal symptom; it may be either general or local, but in the latter case it does not necessarily mark the seat of the disease. In general, it is also an early symptom, and corre- sponds with the remissions and accessions of the constitutional dis- turbance ; it may continue even until death. In more cases, it is absent at the commencement, and is noticed only at an advanced period of the disease. 269. The organs of sense are generally more or less affected; the touch the least so, however. Occasionally, at first, it seems more acute, but subsequently less sensitive, especially when the tumors are seated in the cerebellum, or near the sensitive nerves. M. Barrier mentions a case in which there was paralysis of the trifacial nerve of the right side, in consequence of the tumor pressing upon the fifth pair of nerves.2 The eye and ear will be similarly affected by the pressure of the tumor in the neighborhood of their spinal nerves, and more or less by the general disturbance of the nervous system, from cerebral tumors. Amaurosis and deafness are not uncommon; and it is, perhaps, worth noting, that, in a certain number of cases, there is a discharge from the ear, or an abscess of that organ ;3 but, whether connected, as cause or effect, with the tubercles, it is not easy to say, but as yet I am inclined to think not. 270. During the early stage of the disease, and so long as it is un- complicated, there is rarely much disorder of the intelligence. In some cases, it is true, the temper becomes irritable, especially if the head- ache is severe; or perhaps the child may lose its natural vivacity, and become apathetic and dull, weary of play, and wishing to be alone. At a more advanced period of the disease, even when uncomplicated, so far as we can ascertain, there gradually steals over the countenance an expression of mental feebleness and vacuity; the child is indis- posed to intellectual exertion, even if not actually incapacitated. In proportion as morbid actions (meningitis, encephalitis) are excited by ' On Diseases of the Brain and Spinal Marrow, p. 167. a Mai. de l'Enfance, vol. ii. p. 630. 3 Dr. Green, Med.-Chir. Trans., vol. xxv. p. 193. Abercrombie on Diseases of the Brain, &c, p. 171. 172 TUMORS OR TUBERCLES OF THE the tumors, we find the mind exhibit the same disturbances as is usual in these disorders. 271. Convulsions are by no means uncommon, though not uni- versal ; they pretty constantly occur in those cases where the tubercles occupy the central portion of the brain, or are disseminated extensively throughout. Rigidity or contraction of one or more of the extremities is more common; it generally affects the leg and arm of the same side, sometimes only one limb, and very rarely both upper or both the lower limbs. It is not easy to determine whether it be referable di- rectly to the pressure of the tumors, or whether it be the result of the inflammation and induration, or softening of the surrounding cerebral substance (261). Or perhaps we may observe a weakness of certain muscles, as in a case of Dr. Green's, where the eyeball was convul- sively jerked inwards, or in other cases, in which strabismus Occurs. In the majority of cases, paralysis occurs at some period of the dis- ease; at the commencement in a few', and at a more advanced period in most instances. It may be partial, the result of local pressure,1 or generally affecting the sensation and motion of one side. It is re- markable that, although the child may recover partially and for a time from the affection of the eyes and ears, from the rigidity and deficient sensibility, the paralysis is permanent in almost every case in which it occurs, and continues without mitigation. 272. The stomach and bowels generally sympathize with the cere- bral irritation, and, coincident with the headache, stupor, or coma, we find vomiting to occur, and constipation, sometimes easily overcome, but in other cases very obstinate. The circulation is generally affected, but in an uncertain manner; the pulse is sometimes slow, sometimes quick; in other cases, very unequal. My friend Dr. Johnson attaches great value, as a pathogno- monic sign, to irregularity of the pulse, occurring at an early period of the disease, and without apparent cause. So far, the symptoms may be considered the result of the tubercles alone, and they do not differ, whether the seat of the tumor be the cerebrum or cerebellum ; and they may persist, with intermissions or remissions of varying duration, for a considerable time, and then the child gradually sinks into stupor and coma, and at length dies. Or, which is more frequently the case, a secondary affection, meningitis or encephalitis, may be excited, giving rise to the symptoms formerly described, and masking the proper characteristics of the present affection, and proving certainly fatal. Some cases have terminated in chronic hydrocephalus when the tumor has been so situated as to press upon the large veins or sinuses, or to offer considerable mechanical interruption to the circula- tion. Nine of Dr. Green's cases died with symptoms of acute hydro- cephalus, and a few with those of softening of the brain. In many cases, there are tubercular or scrofulous affections of other organs, which are of value in forming a diagnosis. 273. The duration of the disease is very difficult to be determined; 1 Dr. Green, Med.-Chir. Trans., vol. xxv. p. 205. BRAIN AND SPINAL MARROW. 173 the tumors maybe latent for a long time; the early symptoms are slight and undefined, and, even when marked, they are common to other diseases, or occur frequently without any disease at all. Dr. Green remarks that, in his cases, the chronic stage varied from six weeks to two years. Rilliet and Barthez state that, of twenty-five cases of tubercles with or without chronic hydrocephalus, the disease lasted in 3 cases from 3 to 4 months. 10 " 5 to 7 " 3 " 7 months to 1 year. 2 " 1 year to 2 years. 3 several years.1 And the termination is uncertain, generally occasioned by a se- condary complication, and more quickly than would have happened from the simple disease. I have already spoken of the complications, but as they are of great importance I may as well enumerate them again. 1. Meningitis, either the simple acute or the tubercular form, not unfrequently the latter, and not unnaturally owing to the tubercular cachexia. 2. In- flammation of the substance of the brain, with (probably), first, some degree of induration, and then ramollissement. 3. Effusion of fluid into the ventricles, distending them, and compressing the brain, and constituting a simple form of chronic hydrocephalus. 4. Scrofulous or tubercular disease of the chest or abdomen, becoming active, and in its effects superseding the disease of the brain or cerebellum. 274. Pathology.—Tumors of the brain and cerebellum are of dif- ferent kinds. Dr. Monro mentions a hard tumor, of a dirty yellow color, growing from the inner surface of the dura mater,2 and occa- sionally imbedded in the brain; scrofulous, adipose, scirrhous, and encysted tumors; but they are very rare in children, with the excep- tion of the scrofulous or tubercular. Constant found that, in four years, at the Hopital des Enfans, he met with but three kinds of tumors of the brain,—tubercles, cancer, and acephalocysts; and that the frequency of the first, compared with the latter, was as 40 to l.3 , Dr. Abercrombie described a tumor compressing the brain, which wras formed of a " mass of pellucid, albuminous matter," lodged under the arachnoid; "it resembled much the albumen of an egg, but was much firmer, so that pieces of it could be separated from the mass, and lifted up. Parts of the mass, being thrown into boiling water, became immediately opaque and coagulated."4 275. But by far the most common kind of tumor of the brain, in children, consists of deposits of tubercular masses, varying in size from a pea to a hen's egg, and in number from one to fifty.5 The character of these masses is that of the ordinary tubercular matter; ' Mai. des Enfans, vol. iii. p. 554. a On the Morbid Anatomy of the Brain, p. 45. 3 Gazette Medicale, 1836, p. 487. * Diseases of the Brain, &c, p. 178. 5 Dr. Green, Med.-Chir. Trans., vol. xxv. p. 199. 174 TUMORS OR TUBERCLES OF ME we often find them in a crude state, or perhaps softened in the centre,1 generally very firm, yellowish or greenish in color, less friable than tubercles in the lungs or lymphatic glands, and in appearance like Gruyere cheese. Their form is generally globular, with irregular surfaces; occasionally, however, the shape is modified by pressure, or by the junction of several smaller masses. It has been a matter of dispute whether they possess a regular cyst, but the general opinion seems now to be that they do not, but that the appearance of cellular membrane between them and the central substance is either the remains of the pia matter, or irregular, unconnected shreds of cellular membrane.2 Barrier remarks that, whenever a well-marked cyst exists, it always surrounds an ancient tumor suppurated in the centre. The tumors are generally situated in the cellulo-vascular tissue of the pia mater, and as they increase they depress the substance of the brain or cerebellum, and, as it were, bury themselves in it, except at one point, where they are adherent to the membranes. In other cases, but by no means frequently, they are formed actually in the cerebral substance, unconnected with the membranes. The tubercles may occupy either hemisphere of the brain, or both the cerebellum or the pons Varolii, or we may find them in more than one place in the same case. Dr. Green observes: " In the thirty cases contained in my table, the tubercular deposit existed eleven times in the hemisphere of the cerebrum, nine times in the cerebel- lum, seven times in the cerebrum and cerebellum together, and twice in the cerebellum and pons Varolii together. I have, however, notes of two cases in which the tubercle was confined to the pons Varolii."3 276. So much for the tumors themselves; but as a careful analysis show-s that the more marked symptoms, especially in the more ad- vanced stage of the disease, arise rather from morbid conditions of the surrounding brain or membranes than from the mechanical pressure and irritation of the tumor, it is of great consequence to notice these conditions. In some rare cases no change could be detected in the membranes of the brain, but in the majority there are decisive evi- dences of inflammatory action. The membranes may be thickened or injected, and adherent to the cortical substance, and simple or puriform fluid effused. The surrounding cerebral structure may be injected and softened, but superficially, or the softening may be extensive and deep, with evidences of inflammation,4 or without. In some rare cases, the surrounding substance is fuller and more firm than usual, as if slightly indurated; in others, it appears hypertrophied. Lastly, the ventricles are sometimes largely distended with fluid, as in chronic hydrocephalus; the consequence, most probably, of mechani- cal obstruction to the circulation, occasioned by the pressure of the tubercles. 277. Causes.—No doubt, the deposit of tubercle in the brain de- * Monro, Morbid Anatomy of the Brain, p. 51. 2 Barrier, Mai. de l'Enfance, vol. ii. p. 625. 3 Med.-Chir. Trans., vol. xxv. p. 199. * MoncriefTs case, in Monro on Morbid Anatomy of Brain, p. 51. BRAIN AND SPINAL MARROW. 175 pends upon the same state of constitution which occasions its presence in the lungs or any other organ, and beyond this we know little or nothing. There must be some peculiar cause, certainly, for its greater frequency in children than in adults; for whilst Cruveilhier, Louis, Lugol, and Abercrombie afford testimony to its rarity in adults, Dr. Green found it once in every fifty-one cases out of 1324 admit- ted into the Children's Hospital; and the testimony of Barrier, Con- stant, Rilliet and Barthez, &c, confirms this fact. Scrofulous diathe- sis, hereditary predisposition, and age, therefore, all appear to aid in determining the deposits of tubercular matter in the brain, and this is really all our positive knowledge of the subject. 278. Diagnosis.—After the description I have given, I need hardly say that the diagnosis of tubercles, or tumors of the brain, in children, is extremely difficult, not only from the absence of any very charac- teristic symptom, but from the irregularity and distance of the symp- toms which do arise. In general, we can only arrive at a presumption by carefully collating all the symptoms, their sequence and relation, with the history, habits, and constitution of the patient.1 My friend, Dr. Charles Johnson, relies much upon the occurrence of irregularity of the pulse at an early period, when other symptoms which might explain it are absent. The most common and best marked symptom is the headache, which is either persistent or in paroxysms, and often circumscribed, together with emaciation, without apparent organic disease. But it may be months before any other decided evidence of cerebral disease is developed. " When, however, a child has suffered for some time from severe headache, when the headache is followed by convulsive movements, some paralytic affection, amaurosis, con- traction of muscles, occasional vomiting, accesses of fever, and the train of symptoms already mentioned, and when these symptoms suc- ceed each other at various intervals of weeks or months, we have very great reason to believe that the child has tubercle of the brain."2 279. Still more difficult is it to determine the locality of the tumor; certainly the pain is often limited and fixed in one spot; as, for example, at the occiput, when the tumor is in the cerebellum, and in some cases it has sufficed for a direct diagnosis ; but it is by no means certain; the pain is often too general, and when localized it has been found not to correspond with the seat of the tumor. The pressure of the tumor upon some spinal nerves, or origins of nerves, may give rise to symptoms which explain their source, but these cases are very rare. In like manner, the symptoms which arise when the tumor is seated in the spinal cord possess more peculiarity, as we shall see presently. As to our distinguishing between different kinds of tumors, all we can effect is a calculation of probabilities. We have the evidence of M. Constant, already quoted, that tubercles are forty times as frequent as any other tumor of the brain in children; and if, in addition, we 1 Rilliet and Barthez, Med. des Enfans, vol. iii. p. 565. a Dr. Green, Med.-Chir. Trans., vol. xxv. p. 207. 176 TUMORS OR TUBERCLES OF THE can ascertain the presence of scrofulous diathesis, the presumption will be altogether in favor of tubercle. 280. The prognosis is, in all cases, unfavorable. Almost all die, either of the wasting and suffering caused by the tubercle, or of some cerebral disease excited by it. Yet neither can we say that tubercles are absolutely incurable, for there is evidence that they may be arrested, absorbed, or transformed, at an early period. In a case of M. Leguil- lon's, quoted by JVL Barrier, the child show-ed symptoms of tubercles four years before its death, and after death they were found to have become calcareous. 281. Treatment.—In so hopeless a disease, little is to be expected from treatment; and on that account, perhaps, too little effort has been made to afford relief. So long as we have to deal with the effects of the tumors simply, our chief remedy is counter-irritation, employed pretty freely. Gendrin thinks that it is used too timidly, and has failed in consequence.1 He advises large moxas to the temples, to the neck, behind the ears, &c. I really think that a succession of blisters to the head, and a seton or issue in the neck or arm, will be found as useful and far less painful. The general treatment of tubercles must also be adopted; and it may be worth while, at an early period, to give iodine a fair trial. 282. But when secondary affections arise, such as acute meningitis, chronic hydrocephalus, &c, the treatment will require modification, and it may be necessary to adopt more active measures. The treat- ment I have already laid down for these diseases will be proper, in a minor degree, however, under these circumstances, proportioning it to the violence of the disease, the strength and constitution of the child, &c. The diet should be light and nourishing, but not stimulant; and the child should, at an early period, be much in the open air. 283. I have mentioned that tubercles are occasionally developed in the spinal cord or its membranes. Ollivier has recorded a considerable number of cases,2 and he remarks that although there are cases on re- cord where the tumor occupied the lower portions of the spinal mar- row-, yet that they are much more common in its superior portion. The symptoms, in many cases, are as few and obscure as in tubercle of the brain; in others, we find convulsive movements, contraction, epi- lepsy, feebleness of limbs, loss of sensibility, retention of urine, con- stipation, &c. &c. A certain amount of disturbance is due, doubtless, to the mecha- nical pressure of the tubercle, but still more to the congestion, inflam- mation, and softening of the surrounding tissues, which are observed in the spinal cord, just as we found in the brain. 284. My friend, Dr. Geoghegan, of this city, has recently published3 a very interesting case of a scrofulous tumor in the lowrer portion of the 1 Translation of Abercrombie, p. 262. 3 Traite de la Moelle Epiniere, &c, vol. ii. p. 272. 3 Med. Press, March 8, 1848, p. 148. BRAIN AND SPINAL MARROW. 177 spinal column, some of the details of which I am tempted to extract, in the absence of any systematic statement of this disease. "A boy, aet. 7, of tolerably healthy appearance, was admitted into ' the city of Dublin Hospital in September, 1847, laboring under well- marked paraplegia, and who presented the following conditions: Complete paralysis of sensation of the lower part of the body, com- mencing at a point a little above the upper margin of the pelvis ; se- vere pinching, or the introduction of a needle, not eliciting the slight- est indication of pain. Complete loss of voluntary motion of the same parts, except of the muscles concerned in the adduction and rotation inwards of the thighs, which retain a very slight degree of power. The muscular contractions depending on excito-motory power in the paralyzed parts are extremely well marked; pinching of the integuments of the legs, thighs, scrotum, penis, and lower part of the abdomen, producing abrupt motion, chiefly in the flexion of the leg. These effects are most intense when the stimulus is ap- plied to the integument of the penis or scrotum. When the soles of the feet are tickled, the legs are retracted. Marked motion of the lower extremities is also produced on pressing on the sacrum. The feet are cold, and the legs and thighs somew*hat flexed and rigid, con- ditions which increased, as the case progressed. There is inconti- nence of urine and faeces, the former of which, it is stated, did not immediately follow the paralysis of the limbs. The sphincter ani, when in repose, is closed, and grasps the finger moderately when intro- duced within it. Irritation of the integument covering the sphincter produces abrupt contraction of the muscle. There is stillicidium of urine, which is converted for a few moments into a stream, when the boy is placed on his face. On one occasion, the catheter having been introduced after the patient had been lying on his back, two or three ounces of turbid, faintly acid urine, admixed with pus globules, were withdrawn, the operation producing partial erection of the penis. The fluid removed became putrid and ammoniacal in three hours afterwards." A little precaution prevented the recurrence of this condition of the urine. " On examination of the spinal column, with a view to the detec- tion of the cause of the preceding phenomena, no deviation from its natural figure was discernible. From about the fifth to the eighth spinous process of the dorsal vertebra?,, tenderness is evinced on per- cussion, but not on firm pressure. The functions of the brain are per- fectly natural; the child, however, seeming less lively than is usual at his age." " It appeared that, since last April, this patient had suffered from uneasiness in the back, in the situation of the tenderness, although, from his silent habit, he did not complain of pain; he used, fre- quently, however, to place his hand on the affected part. About the latter end of September, his legs were observed to drag in walking, and pains in his lower limbs were experienced. While out airing, he suddenly stopped and fell, but is reported to have walked home with little assistance, and also to have gone to bed without help. Next 12 178 TUMORS OF THE BRAIN AND SPINAL MARROW. morning, it was discovered that he was perfectly paralyzed in his lower limbs." Dr. Geoghegan came to the conclusion that either a tumor existed in the spinal cord, or that the investing membranes were considerably thickened. Issues were re-introduced, and iodide of potassium given, with a generous diet, and attention to the bowels. For some time, the symptoms continued the same, with emaciation; but, "about the early part of January, symptoms of cerebral disturbance manifested themselves; frontal headache, stiffness of neck, and retraction of head ; slight dilatation of pupils, which were contractile, but oscillating under the appearance of a fixed current of light; slowness and irregularity of pulse; incapacity to answer questions; although volition, in its minor grades, is still capable of being roused, either through the in- tervention of common or spinal sensation ; in a word, symptoms of effusion within the head were manifest. Notwithstanding suitable treatment, he sank about the middle of the month." On dissection, there was observed moderate venous congestion of the brain, with some effusion; the upper part of the spinal cord, as well as the brain, was free from disease; but, "at a point corresponding to the tenth dorsal vertebrae, before the theca was divided, a very per- ceptible enlargement of the spinal cord was discovered." "On dis- section of the diseased portion, it was observed to be of a light, sul- phur-yellow color, having much the aspect of matter often found in scrofulous glands, containing a few minute cavities, and having im- bedded in its lower parts a distinct, reddish-gray mass, about the size of a pea. The tumor, generally examined by a lens, possessed a coarsely granular texture, and throughout the greatest part of its length had completely supplanted the natural texture of the cord ; but, from its oblong, oval figure, its upper extremity and the superior part of its lateral surfaces were invested with a thin coating of nearly healthy medullary texture. The mesenteric glands were enlarged, internally of a reddish-gray color, and gray externally. The lungs contained a considerable quantity of crude tubercles. The rectum was natural, and the urinary bladder contracted and empty; its mu- cous surface not thickened or ulcerated, and presenting livid patches of venous, submucous congestion. The total thickness of its coats, a quarter of an inch." 285. It is more than probable that any treatment will fail in re- lieving this form of disease; but, as it is our duty to make a trial, there appears more hope from counter-irritation, iodine, and due attention to the stomach and bowels, than from any other plan. CONGESTION OF THE BRAIN AND SPINAL MARROW. 179 CHAPTER X. CONGESTION AND APOPLEXY OF THE BRAIN AND SPINAL MARROW. 286. I have already alluded to an effusion of blood which takes place between the cranium and dura mater during parturition, under the term " subcranial cephalaematoma" (103), and the effects of which are manifested shortly after birth, and which generally terminates fatally. Of eight cases collected by Dr. West, two were still-born, one died on the fifth day, two on the ninth, and two on the twenty- first. I have now to direct the reader's attention to effusions occurring after birth, from the age of one or two days up to the period of puberty ; and I may remark that, whilst the disease is more frequent than has been imagined among children, it appears more common at an early age than subsequently. Dr. Condie mentions that, during the thirty-eight years preceding 1845, there occurred in Philadelphia sixty-nine deaths from apoplexy in children under ten years of age, viz. in those under one year, twenty-seven cases; between one and two years, sixteen; between two and five, fourteen; and between five and ten, twelve.1 Rilliet and Barthez give thirty-eight cases; four under two years; ten between two and three; six between three and five; six from five to seven ; three from nine to ten; and seven from ten to fourteen years of age.2 It occurs both in children apparently healthy, and in those of de- bilitated constitutions. 287. As in adults, we find different degrees of morbid action giving rise to nearly the same symptoms and similar results. i. We find that a child may die of apoplexy apparently, and, on making a post-mortem examination, we may discover nothing but excessive vascularity of the brain or membranes resulting from con- gestion. ii. If the congestion of the membranes be carried to a very great extent, the blood escapes drop by drop, or exudes into the cavity of the arachnoid, or into the ventricles, giving rise to the variety called by M. Serres apoplexie meningienne, and which comes next in fre- quency to the congestive apoplexy, and occurs chiefly between one and five years of age. in. When the vessels which supply or permeate the texture of the brain are subjected to great pressure by the accumulation of blood, their tunics may give way, and the blood escapes into the substance ' Diseases of Children, p. 348. 3 Mai. des Enfans, vol. ii. p. 64. 180 CONGESTION AND APOPLEXY OF THE of the brain, constituting the ordinary apoplexy of advanced life. This variety is more rare than the others, and is generally observed a few years later. 288. Let us first consider the congestive apoplexy of young infants. It cannot be a matter of surprise that the vascular action of the brain in infants should be liable to violent and extreme disturbances, nor that these irregularities should act powerfully upon that organ ; the difficulty is to explain why mischief does not more frequently result. The attack is generally sudden, but in some instances we find it preceded for a few days by a disorder of the stomach and bowels; or it may occur in the course of some other disease, as ramollissement of the brain, hooping-cough, &c, or after convulsions. Barrier men- tions its occurrence in a case of general cedema.1 The symptoms are, more or less complete stupor, lividity of the face, which appears tumid, contraction and insensibility of the pupils, laborious respiration, hemiplegia, or occasionally rigidity of the neck and lower extremities, and sometimes convulsions. If not relieved, these symptoms increase in intensity, and the child dies comatose. M. Constant relates the case of a girl who died thirty hours after admission into the hospital, apparently from hemorrhage into the brain. There was loss of power in all the limbs, with insensibility, loss of intelligence, and stertorous breathing. On dissection, nothing but extreme congestion of the brain was discovered.2 289. When the congestion is confined to the spinal marrow, the symptoms are nearly the same; convulsions are more frequent, there is great drowsiness or stupor, the corners of the mouth are drawn downwards, and sometimes the arms are pressed close against the side, or paralysis may occur. 290. Meningeal apoplexy, which constitutes one-third of the causes of death in still-born infants, according to Cruveilhier,3 occurs also after birth, during the first few hours or days of life, as well as sub- sequently. It is not easy to explain why it should occur previous to birth in many cases, for in them there has been neither undue pres- sure in the use of instruments, nor undue delay in the expulsion of the body after the transit of the head; but, in other cases, it sometimes occurs that, after the head is born, the uterine contractions cease for a time, and then the veins of the neck are compressed by the external orifice, and the cord by the body of the child against the walls of the pelvis; the face becomes livid, purple, almost black, and, if the infant be not quickly extracted, it may die of apoplexy.4 The same result may occur in breech, footling, or funis presentations. 291. The symptoms which are developed in young infants some time after birth are very like those of inflammation, and may easily be mistaken for them. M. Legendre, who has carefully investigated that subject, remarks: "After two or three vomitings, or even with- out previous vomiting, the infants were attacked with fever and some i Mai. des Enfans, vol. ii. p. 471. s Gaz. Med., 1835, p. 572. 3 Anat. Path., livr. xv. p. 1. * Churchill's Midwifery, p. 177. BRAIN AND SPINAL MARROW. 181 convulsive movements, most frequently of the globe of the eye, and having some degree of strabismus; the appetite was lost, thirst great, the evacuations natural or easily excited. Soon after, there was per- manent contraction of the feet and hands, followed by tonic or clonic convulsions. During the convulsions, sense and sensibility were abolished, and the face, ordinarily congested, became of a deeper color. During the intervals, there were drowsiness and stupor, which, slight at first, increased as the disease made progress; the fever con- tinued, and became more intense as they approached the fatal termi- nation. Lastly, the convulsions, at first more or less distant, became more and more frequent, and, during the last period, almost constant."1 .In other cases, the incursion is more sudden and marked; the child becomes suddenly drowsy, stupor and coma come on, convulsions or paralysis, and death follows rapidly. The difference of symptoms, and their intensity, will depend very much upon the amount of effu- sion. In some cases, convulsions are almost the only symptom ob- served, as is stated by Dr. Schleifer to have been the case in the Foundling Hospital at Prague. Paralysis is much less frequent. M. Legendre met with it once in nine cases, and Rilliet and Barthez once in seventeen. 292. The course of the disease depends a good deal upon the amount of effusion. When it is great, and has been quickly effused, speedy death is the result. And, no doubt, the great majority of all cases die; but, whilst very few indeed recover, the disease changes its character in some cases, and becomes chronic. In young infants, before the skull is completely ossified, a proportionate amount of dis- tension may take place, and the brain, relieved of some of the pres- sure, to a certain extent becomes accustomed to and tolerant of the remainder, the effused blood separates into its two portions, the more solid is partially, at least, absorbed, the fluid rather increased, a sort of cyst is formed around it, and the child exhibits the symptoms, not of apoplexy, but of chronic hydrocephalus (225), except that the head is more unequally enlarged, running the same course, and ulti- mately proving fatal. Both the acute and chronic forms of the disease, however, are very often shortened by secondary attacks of thoracic or abdominal inflam- mation. This was the case with most of M. Legendre's cases. 293. Cerebral apoplexy, or effusion of blood into the substance of the brain, is much more rarely observed. Guersent states that he saw but two cases in twenty years' practice. Becquerel mentions that, in three years, and among four hundred autopsies, he has not met a single case of simple hemorrhage into the cerebral substance. Some cases, however, have been recorded. M. Rochoux, in 1833, has collected eight cases, one by a physician at Breslau, and one by M. Guibert (aet. 14); one by M. Payen (set. 12); one, of a child ex- posed to the sun, by M. Andral (aet. 12): another of a child who, after being exposed to the sun, died suddenly (in a fit of anger) from hemor- ' Bouchut, Mai. des Nouv.-nes, p. 468. 182 CONGESTION AND APOPLEXY OF THE rhage into the cerebellum; one by Tonnelle (aet. 2); one by Burnet (aet. 1); and one by M. Serres (aet. 3 months). Since then, Lalle- mand has related the history of one case (aet. 3), in his third letter, and M. Constant of another (aet. II).1 MM. Sestie2 and Cazalis have recorded three, M. Valleix three cases,3 M. Billard one, and Dr. West one case.4 But hemorrhage into the brain maybe the result of, or at least con- nected with, ramollissement, and these cases are by no means so rare; for instance, Becquerel met with four such. 294. It appears that this form of the disease is not limited to any peculiar age ; it has occurred as early as three months; but it seems more frequent in children after three years. The symptoms do not differ very widely from those observed in adults laboring under the disease. There maybe previous headache, heaviness, and drowsiness, or the attack may be sudden, and marked by stupor, coma, convulsions, or paralysis. The symptoms are more obscure in delicate children, as Valleix has remarked ; the stupor and loss of powrer being present in all. Nor does there appear to be any special symptoms indicating whether the effusion is into the substance of the brain or the arachnoid. Of course, in cases of tubercles or ramollissement, the symptoms of these diseases will be present, and those of apoplexy merely in addi- tion to them. 295. Pathology.—When a child dies of apoplexy from excessive congestion merely, we find, on examining the head, that the scalp is unusually vascular, the sinuses of the dura mater filled with blood, and the vessels on the superficies of the brain engorged. Very com- monly, the meningeal vessels participate in the general congestion.5 I have seen the former the size of small leeches, with the blood partly fluid and partly coagulated. On slicing the brain, innumerable red spots appear, indicating that the vessels which permeate the substance of the brain are equally the seat of unusual distension, and even so much so as to give a reddish color to the brain. 296. In meningeal apoplexy, the effusion is into the cavity of the arachnoid ; most frequently, according to Cruveilhier, limited to the cerebellum, sometimes surrounding the posterior lobes of the cerebrum ; and occasionally both the cerebrum and cerebellum are covered with a layer of blood. Rilliet and Barthez state that it is more frequent on the convex surface of the brain. It is very rare that the hemorrhage takes place into the ventricles; however, Cruveilhiermet with three examples of it; M. Valleix with one ; and M. Walther has recorded another.6 Still more rare is it for the blood to be effused external to the arachnoid, either on the side of the pia mater or the dura mater, although I have already (103) mentioned the occurrence of i Gaz. des H6pit.,Ap, 1842. Q Bull, de la Soc. Anat., 1832. Bull. xlii. p. 331. ' 3 Clinique des Mai. des Enfans, p. 575. < Lectures, Med. Gaz., June 18, 1847, p. 1062. s Billard, Mai. des Enfans, p. 509. 6 Ranking's Abstract, vol. iii. p. 159. BRAIN AND SPINAL MARROW. 183 the latter; and I may add that, in very young infants who die of apoplexy, it is by no means uncommon to find cephalaematoma, or even patches of blood effused under the scalp or pericranium, quite independent of local pressure. 297. The blood effused into the serous cavity presents different aspects, and undergoes different changes, according to the period which may elapse after its escape. At first it is, of course, fluid, but about the fourth or fifth day it coagulates, the serum is absorbed, and gradually disappears, and the clot becomes adherent to the parietal serous membrane, and undergoes an important transformation. A new membrane is formed, and covers both its surfaces; but the layer on the upper surface gradually becomes thinner, until it is closely ad- herent to the serous membrane; the inferior layer assumes all the character of a serous membrane, and is united to the arachnoid at the circumference of the clot, giving to the latter the appearance of subserous effusion. That this is not the case has been demonstrated by M. Baillarger, who has proved that the true serous membrane can be traced behind the clot.1 The clot increases in firmness and diminishes in volume by the gradual absorption of its serum. At first of the usual red color, it becomes paler by degrees, more slowly internally than externally, and at length is little more than a thin, fibrinous lamella of a fibrous character, resembling in appearance false membrane, which has led to its being attributed to inflammation. In other cases to which I have already alluded, the membranes form around the clot, and the more solid portion is absorbed, leaving, in the species of cyst so formed, nothing but reddish serum, thus con- stituting a kind of chronic hydrocephalus.2 Notwithstanding the large amount of blood thus effused, it is generally quite impossible to detect any opening in the vessels from which it could have escaped; we merely find unusual congestion of the arachnoid, pia mater, and brain, in most cases. M. Piedagnel mentions three sources: 1. Fracture and rupture of the vessels; 2. Exhalation ; and, 3. A morbid alteration of the arach- noid. Although, in some few cases, the arachnoid in connection with the clot is softened, it appears to have occurred subsequently to this effusion, and is even more rare than rupture of a vessel. Other organs participate in the hemorrhage diathesis also; it is not very rare to find ecchymosis, or effusion into the lungs, spleen, intestines, &c. We do not find the brain either hypertrophied or the convolutions flattened. If the child be young, and the effusion great, the cranium expands in proportion; if it be older, and the effusion great, death results immediately. 298. Cerebral apoplexy may present either of two pathological con- ditions : First, in the form of innumerable bloody points, the size of pins' heads, in the gray and white substance of the brain. These are, in truth, small clots, and can be enucleated quite easily; the brain around them may be quite healthy, or it may be softened, and of a ' Bouchut, Mai. des Nouveaux-nes, 466. ' Rilliet and Barthez, Mai. des Enfans, vol. ii. p. 39. 184 CONGESTION AND APOPLEXY OF THE white, yellow, or red color. The apoplexy may be limited, or it may be diffused throughout the hemisphere, giving to it a peculiar spotted appearance.1 Rilliet and Barthez found this capillary apoplexy limited in five cases, and diffused in three.2 Or, secondly, the blood may be effused into the substance of the brain and form a coagulum, and this occurs about as frequently as the former kind, and sometimes in combination with it. These apo- plectic foci are found in various parts of the brain, as in the optic thalami, corpora striata, and either hemisphere, but in the left oftener than in the right, and in the cerebellum not less frequently than in the brain. If the case be recent, the blood will be found in a fluid state; but, if of longer standing, it becomes coagulated, and is im- bedded in, but distinct from, the cerebral substance. When itJis con- nected with ramollissement, however, it has the appearance of being mixed with the softened brain, and does not, generally, form a dis- tinct clot. Rilliet and Barthez relate a case of very extensive effusion, which, in some degree, illustrates the observation ;3 and Billard an- other, of a child who died on the third day after its birth, of hemor- rhage into the left hemisphere. He found a certain degree of soften- ing around the clot; but it would seem to have been rather the consequence of the effusion.4 299. Causes.—Rilliet and Barthez thus enumerate the causes of apoplexy: "1. The untimely cure of diseases of the scalp; 2. Dis- eases of the sinus of the dura mater; 3. Compression of the vena cava superior by the bronchial glands; 4. Vascular compression, owing to hypertrophy of the abdominal organs; 5. Cachexia, or general debility, originally connected with tuberculization; 6. Some- times the hemorrhage is primitive, and unconnected with any ante- rior disease."5 In one of M. Valleix's cases, he attributes the apoplexy to the ob- struction offered by coagula to the return of the blood. In new-born infants, apoplexy may, perhaps, result from some in- jury connected with labor, although we are not able to appreciate it at the time. 300. Diagnosis.—There is so much uncertainty in the symptoms of apoplexy in infants and children, sometimes one and sometimes another predominating, and most of those which are present occur in other cerebral diseases, that the differential diagnosis is, in many cases, extremely difficult. For example:— i. Congestive apoplexy may very closely resemble primary con- vulsions, and, in fact, may be no more than an exaggerated form of the same disease; but, in general, we find that the functions of the brain are restored more completely between the fits in the latter case. In apoplexy, on the contrary, the child is drowsy and heavy, or lies in a state of stupor or coma. ii. Meningeal apoplexy may resemble acute meningitis when the 1 Valleix, Clinique des Mai. des Enfans, p. 594. a Mai. des Enfans, vol. ii. p. 50. 3 Ibid. vol. ii. p. 51. * Mai. des Enfans, p. 600. 6 Mai. des Enfans, vol ii. p. 63. BRAIN AND SPINAL MARROW. 185 effusion is moderate, or chronic hydrocephalus when considerable, and especially when the cyst of serum is formed, as I have men- tioned. In acute meningitis, the symptoms exhibit more of the character of inflammation; in apoplexy, of compression; and the incursion of the latter is generally more sudden, and the destruction of voluntary power more complete; the pulse, too, is less affected, and there is little or no fever. Chronic hydrocephalus is of slower development, a series of symp- toms generally preceding the enlargement of the head, or those evi- dences of compression which present themselves when the sutures are ossified; in meningeal apoplexy, on the contrary, symptoms of effu- sion generally precede all others, although some time may elapse be- fore the head is perceptibly enlarged. m. Cerebral apoplexy, if slight, may be mistaken for an attack of convulsions, or of epilepsy; but it will generally be found that the convulsion is less violent, shorter, and that the patient does not re- cover from it so completely. The stupor, coma, insensibility, and paralysis which follow* a larger effusion, and the rapidly fatal progress of the disease, are quite characteristic, and are in no danger of being mistaken for any other disease, unless, perhaps, the water-stroke. When there is simple hemiplegia, we can have but little doubt of the case being one of apoplexy: but, when convulsions occur, they tend much to confuse the diagnosis. We should, however, always bear in mind that the diseases with which apoplexy may be confounded are much more frequent than the latter; that the causes of the former are generally more patent; and the series of symptoms, the whole aspect and physiognomy of the case, are widely different to an experienced eye. 301. Prognosis.—Nothing can be more serious than the prognosis in apoplexy. From the congestive form of the disease, no doubt, persons who are promptly treated have a tolerable chance of recovery; but meningeal and cerebral apoplexy almost always prove fatal. There is scarcely a case of cure on record, either of primary, second- ary, or chronic apoplexy, in which any reliance can be placed; not from deficient veracity on the part of the writers, but from doubtful diagnosis. 302. Treatment.—WThen the case is recent, and, above all, if we have reason to believe it one of congestive apoplexy, we shall have recourse to blood-letting immediately, either from arm or jugular vein, or by leeches. The effect of this proceeding will probably determine the correctness of our diagnosis, for, if the symptoms have been the effect of congestion merely, they will at once be mitigated, and the more alarming ones disappear. Judging from the result, we may find it advisable to repeat the leeches, and to have recourse to cold appli- cations to the head, purgative enemata, small doses of calomel and James's Powder, if the patient can swallow, and, after a short time, two successive blisters to the head or nape of the neck. Should we see any disposition to a return of the congestion, in addition to a re- petition of these remedies, it will be necessary to establish some per- 186 CONGESTION AND APOPLEXY OF THE manent counter-irritation, either a seton or issue, or a perpetual blister in one arm. 303. If effusion have already occurred, it may be very right to try the above remedies, although we shall probably find but little amend- ment follow them; the disease will run its course, nearly unmodified by our efforts, and terminate, in the great majority of cases, fatally. But, should the case be one of meningeal apoplexy, and take on a chronic character, distending the cranium, as in the cases described by M. Legendre, we shall have an opportunity of trying how much (or rather how little) treatment can effect for the patient. For this purpose, we have four remedies of great value : calomel, cold lotions, counter-irritation, and purgatives. The calomel should be given in small doses, guarded, so as not to affect the bowels too quickly, and should be continued until the constitution is affected, as will be evi- denced by mercurial diarrhoea, or soreness of the gums. Mercurial inunction may be used, or the blisters dressed with mer- curial ointment, for the purpose of more rapidly affecting the system, or in case the calomel should excite irritation. The hair should be removed, and an evaporating lotion constantly applied. I have always found that a succession of small blisters acted more beneficially than one or two large ones, besides being less liable to ulceration. I would recommend, then, that we should begin by applying a blister to the forehead, then, in a day or two, another to the temple, followed by a third on the opposite side, and so on. The bowels should at all times be kept free ; but, after we remit the mercury, we may try the effect of a brisk purgative occasionally. I mentioned before, that, if there should be any sign of teething, the gums should be scarified deeply, and all round. The diet in all cases should be mild and unstimulating, but in some cases a better diet will be necessary, as well as the use of tonics. This will depend upon the state of the constitution. 304. In these latter cases of which I have been speaking, i. e. where a large quantity of blood has been effused and separated into its component parts, without an immediately fatal result, Rilliet and Barthez recommend that the serum should be removed by puncture, as in chronic hydrocephalus. They oppose the practice in the latter disease, because the effusion may be connected with tubercular de- posits; but, in meningeal apoplexy, they conceive that " nothing but good can result from it."1 SPINAL APOPLEXY. 305. In almost every case of meningeal apoplexy, there will be found some effusion of blood into the serous membrane of the spinal marrow, escaped, no doubt, from the cavity of the serous membrane 1 Mai. des Enfans, vol. ii. p. 66. BRAIN AND SPINAL MARROW. 187 of the brain. Occasionally, also, but more rarely, spinal apoplexy occurs as an independent disease, and gives rise to symptoms of compression ; pain in the back, partial convulsions, and partial or complete paralysis. But, as the symptoms are generally identical, or nearly so, with those of meningeal apoplexy, I should have scarcely noticed the occurrence separately, were it not that I wish to supply an omission in the chapter on Trismus Nascentium (p. 93). I find that M. Barrier attributes trismus to hemorrhage into the spinal canal. He refers to a case (case 132), related by Dr. Abercrombie, of a child, aet. 7, who presented symptoms resembling trismus, of which he died on the fourth day, and, on dissection, "in the spinal canal, there was found a long and very firm coagulum of blood lying between the bones and membranes of the cord, on the posterior part extending the whole length of the cervical portion."1 M. Ollivier, in his excellent work on diseases of the spinal marrow, has shown that a similar disease is produced in the adult by spinal apoplexy; and M. Billard, without pronouncing a positive opinion, mentions that he had seen but two cases of trismus nascentium, and in both the only pathological condition was an effusion of blood into the spinal arachnoid membrane, filling the space from the medulla oblongata to the sacrum, and he is inclined to believe that this was the cause of the trismus.2 306. M. Matuszinski has published the result of his observations upon the disease in the Hospital of Stuttgard,3 where, out of 848 children received from 1828 to 1835, there were twenty-five cases of trismus, or about one in thirty-four. The symptoms were exactly such as I have already described, and the course and termination similar,lasting generally from thirty to fifty hours; but in three cases, three days; in two, four days; in one, seven days ; in one, nine days; and in another case, thirty-one days. "Of twenty subjects examined after death, Dr. Matuszinski found in sixteen a semi-coagulated fluid in the spinal canal, between the dura mater and the vertebrae; in some cases, the fluid was limited to the cervical, dorsal, or lumbar region ; in many cases, the coagulum, equally thick throughout, separated the membranes all round from the bony canal; the dura mater was healthy, except in one or two cases, where it was thickened and red ; the arachnoid was normal; the pia mater constantly much injected, and occasionally thickened; the spinal marrow was very red in two cases, softened in one case, and indurated in another, but, with these exceptions, perfectly healthy."4 I may add that M. Matuszinski agrees with Mr. Colles in attributing trismus to the state of the umbilicus after the fall of the cord, aided by the action of cold; and with all writers on the subject as to the hopelessness of treatment. I am far from thinking that these additional researches decide the ' Abercrombie on Diseases of the Brain, &c, p. 362. 2 Mai. des Enfans, p. 689. 3 Gazette Med., 1837, p. 338. * Barrier, Mai. de l'Enfance, vol. ii. p. 478. 188 APOPLEXY OF THE BRAIN AND SPINAL MARROW. question. We have the testimony of Dr. Joseph Clarke, Dr. Labatt, Dr. Collins, and others, who have had most extensive opportunities of investigation, that they could discover no pathological condition which would account for the disease; and, although in M. Matuszinski's cases, we have an adequate cause, the absence of similar causes in so many other cases casts some doubt upon their pathology. However, as it is only by extended observations that any conclusion can be found, I felt it my duty to supply my former omission in this place. • SECTION II. DISEASES OF THE RESPIRATORY SYSTEM. CHAPTER I. I. INTRA-UTERINE DISEASES.--II. CORYZA.--III. EPISTAXIS. 307. Considering that the respiratory apparatus is not used during foetal life, we might naturally expect that it would escape disease; but it is not so. Billard and Cruveilhier observe that, in the bronchial tubes, we find concretions, polypous masses, and evidences of inflam- mation; and the latter mentions a case of death immediately after birth, in which the bronchi wTere filled with a thick mucus, apparently the result of chronic catarrh. Examples of lobular pneumonia are recorded by Cruveilhier; of sanguineous effusion, by Mende, Wrisberg, Joerg; of abscess in the lung, by Koelpin, Mende, and Cruveilhier; of pleurisy, by Veron, Billard, Orfila, and Cruveilhier; of tubercles, by Husson, Chaussier, Cruveilhier, Lobstein, and Billard; of scirrhus, by Wrisberg; of oedema of the lungs, by Zierhold; and of hydro-pneumonia.1 II. CORYZA. 3(08. Nasal catarrh, or, as it is commonly called, "snuffles," is a very common affection among infants, and very troublesome so long as the infant is at the breast, because the nose is obstructed, and of course, when sucking, the child is not able to breathe through the mouth. The attack commences by frequent sneezing, with a snuffling sound in breathing through the nose. We are not, however, to suppose that, because a very young infant sneezes often, it has necessarily taken cold; the impression of light upon the branches of the fifth pair of nerves distributed to the eye naturally gives rise to sneezing. At first, there is but little discharge from the nostrils; in a short time, a secretion of thin mucus takes place, sometimes acrid and irri- tating; and ultimately of an abundant, thick, muco-puriform fluid. The mucous membrane is unusually vascular, and peculiarly irritable ' Graetzer, Die Krankheiten des Fotus, pp. 163, 169. 190 « CORYZA. and tender; and, after the first stage, the sense of smell is lost for a time. The voice, too, is changed to that tone which is popularly ex- pressed by " speaking through the nose." The eyes are in general suffused, and watery, sensitive to light, and there is more thirst than usual. Some degree of feverishness is present, the infant is uncomfortable, heavy, and cross, the skin is hotter than usual, and perhaps, but not necessarily, the pulse may be quicker. If the child be old enough, it will complain of heat and soreness of the nose, of some headache in the region of the forehead, and probably uneasiness in the back and limbs if it be very feverish. The attack is at its height about the third or fourth day, after which the feverishness disappears, the discharge diminishes, becoming more viscid and yellow, and the difficulty of breathing through the nose ceases. It is very liable, however, to be reproduced by any exposure to cold. 309. This is the simple and ordinary form of catarrh of the nasal mucous membrane. Drs. Denman and Underwood, however, describe a much more serious variety, which presented itself to their notice for the first time in the summer of the year 1790. It was characterized by a thick, puriform discharge, great, but not constant difficulty of breathing through the nose, at times requiring an attendant to watch the child, and to keep its mouth open. A curious purple streak was observed at the verge of the eyelids, which Denman considered pathog- nomonic, and in most cases a fulness about the throat and neck ex- ternally. After the symptoms had continued for some days, the infant became feeble and languid, and, upon looking into the throat, " the tonsils were found tumefied, and of a dark red color, with ash-colored specks upon them, and in some there were extensive ulcerations." The patients " gradually declined in strength, and had a peculiar catch in respiration, as if the velum pendulum palati were elongated. They were unable to suck, though not universally; swallowed with difficulty whatever was given in a spoon; and died in convulsions, or with all the marks of great debility, though not on any particular day of the disease."1 Dr. Denman met with eight cases in eight months, six of whom died. One of them was examined, but no internal organic disease was discovered; and the affection seems to have been an intense in- flammation of the entire Schneiderian membrane, with great constitu- tional debility, and accompanied with disorder of the stomach and bowels, as the stools were thick and pasty, and of a green or blue color. , Billard also speaks of a severe form of coryza, accompanied with exudation of lymph, and proving fatal. 310. Causes.—In very young infants, it is owing to cold taken in washing, or by undue exposure—the great transition from the warm temperature of uterine life to the severe and changeable atmosphere ' Underwood on Diseases of Children, p. 175. EPISTAXIS. 191 of extra-uterine existence rendering the infant peculiarly susceptible. It also accompanies certain other diseases, as the exanthemata, and in these countries prevails epidemically during winter and spring, but affecting chiefly infants of more advanced age. 311. Treatment.—WThen it exists simply, and is not a symptom of more general Affection of the mucous membrane, but little treatment will be necessary. A dose of purgative medicine, with warm baths at bedtime for a few nights, will relieve the feverish symptoms and headache; and a gentle diaphoretic mixture maybe given at intervals through the day. It is very necessary to do something for the relief of the local com- plaint, on account of the distress of the infant; and I have found the best thing to be fomentations, by means of a hollow sponge dipped in hot water, and squeezed nearly dry, and then laid on the nose and forehead. The vapor of the water is thus applied both internally and externally, and is very soothing. After this, we may adopt the popu- lar remedy of greasing the nose externally, which I know by expe- rience to be very useful, although I am quite unable to explain why. These measures will apply equally to infants and children: but with the former, if the nose be quite obstructed, it will be better to substitute food for nursing two or three times in the day; and with the latter, if there be much fever, low diet for a few days will be advisable. When the coryza forms but a portion of a more general attack, the proper remedies for the more serious disease will be beneficial, and, in addition, we need only use the fomentations. In the more serious variety described by Dr. Denman, he found great benefit from repeated purgation by castor oil and some cordial, as Dalby's carminative, with the exhibition of the decoction of oak bark, if the discharge continue long. Blisters are inadmissible, for, in some cases in which they had been applied, he found the surface ulcerated and sphacelated. III. EPISTAXIS. 312. Bleeding from the nose is by no means uncommon with chil- dren of all ages; but it is generally very moderate, and, when primary, never to such an extent as to endanger life. M. Valleix, who has analyzed a great number of reported cases, has not found a single example of primary nasal hemorrhage to this extent, and the researches of MM. Rilliet and Barthez confirm his conclusions.1 Secondary epistaxis is not unfrequent in children, and is more serious in its effects. It occurs in purpura hemorrhagica, in the course of eruptive fevers, intermittent typhoid fevers, in hooping- cough, &c. &c. M. Latour relates an example occurring during the access of quartan ' Mai. des Enfans, vol. ii. p. 21. 192 SPASM OF THE GLOTTIS. ague, and which compromised the life of the child. Rilliet and Bar- thez mention a case of very considerable hemorrhage which occurred in an infant attacked with anasarca consequent upon nephritis, and many other cases are upon record. We have all, probably, witnessed cases of epistaxis occurring during hooping-cough, and during an attack of purpura; the hemor- rhage is occasionally sufficient to destroy life. 313. In general, there can be no difficulty in the diagnosis of the disease. The escape of the blood externally marks its source; but it sometimes happens that it may proceed from some vessel situated high up the nostril, and, after it has ceased to flow externally, it may gradually dribble into the back part of the nasal fossa and pharynx, and then, being swallowed and rejected by vomiting, it may be sup- posed to have its origin in the stomach. The only way of deciding this question is by carefully examining the pharynx, to ascertain if any blood be still escaping, and if so, we can no longer doubt the source of the blood vomited. 314. Treatment.—W7hen the amount of this discharge is neither too great nor too often repeated, the effect may be salutary rather than injurious, and in such cases we shall not need to interfere. Should direct treatment be necessary, the best local applications are cold lotions to the forehead and nose, counter-stimulants to the extremities, astringent injections (such as decoction of matico, or oak bark, &c), and, as a last resource, the plug. In many cases of secondary epistaxis, however, there is some mor- bid alteration of the blood, and the disease which has given rise to this will claim our predominant attention; that being relieved, the epistaxis, like the other symptoms, will disappear. It may, however, for present relief, be proper to have recourse to some of the local ap- plications just named. CHAPTER II. SPASM OF THE GLOTTIS.--THYMIC ASTHMA.--LARYNGISMUS STRIDULUS. 315. Much confusion has ariseji concerning this disease, from the use of names, which, to say the least, are inaccurate, and some of which convey altogether false ideas of its nature. Thus, it has been called "Millar's asthma," "Kopp's asthma," "thymic asthma," "suffocative catarrh," " false croup," " spasmodic croup," " cerebral croup;" whereas it has no affinity at all either to asthma, catarrh, or croup. The complaint which is characterized by crowing inspirations, occurring at intervals, and repeated irregularly but frequently, appears, at first sight, to be a simply local affection; but, upon close investiga- SPASM OF THE GLOTTIS. 193 tion, will be found to have a deeper origin and a more important cha- racter. It is not unfrequent in Great Britain and Germany, but very rare in France; as Barrier, Rilliet and Barthez, are mainly indebted for their descriptions to British or German physicians. Drs. Stewart and Condie speak of it as common in America. It occurs in infants of from a few months to three or four years old. M. Blache found it most frequent from four months to a year, and Guersent from one year to six; but in these countries it is uncommon at the latter age. 316. The first record we have of the disease, I believe, was in 1761, by Dr. Simpson, who termed it " the spasmodic asthma of in- fants." A few years afterwards, Dr. John Millar described it, and from him it was called Millar's asthma. Dr. Rush, of Philadelphia, followed him, and both he and Dr. Warburton, in 1809, give a fair account of it. But by far the most complete description of it is given by Dr. John Clarke, under the title, "A peculiar species of convul- sion in infant children." " The child," he says, " is suddenly seized with a spasmodic inspiration, consisting of distinct attempts to fill the chest, between each of which a squeaking noise is often made. The eyes stare, and the child is evidently in great distress; the face and the extremities, if the paroxysm continue long, become purple; the head is thrown backward, and the spine is often bent as in opistho- tonos ; at length a strong expiration takes place, a fit of crying gene- rally succeeds, and the child, evidently much exhausted, generally falls asleep."1 There appears to be a considerable resemblance between this dis- ease and the very rapid form of hydrocephalus, described by Dr. Munro, which I have formerly noticed (175). Dr. Golis also alludes to this affection, and includes it among the predisposing causes of hydrocephalus. He speaks of it as " a peculiar disorder of respiration, in which infants, after a sudden waking out of sleep, or from terror or anger, often, without any cause, are suddenly seized with a deep, shrill respiration, which for many seconds, some- times even for minutes, threatens suffocation. The whole body be- comes stiff; the face, hands, feet, and particularly the finger and toe nails, black or blue; and the little patients lose their breath and con- sciousness; at length, however, with a cry of alarm, they again re- cover both." Dr. Underwood evidently embraces spasm of the glottis in that mysterious term, "inwrard fits," which, he says, is occasionally ac- companied "with a peculiar sound of the voice, somewhat like the croup," with a quick breathing at intervals.2 Dr. Cheyne thus describes the disease in his work on hydrocepha- lus: "It begins with crowing inspiration, like that which takes place at the commencement of a paroxysm of pertussis. At first, there are long intervals between the spasmodic inspirations (several days, per- haps), as they appear to be connected with a disordered stomach and ' Commentaries on Diseases of Children, p. 87. 3 Diseases of Children, p. 181. 13 194 SPASM OF THE GLOTTIS. the absence of bile in the bowels—to arise from sudden exertion or fits of passion; and as the child often continues to thrive, notwith- standing, the disease is not much attended to." Very valuable monographs on this affection have since appeared by Mr. Pretty (cerebral croup), Dr. Montgomery (thymic asthma), Sir Henry Marsh (spasm of the glottis), Dr. Ley (laryngismus stridulus), MM. Blache, Guersent, Kopp, Hirsch, Kyll, Caspar, Fricke, Oppen- heim, &c, and it is noticed in almost all the systematic treatises. 317. Symptoms.—The disease appears, then, to consist essentially in a spasmodic closure of the rima glottidis and larynx, terminating by a forced inspiration, rather than in a spasmodic inspiration, as Dr. Clarke supposed. In the milder cases, there are no premonitory symptoms; the attack occurs quite suddenly, perhaps on first awaking out of sleep, some- times even during sleep; after a full meal, or whilst at play, or in a fit of passion. In other cases, the attack has been preceded for some days by slight wheezing respiration, and an occasional cough, then suddenly the spasm occurs. Lastly, I have seen spasm of the glottis superadded to general con- vulsions, commencing subsequently, and continuing after they had subsided. 318. Whether there be preliminary symptoms or not, the muscles ' of the glottis and larynx are first affected; the child is suddenly startled by finding that it cannot breathe; it struggles violently, be- comes red or even purple in the face, the eyes are injected and suf- fused, the eyeballs protruding, the hands clenched, the head thrown back, and the whole body agitated with distress and fright, presenting the aspect of one in imminent danger of suffocation. This state lasts generally for a minute or two, and at length, after many fruitless attempts, by a vigorous effort, or owing to relaxation of the spasm, inspiration is effected with a loud crowing sound, resembling the whoop of pertussis. A good fit of crying generally succeeds, and then the child, exhausted by the fright and struggles, falls asleep. In some rare cases, the countenance remains pallid, though not less expressive of anguish and fear. M. Kopp has remarked, that in many cases the tongue is protruded during the paroxysm, and that even during the intervals there is a similar tendency. M. Hirsch mentions that the urine and faeces are often discharged involuntarily during a paroxysm. I have mentioned that the hands are clenched during the paroxysm, as a portion of the general muscular effort; but if we observe care- fully, we shall find that the remarkable spasm of the thumbs and great toes, described by Dr. Kellie, is present; the thumbs are spas- modically contracted, and thrown across the palm of the hand ; the toes are bent towards the sole of the foot, and both wrists and feet are rigidly bent downwards, and somewhat inwards. The backs of the hands, wrists, and feet, appear swollen. This local spasm may con- tinue in a slighter degree after the spasm of the glottis has subsided. SPASM OF THE GLOTTIS. 195 The duration of each attack of difficult inspiration is generally about half a minute or a minute; but Dr. Condie mentions their lasting fifteen or thirty.1 319. At the commencement of the disease, especially in the milder cases, the spasms occur at distant intervals, perhaps once in the day, or with some days' intermission, increasing in frequency and in severity, unless checked. In severe cases, the paroxysm may occur many times in the day. I have known it repeated thirty or forty times; and in such cases, although the spasm is at first confined to the muscles of the glottis and larynx, yet, if the disease be neglected or mismanaged, the spasmodic action is extended to the extremities, and may terminate in a general convulsion, as Sir H. Marsh has observed.2 During the intervals, the child appears pretty well, but pale, ex- hausted, and irritable, if the fits are frequent. There is no fever, the pulse is quiet, the tongue clean, the appetite pretty good, and in many cases the bowels are regular. In others, as Dr. Cheyne remarks, there is evidence of biliary and gastric derangement. The respiration is much as usual between the paroxysms, provided they are not very frequent. In the worst cases I have seen it was very hurried. When the disease is complicated with dentition, intestinal disorder, or general convulsions, of course the constitutional symptoms will be more marked; there will be a quick pulse, loaded tongue,pale, flabby skin, hurried respiration, and unhealthy evacuations. The spasm may return at very uncertain and unequal intervals, as I have said, and without any apparent cause, or the very slightest. Trivial irritation or annoyance, contradiction, sudden noises, are quite sufficient to provoke a return. Sir H. Marsh mentions that the smell of new paint always reproduced it in one of his patients. 320. Dr. H. Davis states that, in all the cases he had lately ex- amined, the tonsils were enlarged, the fauces puffy and swollen, and the uvula elongated; but as these symptoms have not been observed by other writers, it is possible that the cases may have been com- plicated with this affection. He mentions also, that in one case there was obstinate constipation, with dysuria, and that every attempt to evacuate the bladder brought on the spasm.3 To another symptom, which has been occasionally observed, con- siderable importance has been attached, from its correspondence with a pathological condition to which the disease has been attributed. I allude to a swelling of the thyroid and thymus glands. Dr. Mont- gomery mentions a case in which he observed this enlargement, and by directing his treatment to this point the child was cured.4 In four cases, Dr. Ley observed a swelling extending from the jaw to the sternum, and laterally parallel to the clavicles. Just in proportion to the reduction effected in this enlargement, was the diminution of the spasm of the glottis and the other symptoms. 1 Diseases of Children, p. 316. 3 Dublin Hosp. Reports, vol. v. p. 618. 3 Underwood on Diseases of Children, p. 187. 4 Dublin Journal, vol. ix. p. 439. 196 SPASM OF THE GLOTTIS. This enlargement, which would be a most important symptom if general, has not been very commonly observed. One cannot doubt the accuracy of those w'ho have mentioned it; but, to have the signifi- cance they have attributed to it, it should have been far more frequently noticed. 321. The duration of the disease, as well as its termination, is very uncertain. It may continue a few weeks, and then cease spontane- ously, or in consequence of suitable treatment; or it may persist longer, and subside after the cutting of some teeth, or from Jong-continued treatment. A considerable number of cases run either of these courses, and terminate favorably. Others, however, prove more serious and end fatally, either sud- denly, during the first attack, or during a fit subsequently; or they die after a long illness, in convulsions, or worn out by continual distress. It has been suggested that fatal spasm of the glottis may be the cause of the sudden deaths, without any apparent cause, that are met with among children. Such cases are recorded by Maunsell and Evanson, Montgomery, and very many writers. The infant may be perfectly well, or perhaps only slightly indisposed, when in a moment it falls back dead, as happened to the infant of a friend of mine. I confess, that I am inclined to believe, that many of the deaths attributed to the nurse or mother overlaying the child, are, in truth, cases of sudden death from spasm of the glottis. 322. Pathology.—As one might expect in a disorder which is but a symptom, the appearances on dissection present great variety, ac- cording to the other diseases with which it may happen to be compli- cated. For instance, in many cases, no appearance of disease whatever, in any organ, could be detected.1 In others, there have been found tumors in the brain, congestion, and effusion of serum, effusion of blood into the cranium, partial closure of the rima glottidis, open foramen ovale, congestion of the lung, congestion of the glands at the root of the lung, enlargement of the bronchial glands, of the thymus gland, of the mesenteric glands, and disease of the intestines, but no one morbid change is found in the majority of cases. This has given rise to an equal variety of opinions, but the very absence of morbid phenomena is a sufficient answer to some of them; as, for example, it is thus proved not to be of the nature of croup, as supposed by Underwood, Ferriur, Hecker, Albers, &c, or of asthma, as stated by Millar and others, because none of the post-mortem appearances of either are ever found. Dr. John Clarke regards it as a convulsive affection, depending upon diseased action of the brain, and induced by over-feeding, the sudden cure of ophthalmia, suppression of cutaneous eruptions, &c.; and he found congestion of the vessels of the brain, water in the ven- tricles, and mesenteric disease.2 1 Sir H. Marsh, Dublin Hospital Rep., vol. v. p. 616. ' Commentaries on Diseases of Children, p. 90. SPASM OF THE GLOTTIS. 197 Dr. Cheyne has no doubt that the brain is really the seat of the disease, although the precise morbid condition has not been ascer- tained. He had seen twenty cases, of which one-third were fatal, and he has given descriptions of these cases: in the first, there were two scrofulous tumors imbedded in the brain; in the second, the con- volutions were obliterated, and the substance of the brain unusually firm (hypertrophy and induration); in the third, congestion and serous effusion. Dr. Merriman could detect no cerebral disease in two children who died during the paroxysm. He found a collection of enlarged glands of the neck pressing upon the par vagum. Gardien regards the disease as a spasm of the diaphragm, and of the muscles of the chest and larynx. The name "cerebral croup," given to it by Mr. Pretty, sufficiently expresses his view of its nature. Kyll attributes it to inflammation of the cervical portion of the medulla spinalis, or to enlargement of the cervical and thoracic glands compressing the pneumogastric nerve. 323. As early as 1723 it was attributed to enlargement of the thy- mus gland by Richa, and in 1726 by Verduis. This viewT has been revived in late years by Kopp, who published a work on the subject in 1830. He found the trachea and larynx healthy, the tongue large and thick at the root, and the body generally exhibiting marks of suf- focation ; but the most remarkable post-mortem appearance was the state of the thymus gland: "In one case it might have been mistaken for the lung, it was so thick and hypertrophied; it extendecf from the thyroid gland to the diaphragm, was two inches wide, weighing more than an ounce, and pressing strongly against the trachea; on cutting into it there flowed out of its whole tissue a quantity of milky fluid. In another post-mortem, the thymus was found occupying the whole of the anterior part of the chest, and forming, with the superior part of the thorax, adhesions that could be removed only by the scalpel; it was united to the thyroid gland by thick cellular tissue. By the thymus covering the whole heart, the sounds of that organ had been intercepted during life. The lobes of the gland were elevated and enlarged; its parenchyma presented no trace either of suppuration or tubercles, or any other degeneration; on pressure being applied, there came away an abundant milky humor, like the spermatic liquor in consistence."1 Dr. Hirsch published five cases; three proved fatal, and in two there was a post-mortem examination : " The thymus of the first of these occupied all the anterior mediastinum, and was composed of two large lobes, besides several smaller ones. An appendix of the gland arose about its middle, and surrounded the common jugular vein; the glandular parenchyma was firm, and weighed nine drachms and a half. The thymus of the second child was not so thick nor of so close a texture; it extended from the thyroid gland beyond the peri- cardium, which it covered; it had contracted adhesions with the ' Dublin Journal, vol. ix. p. 514. 198 SPASM OF THE GLOTTIS. arteria innominata and right carotid, and its weight was six drachms six grains."1 It may be as well to mention here, that the thymus gland, in its normal state, weighs about half an ounce, or six drachms, and ex- tends from the thyroid gland into the upper part of the thorax, lying over the pericardium, lungs, and roots of the great vessels. Dr. Kornmaul mentions a thymus gland weighing fourteen drachms; Dr. Hirsch one weighing nine and a half drachms; and Dr. Van Velsen one weighing nine drachms. Dr. Montgomery mentions that in tw*o cases the gland was enlarged, one of which, he feels assured, weighed two ounces.2 On the other hand, the researches of Caspari, Pagenstecker, Rosch, Fricke, Oppenheim, &c, led to the conclusion that the disease did not depend upon enlargement of the thymus. The latter physician found the plexus choroides full of blood, effusion into the chest, glottis erect, and the rima open ; no swelling in the neck, thymus gland much as usual, perhaps rather heavier, but not corresponding to the descrip- tion of Kopp and Hirsch, and neither pressure nor displacement of the par vagum, nor recurrent. Dr. Roberts mentions five cases of enlarged thymus gland, and the editor of the New York Medical Journal two, in which the accom- panying symptoms were not those of spasm of the glottis,,but of pneumonia. Sir H. JVIarsh seems to think that the seat of the irritation may be at the origin of the pneumogastric nerve. In one post-mortem exami- nation which he mentions, there was found effusion into the ventricles, but no other trace of the disease ; in another, contraction of the rima glottidis, engorgement of the right lung, and erosion of the mucous membrane of the stomach; but in neither is any enlargement of the thymus mentioned, and the author is far too acute and careful an ob- server to have overlooked it had it been present.3 M. Trousseau refers the disease to a spasmodic condition, with a wrant of harmony in the action of the respiratory muscles; and he states that, during the six years he has been at the head of his hos- pital, he has never met with a single case of thymus sufficiently en- larged to occasion the slightest inconvenience. Dr. Hugh Ley attributes the disease to a suspended or impeded state of the functions of that portion of the eighth pair, which is distributed to the larynx, caused by enlarged cervical or thoracic absorbent glands, but not from enlarged thymus.4 324. I have thus given a cursory glance at the chief of the post- mortem observations, upon which the different views of the pathology of the disease have been founded. These views may be divided into—1, those which adduce the evidence of irritation into the central nervous system; 2, those which attribute the affection to pressure upon some particular nerves; and 3, those which look to the en- largement of the thymus gland as the ufons et origo mail." Let us ' Dublin Journal, vol. ix. p. 517. 2 Ibid., p. 433. 3 Dublin Hosp. Rep., vol. v. p. 615. * On Laryngismus Stridulus, p. 113. SPASM OF THE GLOTTIS. 199 examine the two latter views a little more closely. The advocates of the last-named hypothesis generally consider that the enlargement of the thymus, from engorgement, acts mechanically, by pressing upon the larynx and trachea, and obstructing respiration ; that relief is afforded, and a cessation of the paroxysm effected by the diminution of the congestion; and the cure completed by the reduction of the gland to its normal size. Dr. Montgomery mentions three ways in which enlargement of the gland may occur: 1, either as simple hypertrophy; 2, comparative hypertrophy, when there is a disproportion between the size of the gland and the capacity of the upper part of the chest; or 3, as the result of disease; and he thus explains its modus operandi in pro- ducing spasm of the glottis: " Supposing any cause to occur capable of producing agitation or strong mental excitement in the child, and that the gland has been previously enlarged, and capable of great dis- tension, a number of circumstances will occur which combine in ren- dering that distension still greater, and increasing the size of the gland in such a manner as to affect materially the condition of the surrounding parts. Any cause producing agitation on the part of the child excites the heart's action, the enlarged gland becomes distended and increased in size, presses on the vena innominata, and prevents the return of blood from the head. The same pressure prevents the venous blood of the thymus itself from getting into the innominata, and thus becomes a fresh source of distension. The combined result of this is great and dangerous pressure exercised on the great vessels, preventing the return of blood from the head, and thereby suddenly producing cerebral congestion; on the trachea, by which respiration is impeded; and on the important nerves in that situation, especially the sympathetic, the par vagum, and its recurrent branches; any interference with which has been found, by the experiments of Dr. Alcock, of this city, most powerfully to influence respiration, &c.m No doubt these views are stamped with high authority, and with a considerable array of learning and research, but there are two import- ant facts which meet one at the outset, and which have very great weight, so far as the mechanical production of the disease is con- cerned:— 1. That in a great majority of cases of spasm of the glottis, there is no universal hypertrophy of the thymus perceptible during life, or discovered after death. It is impossible to suppose that such ob- servers as Clarke, Cheyne, Hall, Ley, Marsh, &c, could overlook such enlargement; and yet we have their positive testimony that, in many cases, no morbid changes whatever could be detected, and in others, the disease existing was not enlargement of the thymus gland; and 2. That many cases of enlarged thymus are on record, in which the symptoms of spasm of the glottis never occurred; nay, that no affection of the glottis or trachea was observed; although, at the same time, the lungs were seriously affected. 1 Dublin Medical Journal, vol, ix. p. 437. 200 SPASM OF THE GLOTTIS. Dr. Condie remarks: "There has not been adduced a single well- established fact to show that a hypertrophied condition of the thymus is capable, under any circumstances, of exerting upon the nerves in its vicinity such a degree of pressure or irritation as would produce the phenomena of the disease under consideration.1 I may add, that the enlargement of the thymus gland, when it does occur, has been regarded as the effect, and not the cause of the spasm of the glottis, by Dr. Marshall Hall, and more recently by M. Suiron.2 As to the mechanical pressure upon the trachea of the enlarged gland producing the disease, it appears more than doubtful, when we con- sider the structure of the trachea, and that the peculiarity of the dis- ease is not difficult or impeded respiration, but complete arrest of inspiration; expiration, when effected, being quite easy. I doubt whether pressure from an enlarged thymus would affect respiration at all; and if it did, I believe it would affect inspiration and expiration equally ; that the dyspnoea would be less in amount than in the present affection, and not so temporary. 325. With regard to the agency of pressure upon the nerves in causing this disease, whether exercised by enlarged thymus, or ab- sorbent glands of the neck or thorax, according to Dr. Ley, I prefer quoting the observations of my friend, Dr. Marshall Hall. " In the first place," he remarks, " as far as my memory and judgment serve me, the cases adduced to support this view are not cases in point, but in reality cases of other diseases. Secondly, supposing pressure upon the par vagum to exist, it would induce totally different phenomena from those actually observed in this disease; and it would not explain the series of phenomena which actually occurs in it; for— "1. Such pressure would induce simple paralysis. This would, in the first place, affect the recurrent nerve, and the dilator muscles of the larynx; it would not induce a partial, but constant closure of that orifice,—a permanent state of dyspnoea, such as occurred in the experiments of Legallois, or such as is observed to be excited in horses affected with the " cornage" or roaring. Secondly, it would induce paralysis of the inferior portion of the pneumogastric, with congestion in the lung or lungs, and the well-knowTn effects upon the stomach of a division of this nerve. "2. The disease in question is obviously a part of a more general spasmodic affection; and frequently, indeed most frequently, comes on in the midst of the first sleep, in the most sudden manner, receding equally suddenly; to return, perhaps, as before, after various intervals of days, weeks, or even months. Very unlike paralysis from any cause. " 3. It not unfrequently involves, or accompanies, as I have said, other affections, indisputably spasmodic; as, distortion of the face, strabismus, contraction of the thumbs to the palms of the hands,— of the wrists, feet, and toes,—general convulsions !—sudden dissolu- tion!—a series of phenomena totally unallied to paralysis. " 4. Indeed, the larynx is sometimes absolutely closed, an effect ' Diseases of Children, p. 318. 2 Ranking's Abstract, vol. i. p. 246. SPASM OF THE GLOTTIS. 201 which paralysis of the recurrent nerve and of its dilator muscles can- not effect. " 5. Paralysis from pressure of diseased glands would be a far less curable, a far less variable disease, a far less suddenly fatal disease, than the complete convulsion. " Thirdly. Almost all recent cases are at once relieved by attention to three or four things, viz.: 1, the state of the teeth; 2, of the diet; 3, of the bowels; and, 4, of change of air. They are as obviously produced by the agency of errors in one or more of them. " Fourthly. In fact, the complete convulsion is a spasmodic disease, excited by causes situated in the nervous centres, or eccentrically from them; in a case of spina bifida, a croupy and convulsive inspiration was induced by gentle pressure on the spinal tumor; in cases from teething, the attack has been induced and removed many times by freely lancing the gums; and when it has arisen from crudities, it has been relieved by emetics and purgatives, and by change of air, &c. " Fifthly. There is a series of facts which prove the connection of this disease with the other forms of convulsions in children, and with epilepsy in the adult subject. " Sixthly. In protracted cases, congestion and effusion within the head occurs as effects of this disease. " Lastly. Innumerable cases of undoubted croup-like convulsions have occurred, in which no enlarged glands could be detected in any part of the course of the pneumogastric nerve."1 326. These reasons appear to me as conclusive against the suppo- sition of the disease being caused by the pressure of enlarged thymus or bronchial glands upon the nerves, as the former facts were against the supposed effects of mechanical pressure upon the trachea by the hypertrophied thymus : and we have now remaining only those cases in which a post-mortem examination records no morbid change, or some lesion of the brain, or its membranes, i. e., as Dr. M. Hall has observed, those cases where death has anticipated organic change, and those where time has allowed the organs, at first functionally, to be afterwards organically disordered. Irritation is excited in the brain from some distant point, and is again projected, as it were, to another. I know of no case of disease so illustrative of Dr. Marshall Hall's physiological discoveries. " It is an excitation," he observes, " of the true spinal or excito-motory system. It originates in— "1. a. The trifacial, in teething. b. The pneumogastric, in over-fed or improperly-fed infants. c. The spinal nerves in constipation, intestinal disorder, or catharsis. These act through the medium of, " 2. The spinal marrow, and, " 3. a. The inferior or recurrent laryngeal, the constrictor of the pharynx. b. The intercostals and diaphragmatic, the motors of respira- tion."2 ' Underwood on Diseases of Children, p. 184. 2 Diseases and Derangements of the Nervous System, p. 71. 202 SPASM OF THE GLOTTIS. 327. Causes.—Among the predisposing causes has been men- tioned the peculiar condition of the larynx in infants, scrofulous con- stitution, hereditary peculiarities, and climate. It certainly is often kobserved in several children of the same family successively,1 and is undoubtedly more prevalent in moist and damp situations. In dry, pure air in the country, it is almost unknown, whilst it is sufficiently frequent in towns. The exciting causes may be stated to include any species of irrita- tion capable of exciting the nervous system into irregular, but not excessive action. Dentition is, perhaps, the most common of such causes; next, indigestible food, or over-feeding, constipation, or dis- order of the bowels, suppressed eruptions. Mr. Coley mentions a curious kind of constipation giving rise to it, in which there was an accumulation of faeces in the colon, with a secretion of viscid mucus, like white paint, in the duodenum, and until this was evacuated, no relief was obtained.2 After what I have just said, I can hardly admit tumors pressing upon nerves as exciting causes, except in a different sense to that proposed by Dr. Ley. It is quite conceivable that irritation in, or from a tumor, may act in producing the disease in the same way as dentition, though not from pressure. 328. Diagnosis.—The pathognomonic sign of this disease, as Dr. Cheyne has well observed, is " a crowing inspiration, with purple complexion, not followed by cough." The suddenness of the attack, the temporary character of each paroxysm, its facility of reproduction, the absence of the normal symptoms of inflammation of the larynx or trachea, or of much constitutional suffering, are sufficiently charac- teristic, and render the differential diagnosis tolerably easy. 1. It has been considered as a variety of croup, and has been mis- taken in practice for a variety of that disease, or of laryngitis ; but in these affections the dyspnoea is permanent, and affects expiration, as well as inspiration, though not to tlje same degree, and, notwith- standing, respiration is steadily performed ; but in spasm of the glot- tis, it is the inspiratory effort which is arrested, and, for the time, in- spiration is absolutely stopped. The rough, metallic sound of croupy breathing is quite different from the clear, ringing, crowing of the present disease; and, moreover, it is evident in expiration, and is accompanied and aggravated by a severe cough. In spasm of the glottis there is no cough, and in the intervals between the spasms the respiration is natural. Lastly, in the present complaint, there is ge- nerally little or no disturbance of the circulation, and no fever; but, as the disease increases, a disposition to general convulsions; whilst in croup we have high fever, quick pulse, thirst, heat of skin, and no convulsions, except quite at the termination. 2. The milder forms of the disease are distinguished from convul- sions by the purely local nature of the spasm, and the absence of ' Ley on Laryngismus Stridulus, p. 53. 2 Diseases of Children, p. 253. SPASM OF THE GLOTTIS. 203 constitutional irritation ; but, as the more severe cases may merge into general convulsions, the distinction will cease. 3. From hooping-cough it is easily distinguished, although there is a great resemblance between the sound of the whoop and the crowing inspiration, owing to both resulting from the same mechanical con- dition of the larynx, viz., more or less perfect closure, terminating in a forcible inspiration. But in spasm of the glottis there is very rarely any accompanying cough, and the spasm occurs quite independently. There is no kink, no expectoration, nor vomiting, nor any catarrhal sounds in the lungs. 329. Prognosis.—In all cases, the prognosis is grave, and in the severe cases very serious, because of the implication of the brain, and the tendency to terminate in convulsions, or in sudden death. One- third of Dr. Cheyne's cases died ; Dr. John Clarke says that the patient rarely recovers ; Gervino and Gardien think it almost always fatal, if remedies be not employed in the early stage ; and this seems to be the general opinion ; but, on the other hand, if the complaint be recognized, and the treatment early and prompt, the symptoms will, in many cases, yield to the remedies employed. The change which indicates a favorable termination is a diminu- tion in the frequency and duration of the paroxysms, and freedom from any complications. The unfavorable symptoms are an increase of the spasms, spasmodic affections of the limbs, or general convulsions. 330. Treatment.—Fortunately, however different opinions may be as to the nature of the disease, all are unanimous as to its treatment. The first thing to be attended to is to remove all exciting causes, and according to them will be the treatment. If the child be teething, " the augmented arterial action within the gums and alveolar pro- cesses must be subdued by deep, diffused, and repeated scarification of the gums, conducted with every precaution to avoid excitement of a mental kind."1 If we suspect over-feeding, or that indigestible food has been taken, the stomach must be emptied by an emetic, or by tickling the fauces with a feather; and the effect of accumulation, or disorder of the bowels, may be removed by one or two brisk purgatives of calomel and jalap, or rhubarb, or by large enemata of warm water. If the air of the room in which the child has been confined be close and impure, it must be removed to a larger apartment, or fresh pure air admitted. 331. During the paroxysm, the child snould be placed in an up- right position, with the head leaning a little forward, and exposed to a current of pure fresh air, whilst cold water is sprinkled on the face. If this fail, the child may be placed in a warm bath, and cold water sprinkled in its face; in short, whatever is calculated to induce a more forcible effort at inspiration. Dr. Condie mentions that the ap- plication of ammonia to the nostrils is useful, or tickling the fauces with a feather, so as to induce vomiting.2 ' Lancet, July 12, 1847. 2 Diseases of Children, p. 321. 204 SPASM OF THE GLOTTIS. Generally speaking, the paroxysm terminates too quickly to allow of much interference. 332. During the intervals, our object should be to diminish the frequency of the spasm, and to improve the general health. In very few cases, is bleeding either necessary or useful; in many, it wTould do mischief by weakening the vital powers. When the child is robust, florid, and plethoric, a few leeches may, perhaps, be bene- ficial; but, when there is any threatening of general convulsions, or any other evidence that the brain is more than usually involved, then prompt blood-letting will form a necessary and important part of the treatment. Purgatives are universally recommended, not powerful doses, but moderate ones, repeated three or four times a week, so as to clear . out the bowels, and act as a derivative. Dr. M. Hall strongly re- commends the antacid aperients. Antispasmodics have been found useful. Millar gave assafetida in large doses; the proper dose, however, for a child of two years is from one to two grains, and four to six grains for a child from five to ten years. Dr. John Clarke used ether and ammonia; Dr. Under- wood assafetida, oleum succini, tinct. fuliginis, of the old Pharma- copoeia, musk, cicuta, &c. Musk may be given in doses of two to five grains every six or eight hours, to a child of three years old and upwards. Sir H. Marsh tried the tincture fuliginis with benefit; and, in one case, an infusion of tobacco leaves (gr. v to 3vi) as an enema. Dr. Stewart speaks highly of a poultice sprinkled over with Scotch snuff. Drs. Ley and Davis gave henbane with relief; or, if the child be restless, a little Dover's powder may tranquillize it. In cases where dysuria was present, Dr. Davis derived great bene- fit from a combination of hyoscyamus, spirits of nitrous ether, and almond milk. When the fauces are swollen, they may be washed over with a solution of the nitrate of silver, with a camel's-hair pencil, or with a mixture of dilute sulphuric acid and syrup. 333. It will be advisable, in most cases, to apply some form of counter-irritation, either some irritating liniment, or a blister; or, what I have found far better, a small seton in the arm. In one case under my care, the moment the seton discharged fairly, the spasms ceased; and, whenever it was left out, they returned. 334. With almost all children who have the disease for some time, but especially witTi those of a delicate constitution, tonics will be found beneficial; sulphate of quinine, infusion of cascarilla, ov of hops, as advised by Dr. Ley, or some of the preparations of iron, may be given in doses suitable to the age of the child. Dr. Davis re- commends the vinum ferri, combined with the carbonate of ammonia and hyoscyamus, if the child be languid and irritable. Attention to the diet of the child is of great importance; we may succeed in removing the disease, and improper food will instantly re- produce it. The food should all be of a bland, nutritious character, and moderate in quantity. If there be any danger of over-indulgence, or of imprudence, it will be better to adopt Dr. M. Hall's plan, and PERTUSSIS. 205 fix upon one kind of food to the exclusion of all other. Dr. Mont- gomery very wisely cautions us against laying infants on their back when feeding, if they are liable to this disease, and against hasty feeding. In the case of infants at the breast, it will be prudent in many cases to change the nurse. Lastly, I have already alluded to the necessity of a pure at- mosphere within the room in which the child lives. I must add, that the temperature ought to be carefully regulated, so that it shall neither be too hot nor too cold, and also that the clothing of the child should be sufficient, according to the season, without being oppressive. But very special benefit, as Sir H. Marsh has shown, is derived from change of air. After we have removed all the causes within our reach, prescribed antispasmodics and tonics, we shall often find more immediate benefit from a removal to the pure, mild air of the country, than from all our medical treatment in town. This should be done as early in the disease as possible, in order to check its progress. Should the disease increase, in spite of all our efforts, and issue in general convulsions, then the treatment must be adopted which I have recommended for that disease. CHAPTER III. PERTUSSIS.—HOOPING-COUGH.--COQUELUCHE.--KEICHHUSTEN. 335. I have placed hooping-cough next in order to spasm of the glottis, because of the similarity betw-een them, the former constitut- ing a transition from purely spasmodic to inflammatory affections, being a mixture of both. Dr. Cullen has given a brief but accurate description of this disease: "Morbus contagiosus, tussis convulsiva, strangulans, cum inspira- tione sonora, iterata, saepe vomitus." Dr. Copland's definition is an expansion of this, with more details. He says that it is "a convul- sive and suffocative cough, accompanied with a reiterated hoop, or consisting of many successive, short expirations, followed by one deep and loud inspiration, and these alternating for several times; occur- ring in paroxysms, ending with the expectoration of tough phlegm, and frequently with vomiting: infectious, and often epidemic, appear- ing but once during life." It has obtained various popular and learned names: chin-cough, kink-cough, and hooping-cough, in England ; kinkhoast, in Scotland ; coqueluche, in France; and in Germany, keichhusten, stickhusten, eselshusten, &c. By Willis, it was called tussis convulsiva; by Hoff- mann, tussis ferina; and by Sydenham, pertussis. 336. It is very doubtful whether it was known to the ancients. 206 PERTUSSIS. No accurate description is to be found in the Greek or Arabian writers; and the disease is so peculiar that they could hardly have omitted to notice it, had it been familiar to them. It has, therefore, been supposed by Rosen that it came from the East Indies and Africa into Europe. The earliest record of it we find is by Mezeray, as it occurred in France in 1414; but Dr. Copland considers that there is nothing cha- racteristic about his description, or the subsequent ones of De Thou and Pasquier, but the name " coqueluche." The first accurate account is by Willis,1 who was followed by Millar,2 Sydenham,3 Alberti,4 Brendel,5 Butler,6 Danz,7 Paid am,8 Per- rada,9 Watt,10 Marcus,11 &c.; and more recently by Guibert,12 Desru- elles,13 Blaud de Beaucaire,14 Blache,15 Roe,16 C. Johnson,17 Duges,18 Copland,19 &c.; besides excellent notices in the systematic works of Dewees, Eberle, Stewart, Condie, Maunsell and Evanson, Coley, Barrier, Barthez and Rilliet, Bouchut, &c. 337. Hooping-cough has this peculiarity in common with some eruptive diseases, that it occurs once, and in general but once in a lifetime; and consequently almost always in infancy or childhood, i. e. the first time the child is exposed to the peculiar exciting cause, whether that be epidemic miasma, or contagion. Thus we find the most common age is between two and ten years. Dr. Watt has given the following table of the ages at which death from hooping-cough occurred in Glasgow during 30 years:— Under 6 months, in 135 cases. Abov e 6 " and und 2r 1 year, " 357 a 1 year a 2 years, " 596 a 2 years a 3 tt " 333 a 3 " a 4 a " 186 a 4 " a 5 n " 109 a 5 " a 6 n " 37 a 6 " a 7 it " 34 a 7 " a 8 a " 12 a 8 " a 9 a " 10 a 9 " a 10 a " 5 a 10 " • ■ ■ ' . 3 1817 ' Opera Omnia, Amst. 1682, vol. ii. p. 169. De Morb. Convulsiv. Puerorum, &c. 2 Obs. on Asthma and Hooping-cough, 1769. 3 Opera Universa, 1726, p. 311. ■» De Tussi Infant. Epidemica, 1728. 6 Prog, de Tussi Convuls., 1747. 6 A Treatise on Kink-cough, 1773. • Versuch einer Allgem. Gesch. des Keicbhustens, 1791. 8 pjer Stickhusten, 1805. 9 Memoria, &c. Verona, 1815. 10 Treatise on the History and Treatment of Chin-cough, 1813. " Der Keichhusten, 1816. " Recherches sur la Croup, et la Coqueluche, 1824. '3 Traite de la Coqueluche, 1824. '" Revue Med., 1831. 15 Archives Gen., vol. iii. 1833. 16 Treatise on the Nature and Treatment of Hooping cough, 1838. 17 Cyclopaedia of Practical Med., vol. ii. p. 428. 's Diet, de Med. et de Chir. Pratiques, vol. v. p. 487. '9 Diet, of Medicine, part v. p. 236. 7£ n PERTUSSIS. 207 The author states that this may be considered about half of the deaths in Glasgow from this cause. Out of 130 cases collected by M. Blache, 106 were from one year old to seven, and twenty-four from seven to fourteen years. Of twenty-nine cases observed by Rilliet and Barthez, three were from one to two years old ; five, three years; seven, four years ; six, five years; two, six years; three, seven years; one, eight years ; one, nine years ; and one, tw7elve years old.1 Dr. Hood mentions having seen a child of a fortnight old,2 and Dr. C. Johnson one of three weeks old, attacked by the disease. On the other hand, it has undoubtedly occurred more than once in the same individual, some say even three times; and cases are on record of persons who had escaped until a very advanced period of life. Eberle mentions two cases occurring after fifty years; and He- berden one in a woman of seventy, and another in a man of eighty. Boys and girls are of course equally exposed to the attack, and yet, according to the researches of Blache and Constant, a greater number of boys arrive at maturity without having had the disease. Blache proved the proportion of such cases to be seven boys to six girls; and Constant, three boys to two girls.3 338. Symptoms.—The disease has been divided generally into two or three stages. Desruelles and Lombard have a period of invasion, a period of increase, and a period of decline; Blache and Williams divide it into the inflammatory, congestive, and nervous stage; others into the catarrhal and spasmodic stages, which is, at any rate, the simplest and most natural division. The period of decline is simply the termination of the second or spasmodic stage. The first stage commences with the usual symptoms of catarrh. The child appears to have caught cold; it is languid, restless, feverish, and irritable, without cause. There are loss of appetite, sneezing, coughing, and an extra secretion of mucus from the membrane lining the nose and bronchial tubes after the first day or two. This is by far the most general mode of invasion, a well-marked but not very severe catarrh; but occasionally we find the patient suf- fering much more, the fever intense, great thirst, the pulse quick, the oppression and general distress considerable, the cough very frequent and painful, dry at first, but with profuse expectoration afterwards. The bowels, according to Dr. Watt, are generally constipated, and require large doses of medicine for their relief; but this, I think, is not generally the case. In some few cases, there is no evidence of the existence of this first stage; the child is at once seized with the characteristic cough, with- out any irritation of the mucous membrane. M. Blache mentions that the child of his colleague, Dr. Tavernier, aged two years, was brought home from the country in perfect health, and without the slightest cold. The day after, she was playing with two children who ' Mai. des Enfans, vol. i% p. 230. a On the Fatal Diseases of Children, p. 103. 3 Barrier, Mai. de l'Enfance, vol. i. p. 370. 208 PERTUSSIS. had hooping-cough. In the evening of the second day, she had an attack of shrill, spasmodic cough, which proved to be hooping-cough, and continued for two months without any complication.1 On the other hand, Dr. Watt observes that the disease, throughout its course, may present this character only.2 "I have had instances of a disease," says Dr. Cullen, "which, though evidently arising from the chin-cough contagion, never put on any other form than that of a common catarrh."3 And Dr. Burns observes that, "In young children, even death may take place, although the disease never fully forms;" and his observation is confirmed by M. Duges. I think, however, that, in such cases, there must ever remain a doubt as to the true na- ture of the disease. 339. These catarrhal symptoms continue for twTelve or fourteen days, but gradually subside, the fever and coryza diminish, the pulse becomes quiet, and the appetite returns. The cough, indeed, persists, or even appears aggravated ; but it exhibits a change of character. Instead of being a simple cough, with few succussions, we find it prolonged by a succession of expi- ratory efforts, and at its termination we occasionally hear a forcible inspiration, accompanied by a loud ringing sound. The prolonged paroxysm of coughing, or kink, and the whoop, mark the commence- ment of the second stage, as the subsidence of the catarrh does the termination of the first. The cough is very peculiar; when fully established, we find " a number of expirations made with such violence, and repeated in such quick succession, that the patient seems to be almost in danger of suffocation. The face and neck are swollen and livid, the eyes protruded, and full of tears; at length, one or two inspirations are made with similar violence, and by them the peculiar whooping sound is produced: a little rest probably follows, and is succeeded by another fit of coughing, and another whoop; until, after a succession of these actions, the paroxysm is terminated by vomiting, or a discharge of mucus from the lungs, or perhaps by both."4 The child is perfectly conscious of the approach of the cough ; he feels a sensation of rattling in the chest, and tickling in the larynx, which he endeavors to sup- press, and the struggle continues until his resistance is overpowered by the irritation. The paroxysms, or a rapid succession of them, may last from one to fifteen minutes, and in proportion to the violence and length will be the breathlessness and fright of the child, and its efforts to inspire. If lying down, it will suddenly jump up, and seize hold of whatever is nearest, so as to make a fulcrum, as it were, for the whole muscular force of the body, which is employed in overcoming the spasm. The paroxysm most generally terminates in vomiting; but, if it be very violent, some small vessels may be ruptured, and blood escape ' Diet. Gen. des Sciences Med., Art. Coqueluche, p. 24. B On the Chin-cough, p. 37. 3 First Lines of the Practice of Physic, sect. 1406. « Dr. C. Johnson, Cyclop, of Pract. Med., vol. ii. p. 428. PERTUSSIS. 209 from the nose or mouth, or it may be effused beneath the conjunctiva, or be mixed with the expectoration. After the fit of coughing is over, the child appears exhausted, and requires a short rest to recover itself; but then, and during the interval until the next cough, it appears tolerably easy and cheerful, occupied with its usual plays, and not averse from food. If the attack be severe, it will be pale, thin, and languid. 340. The length of the intervals, and the frequency of the parox- ysms, vary a great deal. At first, and for some time, they are very frequent when the disease is severe. I have known them to occur every half hour during the day and night; but, in other cases, they return every five or tea-minut£&> during the day, and less frequently at night, though the paroxysms are rather more severe.1 _____-=,----- The principal cause of their return is the accumulation of mucus, if the secretion is profuse. Frequent efforts will be made to get rid of it; and, if it be easily expelled, in sufficient quantity, the fit will be light, and the interval easy. If it be scanty and tenacious, the paroxysm will be violent, the efforts great, and the cough renewed almost immediately, or it will occur in double paroxysms. y A full meal, a fit of anger, crying, fright, or laughter, will gene- rally bring on the cough; nay, even the force of sympathy will have a similar effect, for it is mentioned that, in the case of two children who had hooping-cough, when one had a fit of coughing, the other immediately began also. In some rare cases, towards the decline of the disease, the parox- ysms have assumed a periodic character, returning at a given hour. A case of this kind is mentioned by Dr. Good ;2 it occurred daily at a certain hour, continued obstinately for several months, and returned at the same season for two years. 341. The expectoration which, during the first stage, was a frothy mucus, assumes, in the second stage, a very tenacious character; it may be clear and transparent, or yellow, and even puriform, but still thick, tenacious, and ropy, so that it may be drawn out of the infant's mouth with the fingers. If we make a stethoscopic examination of the chest during the first stage, we shall find the mucous or sibilant rhonchi characteristic of the catarrh; and the respiratory murmur somewhat weaker than usual. / The chest is clear and sonorous on percussion. During the second stage, when the hooping-cough is fully developed, Laennec observes that, " during an interval, we find but the ordinary symptoms of catarrh, i. e., the respiratory murmur more feeble than usual, or altogether absent in some parts, otherwise resonant; puerile in others, with mucous or sibilant rales. During the paroxysms, we perceive only the vibration of the trunk, from the shock of the cough, and we only hear a slight rhonchus or the respiratory murmur in the 1 Marley on Diseases of Children, p. 157. a Study of Medicine, vol. ii. p. 393. 210 PERTUSSIS. short intervals between the succussions. The whooping inspiration, so characteristic, seems limited to the larynx and trachea. Neither pulmonary nor bronchial respiration is heard, even in those parts where puerile respiration had been audible a few minutes before."1 Similar testimony is borne by Dr. WTilliams; he says, "On ap- plying the ear to the chest during a fit of hooping-cough, one is sur- prised, with such violent external motions, to hear so little sound of respiration within the chest; and, during the sonorous back-draught, there is scarcely any sound of air entering the lungs. This is to be ascribed to the continued contraction of the glottis and large bronchial tubes, preventing the air from entering the pulmonary texture with sufficient force to produce the ordinary respiratory murmur."2 All writers agree pretty much with this description when the dis- ease is uncomplicated; and, so far as the positive part is concerned, I have no doubt it is true; but I think more can be heard during the intervals, in well-marked cases, than is here mentioned. I have ex- amined a great many children at intervals, from one paroxysm to another, and I have in a great many cases found that, after the chest had been cleared by the last cough and vomiting, the respiratory murmur or inspiration was louder and more rough than usual; nay, in some cases, that it had a rather loud, brazen sound, something re- sembling aloud, sonorous rale, as if the air was passing through tubes much narrower than usual. It is perceptible, also, in expiration, though more feeble. This sound may continue until the mucus begins again to accumu- late, and then it will be exchanged for the large, mucous, bubbling sound, which increases until the next cough, and is almost universal. In milder cases, the rough, dry sound is more feeble, though gene- rally audible ; and I think this loud, rough murmur of inspiration and expiration quite peculiar to pertussis. The chest is clear on percus- sion throughout this stage in simple cases. The explanation given of the cough and the whoop by Dr. Roe is, I think, satisfactory: "Anyone who will make the experiment will perceive that, by the exercise of the voluntary muscles of respiration, he cannot either continue coughing loudly for so long a time, or empty the lungs so completely of air, as a person does in a paroxysm of hooping-cough; it must, therefore, be inferred that the involuntary muscles, namely, those pointed out by Reisseissen, as connecting the extremities of the cartilaginous rings of the trachea and bronchiae, powerfully assist in accomplishing both these objects. They seem, by acting spasmodically, to expel the air from the lungs, and to excite, by sympathy, the voluntary muscles of inspiration; the combined action of both sets of muscles appears to produce this peculiar cough." I think it extremely probable that the spasmodic action involves the smaller bronchial tubes as well as the larger. "The whoop takes place in the larynx and trachea, and appears to be caused by a rush ' De l'Auscultation Mediate, vol. i. p. 188, 2d ed. a Pathology and Diagnosis of Diseases of the Chest, p. 89. PERTUSSIS. 211 of air through a contracted passage, for no sudden or violent inspira- tion could produce this sound in the natural healthy state of the air- tubes. The lungs are so completely emptied of air, by long-continued expirations, that a most distressing sense of suffocation is produced, to relieve which, a full inspiration is instinctively made, and at the same moment the rima glottidis is contracted, and the air, passing quickly through a very narrow opening, causes the whoop."1 The action of the heart is excessively quick and strong, and it is a little time before it subsides to the natural standard during an interval. 342. The second or spasmodic stage persists a considerable time, generally six weeks or two months, but often three, four, or six months: if we make a third stage, one month may be allotted to the spasmodic stage, and the remainder to the stage of decline. The effects upon the child will be pretty much in proportion to the violence and duration of the disease, and the susceptibility and de- licacy of the constitution. They are seldom of serious importance, however, if the pertussis be uncomplicated. The appetite is generally diminished, and the digestion disturbed by the frequent vomiting; nutrition is not very effective, and the child loses flesh. The sleep is interrupted, the circulation deranged by the excitement of the cough, the surface is moist, with profuse sweating sometimes ; the flesh is generally flabby, and the skin is of a darker hue, especially under- neath the eyes; the spirits are unequal, often depressed. As the disease declines, the paroxysms become less frequent, though, perhaps, equal in violence. They nowT occur but four or five times during the day, and rarely at night; ultimately, towards evening only, and under special excitement, and then are reproduced at distant intervals only, and with much less violence, until they cease alto- gether. Meanwhile, if not too much exhausted, the constitution begins to recover its healthy condition; tranquil sleep restores the nervous system; the absence of vomiting allows the food to be di- gested, and the child recovers flesh and spirits; the circulation re- turns to its normal condition, and the surface assumes its natural aspect. 343. Thus we find that, in simple pertussis, the first stage is cha- racterized by the symptoms of common catarrh, which, however, are occasionally absent; and the second stage by the peculiar prolonga- tion of the cough in expiration without inspiration, i. e. the kink and the forcible inspiration, or whoop. In some very rare cases, the kink is but little remarked; but it is always present in a greater or less de- gree, and is, so far, more characteristic than the whoop, which is not unfrequently absent. The presence of either will prove the nature of the disease, but the absence of both would, of course, deprive us of the powrer of diagnosis. The entire duration of the disease is from two to four months. According to popular belief, it is six weeks coming to its height, and six weeks going off; but it may be almost indefinitely prolonged, as, 1 On Hooping'cough, p. 44. 212 PERTUSSIS. for some time afterwards, the whoop returns when the child catches cold. Marley mentions a case in which the symptoms did not dis- appear for two years -,1 and Dewees and others mention its continu- ance for twTelve months. According to Barrier,2 the child may die in simple hooping-cough, from the intensity of the kinks; it may, in short, be suffocated. The disease may also prove fatal from exhaustion, and the child die, utterly worn out, according to Hamilton,3 Barrier, and others; or, what is more common, it may lay the foundation of other diseases, such as dilatation of the bronchial tubes, phthisis, epilepsy, struma, ophthal- mia, &c. "In scrofulous habits," says Dr. Watt, "the disease is not so apt to prove suddenly fatal; but, if it be severe and protracted, it generally ends in some affection of the glandular system, laying the foundation for tabes mesenterica, rickets, or pulmonary consumption."4 344. Complications.—So far, I have spoken only of simple hooping- cough ; but we find that a very large proportion of the cases, during some part, at least, of their course, are complicated with other secondary affections; and a careful inquiry will establish the fact that it is to these complications that almost all the mortality is owing. Simple hooping-cough is rarely fatal, and yet the mortality in hooping-cough is very great, arising from the liability of other organs to take on mor- bid action. I shall notice complication with, 1. Bronchitis, or pneumonia. 2. Infantile remittent. 3. Congestion of the brain, convulsions, or hydrocephalus. 4. Sanguineous apoplexy. Other minor or more rare complications are mentioned occasionally by authors; but I shall content myself by noticing, briefly, the fore- going. 345. i. Pertussis complicated with Bronchitis and Pneumonia.— This will be found, in these countries, the most frequent, and probably the most fatal of all the secondary diseases. Of Barrier's cases, seven out of ten died of lobular pneumonia. Of twenty-seven fatal cases under Dr. WTest's care, thirteen died from bronchitis or pneumonia.5 Dr. Copland attributes the frequency of this complication, during the winter, to the variable climate of these countries, and the prevalence of easterly winds. The attack, as we have seen, commences with some degree of bron- chitis; this may be very intense; and it may continue on during the second stage, instead of subsiding, or it may occur at any subsequent period, either from the stress thrown upon the lungs, from a strong predisposition, or from cold. The same may be said of pneumonia, except that the latter is more common during the second stage than the first, and in children of a full habit of body. The age has little to do with these complications. They are met ' Diseases of Children, p. 159. 2 Mai. de l'Enfance, vol. i. p. 378. 3 Diseases of Infants, p. 169. * On the Chin-cough, p. 75. 6 Medical Gazette, Feb. 25, 1848, p. 311. PERTUSSIS. 213 with in children of all ages, and very often creep on very insidiously, so as to deceive the physician as well as the nurse, unless he adopt the proper precaution of auscultating the chest very frequently. I would strongly recommend that this should be done at each visit, as a matter of duty, in all cases of hooping-cough, and minutely and thoroughly, whenever we suspect the existence of more than the simple affection. The presence of bronchitis or pneumonia, during the first stage, may . be suspected by the greater amount of constitutional disturbance, the quick pulse, high fever, loss of appetite, dyspnoea, and incessant cough, and we may certainly ascertain the fact by percussion and ausculta- tion. 346. During the second stage, after the subsidence of the catarrhal fever, the occurrence of bronchitis or pneumonia will generally be marked by the return of the fever, loss of appetite, the increase of the cough, and the addition of difficult or hurried respiration during the intervals, as well as by constitutional disturbance in proportion to the intensity of the disease. We need, however, to be very watchful, for in some cases the inroad of the disease is very gradual, and marked by fewr symptoms, until the little patient is beyond aid. It is not necessary that I should here detail minutely the symptoms and course of either complication; they will be found in the proper place; it will be sufficient to notice that the child will generally be found to be very feverish, restless, sleeping uneasily, with a quicker pulse, greater thirst, hotter skin than usual, and a red flush on one or both cheeks. The respiration is considerably affected, quick, hurried, and difficult; the chest heaves, the alae nasi expand, and the muscles of the chest and abdomen are in vigorous action, even during the in- tervals of coughing. We may sometimes count thirty, fifty, eighty, or a hundred respirations per minute, and the pulse will be, in pro- portion, frequent, and in general hard. The cough is generally aggravated in frequency, and more distress- ing; but, in severe cases, it may altogether lose the spasmodic cha- racter, and exhibit that of the cough in bronchitis or pneumonia. If the cough had already declined, it may return, as during the early part of this stage. The expectoration is more difficult, the sputa being less profuse and tenacious, and of a puriform appearance. As the disease advances, the cough may diminish; but the wheezing and dyspnoea increase, the fever continues, the respiration is more fre- quent, hurried, and labored, the pulse very rapid, small, and feeble, the cheeks and lips purple, the surface cold and clammy, and death soon closes the scene. 347. If the child be attacked by bronchitis, we shall find the chest generally clear on percussion; in some parts, there maybe a degree of dulness, but it is never either extensive or absolute. By the stethoscope, sonorous, sibilant, and mucous rales will be heard over a portion or the whole of one or both lungs. I think I 214 PERTUSSIS. have more frequently seen both lungs affected than one alone, and it will be observed that these rhonchi are as audible immediately after a fit of coughing, and during the interval, as just before the cough comes on, therein differing widely from simple hooping-cough. The respiratory murmur will be feebler than usual, and more or less masked by the bronchitic rales. In cases of secondary pneumonia, the chest is dull on percussion over the diseased portion of the lung, but resonant in other parts. The stethoscope will detect a crepitating rale in the early period of inflammation, with puerile respiration in the surrounding lung; or, if the entire lung be involved, the respiration will be puerile in the other. At a more advanced stage, we may find a portion of the lung solidified, absolutely dull, without respiration or rhonchus, but in which bronchophony will be audible. If the child live until suppuration be established, which is very seldom the case, there may be heard a large mucous bubble, or a large crepitus, with, perhaps, cavernous respiration, and the dulness, on percussion, may diminish. So, in the progress of recovery, the lung which was solidified, and impermeable to air, will now yield at first a mucous or crepitating rale, and then gradually more and more respiratory murmur, with increasing resonance on percussion; and, along with this local ame- lioration, we shall have a diminution of the dyspnoea and rapid breath- ing, a return of the natural cough, a quieter pulse, calmer sleep, and restoration of appetite. 348. ii. Pertussis complicated with Infantile Remittent.—I have already mentioned that the condition of the stomach and bowels is variable in hooping-cough; they may be pretty regular, or they may be much disordered; and, in our anxiety about the principal affection, they are liable to be neglected. During the first stage, the effect upon the concurrent disease, and upon the infant, may be compara- tively slight; but, in the second stage, when the constitution is some- what shaken, it may prove more serious, and require great attention and prompt treatment to prevent it running on into infantile remittent and its consequences. This disordered condition of the bowels will be marked by a foul, loaded tongue, loss of appetite, tympanitic ab- domen, and unhealthy discharges. These may continue for some time, and then, if not relieved, symptoms of infantile remittent will arise. " After the symptoms just enumerated have continued for a longer or shorter time, the fever makes its appearance, sometimes commencing with a rigor; more frequently, however, it comes on so gradually that we do not know precisely when to date its commence- ment. The paroxysms of coughing become more frequent, and the breathing is quickened and oppressed; but still it may be, with a little care, distinguished from the attack of bronchial inflammation. The stethoscope affords us useful, though negative evidence. The usual symptoms of bronchial inflammation are absent. The frequency PERTUSSIS. 215 and force of the respiration are found increased, but this increase is not accompanied by any rale indicative of bronchial inflammation; while the daily remissions, the loaded tongue, the nature of the alvine discharges, the aspect of the child, constantly picking its nose and lips, all serve to determine the true character of the disease."1 There is a marked difference between the inspiration in this and the last complication; in the former, it was quick, hurried, and difficult; in the present, it is quick, hurried, and somewhat unequal, but not difficult. The fever, also, unlike that which accompanies hydrocephalus, has distinct remissions in the morning, and increases towards evening; whereas, in the majority of cases of meningitis, it is nearly equal, and certainly without distinct remissions. It must not be forgotten, how- ever, that infantile remittent may terminate in hydrocephalus, if not relieved. This complication is neither so frequent nor so formidable as the last, but quite sufficient to render the disease very intractable, and often fatal. 349. m. Pertussis complicated with Congestion of the Brain, Convulsions, or Hydrocephalus.—We might anticipate the occurrence of these complications, even before experience had proved the fact. If we watch a child during a paroxysm of hooping-cough, and notice the great congestion of the vessels of the head, face, and neck during the fit, and observe how often this is repeated during the day for weeks together, and remember the delicate condition of the brain in young children, and especially in infants, our wonder will be, not that these cerebral affections occur at all, but that they are not more frequent. These attacks may occur in children of any age, but I think are more common in young infants, or about the period of the first denti- tion, and they are highly dangerous, if not generally fatal. Dr. West mentions that fourteen of his twenty-seven fatal cases died from con- gestion, convulsions, or hydrocephalus; and all who have had much experience will admit the rarity of cure, and the rapidity with wThich they run on to a fatal termination. These complications may accompany the disease at its commence- ment, or may arise at any period of its course. Dr. West remarks, very truly, "The nervous system sometimes suffers so severely from the very first, that death takes place almost before the disease has had time to assume its usual character. At other times, hooping-cough comes on naturally; its two elements, the bronchitic and the nervous, if I may be allowed the expression, increase daily in intensity, till, all at once, the symptoms of the former recede, and are almost lost in those of the latter, which, in a day or two, bring on the fatal ter- mination of the case. Or, lastly, no symptoms referable to the nervous system call for our solicitude until after the hooping-cough has con- tinued many weeks; but then the long continuance of the disease ' Dr. C. Johnson, Cyclop, of Pract. Med., vol. ii. p. 430. 216 PERTUSSIS. seems to excite mischief in the brain, and death overtakes the patient when we had already begun to hope that nothing more than time was needed to perfect his cure."1 350. We may fear the occurrence of one of these complications when we find the cough increase in severity, without either of the former complications; the face become livid, and remain so longer than usual; the existence of the carpo-pedal spasm, the previous oc- currence of nervous affections, any hereditary taint, or the occurrence of convulsions or hydrocephalus in other members of the family. Probably, the earliest symptoms will be an unusual sleepiness and heaviness after the fits of coughing, with an uncertain look of the eyes, or stare, or spasmodic twitchings of the face or extremities, carpo- pedal spasm, sometimes an attack resembling spasm of the glottis; and any of these may be followed by an attack of convulsions and coma, or coma without marked convulsion. Or, perhaps, the first evidence of the brain being seriously affected may be a fit of convulsions, fatal in some cases, but from which the patient generally recovers, to be again attacked when the congestion from coughing reaches a certain point. The convulsion, when re- peated, does not return with every fit of coughing, but generally as the result of a very severe paroxysm. This constitutes our great dif- ficulty in the treatment; we may relieve the head temporarily, but, just as we fancy ourselves successful, a cough of unusual violence destroys all the effects of our previous exertions. Meningitis or hydrocephalus may set in in the same manner, or it may creep on more insidiously, until at length it be manifested by the usual symptoms, as heretofore described. Dr. West has given a striking example of the insidious manner in which tubercular meningitis may come on during hooping-cough, and prove fatal, without affording us an opportunity of suitable treat- ment.2 351. These diseases will generally run the course I described when treating of them, modified partly by the presence of the cough, as a permanent exciting cause; partly by the influence they in turn exer- cise upon the cough; and partly by the state of health of the child. Thus, they are even more unmanageable than in their ordinary form, in consequence of the repeated cerebral congestions; they may either partially suspend the cough, i. e. diminish its frequency, but not its violence; or, by adding force to the spasm, death by suffocation may be the result of the sudden closure of the larynx; or, lastly, if the child have been harassed and broken down by hooping-cough for some time previously, the constitution will offer but little resistance to the secondary attack. With regard to the distinction between convulsions and hydroce- phalus, occurring as secondary affections, it does not appear easy, nor do I deem it very important, and therefore I have grouped them to- ' Lectures in Medical Gazette, Feb. 25,1848, p. 312. • Ibid., p. 314. PERTUSSIS. 217 gether. It is almost certain that, if the convulsions continue for any length of time without proving fatal, they will terminate in hydro- cephalus. My experienced friend, Dr. Johnson, observes, in his ex- cellent essay, "It is said that in hydrocephalus one side of the body is more affected than the other; but in convulsions, which are inde- pendent of organic disease of the brain, that both sides are equally affected. If the convulsions are confined to one side of the body, there is every reason to fear the existence of hydrocephalus; but it certainly does not follow, because the convulsions are general, that the brain is unaffected. In the latter case, we must wait till the convulsions subside before we can discover their cause, and then we must form our opinion from the general state of the child, and the history of the case, rather than from any peculiarity in the convulsion itself.'"1 352. iv. Pertussis complicated with Apoplexy.—We have already seen that fatal apoplexy may occur from excessive congestion of the brain; it cannot, therefore, surprise us to find, in a disease involving such frequent congestion of the vessels of the head, that occasionally cases occur in which the vascular fulness produces not merely con- vulsions, but a true apoplectic attack. The same result may take place from a higher degree of pressure, under which the texture of the vessels gives w7ay, and effusion of blood takes place between the membranes, or into the cerebral sub- stance. Although this appears a natural result of the pressure exercised upon the brain by the repeated force of the cough, it does not seem to be a frequent complication, unless we suppose that the sudden deaths on record are really such cases. It is mentioned by Marley2 and others; and I shall quote a case from Barrier, as illustrating the mode of attack, and in some degree countenancing the suggestion I have just made, that some at least of the sudden deaths may have been owing to sanguineous apoplexy :— "Claude Charmillon, set. 17, had suffered six weeks from hooping- cough, when admitted into the Hopital des Enfans, May 5, 1848. The first stage had lasted about fifteen days, and for a month past the cough had been accompanied with whoop, and followed by vomiting of glairy matters, more frequent during the night than the day, free from complications, and the condition good during the intervals. "During the first few days he was under M. Barrier's observation, the cough was forcible and frequent, sometimes followed by epistaxis. Auscultation gave evidence of fluid in the bronchial tubes. May 9. The patient, being feverish, was bled. May 10. Considerable catarrh. May 11. Slight eruption of scarlatina. After this, the eruption con- tinued quite as usual; but the bronchitis increased, and the bleeding was repeated with benefit. But the patient became emaciated, and phlebitis set in where the vein had been punctured, and two abscesses formed in the fold of the arm. The hooping-cough had necessarily ' Cyclop, of Pract. Med., vol. ii. p. 431. 3 Diseases of Children, p. 159. 218 PERTUSSIS. diminished, when, in the night of the 31st May, the patient died sud- denly, after a severe fit of coughing. On making a post-mortem ex- amination, the lungs were healthy, the bronchial mucous membrane inflamed. The bronchial and thymus glands, the head, and abdomi- nal viscera were healthy; but, on opening the cranium, a great effu- sion of blood was found in the cavity of the arachnoid, covering the convexity, and also at the base of the right hemisphere of the brain and cerebellum, with some blood infiltrated between the pia mater and arachnoid of the same side."1 The symptoms, then, which ought to excite alarm are a continu- ance of the congestion about the head and face, unusual drowsiness, &c.; and we find that the attack may either occur suddenly, proving instantly fatal, or the drowsiness may degenerate into stupor and coma, equally fatal, but less rapidly so. Though not a frequent complica- tion, it is in all cases a most serious one. 353. Pathology.—WTe have very rarely any opportunity of examin- ing the condition of the organs engaged in simple hooping-cough, on account of its rarely proving fatal, unless complicated, and then there is danger of mistaking, as many have done, the effects of the latter for the former. It is only when the child dies from some other disease, or from some distant complication, that we can ascertain the real condition of the lungs. In such cases, there is most frequently no trace at all of disease in the larynx, trachea, or lungs; in other cases, there is slight vascu- larity of the mucous membrane of the glottis and larynx, and some- times submucous oedema of these parts. When the cough has been violent, we may occasionally discover some interlobular emphysema, owing to the rupture of some of the air-cells; and, though rarely, this emphysema has extended to the surface. Ulceration of the glottis, and in the larynx and trachea, has been mentioned by Astruc, Mackintosh, and Alcock. The bronchial tubes are found more or less filled by mucus, and occasionally by muco-purulent fluid. 354. In fatal cases from any of the complications, the usual post- mortem appearances are discovered. In bronchitis or pneumonia, there is vascularity of the lining membrane of the air-passages, with muco-purulent secretion, congestion, and hepatization of the lung. Simple convulsions generally leave no trace, or merely an unusual degree of vascularity. When the child has been attacked by hydrocephalus, the usual evi- dences have been found: extreme vascularity of the membranes, con- gestion of the vessels of the cerebrum and cerebellum, effusion of serum* tubercular deposition, &c. And in cases complicated by apoplexy, extreme congestion and vascularity of the substance of the brain, or sanguineous effusion, as in M. Barrier's case. 1 Mai. de l'Enfance, vol. i. p. 381. PERTUSSIS. 219 Thus, the rarity of opportunities for examining cases of simple hooping-cough after death, and the fact that, in those which have been examined, some of the appearances I have enumerated have been found, have misled many observers as to the essential nature of the disease, and given rise to very various and contradictory views on the subject. 355. Linnasus maintained that it arose from inhaling, in respiration, the minute eggs of a peculiar species of insect;1 and his view, some- what modified, was advocated by Riverius, Dessault, Rosenstein, &c. Hoffmann attributed it to an acrid serum in the blood; Sydenham to some irritating effluvia cast off from the blood into the lungs, in consequence of suppressed transpiration. Huxham thought it was owTing to a morbid condition of the intestinal canal; Butter that it de- pended upon derangement of the liver; Waldschmidt and Stoll that it^was caused by crude and bilious matter in the stomach. Dr. Watt, judging from the results of his post-mortem examina- tions, attributes it in all cases to inflammation of the bronchial tubes, either so mild as to cause no inconvenience, or so severe as to cause death. Dr. Dawson limits the inflammation to the mucous membrane of the glottis and larynx; MM. Marcus,2 Broussais, Boisseau, Guersent, Rostan, and Duges regard it as a specific inflammation of the bronchi. M. Danz places the seat of the disease in the lungs, and Strong, Cullen, Astruc,'Lettsom, and Darcy mention having found evidences of inflammation of the mucous membrane of the larynx and trachea. Dr. Webster considers the hooping-cough as essentially a cerebral disease; he found, on examination, the hemispheres of the brain very vascular, the convolutions almost obliterated, serous effusion, &c.3 Lobenstein Lobel met with a case in which a considerable portion of the diaphragm was covered with pustules. Dr. Alcock states that he found the larynx invariably inflamed, and sometimes so much so as to close the glottis mechanically; that the mucous membranes of the trachea and bronchi were very vascular; and that the cavities of the latter were filled with fluid mixed with air.4 M. Alph. le Roi agrees with Dr. Webster that hooping-cough should be classed among diseases of the membranes of the brain. M. Gilbert considers the disease as essentially nervous or spasmo- dic, the cough being caused by a spasmodic affection of the glottis and diaphragm. Inflammation of the pneumogastric nerves has also been regarded as the essential cause of hooping-cough. It has been observed twice by MM. Breschet and Autenrieth, and fifteen times byKilian; but notwithstanding the most careful dissection, MM. Jadelot, Guersent, Baron, and Billard could discover none. M. Albers, of Bonn, out of 1 Diss. Exanth. viva in Amcenit. Acad., vol. v. p. 82. 3 Traite de la Coqueluche, 1816; trad, par M. Jacques, p. 67. 3 London Med. and Phys. Journal, vol. xlviii. * Lectures on Surgery, p. 132. 220 PERTUSSIS. forty-seven cases, found that in forty-three the nerve was healthy; in one it was reddish on the left side, and in three on the right side.1 Laennec admits that the suspension of inspiration may be owing either to congestion of the mucous membrane, or to spasm, and that the larynx and bronchia? are affected. Dr. Alderson makes the disease to consist in inflammation of the lungs.2 Dillon, Hufeland, Lobel, Breschet, Albers, and Eberle3 regard it as a nervous disease, perhaps of the brain, or perhaps of the pneumo- gastric nerve. Desruelles says that" hooping-cough is nothing more than bronchitis complicated with irritation of the brain ; and that the inflammation of the bronchia? is always primitive, the irritation of the brain consecu- tive. So long as the bronchitis is simple, the cough is without any peculiarity; but when the diaphragm, muscles of expiration, and of the glottis, larynx, and posterior membrane of the bronchia?, and the air-cells of the lungs, come into action, and are simultaneously af- fected with spasm, under the influence of the cerebral irritation, the cough changes its character, and becomes convulsive ; and every time that an afflux of blood takes place into the brain, the cough re- turns, and appears in paroxysms."4 M. Blache is of opinion " that hooping-cough is a nervous affec- tion, having its seat both in the mucous membrane of the bronchia? and in the pneumogastric nerves—an affection very frequently com- plicated with bronchitis and pneumonia, but which may exist without them ; and, like all other diseases of the same kind, having no appre- ciable anatomical character."5 In this opinion, Dr. Roe, MM. Bar- rier,6 Rilliet and Barthez,7 and many of the more recent writers, coincide. Dr. Copland considers the " medulla oblongata, or its membranes, to be early implicated in this disease ; evidences of inflammatory irri- tation of these parts having been very generally observed in the post- mortem inspections I have made. I conceive that the morbid impres- sion or irritation occasioned by the exciting cause in the upper parts of the respiratory surfaces, particularly the glottis and its vicinity, affects the respiratory nerves, especially the pneumogastric ; and that the irritation is extended to the origin of the nerves, when it aggra- vates and perpetuates the primary affection."8 Dr. James Duncan has recently proposed to class hooping-cough with exanthematous diseases, a view which was formerly broached by Volz, the resemblance having been already noticed by Jos. Frank. The essence of the disease, according to Dr. Duncan, consists in tur- gescence of the bronchial glands, coinciding with or arising from a peculiar fever, and the result of a specific poison; and acting upon ' Roe on Hooping-cough, p. 57. 2 Med.-Chir. Trans., vol.xvi. part 1. ' Diseases of Children, p. 479. * Traite de la Coqueluche, p. 77. s De la Coqueluche. Archiv. Gen. de Med., 1833. vol. iii. second series. 6 Mai. de l'Enfance, vol. i. p. 39. • Mai. des Enfans, vol. ii. p. 228. 8 Diet, oi Med., Part v. p. 242. PERTUSSIS. 221 the pneumogastric nerve in the way Dr. Ley supposed in the case of spasm of the glottis.1 Dr. Fyfe, in a late paper, looks upon the disease as a neurosis alto- gether distinct from bronchitis, and he affirms that the two diseases cannot co-exist.2 356. It would have been very easy to have multiplied conflicting opinions; for most writers, having preconceived opinions of the school in which they had been educated, were prepared to view the disease in a certain light. Thus, the humoral pathologist saw in it some peculiar acrid quality of the fluids; and the morbid anatomist mistook the results of a post-mortem examination for the active patho- logy of the affection ; and both were undoubtedly in error. The different views of the nature of the disease may be thus summed up:— 1. That it consists simply in inflammation of the mucous membrane lining the air-passages, the glottis, larynx, trachea, bronchial tubes, and air-cells. 2. That this inflammation is of a specific character. 3. That it is an affection either of the pneumogastric nerves, spinal nerves, medulla spinalis, the brain, or the nervous system generally; either of a nervous or inflammatory character, or a reflex irritation. 4. That it is a compound affection : in the beginning, an inflam- mation of the air-tubes; and, subsequently, a spasmodic or nervous affection. 5. That it is a nervous affection, having its seat in the bronchial mucous membrane, and in the pneumogastric or other nerves. 357. Now, if we are to decide the question by the results of post- mortem investigations, we must necessarily conclude that none of these theories can be the true one, because the facts upon which they are based are by no means sufficiently general; some, indeed, are so rare that it is evident they are additions to the primitive dis- ease ; and others so very uncommon, that one must conclude that they have nothing at all to do with it. Again, if we analyze minutely the history of the disease, and com- pare many cases together, we must arrive at the conclusion that they are divisible into two great classes, the simple, and the complicated, and these differ, not merely in degree, but in kind; that the former present, upon the whole, a very uniform appearance, with similar stages, symptoms, and course; but that the latter possess additional symptoms, of different kinds, by which their history is altogether modified: they are, in short, hooping-cough, plus the peculiar com- plication of each. This is so evident, that the best modern authori- ties have based their description of the disease upon it. On this ground, we must reject those post-mortem evidences of ex- tensive bronchitis, pneumonia, arachnitis, congestion of the brain, and spinal marrow, redness and swelling of the pneumogastric nerves, &c, as being foreign to cases of simple hooping-cough ; and, if we then ' Dublin Quarterly Journal of Medical Science, &c, Aug. 1847. a Prov. Med. and Surg. Jour., June 16, 1847. 222 PERTUSSIS. proceed to the consideration of the question of the nature of the dis- ease, we find very little assistance to be obtained from morbid ana- tomy ; for, in the majority of cases of death from other affections during hooping-cough, the air-passages exhibited little or no trace of disease. If we turn to the history of the disorder, we find that it generally commences by a catarrhal affection of the mucous membrane of the eyes, nose, and air-passages, amounting, in some cases, to actual bronchitis; but it may be doubted how far this must be considered essential to the disease, inasmuch as many cases occur in which it is altogether absent. And as this affection subsides, in its place we have a peculiar spasmodic cough, consisting of a series of forcible succus- sions during expiration, with an impossibility, for a time, of making a complete inspiration. This impediment to inspiration evidently arises-from spasmodic action of the muscles of the larynx, trachea, and bronchial tubes, extending^ probably, to the smallest, as it comes on quite suddenly, and subsides as suddenly. And, although the cough is excited by the presence of mucus, and has for its object its removal, yet its character is peculiarly spasmodic, and unlike any ordinary cough. Now, without attributing it to organic disease of the brain or spinal marrow, wTe cannot but refer the peculiarity of this cough and whoop to a state of the nervous system analogous (shall I say?) to that which gives rise to spasm of the glottis. In other words, that hooping- cough is also a case of reflex irritation of the nervous system, excited, no doubt, by other and different causes, but exhibiting a similar transference of effects. We are, at present, I believe, quite ignorant of the'nature of the peculiar exciting cause ; we know that it exists, and that, when it is applied, the primary irritation of the mucous membrane arises, fol- lowed by the reflected nervous irritation which gives rise to the peculiar phenomena of the disease. 358. Causes.—I have already mentioned that this disease is most common in infants and children, though not absolutely confined to them ; and although, doubtless, the chief cause of this is, as Dr. Watts observes, " that few individuals can pass many years of their lives without being so much exposed to the contagion as to bring on the disease," yet there does appear to be something in the consti- tution of children which renders them peculiarly susceptible to its influence. Dr. Butter observes that "the nervous system bears a much larger proportion to the other solid parts in children than in adults; the solid parts are likewise of a much softer texture and of a much quicker growth; the human body is then indued with much more irritability than at any other period of its existence," and consequently more easily affected. "One can hardly doubt," says M. Gendrin, "that, owing to the development and extreme activity of the circulation, and the permea- PERTUSSIS. 223 bility of their tissues, that infants are in the most favorable state for the absorption of miasmata." On these grounds, it has been attempted to explain the fact that more girls have the disease than boys. Climate has much influence upon the mortality in the disease, though little, if any, upon its presence and extension. It is very prevalent and very fatal in northern regions; less frequent and much less severe in the south, as a general rule, to which, however, there are exceptions, as in the fatal epidemic of 1808, in Madeira. In these countries, it appears more frequent in winter and spring; and, according to Dr. Watts's tables, March was the most fatal month, and July, August, and September the least. The agency of a cold and moist atmosphere in the production of the disease is much insisted upon by Richter, Marcus, Desruelles, &c. It appears, also, to be in some way connected with other epidemics, often appearing just before, during, or immediately after, an epidemic of measles or influenza. 359. Now and then, we meet with single cases of hooping-cough, but such are comparatively rare, for the disease almost invariably spreads through a town or village, either by epidemic influence or by contagion. No one questions the occurrence of the disease as an epidemic; it has repeatedly spread thus over extensive districts, and proved most fatal. De Thou, Sennert, Sauvages, Riverius, &c, notice epidemics as occurring in 1510, 1557, 1580, 1757, 1767, and 1769, and many of them spreading over a gre*at part of Europe. According to M. Desruelles,1 Pasquier mentions an epidemic of this kind in 1411, in Paris, which attacked more than 100,000 people. De Thou and Sennert mention another in the same city in 1510; Ri- verius one that spread almost over Europe in 1557; Baillou one in 1578. In Sweden, Rosen has noticed their prevalence from 1749 to 1764, during which 43,393 deaths occurred. Geller one in 1757, in the duchy of Magdeburgh; Arand one that occurred in Mayence, in 1769; Aaskou one that happened at Copenhagen in 1775. Dr. Willey mentions that, in 1805, it was introduced into Block Island, and prevailed epidemically.2 Dr. Tretis, that it was epidemic in Madeira in 1808,3 and proved very fatal. In 1817, it is said by Marcus to have been epidemic in Milan and at Bamberg. Since then, partial epidemics, with which we are all familiar, have occurred, limited, generally, to a city or town, but occasionally spread over a tract of country more or less extensive. No doubt, the characters of these epidemics, and especially of the complications of hooping-cough, differed very much. Thus, some- times the patients were attacked by epistaxis, sometimes by convul- 1 Traite de la Coqueluche, p. 100. a American Med. Repos., vol. x. p. 95. 3 Med. and Phys. Jour., vol. xxiii. p. 100. 224 PERTUSSIS. sions; in other cases, by eruptive fever, or by some visceral inflam- mation, as is recorded by Ozanara.1 360. It must ahvays be extremely difficult, if not impossible, ab- solutely to prove the contagiousness of an epidemic disease, inasmuch as proximity or contact involves also exposure to the same atmo- spheric influence. Nevertheless, there are diseases which prevail epi- demically (small-pox and measles, for instance) which are admitted by all to be contagious, and among them we must class hooping- cough. No doubt, its great extension is as an epidemic; but yet we see, now and then, cases which appear to be fairly communicated from one person to another—as, for example, in the case related by Barrier, of children who caught t,he disorder at a day-school, and, being con- fined at home by it, communicated it to their father and mother;2 and those related by Duges.3 The weight of opinion is certainly in favor of its being propagated by contagion. On this side, we have the authority of Cullen, Sims, Hillary, Watt, Hamilton, Underwood, Dewees, Eberle, Stewart, John- son, Roe, Barrier, Duges, &c. Laennec, Desruelles, and others have expressed a doubt of this being the case, and others have altogether denied it; but to my mind the evidence is conclusive. 361. Diagnosis.—We must always take into consideration the positive and negative evidence in forming our judgment. The most striking characteristics of the disease are the subsidence of the catar- rhal and setting in of the spasmodic stage, with the remarkable kink and whoop. It is not very easy to mistake either; but I must recall to my readers what I have mentioned before, that the whoop is not always present, and also that, in very young infants, a common cough is often accompanied by an occasional whoop, if they are at all alarmed by the cough. The kink, however, is almost never absent (both cannot be absent together, of course, or the case would not be hooping-cough); and the series of forcible and rapid succussions, without intervening in- spiration, is observed in no disease that I know of, to the same extent, except asthma, which is not an affection of childhood. No doubt, in some forms of bronchitis there is a paroxysmal cha- racter of cough, kinks of coughing, in fact, though different from those of hooping-cough. Rilliet and Barthez have laid down the differences very distinctly. In pertussis, we have the catarrhal stage generally preceding the kink; in bronchitis, the paroxysm of coughing is coin- cident with the commencement of the disease. In pertussis, we have the whoop, the glairy, tenacious expectoration, and almost always vomiting; in bronchitis, the kinks are shorter and less intense, no whoop, but little expectoration, and no vomiting. In simple per- tussis, there is little fever, no hurry of respiration during the intervals, and the respiratory murmur pure; in bronchitis, the fever is intense, the respiration hurried and increasing in frequency, rales sibilant and ' Barrier, Mai. de l'Enfance, vol. i. p. 372. a Ibid., vol. i. p. 373. 3 Diet, de Med. et de Cbir. Prat., vol. v. p. 488. 0 PERTUSSIS. 225 mucous, afterwards subcrepitant. In pertussis, the kinks continue for a time, then decrease until the cough becomes simple, and the child convalescent; in bronchitis, the smallness of the pulse, the extreme dyspnoea, paleness of face, persist or increase, and the disease almost always terminates fatally.1 362. Prognosis.—In simple hooping-cough, there is comparatively little danger, the principal risk being from exhaustion, or from the setting in of some of the diseases already mentioned as following upon hooping-cough in delicate, broken-down children. Young infants, even, who are carefully nursed, go through the disease very well. But- in epidemics, because of the complications, and in single cases which are complicated, the danger is very great and the mortality very high. In the epidemic of 1580, 9000 children are said to have died at Rome. In Sweden, from 1749 to 1764, Rosen states that 43,393 deaths occurred from this disease, and of these 5832 occurred in the year 1755. Dr. Armstrong mentions that, from 1769 to 1777, 732 cases oc- curred at the dispensary for the infant poor, and that twenty-five died.2 Dr. Watt mentions that, on the whole, the deaths from hooping- cough, in Glasgow, amount to five or five and a half per cent, of the entire deaths in the city; and that, in 1809, they amounted to 259, or more than eleven and a half per cent.3 In Prussian Pomerania, the deaths were as 1 to 25^- of the entire mortality; in Denmark, as 1 to 21^; in Brandenburgh, as 1 to 291; in Sweden and Finland, 1 to 13J; in Strasburgh, 1 to 94; in Boston, 1 to 82; in Charleston, 1 to 46.6 ; in Baltimore, 1 to 95.38; in New York, 1 to 64.7; and in Philadelphia, 1 to 63.1.4 In the admirable Report upon the Population Census of Ireland, Mr. Wilde states the mortality from hooping-cough to have been 36,298 in ten years, in the proportion of 100 males to 115.43 females. "It has proved most fatal in the rural districts, being then in proportion to all other diseases as 1 in 30.48, and to those of the epidemic class as 1 to 9.09; while in the civic districts it is 1 in 36.76 of the deaths from all other causes, and 1 in 14.04 of those denominated epidemic or contagious. Its general mortality, in comparison with all other affections, for the entire kingdom, is 1 in 32.71, and of the total epi- demic diseases, 1 in 10.5. In the metropolis, this affection wras, to the total epidemics, 1 in 17.47; in the province of Leinster, 1 in 12.24; in Munster, 1 in 11.24; in Ulster, 1 in 9.4; and in Con- naught, 1 in 9.1.5 363. With such evidence of the fatal results of the disease, it will become us to inform ourselves most carefully as to the age, constitu- tion, previous health, and the actual state, not merely of the lungs, but of every organ of the body, before giving our prognosis; and even ' Mai. des Enfans, vol. ii. p. 223. 2 An Account of the Diseases most incident to Children, p. 142. 3 On the Chin-cough, p. 24. 4 Condie on Diseases of Children, p. 329. 5 Report upon the Tables of Deaths, p. 15. 15 226 PERTUSSIS. then it will be wise to be very guarded, and to watch well for the first symptoms threatening any of the complications. The symptoms which justify a favorable prognosis are the parox- ysms being distant, with intervals of complete relief and quiet respira- tion, the rest at night not much disturbed, the appetite good, no local complications, and the absence of fever. The unfavorable symptoms are, frequent and violent cough, hurried respiration, dyspnoea, fever, loss of sleep and appetite, and any indication of local complication. 364. Treatment.—As it is generally admitted that hooping-cough will run its course notwithstanding all our efforts, it is pretty clear that but little treatment, and that palliative, is necessary in the milder cases. During the first stage, a gentle antimonial emetic may be given, follow'ed by an expectorant every four or six hours, with a dose of aperient medicine, and a repetition of the emetic occasionally, a warm bath at bed-time, and confinement to a warm, equable tem- perature. Burton, Millar, Lieutaud, and others deprecate blood-letting, and certainly, unless the disease be complicated, or the first stage set in with considerable violence, it is quite unnecessary ; but in the latter case loss of blood will lower the fever, relieve the catarrhal oppres- sion, and render the second stage milder; but the amount should be carefully regulated, and be rather under than over the mark. Willis, Sydenham, Lettsom, Dewees, Duges, &c, recommend the abstraction of blood under these conditions. The use of emetics of tartarized antimony was first recommended by Dr. Armstrong, who had employed them "for eighteen years with very good success,"1 and they have since been advised by the highest authorities. They may be given, as I have said, at the commence- ment, and repeated occasionally. A mixture with ipecacuanha wine, syrup of squills, a little syrup of white poppies, and almond milk, or mucilage and water, will answer very well as an expectorant; or, we may give Coxe's hive syrup, as recommended by Dewees, which is made by boiling half a pound of senega root and dried squills in eight pounds of water, over a slow fire, until half is consumed, and then adding to the strained liquor four pints of strained honey, and again boiling down to six pounds, and adding a grain of tartar emetic to each ounce. The dose must be regulated according to the age of the child, from six to eight drops or upwards, every hour or two.2 Probably the best aperient medicine is castor oil or rhubarb, mag- nesia, and ginger; and the frequency of its administration must be regulated by the state of the bowels, which should be well evacuated. The diet should be bland, and, if there be much fever, confined to milk and vegetables; if otherwise, a little chicken broth may be allowed. 365. During the second stage, marked by the peculiar cough and whoop, the tenacious mucus, and the absence of fever, we shall find it ' On the Diseases most incident to Children, p. 50. 2 On Diseases of Children, p. 437. PERTUSSIS. 227 beneficial to continue the emetics occasionally, and also the expectorant medicine; but, in addition, it will be necessary to employ some anti- spasmodic remedy for the relief of the paroxysm. Probably the most common is opium in some form. A few drops of laudanum may be added to the expectorant mixture, or we may adopt Mr. Pearson's1 plan, who, after an emetic, prescribed one drop of laudanum, five drops of ipecacuanha wine, and two grains of carbonate of soda, every fourth hour. As the cough subsided, he diminished the opiate, and substituted gum myrrh for the ipecacuanha wine. Dr. Dewees recommends a combination of paregoric, antimonial wine, liquorice, gum Arabic, and water as a mixture, and I can add my testimony, if it be necessary, to its value. Lombard recommends the syrup of white poppies, Condie the watery extract of opium, and others Dover's powder. There is no reason, however, for believing that opium will cure the disease; but it renders the paroxysms less severe, and composes the patient. Hemlock is highly recommended by the older writers. Dr. Butter, in 1772, praised it as a specific. Dr. Armstrong tried it in 357 cases, of whom seventeen died; but nine of these, he says, were unfavorable cases.2 The formula he employed was this :— R-. Extr. cicutse gr. x ; Aq. purae, Aq. menth. pip., aa. ^iv ; Sacch. alb. ad grat. sapor, q. s. M. A dessertspoonful was given to an infant six months old, every four hours; three teaspoonfuls to a child of a year; and a tablespoonful to one of two years of age. Dr. Gumprecht speaks most highly of the extract of the lactuca virosa in the second stage. He advises half a grain, with sugar, three times a day, for children of two years of age.3 Acetate of lead has been highly praised by Dr. Reece.4 He pre- scribed the following mixture: Four grains of the acetate of lead, two drachms of syrup of violets, and two ounces of water; of which he gave to a child four years old a teaspoonful every six hours, increasing the dose to two teaspoonfuls the following day. But perhaps the most influential narcotic and sedative we possess is the belladonna; it has been very extensively employed, and the evidence in its favor is very strong. Hufeland, Jackson, Guersent, Blache, Stewart, Condie, &c, speak highly of it. As it is very powerful, and somewhat uncertain, we should begin with small doses, and watch it very closely. From one quarter of a grain to one grain of the powdered root, and from one-eighth to one-half a grain of the ex- tract, may be given two or three times a day. Dr. Jackson advises that one-sixth of a grain should be given to a child of three months old, every three hours; to a child of two years old, one grain; and 1 Med.-Chir. Trans., vol. i. p. 25. 2 On Diseases of Children, p. 142. 3 Med.-Chir. Trans., vol. vi. p. 608. 4 Med.-Chir. Rev., vol. xv. p. 37, 228 PERTUSSIS. to a child of four years, a grain and a half in each dose.1 Jackson, Guersent, and Blache recommend its continuance until the effect upon the pupil is evident; it may then be discontinued.2 Kahleiss gave it in combination with Dover's powTder, and between each dose a mixture containing prussic acid. M. Trousseau combines it with opium and valerian. M. Guersent recommends equal parts of henbane, belladonna, and oxide of zinc; of the latter he gives one grain every hour to a child of six months old. M. Carron du Villards derived great benefit from laurel water, in doses of six drops every two hours. Dr. Krimer, of Halle, and Dr. Brofferio, recommend the inhalation of its vapor. Hydrocyanic acid was first used, I believe, in hooping-cough, by Fontaniottes and by Coullon, in 1808, and since by Heineken, Behr, Kahleiss, Muhrbeck, &c. It was introduced into this country, as a remedy in this disease, by Dr. Granville, in 1819; and has been tried successfully in America by Drs. Edwin Atlee, Stewart, Condie, and others. Dr. Roe has found it most valuable in checking and cutting short the spasmodic stage. I have tried both the laurel water and the acid repeatedly, and certainly with great benefit, though it failed, in many cases, to shorten the disease. "The dose of hydrocyanic acid," says Dr. Roe, "for an infant, is about three-quarters of a minim, of Scheele's strength, gradually increased to a minim, which may be given every fourth hour; for a child of three years of age, about one minim, gradually increased, if necessary, to a minim and a half every fourth hour; for children of ten or twelve years of age, a minim and a half, increased to two minims every fourth hour. It is safer to give this medicine in small doses, at very short intervals, than to run any risk of producing too great a depression by a large dose. The frequency of its exhibition must depend upon the strength of the patient and the severity of the attack. The dose should be repeated when the effects begin to subside, which, in mild cases, generally happens in three or four hours; but, when much fever is present, its influence is felt but a very short time: under such circumstances, a larger quantity may be given, and at shorter intervals, without any apprehension of danger, so long as the fever lasts. In some very severe cases, when the pulse was up to 120, with a good deal of fever, and a very hot skin, I have given to a girl of ten years of age a minim and a half of this medi- cine every quarter of an hour for twelve hours; at the end of twenty- four hours, she was free from fever, and her strength was not in the least reduced by the effects of the remedy. As some catarrhal symp- toms are generally present, a few drops of ipecacuanha or antimonial wine may be advantageously combined with the hydrocyanic acid; but the latter alone possesses the power of curing this formidable complaint."3 1 American Journal of Med. Science, Aug. 1834. 3 Barrier, Mai. de l'Enfance, vol. i. p. 392. 3 On Hooping-cough, p. 89. PERTUSSIS. 229 I would suggest that this medicine should always be given in draughts, and not in a mixture, because then only can we be quite sure that the child will not get an overdose. I have found almond milk an excellent vehicle. Other narcotics have been recommended, but I need hardly occupy the reader's time with them; I will only add a general observation or two; and first, that, as narcotics have the effect of diminishing secretion, that effect should be corrected by some expectorant, or the original tenacity of the mucus of the second stage will be increased, and its expectoration rendered more difficult; secondly, that (with the exception of the prussic acid) narcotics are of less efficacy in propor- tion to the amount of fever, and it is when that has subsided that they possess so much power over the spasm; and lastly, as they also constipate the bowels more or less, we must counteract this effect by an occasional purgative. Among the antispasmodic remedies we find also assafetida, castor, musk, valerian, sal ammoniac, &c. highly recommended, and which may, perhaps, in some cases, be useful, but which are evidently in- ferior to the narcotics. 366. Variations in the mode of administering narcotics and anti- spasmodics have been adopted. Mr. Warren recommends liquid laudanum to be rubbed on the abdomen and pit of the stomach daily. Morphia, applied to a blistered surface, has been useful, according to Brendt and Meyer of Minden, who state that five cases were so much relieved by it in eight days as to require no further treatment. Em- brocations, consisting in part of laudanum, have been very long em- ployed with benefit. Another mode is by inhalation. Marley mentions that he has known " inhaling the steam of a decoction of the fresh leaves of hemlock, alone or with ether, to be of use."1 Dr. Stew7art mentions that fumigation with the vapor of benzoin was accidentally discovered, a few years since, to allay, with remarkable quickness, the paroxysms of hooping-cough.2 Dr. Watt and Mr. Waddington3 have used the vapor of tar with success; and it is said that relief has been afforded by the fumes of warm spirits of turpentine. M. Paterson made some experiments with the nitrous ether, but I do not know that they were very suc- cessful. Soon after the discovery of the anaesthetic effects of sulphuric ether, it struck me that it would be likely to modify or suspend the spasm in hooping-cough; and, having a case under my care, I directed that a little (I suppose about half a drachm) should be spilled upon the nurse's hand, and held before the child's nose and mouth, at the com- mencement of a fit of coughing. I preferred this simple mode of administration (and do so still), because of the impossibility of there- by giving an overdose. The effect surpassed my expectation; most generally the paroxysm was shortened more than one-half—often stopped immediately—and the duration of the disease unquestionably 1 Diseases of Children, p. 163. 3 Diseases of Children, p. 109. 3 Lancet, June 21, 1845. 230 PERTUSSIS. considerably diminished. Since then, I have tried the ether in twelve or fourteen cases, and chloroform in six. In one or two cases, no benefit accrued, in others great mitigation of the spasm, and in three or four almost complete relief when the ether was applied at the beginning of a fit of coughing. Decidedly, also, in two-thirds of the cases, the course of the disease was much shortened, so that I look upon this as a valuable addition to our remedies. In no instance was insensibility or the least inconvenience occasioned. 367. When the disease is pretty well advanced, and especially when the constitution has suffered, if there be neither complication nor fever, great benefit will be derived from tonics, and of these, perhaps, cinchona has the most advocates. Dr. Burton, Mr. Sutliff, Dr. Lettsom, and Dr. Armstrong recom- mend it very highly in combination with tincture of cantharides and paregoric, as in the following formula for a child three years old:— R. Decoct, cort. Peruv. ^ vi; Elixir sudorif (paregoric) ^ill; Tinct.cantharid.3i- M. Capiat semi-unciam ter in die. Dr. Hamilton speaks highly of the Peruvian bark. We have the evidence of Dr. Beatty as to the value of Mr. Sutliff's compound of bark, paregoric, and tincture of flies; and, on his recom- mendation, Dr. Graves was induced to try it, and found it very suc- cessful.1 Dr. Golding Bird speaks most highly of alum in the second stage, after all inflammatory symptoms have subsided, and the mucus is tenacious and expectorated with difficulty. He gives from two to six grains of alum, every four or six hours, to children from one to ten years of age. The following is his formula for a child of two or three years:— R. Aluminis gr. xxv; Ext. conii gr. xii; Syr. rhceados gii; Aquae anethi 3", iii. M. Capiat cochl. med. 6ta quaque hora.. Dr. Davies, in his edition of Underwood, " attaches more value to alum than to any other form of tonic or antispasmodic." Oxide of zinc has been praised by Guersent and Lombard; the lobelia inflata by Eberle; the rhus vernix, garlic, and electricity by others; arsenic by Dr. Ternan and Mr. Simmons; sulphuret of potash by Dr. Bland; the sesquioxide of iron by Drs. Steymann, Lombard, &c.; liquor ammonia? by Dr. Peyroton, &c. In fact, there is no end to the list of remedies which have been recommended in hoop- ing-cough; and, probably, my readers may thank me for not extend- ing mine further. I think I have included the most important; and I shall only notice, in conclusion, the use of external counter-irritants and change of atmosphere. That external rubefacients are of use, there is no doubt, especially ' Graves's Clinical Med., p. 762. PERTUSSIS. 231 when combined with a narcotic, as already mentioned; but that they will cure or cut short the disease, I do not believe. Roche's embroca- tion is a popular liniment, or we may order one of compound camphor liniment and laudanum, two ounces of the former to two drachms of the latter. The chest and back should be rubbed alternately morning and evening. Dr. Hamilton seems to approve of garlic to the soles of the feet; and a popular use of it is to steep it in brandy and rub the spine. The celebrated "pommade d'Autenrieth" is simply tartar- emetic ointment, which is most strongly recommended by many writers of high authority. 368. Great stress has been laid upon change of air ; and, no doubt, at a certain period, the removal from a town to the country, if the air be mild, and the weather fine and warm, does promote convalescence; but, on the other hand, much mischief may result from indiscreet changes and undue exposure. Dr. Merriman remarks most judiciously: "I am not acquainted with many, if with any, instances in which the force of the disease has been abated by change of air. I should not recommend it for this purpose ; but I have often witnessed its useful- ness in shortening the stay of the distemper after its force was abated. I believe that change of air is seldom advisable (unless the patient be placed in a house particularly close and unventilated) during the active stage of hooping-cough; but, when the violence of the complaint is subdued, it is highly beneficial, particularly if the change tbe from a cold situation to one of a warm temperature, or when the coldness of winter and the bleak east winds of March are changed to the more genial warmth of spring, and the mild western breezes of April and May. But even then much discretion is required to regulate the time and mode of exposure to the open air; otherwise, ill consequences are likely to ensue."1 Dr. Mackintosh remarked, in a severe epidemic, that all the children that were removed for change of air had the disease the longest. The late Dr. Beatty made it a rule to confine his patients to their bed-room until the cure was completed; and Dr. Graves seems to approve of this plan.2 Of the two extremes, doubtless it is the best. During the catarrhal stage, I have always confined the child to the house, and during the commencement of the second stage, unless the weather was very mild and dry. After this, the child will benefit by an occasional walk or drive on fine days, and during the warm parts of the day; then, when the cough is fairly on the decline, a change from town to the country will accelerate the convalescence. Great care should be take» that the rooms in which the child passes the day and night should be well ventilated, and of a comfortable tem- perature. This will be particularly necessary in very severe cases, or in winter, because the child must then be confined altogether to the house. The diet at first should be rather restricted; all stimulating food ' Underwood on Diseases of Children, p. 428. Note. 9 Clinical Medicine, p. 763. 232 PERTUSSIS. should be withheld, and cooling drinks allowed freely. As the second stage advances, the diet must be improved, broth or meat allowed according to the age of the child and its condition, and perhaps a little wine and water. 369. Treatment of the Complications.—A considerable deviation from, or addition to, the treatment already indicated, will be neces- sary when either of the complications I have described exists. It will not, however, be necessary to enter at length into the subject at pre- sent, as the reader w7ill find all the details in the chapter on bronchitis, pneumonia, convulsions, &c. I shall mention so much of it only as will indicate the line to be pursued and the modifications required. Whenever we detect the evidences of bronchial or pneumonic in- flammation, it will be necessary, notwithstanding the hooping-cough, to adopt prompt and energetic treatment. Unless the child be greatly exhausted, we must have recourse to blood-letting, either by a free use of the lancet or by an equivalent number of leeches, arresting the bleeding when the leeches fall off, or by cupping, if the child be old enough. Dr. Mackintosh states that he found great benefit from leeches applied over the larynx. After relief from bleeding, and as soon as the fever has somewhat subsided, a blister may be applied to the chest; and here let me repeat, that I have found a succession of small blisters much more effectual with children than one large one, and also that we must be cautious not to leave them on too long, especially with infants, as the surface, when much inflamed, is apt to ulcerate. Two or three hours are sufficient for children up to five or six years of age; and, although there may be no vesication when we remove it, it will take place afferwTards. Let me add, that it is better not to cut the blister, unless its prominence makes the child uncomfortable; and that the best dressing, if the surface be not broken, is French wadding or cotton wool. Internally, we must increase the quantity of ipecacuanha wine in case of bronchitis; but in pneumonia we must have recourse to tartar emetic in small doses, from its well-known power over that disease. Either remedy may be added to the expectorant mixtures formerly advised, and continued, so as to keep up a slight nausea, unless the bowels become affected. In such a case, we may try small doses of calomel and Dover's powder, or some other antiphlogistic remedy. If the child be much weakened, the addition of ammonia to the ex- pectorant mixture, or its alternation with it, will be advisable. I have also seen great benefit from spirits of turpentine given alternately with the ipecacuanha or tartar emetic. The bowels must be carefully regulajed. Brisk purgation rather does mischief than good, but a gentle purgative now and then may be necessary. If there be diarrhoea, chalk mixture with aromatic confection, and a very small quantity of laudanum, will be of use. 370. If the child be attentively watched, the second complication, disordered bowels and remittent fever, may, in most cases, be pre- vented. At each visit, an accurate account of the state of the stomach and bowels should be obtained, and the treatment judiciously adapted PERTUSSIS. 233 to avoid these inconveniences. If the bowels be constipated, a brisk purgative may be given, followed by an enema, if the medicine be ineffectual. When the congestion about the head is considerable, it is often ac- companied by obstinate constipation, which does not yield until the cerebral condition has been relieved by bleeding. If the bowels be not constipated, but the discharges are unhealthy in color or smell, which is by no means uncommon, mild laxatives, with small doses of hydr. c. creta or calomel, will probably excite beneficial action upon the mucous membrane, and restore the natural secretions. When diarrhoea is present and considerable, we must have recourse to some astringent medicine—chalk mixture, compound powder of chalk, powder of chalk and opium, &c. I generally order the follow- ing simple mixture for a child a year old:— R. Mist, cretae^i; Confect. arom. gr. v; Syr. zingib. gii; Tinctura? opii gutt. ii. M. Cap. cochl. i parv. ter quaterve in die. Increasing the quantity of laudanum if the child be older, and adding a little tincture of kino or catechu if the purging be obstinate. Gentle frictions of the abdomen, with compound camphor liniment and laudanum, or fomentations, are very useful. A small starch enema, with a few drops of. laudanum, will often arrest the disease after other measures have failed. The diet must be carefully guarded, nutritious but not too stimu- lating, and rather of solid food than fluid, if the child be old enough. For the management of remittent fever, I must refer to the chapter on that subject, as the only result of its being a complication will depend upon the constitution of the child. 371. With regard to the treatment of convulsions occurring in hoop- ing-cough, the first thing is to remove the ordinary exciting causes, if they exist; the gums should be freely divided, the bowels freed, and a warm bath administered. Notwithstanding, the convulsions will constantly recur, and in these cases there are two plans strongly recommended by Dr. Johnson: " One is a total alteration of the child's diet, and the other is change of air. When the child affected is at the breast, defectiveness in quantity or quality will usually be detected. in the nurse's milk. Often it will be found that she has menstruated, or, as sometimes happens, without the discharge actually occurring, she has experienced sensations similar to those which attend the ac- cession of the catamenia. In such cases, the milk almost uniformly disagrees, and hence it is a good rule, whenever the convulsive attacks withstand ordinary treatment, to inquire into the state of the nurse, and, if there be any ground of suspicion, to have a young and healthy one procured. Change of air, often in the most remarkable manner, puts a stop to the recurrence of convulsions, and will be found par- 234 PERTUSSIS. ticularly beneficial in those cases of spasm of the glottis to which we have alluded." More active treatment than this will, of course, be necessary; leeches to the forehead, or behind the ears, cold lotions, and probably a blister to the nape of the neck, with a purgative, should immediately .follow an attack of convulsions. If we succeed in mitigating their severity, it will be well to establish a permanent drain by a seton of two or three threads in the arm, as heretofore recommended. But, in the majority of cases, all our treatment will be in vain, unless we can contrive to lessen the frequency and violence of the cough; the reiterated arrest of the circulation will shortly reproduce the con- vulsion. For this purpose, I have found the hydrocyanic acid of great value ; if anything will check the cough, it will be either that or the belladonna. I should think it probable that the same effects would follow the chloroform or ether, but as yet I have had no oppor- tunity of trying either. I am not prepared to say whether the con- vulsion ought to prohibit their use ; but I rather think not. 372. These observations will apply as well to hydrocephalus, with the addition that, as the disease is more hopeless and more serious, our treatment must be more active, limited only by the state of the child's constitution, and by the recollection that, in the event of re- covery from the complication, it has still a long and exhausting dis- order to encounter. In addition to the leeching, cold applications, blisters, and purga- tives, we must give a fair trial to mercury, in whatever mode it is best borne by the child ; and if we are successful in controlling the secondary affection, a more liberal use of tonics, and a more generous diet, will be necessary at an earlier period than usual. 373. When the symptoms of cerebral congestion or apoplexy make their appearance, no time is to be lost in abstracting a sufficient quan- tity of blood, and the effect of this first blood-letting will guide us as to the necessity for its repetition. If the stupor diminishes, the intel- ligence returns, and the child appears more conscious of what is passing, we may either repeat the bleeding after an interval, or have recourse to counter-irritation, cold lotions, and purgatives. If there be no return of sensibility, or diminution of the stupor or coma, the case is one of apoplexy from effusion ; and with so powerful an exciting cause continuing as hooping-cough, it is not likely that any treatment will be of use. We may, as a matter of duty, try the remedies I have recommended for apoplexy ; but it is most likely that they will altogether fail. CROUP. 235 CHAPTER IV. CROUP.—CYNANCHE TRACHEALIS.—ANGINE PSEUDO-MEMBRANEUSE. 374. The disease which is the subject of the present chapter con- sists, essentially, in inflammation of the larynx and trachea primarily, but which may occupy a greater extent of the respiratory organs; accompanied by a peculiar pellicular secretion, with a certain amount of spasmodic action, modifying the respiratory and vocal functions. By the ancients, it seems to have been confounded with other dis- eases of the air-passages. According to Cheyne, Michaelis, &c, Baillou, of Paris, in 1576, was the first to indicate the anatomical characters of croup. Ettmuller described a disease strongly resem- bling it, and after him Molloi, 1743; Malouin, 1746; Ghisi of Cre- mona, in 1747, who called it angina strepitosa; Starz, in 1749 (mor- bus strangulatorius); Middleton, 1752; Bergius, 1755; Rudberg, 1755; Berghen, 1759; Wahlbom, 1761; and Wilcke, 1764. It was first noticed by its present name by Dr. Blair, of Cupar Angus, in 1718. In 1765, Dr. Home, of Edinburgh, published his essay, in which the disease was first accurately described, and from original ob- servations. He was succeeded by several writers, among whom I may mention Eller, 1766; Engstroem, 1767; Rosen, 1771; Rush, 1769: Bard, 1771 ; Callisen, 1776; Buchan, 1776; Turnbull, 1776; Mahon, 1777; Middleton, 1780. Since this period, numerous monographs of greater value have appeared, by Jurine, Albers, Vieussieux, Valentin, Cheyne, Blaud, Bretonneau, Guersent, Trousseau, Desruelles, &c. ; and it has formed a very important chapter in the systematic works on diseases of children, besides being more or less described by writers on diseases of the respiratory organs. It has been described under various names ; but I prefer the or- dinary name " croup," as being generally intelligible, and as involving no pathological opinion. 375. It is one of the most alarming and fatal diseases to which children are liable; sudden in its attack, alarming in its symptoms, and rapid in its results, it sweeps over a family, leaving behind it distress and desolation. Generally speaking, it attacks children betwreen the ages of one and twelve years, and most frequently those under five years. Marley mentions having seen it in an infant at the breast j1 Hamilton in one of six or eight months ;2 Cheyne in one of three months ;3 ' Diseases of Children, p. 139. 2 Diseases of Infants, p. 142. 3 Pathology of the Larynx and Bronchia, p. 15. 236 croup. Bouchut in one of eight days old.1 M. Andral gives the follpwing table of ages in 332 cases. It occurred During the 1st month in " 3d " " " 5th " " From 5 to 12 months " to 2 years " to 3 1 case. 1 a 1 a 18 cases 61 (( 45 a 54 a 42 a 29 a 29 a 3 a 6 a 7 a 13 it 10 a 12 a to 4 to 5 to 6 " 6 to 7 " 7 to 8 " 8 to 11 " 11 to 15 " 15 to 30 " 30 to 50 " 50 to 70 In thirty cases observed by M. Trousseau, thirteen were from eleven months to three years of age, eleven from three to five years, and six from five to twTenty-six.2 " In Philadelphia, during the ten years preceding 1845,475 deaths are reported from croup, in infants between two and five years; 238 in those between one and twro years; 319 in those under one year; 112 in those betwreen five and ten yrears; and six in children over ten years."3 MM. Rilliet and Barthez state that primary croup is most frequent between the ages of two and seven years; and of eleven cases of secondary croup, six were from two to five years, and five beyond that age.4 Dr. Vauthier states that, of thirty-seven cases, twenty-five occurred at or under twTo years of age.5 Mr. Wilde observes, in his Report upon the Irish Census of 1841, " This fourth most fatal epidemic affection carried off 42.705, in the proportion of 100 males to 82.89 females. The registries of this disease afford returns of death up to the adult age, even so high as 30, and one at 40." From the fifth to the tenth year, the deaths amounted to 1316 males, and 1292 females. "Compared with other infantile diseases, the deaths during the first year are 100 to 48.29 of measles; 100 to 6.82 of scarlatina; 100 to 92.62 of hooping-cough; 100 to 4.98 of thrush; and 100 to 60.1 of pemphigus."6 From these details, it will be seen that it is not altogether confined to infants or children; but that adults, and even old people, are occa- sionally attacked, upon which M. Louis has published a valuable paper.7 1 Mai. des Nouv.-nes, p. 265. a Barrier, Mai. de l'Enfance, vol. L p. 414-5. 3 Condie, Diseases of Children, p. 303. 4 Mai. des Enfans, vol. i. p. 351. 5 Arch. Gen. de Med., May, 1848, p. 10. « Wilde's Report, p. 16. 7 Recherches Anat. Path., p. 203. Sur le Croup considere chez l'Adulte. CROUP. 237 There is another fact concerning croup, in direct opposition to what occurs in hooping-cough, alluded to in Mr. Wilde's report, viz., that it is more frequent among males than females, and which is confirmed by general experience. Of M. Trousseau's thirty cases, twenty-two were males and eight females; and of M. Jansecowich's twenty-five cases, there were seventeen boys and five girls. 376. Different classifications have been made of the varieties of croup, according to the predominance of peculiar symptoms. Thus, we have the catarrhal, the spasmodic, and the inflammatory croup of some authors; the acute and spurious of Ferrier; the three varieties of M. Blaud, dependent mainly on the intensity of the attack; the three species of M. Porter,1 the spasmodic, the inflammatory, and a third, in which the lining membrane has become thickened and altered, so as to spoil the appearance of the organ and interfere with its func- tions. The commencement is insidious, its progress slow, and its termination fatal. Dr. Stokes divides croup into primary and secondary; the latter, being an extension of the disease from the neighboring parts, or a complication with other diseases.2 It appears to me, however, that most of these distinctions are only differences in degree, or in the predominances of certain characters over others; the only invariable one, if the disease be allowed to run on, being the inflammation and the false membrane. Experiments made by Schwilgue, Schmidt, Chaussier, and others have proved that the same causes, applied to animals of the same class, have given rise to each variety, according to the peculiar constitution and age of the animal. The plan I propose, therefore, is to describe inflammatory or pri- mary croup, as it ordinarily occurs; then to speak of the modifications arising from the predominance of some one characteristic, as the spasm; of its complications; and lastly, of the secondary form of the disease, either owing to its extension, or to its complicating other diseases. 377. Symptoms.—The course of the disease has been divided into four stages by Golis—the invading or catarrhal, the inflammatory, the albuminous, and the suffocative stage. Dr. Cheyne makes two stages: the] incomplete or inflammatory, and the complete or purulent; Dr. Dewees into three—the forming, the completely formed, and the con- gestive stage; M. Guibert into three—the stage of irritation, that of albuminous secretion, and that of suffocation. I prefer adopting that of Dr. Copland,3 nearly the same as Dr. Stokes's, and shall speak, first, of the precursory stage; second, of the stage of development; and third, of the stage of collapse, or threat- ened suffocation. 1 Surgical Pathology of the Larynx and Trachea, p. 29. 3 Diseases of the Chest, p. 205. 3 Let me here, once for all, acknowledge my obligations to the learned and accurate work of Dr. Copland; to it, and to the works of MM. Barrier, Rilliet and Barthez, I am more indebted than to any others. My deep sense of their value must be my apology for the free use I have made of them. 238 CROUP. i. The Precursory Stage.—As a general rule, some catarrhal symp- toms precede an attack of croup. The child is cross and feverish, the skin hot, the pulse quick, the thirst increased; there may be sneezing, lachrymation, and cough. There is always a change in the voice, a degree of hoarseness, to which, as the surest sign of an approaching attack of croup, Dewees and others attach great import- ance. It is not, however, like the subsequent hoarseness, but rather an unusual huskiness, as though the throat needed clearing. If we examine the pharynx, we shall discover no trace of disease; the tongue is generally loaded, but moist; there is evident uneasiness in the windpipe, and the cough is short and generally dry. The chest is resonant; and it is rarely that we can detect any morbid sounds with the stethoscope, and then only some slight bronchial rales. The rapidity of breathing will be in accordance with the amount of the fever, quickness of pulse, &c. In some cases, it is greatly hurried; in others, pretty quiet. Vieussieux lays great stress upon the catarrhal symptoms and changes in the voice; but, although the latter is very characteristic when present, many cases occur in which there is neither the pre- monitory catarrh nor hoarseness, but where the disease first appears fully formed.1 The duration of the precursory stage is very uncertain, varying from a few7 hours to a day or two; as a general rule, it does not ex- tend beyond eighteen or twrenty-four hours. 378. n. Stage of Development.—After the symptoms I have men- tioned have characterized the first stage, increasing towards evening— or, without any warning in cases where the first stage is absent—the child is suddenly awoke out of sleep by a sensation of suffocation, with a hoarse, ringing cough, hurried and hissing respiration, and a rough, hoarse voice, with great alarm, agitation, and distress. Ferrier,2 Cheyne,3 and, indeed, most writers, have noticed, as a peculiarity, the first occurrence of the croupy cough at night, without giving any explanation of it. It seems probable that it may be another example of the disposition there is in nervous or convulsive attacks to occur in the night. After mentioning the setting in of this stage with "increase of fever, anxiety, and distress, and by indica- tions of mechanical obstruction in the larynx itself" Dr. Stokes re- marks : " Indeed, one of the most remarkable circumstances connected with the disease is the rapidity with which this latter symptom shall occur, a fact strongly confirmatory of the opinion that the mere effusion of lymph is not the principal cause of the obstruction, but that it is owing to the inflammatory spasm of the part."4 I have no doubt that, thus early, the dyspnoea and peculiarity of the cough are chiefly owing to spasm of the larynx; and, like similar nervous affections, it is peculiarly apt to occur in the night. 1 Dewees, Diseases of Children, p. 456. Porter, Diseases of Larynx, &c, p. 34. 3 Med. Histories and Reflections, vol. iii. p. 134. 3 Pathology of the Larynx and Bronchia, p. 16. 4 Diseases of the Chest, p, 208. CROUP. 239 " The child's illness," says Dr. Cheyne, " does not prevent him from going to sleep at the usual time, but he awakes with an unusual cough, suffocative, acute, and ringing. His breathing is difficult; often the inspirations, particularly those which follow the cough, are crowing. His face is swelled and flushed, and his eye is watery and bloodshot, and he seems in danger of suffocation; his skin is hot, and he has some thirst. He labors in breathing, and still the difficult, and perhaps crowing, inspiration continues, and the distinctive cough. He tries to relieve himself by sitting up, or coming out of bed ; no change of position gives him relief. Generally, his sufferings are thus protracted until morning, when, perhaps, there is a slight remis- sion."1 The cough, then, with the rough breathing (bruit serratique) and the hoarse voice, are the distinctive characteristics of this stage. The sound of the cough is so peculiar that, once heard, it is never forgot- ten ; it resembles, slightly, the crowing of a cock, or the bark of a dog, but still more, succussions of air through a brazen tube; it has a ringing, metallic tone in it. The breathing is evidently changed by the air being forced through a narrower orifice than usual, and the voice has a rough hoarseness even when the child is quiet, but very marked when crying. The paroxysms of coughing become more frequent and spasmodic, during which, the inspiration is almost suspended, and the heart's action accelerated. The difficulty of respiration, and the consequent efforts on the part of the child, are very great; the countenance is flushed, sometimes almost livid, and covered with sweat ; the hands are clenched, the arms thrown about, all covering rejected, and what- ever might impede the access of air is hastily removed ; the body is sometimes erect, sometimes recumbent, and occasionally with the head rigidly bent backwards.2 The eyes project, and are injected and suffused; the carotid arteries beat strongly, the pulse is quick and hard, the skin burning, and the thirst great. The little patient refers the seat of distress to the larynx, to which the hand is fre- quently carried, as if to remove some obstruction, and where, as Dr. Ferrier has remarked, a degree of tumefaction is sometimes observed. As yet, there is scarcely any expectoration. 379. In a simple case of croup, the stethoscopic signs are chiefly of a negative character: the chest sounds clear on percussion ; the respiratory murmur is hurried and unequal; the croupy sound and sibilant breathing are heard over the larynx. But occasionally the information is more positive. Dr. Stokes observes : "The active phy- sical signs referable to the lungs, which I have had an opportunity of detecting, have been as follows: First, a diffuse, sonorous rale, not so intense as to extinguish the vesicular murmur; secondly, the same rale, 1 Pathology of the Larynx and Bronchia, p. 15. 3 This peculiar symptom is observed in several different diseases, and, among others, pleuritis, pericarditis, &c.; and I have in vain strived to make out its exact import. In croup, however, it appears to be a mechanical arrangement to facilitate the passage of air, by straightening the primary air-tubes, 240 CROUP. but with more intensity, indicative of disease in the more minute tubes; thirdly, a combination of the sonorous and mucous rales, causing a loud sound, and a feeling of vibration when the hand is applied to the chest; fourthly, the crepitating rale of pneumonia in one or both lungs; in some cases, with distinct dulness of sound on percussion. I have not heard the bronchial respiration of hepatization, or the frotte- ment of pleurisy ; but there can be no doubt that, if these conditions existed before the laryngeal disease had obtained its maximum, these signs would be distinctly audible."1 Several of these signs are referable to the complication of croup, as we shall see by and by. Dr. Williams notices " a weak respiratory murmur in the chest, which yet sounds we'll on percussion," and " a concave state of the intercostal spaces at each inspiration." He further states, that " the sonorous inspiration of croup is audible through the stethoscope, ap- plied to the throat or upper part of the chest, before it can be heard by the ear unapplied."2 In addition, M. Barthez remarks that, at a certain period of the disease, when the stethoscope is applied to the larynx, we may perceive a peculiar vibration, as of something flap- ping, which always indicates the existence of loose false membrane ; and, if this be confined to the larynx, it is so far a favorable sign, that it announces the concretions to be slightly adherent, and capable "of being removed by expectoration. If, on the other hand, this vibra- tion be prolonged into the trachea and bronchial tubes, it is unfavor- able, from the evidence it affords of the great extent of the disease.3 Thus, the physical examination of the chest may yield either posi- tive or negative results of great practical value in the treatment of the disease, and at each visit we should make ourselves acquainted with its exact condition. 380. The symptoms already mentioned, the cough, dyspnoea, and hoarseness, first appear, and afterwards increase, during the evening and night, along with the fever, and diminish in the morning, when we find the fever less, the cough not so frequent, perhaps less charac- teristic, and the inspiration less labored. This intermission may continue during the greater part of the day; but the exacerbation re-appears towards evening, probably after «a sleep, with greater severity than before. The cough, dyspnoea, anxiety, and fever are increased; the hand is constantly applied to the throat to remove the obstruction; and the larynx, when pressed, is sometimes painful. The countenance is swollen, puffy, and flushed or livid; the eyes prominent and suffused; the expression that of agony. The pulse is quick, hard, and small; the skin is hot and dry, except the face and head, which generally perspire profusely during the fits of coughing. The child is restless, and constantly changing its position, in the hope of obtaining relief. The respiration increases in difficulty, and the voice in hoarseness; the cough is sudden, convulsive, and ringing, terminating often in a crowing inspiration. There is little or no expectoration. 1 Diseases of the Chest, p. 214. 3 Diseases of the Chest, p. 84. 3 Archives Gen. de Med., July, 1838. CROUP. 241 381. Arrived at this period, the progress of the disease becomes very rapid, and its advance is marked at every step by an aggrava- tion of the symptoms. The remissions are less perceptible, the cough more difficult, suppressed, and strangulating; suffocation more im- minent ; and the paroxysms are occasionally followed by vomiting, and the expulsion of a glairy mucus; sometimes, but rarely, mixed with flocculent or membranous shreds, which affords temporary relief. The croupal respiration is permanent and increases; the voice becomes broken, whispering, and .suppressed; partly from the pain it excites, and partly from its bringing on the cough. Deglutition is occasionally difficult, and gives rise to fits of coughing and strangulation. The bowels are generally constipated, and the urine sometimes clear, pale, and abundant; in other cases scanty, thick, and high colored, and occasionally whitish and turbid, particularly towards the close of the second stage.1 382. It is during this second stage or period of development that the pathological peculiarity of the disease, the secretion of false mem- brane, occurs; but at what period,or by what symptoms it is indicated, it is difficult to determine. M. Blaud states that he has found the larynx and trachea lined with false membrane, in cases whose whole course did not occupy more than twenty hours, whilst in others several days elapsed before it was formed. The evidence derived from auscultation, on this point, is not alwrays certain or precise. The vibration spoken of by M. Barthez is, I should think, pretty conclusive; but it is by no means common, and it is not easy to say whether the sonorous laryngeal inspiration is, at the mo- ment we examine, due to inflammatory spasm, to the mechanical obstruction of the false membranes, or to both combined. M. Trous- seau states that when the cough, having been clear, loud, and ringing, becomes less frequent, and at length almost without sound and suf- focating, we maybe certain that exudation has taken place.2 Occasionally, the expectoration will throw some light upon the matter. Early in the disease, the child expectorates nothing, or a little frothy mucus; but in some more advanced cases shreds of lymph are thrown off, and on this account we should never omit to examine the sputa carefully. Dr. Hegewisch3 recommends their being put into hot water, to render them more apparent: they should always be placed in water for examination. No doubt this is a symptom of considerable importance; but, as Rilliet and Barthez have observed, it is far from being frequent, and rarely occurs before an advanced period of the disease, perhaps the day before death. In one of their cases it oc- curred on the fourth day. It does not appear, then, that we can lay down any symptom which will prove that lymphatic exudation has actually occurred, nor have we any evidence to show that this occurs at any regular period of the 1 Valentin, sur le Croup, p. 219. 3 Journal de Connois. Med.-Chir., 1834, p. 3. 3 Rust's Magazine, vol. xxxii. p. 2. 16 242 CROUP. attack. It cannot be doubted that it does take place during the second stage; but the exact time seems to vary in different cases. 383. in. Period of Collapse.—This stage may set in from the third to the seventh day after the invasion, according to the intensity of the inflammation, or the peculiar constitution of the child. It is charac- terized by the absence of any remission, by the aggravation of all the symptoms, especially the pulse and respiration, which are greatly accelerated, and with diminished power. The pulse is not only quick and weak, but often unequal and intermitting; the cough is less fre- quent, less sonorous, suppressed, and suffocative. The voice is low, whispering, or perhaps entirely abolished; the speech quick, imperfect, or lost. The respiration is extremely difficult, and accompanied with a loud hissing noise. All the muscles of inspiration are called into powerful action; thus the ala? nasi, the muscles of the neck, chest, diaphragm, and abdomen, all act with great force, and the movements of the larynx are extensive and incessant. The head is constantly thrown back, the forehead is covered with cold perspiration, the eyes are sunken and dull, and the complexion is livid, or of a leaden color. The surface generally is pallid, and the veins are very visible, espe- cially those of the neck, which seem unusually distended. The tongue is dark-colored and loaded, the lips sometimes purple, in other cases of a livid paleness; the thirst is often intense, but can only be gra- tified at the risk of suffocation. The bowels are rather confined; the motions are dark and fetid. There is generally some little expectoration, and it may be that, by great efforts, some shreds of the lymph maybe thrown off from the larynx, with manifest relief for the time, but followed by a return of the distressing suffocation. The whole expression of the child's face, figure, and posture, is one of unmitigated distress, of the agony of oppressed breathing, of the horrible dread of suffocation. It turns on every side for relief, and finds none; it changes its position, lying down or sitting up, restless and anxious as those who strive for the breath of life, and despairing as those whose efforts are in vain. Awake or asleep, the distress con- tinues ; it finds no relief in the arms of its mother, no comfort in her caresses. From this condition the child rarely recovers ; there may be occa- sional remissions, as I have mentioned, after the expectoration of mucus and lymph; but this is only temporary, and as the disease ex- tends itself downwards, along the bronchial tubes, all chance is excluded. The local and general distress increases; the efforts at respiration partake of a convulsive character; the passage of air through the larynx becomes more and more difficult; and after a short time, seldom above twenty hours, death terminates the painful scene. The child may either expire with signs of convulsive suffocation, or it may fall into a state of stupor from exhaustion of the vital powers, and die lethargic. The younger the child, the more liable it is to have the disease terminate by convulsions. CROUP. 243 Occasionally, the disease terminates more suddenly than I have described; the child has appeared to be instantly suffocated just when the symptoms had become somewhat more favorable; and in some of these cases it has been owing to the partial detachment of the false membrane, and the formation of a valve whose closure proved fatal. 384. Such is the course of the severe form of croup, when uncom- plicated, and unchecked by treatment. It may, however, run a dif- ferent and less fatal course. The fever may be slight, and the laryn- geal affection much milder. Still, there will be the sibilant and impeded respiration, the croupy cough, and the hoarseness, never to be mistaken, when once they have been heard. These will be trouble- some during the night, and perhaps there may be more or less com- plete remission during the day. No matter how slight the attack may be, the most vigilant care is requisite, as the disease very often ac- quires great intensity in a very sudden manner, and a few hours lost can never be regained. Or if the treatment be early, active, and judicious, the disease may be checked in either the first or second stages, and we shall then find that the character of the cough will be changed; it becomes softer and more moist; the respiration, although for a time rough, is much easier and less hurried, and the voice acquires some tone; the case assumes the aspect of common catarrh, with hoarseness. I have seen this change take place in ray own children in two hours, when the disease was attacked in the very commencement. In more severe cases, the fever, with evening exacerbations, may continue for some time after the voice, cough, and breathing have lost all croupy cha- racter, as in a case at present under my care. We must never forget the great liability of the disease to relapse, nor cease our watchful care until the patient has perfectly recovered. It is also very apt to recur in the same individual. According to Jurine and Albers, it has been known to recur seven and nine times. I have seen it occur two, three, or four times. Nor can we be sure that every attack will be equally mild; a child may recover from two or three attacks, and be destroyed by the next. Much of the chance of recovery depends upon our seeing the disease at its commencement; for even the milder cases, if neglected, may assume greater intensity, and destroy the patient. 385. The duration of the disease depends partly upon the severity of the inflammation, and partly upon the vital energy of the child. It may prove fatal in twenty-four or thirty-six hours, as Dr. Hamilton mentions, or it may last nine or ten days. Dr. Cheyne states, that it generally proves fatal on the third, fourth, or fifth day. Probably from three to six days will be found to include the greater number of cases. 386. Pathology.—The morbid phenomena exhibited on dissection, by the structures chiefly occupied by this disease, are the following: i. The mucous membrane of the larynx and trachea, in the ma- jority of cases, shows evidences of inflammation ; it is of a bright red, 244 CROUP. vascular, and thickened, so that it can be peeled off easily. Occa- sionally the redness is partial, with patches of ecchymosis around the follicular orifices; and, in some rare cases, as has been noticed by Albers and Jurine, Rilliet and Barthez, the mucous membrane is pale, and apparently perfectly healthy, underneaththe false membrane. This Albers explains by supposing that the inflammation subsides after the peculiar secretion is accomplished. The orifices of the mucous follicles are often in a state of dilatation. Jurine remarks that they gave the mucous membrane a dotted appear- ance, and that they are larger on the membranous portion of the trachea, in the direction of its longitudinal fibres, and in their in- tervals. 387. n. But the characteristic morbid appearance is the false mem- brane which lines the air-passages, lying upon the mucous membrane. We find a layer of lymph of considerable consistence, of varying thickness, and of a whitish or yellowish color, lining the larynx and trachea, and sometimes extending into the bronchi. This extension to the bronchial tubes occurred in forty-two cases out of 120, according to M. Guersent, or in about one-third. In some cases, it is of small extent, resembling grains or patches, between which we see the mucous membrane, and occupying different parts of the larynx and trachea; in others, it forms demi-cylinders, or more rarely, entire cylinders, or tubes of different lengths,—casts, in fact, of the tubes in which it is moulded. It is thinner, and more fragile in the larynx than in the trachea, and its consistency is least in the bronchial tubes. The less the consistence, the greater the probability of its being ex- pectorated. The free surface of the false membrane is generally smooth, and often covered by a layer of muco-purifbrm matter. The other surface adheres more or less strongly to the mucous membrane. In some cases, it is partially separated by puriform matter;. in others, an at- tempt to remove the false membrane brings away the mucous coat. When the secretion is extensive and general, it is generally less ad- herent; and when removed, the surface which had been in contact with the mucous membrane is generally smooth, and of a whitish yel- low color, with longitudinal stria?, owing, probably, to the impression of the muscular fibres of the trachea. In this adherent surface, also, w7e may sometimes see a number of small red points, which, according to M. Hache, correspond to the little ecchymoses of the mucous membrane which I have already noticed; and it has been doubted whether this may not be the com- mencement of organization in the false membrane.1 Soemmering, Royer, Collard, Guersent, Blache, and others, believe in the possibi- lity, and have discovered, vascular stria?, which penetrate the sub- stance. Portal, Valentin, and others, have denied the development of vessels. Rilliet and Barthez, without deciding positively, admit the possibility, but very sensibly remark that such cases must be ex- tremely rare on account of the rapidity of the disease. 1 Mai. des Enfans, vol. i. p. 319. CROUP. 245 As to the chemical properties of the false membrane, I cannot do better than quote the following passages from M. Bretonneau's val- uable work: "I have endeavored," he observes, "by means of dif- ferent chemical re-agents, to establish the differential characters of the croupal concretions, the albuminous concretions which are the consequence of inflammation of the serous membranes, and the fibrin of the blood; and I have not been able to discover any." "Sulphuric, nitric, and hydrochloric acids coagulate all; acetic acid, liquid am- monia, and alkaline solutions, dissolve all, and convert them into a diffluent and transparent mucus, exactly at the same temperature, and in the same vessel."1 It consists, therefore, of albumen; and, according to Lelut, it is the mucus, enriched with fibrin, in consequence of the inflamed condition of the part. Dr. Hosack attributes the membrane to the rapid passage of the air. Dr. Seitz has recorded a microscopic examination of this membrane; it was about half a line thick, and of a slight consistence; it was seen to be composed almost entirely of pus globules, mixed with inflamma- tion corpuscles, and a species of cell double the size of the pus globule, but otherwise similar to it.2 Instead of this plastic lymph, we occasionally find the air-passages inflamed, and to a greater or less extent lined with a layer of viscid puriform or muco-puriform matter; offering, of course, an impediment to respiration, but more easily expectorated.3 388. It may be as well to notice here certain other morbid condi- tions, although they result from the complications of croup, which I shall notice by and by. The pharynx occasionally participates in plastic exudation, and on examination we find it either disposed in patches, or continuous and ex- tending into the larynx. In almost all cases the oesophagus is healthy; in two cases related by Bretonneau, however, the false membrane lined the whole extent of the tube to a little beyond the cardiac orifice of the stomach. In one case, by Ferrand, it extended to the commence- ment of the oesophagus; and in another, reported by M. Lespine, it occupied the inferior third. It is rare to find any morbid appearances in the stomach or bowels. Rilliet and Barthez met with minute ecchymoses of the mucous mem- brane of the stomach, and a considerable development of the isolated follicles of the small intestines, but nothing more. The bronchial tubes are often found inflamed, even when there are no false membranes; in some cases, the mucous membrane is simply vascular; in others, red and softened. Moreover, they contain a quan- tity of mucous or puriform fluid. In a large proportion of cases—five-sixths, according to Rilliet and Barthez—lobular pneumonia exists, and occasionally it is general and extensive; nor does it depend upon the extension of false membranes ' Traite de la Diphtherite, p. 293. a Ranking's Abstract, vol. iv. p. 334. 3 Dr. Francis, New York Med. and Phys. Journal, vol. iii. p. 56. Stewart on Diseases of Children, p. 73. 246 CROUP. to the bronchi, for it is present in many instances when they are absent. An emphysematous condition of the lungs exists in a large propor- tion of cases in consequence of the asphyxia; it is generally vesicular, in children. Dr. Cheyne mentions, that serous effusion and evidences of inflam- mation are occasionally found in the cavities of the pleura and peri- cardium in severe and protracted cases, and that the cavities of the heart are sometimes full of blood. The sub-maxillary and bronchial glands are generally swollen and soft; and in one case Dr. Cheyne found a quantity of glutinous matter surrounding the thyroid gland, and passing from behind it round the trachea.1 389. Now, from the morbid appearances I have mentioned, there cannot be much doubt of the pathology of the disease: that it con- sists of inflammation of the mucous membrane, giving rise to a peculiar secretion, and exciting spasmodic action; and the result is a great impediment to the ingress of air, to its access to the minute blood- vessels, and a less perfect aeration of the blood. Dr. Copland has given an admirable series of inferences from the post-mortem appearances, which I shall make no apology for quoting: "1. That the mucous membrane itself is the seat of the inflamma- tion of croup; and that its vessels exude the albuminous or character- istic discharge, which, from its plasticity, and the effects of temper- ature, and the continued passage of air over it, becomes concreted into a false membrane. "2. That the occasional appearance of blood-vessels in it arises from the presence of red globules in the fluid when first exuded from the inflamed vessels, as may be ascertained by the exhibition, upon the approach of the symptoms, of a powerful emetic, which will bring away this fluid before it has concreted into a membrane; these glo- bules generally attracting each other, and appearing like blood-vessels, as the albuminous matter coagulates on the inflamed surface. "3. That the membranous substance is detached in the advanced stages of the disease, by the secretion from the excited mucous fol- licles of a more fluid and less coagulable matter, which is poured out between it and the mucous coat; and as this secretion of the mucous crypta? becomes more and more copious, the albuminous membrane is the more fully separated, and ultimately excreted, if the vital powers of the respiratory organs and of the system are sufficient to accom- plish it. "4. That subacute or inflammatory action may be inferred as having existed, in connection with an increased proportion of fibro- albuminous matter in the blood, whenever we find the croupal pro- ductions in the air-passages; but that these are not the only morbid conditions constituting the disease. "5. That, in conjunction with the foregoing—sometimes only with ' Pathology of the Larynx and Bronchi, p. 25. CROUP. 247 the former of them in a slight degree—there is alwrays present, chiefly in the developed and advanced stages, much spasmodic action of the muscles of the larynx, and of the transverse fibres of the membranous part of the trachea, which, whilst it tends to loosen the attachment of the false membrane, diminishes, or momentarily shuts the canal (of the larynx) through which the air passes into the lungs. "6. That inflammatory action may exist in the trachea, and the exudation of albuminous matter may be going on for a considerable time before they are suspected, the accession of the spasmodic symp- toms being often the first intimation of the disease; and these, with the effects of the previous inflammation, give rise to the phenomena characterizing the sudden seizure. "7. That the modifications of croup may be referred to the vary- ing degree and activity of the inflammatory action, the quantity, the fluidity, or plasticity of the exuded matter, the severity of spasmodic- action, and to the predominance of either of these over the other, in particular cases, owing to the habit of body, temperament, and treat- ment of the patient, &c. "8. That the muco-purulent secretion, which often accompanies or follows the detachment and discharge of the concrete or membranous matters, is the product of the consecutively excited and slightly in- flamed state of the mucous follicles, the secretion of which acts so beneficially in detaching the false membrane. "9. That a fatal issue is not caused merely by the quantity of the croupal productions accumulated in the larynx and trachea, but by the spasm, and the necessary results of interrupted respiration and circulation through the lungs. " 10. That the partial detachment of fragments of membrane, par- ticularly when they become entangled in the larynx, may excite severe, dangerous, or even fatal spasm of this part, according to its intensity, relatively to the vital powers of the patient; and that this occurrence is most to be apprehended in the complicated states of the malady, where the inflammatory action, with its characteristic exuda- tion, spreads from the fauces and pharynx to the larynx and trachea; the larynx being often chiefly affected in such cases, and, from its irritability and conformation, giving rise to a more spasmodic and dangerous form of the disease. "11. That the danger attending the complication of croup is to be ascribed not only to this circumstance, but also to the depression of vital powers, and the characteristic state of fever accompanying most of them, particularly in the more advanced stages. "12. That irritation from partially detached membranous exuda- tions in the pharynx, or in the vicinity of the larynx or epiglottis, may produce croupal symptoms in weak, exhausted, and nervous children, without the larynx or trachea being materially diseased ; and that even the sympathetic irritation of teething may occasion the spasmo- dic form of croup, without much inflammatory irritation of the air- passages, particularly when the prima via is disordered, and the mem- branes about the base of the brain are in an excited state. 248 croup. "13. That the predominance in particular cases of some one of the pathological states noticed above (5) as constituting the disease, and giving rise to the various modifications it presents, from the most in- flammatory to the most spasmodic, may be manifested in the same case, at different stages of the malady, particularly in its simple forms, and in the relapses, which may subsequently take place; the inflam- matory character predominating in the early stages, and either the mucous or the spasmodic, or an association of both, in the subsequent periods. " 14. That the relapses which so frequently occur, after intervals of various duration, and which sometimes amount to seven or eight, or are even still more numerous, may each present different states or forms of the disease from the others; the first attack being generally the most inflammatory and severe, and the relapses of a slighter and more spasmodic kind; but in some cases this order is not observed ; the second or third, or some subsequent seizure, being more severe than the rest, or even fatal; either from the inflammation and extent of exudation, or from the intensity and persistence of the spasmodic symptoms, most frequently from the latter circumstance." We find, then, that the cause of the peculiar sound of the cough and sibilant breathing, is not simply that the lining membrane is in- flamed and coated with lymph, but also because the larynx and trachea are spasmodically affected, and it is most important to bear this in mind."1 Dr. Stewart remarks, that "the cough, or the pecu- liar sound, so remarkable in expiration in croup, is observed to ex- hibit two kinds of sound: the first acute, from the active spasmodic contraction of the muscles of the larynx, excited at first by the column of expired air; the grave, which succeeds it, from the forced enlarge- ment of the glottis, by the shock of the same column of air overcom- ing the contraction of the muscles."2 Dr. Stokes considers the " cause of obstruction in this disease to be more spasm than effusion of lymph," and adduces in proof, the temporary suppression of the sibilant breathing which follows vomiting.3 390. It is not very easy to explain, satisfactorily, why children are so much more liable to the disease than adults. Dr. Cheyne con- siders that, in the latter, "the constitution is, in a great measure, secured from croup by the increase and vigor which the larynx and trachea acquire at puberty."4 This might explain their immunity from spasm, but surely not from inflammation and the exudation of plastic lymph. Dr. Stokes suggests, that it may be owing to the preponderance of white tissues in children, and to these tissues possessing the greatest reproductive power. "In the child, too, there may be a greater re- lation between the physiological, and consequently the pathological states of the mucous membrane of the larynx and trachea, and their subjacent (white) tissues, than in the adult; and the same condition 1 Desruelles, Traite du Croup, p. 170. a Diseases of Children, p. 75. 3 Diseases of the Chest, p. 216. * Pathology of Larynx and Bronchia, p. 28. croup. 249 which determines the progressive development of the larynx up to the period of puberty, may also predispose the mucous surface to the plastic or formative irritations.1 I confess, I do not think the explana- tion altogether satisfactory, nor have I any better to offer. I may add the fact, that the disease attacks animals: dogs, cats, lambs, horses, and cows, according to Duval, Rush, Valentin, Youatt, &c, especially the young; and a similar disease is said by Duval, Jurine, Albers, Porter, &c, to have been induced by the injection of stimulating fluids into the trachea.2 391. Causes.—The principal causes appear to be constitutional aptitude, exposure to a cold, damp, changeable atmosphere, insuf- ficient clothing, and epidemic miasma. No doubt that children of an irritable, nervous habit, and great sus- ceptibility, are the most liable to its attacks. Contrary to M. Barrier's statement, children are very liable to a return of the disease,3 and different children in the same family sometimes share the liability.4 One of my own children has had three or four attacks, and another two; the predisposition has ceased, however, with advance in age. There does not appear to be any ground for attributing it to hereditary influence. It prevails much in countries or localities exposed to great vicissi- tudes of weather: Savoy, Switzerland, the east of England, north-west of Europe generally, the middle and south of France, the north of Italy, &c, are countries in which it is very prevalent. In tow7ns, too, it is more frequent than in the country: it is common in London, Edinburgh, Leith, Dublin, &c.; and more so in the low, damp parts of towns. I am informed that it is rare in the north of Ireland; but Underwood mentions that it infests Mullingar. It is more common during winter than summer; owing, probably, to the frequent changes of weather, and the prevalence of east and north-east winds. I have no hesitation in saying that the fashion of clothing children lightly, exposing their legs, arms, and necks, under the foolish notion of hardening them, is extremely favorable to the production of croup. Dr. Eberle has given a striking illustration of this, in the case of a German settlement in America, "who are in the habit of clothing their children in such a manner as to leave no part of the breast and lower portion of the neck exposed." " During a practice of six years among this class of people, I recollect having met but a single case of this affection, and this case had occurred in a family who had adopted the present universal mode of suffering the neck and superior portions of the breast to remain uncovered."5 The suppression of cutaneous eruptions, the breathing of noxious gases, swallowing boiling water, &c, are all occasional causes of the disease. ' Diseases of the Chest, p. 211, note. a Valentin, Sur le Croup, p. 464. 3 Porter, Surgical Pathology of Larynx and Trachea, p. 31. 4 Cheyne, Pathology of Larynx and Trachea, p. 15. Eberle, Diseases of Children, p. 346. 5 Diseases of Children, p. 347. 250 croup. It may attack children in perfect health, or those whose constitution has been weakened by previous disease; and it not unfrequently occurs during an epidemic of influenza or scarlatina; primary in the first, secondary in the latter; or as an extension from the neighboring parts. Lastly, it has prevailed epidemically at different times, to a consi- derable and fatal extent. The principal epidemics of which we have authentic account, are those of Paris in 1556 (Baillou); Cremona, in 1747(Ghisi); Cornwall, in 1748 (Starr); Upsal,inl762 (Rosenstein); Frankfort, in 1764 (Van Bergen); Sweden, in 1768-72 (Wahlbom andBaeck); Wertheim, in 1772(Zobel); in Gallicia, in 1778 (Hirsch- feld); Clausthal, in 1783 (Boehmer); United States, in 1805 (Barker); Stuttgard, in 1807 (Autenrieth); Saxony, in 1807-8 (Albers); and in 1811 (Schundtmann);1 at Vienna, in 1807-8 (Golis); and in Mary- land, in 1807 (Chatard). Several partial or local epidemics have since occurred, but none so general as the above, that I arn aware of. Dr. Vauthier has published an account of the epidemic which prevailed in the Hopital des Enfans at Paris in 1846-7.2 Several authors, as Wichman, Boehmer, Field, and others, main- tain the contagiousness of croup; but this is denied by the majority of writers, at all events in the case of primary croup. Certain forms of diphtheritic inflammation of the fauces and pharynx, are undoubtedly contagious; and as the inflammation and exudation sometimes spreads to the larynx, constituting secondary croup, it may be so far regarded as sharing in the same mode of propagation. 392. Modifications and Complications.—I shall now proceed to consider the modifications of croup, i. e. croup with certain of its symptoms predominating sufficiently to give a peculiar character to the attack. i. Croup with Predominance of Inflammatory Symptoms: the acutely inflammatory croup of some authors.—This is nearly the severest form of the disease, attacking plethoric children of a sanguine temperament, and perhaps at a more advanced age. It is preceded by chilliness, horripilation, and rigors, and characterized by a more continuous and unremitting severity of symptoms; by strength and rapidity of pulse, heat of skin, difficult and forcible respiration, redness or lividity of cheeks and lips, and the inflammatory appearance of the blood taken from the child. When limited, as it may be, to the larynx, it has been called by Guersent and others laryngeal croup, and the symptoms connected with the respiration, voice, and cough are peculiarly severe; the pain and swelling of the larynx are remarkable, and convulsions occasion- ally occur. The attack may terminate fatally in twelve hours, or be prolonged to four or five days, but rarely longer. On the other hand, the disease may be confined to the trachea, constituting the tracheal croup of continental writers, and having a less rapid and less fatal progress, with some variation in the symp- ' Albers, de Trachaeatide, p. 70. Valentin, Sur le Croup, p. 402. a Archiv. Geo. de Med., May and June. 1848. CROUP. 251 toms. For instance, although the cough and breathing are sonorous, they have not the brazen sound of ordinary croup, and the voice is far less affected; the sense of suffocation is not so oppressive. Pain, or a burning sensation, is felt along the trachea; the croupy sound of breathing will be heard if the stethoscope be applied over the trachea, and there is severe inflammatory fever present. The attack may be prolonged to twelve or fifteen days; and in some cases it has subsided into a chronic form, or, passing downwards, has term- inated in bronchitis. ii. Croup with a Predominance of JYervous or Spasmodic Symp- toms.—The attack may come on like ordinary croup, with feverish- ness, cough, &c, or, as I have more frequently found, the child may go to bed perfectly well, and in the course of an hour or twro may awake with perfectly formed croup, hoarse voice, ringing cough, dys- pnoea, and threatened suffocation, which, if not relieved by treatment, will continue during the night, and have a remission during the day. There is, on the whole, less fever, but not less distress; and if the attack be neglected, it will run a course similar to ordinary croup, characterized by greater dyspnoea, louder cough, and more sibilant respiration, and prove fatal, as in the other forms.1 Fortunately, if taken early, it is far more manageable; the spas- modic irritation may be relieved before there has been time for false membranes to form, and with the relief of the spasm the inflammation may either disappear or be modified. Thus, with my own children I have repeatedly subdued the croupal affection in the course of two hours, and there remained only catarrh with hoarseness. 393. Now let us notice the diseases with which croup may be complicated, or in other words, its secondary affections. These are not numerous, but they add much to the severity and danger of the disease. i. Bronchitis.—I have already mentioned that morbid appearances, indicating inflammation of the bronchial tubes, are found even in cases where the croupy exudation does not extend below the trachea; and in practice we find that this complication is not very uncommon. It seems more frequent in young and delicate children, and is marked by the predominance of catarrhal symptoms from the beginning gene- rally. We find the croup, dyspnoea, and hoarseness, much as in an ordinary case, but there are more wheezing in the chest, and more expectoration. There is generally less fever; the skin is cooler; and the throat and larynx seem less permanently the seat of the mischief. After three or four days the cough is softer, the paroxysms shorter, and the expectoration increased. If the croupy sound be not very loud, we shall be able lo hear bronchial rales in one or both lungs; the chest is resonant on percussion. In the progress of the attack, either affection, the croup or the bronchitis, may predominate, and give to it its peculiar character, i.e., it may merge into a case of marked croup, such as I have described, ' Blaud, Recherches sur le Croup, p. 312. 252 CROUP. with some bronchi-tic symptoms, or it may degenerate rather into a bronchitic affection, with very little of croup. The latter is much safer, for in the former we have the danger from the croup augmented by the disease of the air-tubes. 394. n. Pneumonia.—This disease complicated five-sixths of the cases collected by MM. Hache and Rilliet and Barthez; and, accord- ing to the observations of Blache, Guersent, Trousseau, and others, it is the most frequent complication of croup, and I need not say how fearfully it increases the danger of the primary disease. It seldom occurs at the commencement of the disease, or during the precursory stage, but makes its inroad in the course of the second, or towards its termination. The pneumonia may be either general or lobular; and this, together with the loud croupy sound, renders its detection often extremely difficult. We ought to examine the chest daily; to seize upon a moment of comparative quiet; and if we can avail ourselves of the temporary suspension which follows vomiting, as suggested by Dr. Stokes, we may be able to detect the crepitant rale in the portion of the lung occupied by the inflammation. The only symptoms which will indicate the deeper mischief, will probably be an increase of fever, and a more rapid sinking of the vital powers. The cough is sometimes less ringing, but the sibilant breathing, the hoarseness, and the fever, are as well marked as in the other cases. The disease thus complicated, runs a very rapid and almost univer- sally fatal course, without remission or mitigation. 395. iv. Other complications have been noticed, but they occur much less frequently; thus Cheyne, Condie, and others, mention the occurrence of pleuritis ; several authors speak of emphysema ; others of partial rupture of the trachea; and Martin,1 of a case in which vomiting of blood occurred. 396. Secondary Croup.—So much for the complications of croup ; but we must not forget that croup may complicate other diseases, and be to them a secondary affection.2 Thus, for example, in some cases of diphtherite, cynanche maligna, scarlatina maligna, cynanche ton- sillaris, or cynanche pharyngea, the inflammation which in those parts gives rise to the ash-colored or whitish membranous exudation, may extend itself to the larynx and trachea, giving rise to croup, and adding a formidable complication to the primary affection. Again, croup, though rarely, supervenes upon thrush ; in this case, it takes its character from the state of the constitution induced by the primary disease ; and, generally speaking, the pharynx and larynx are more severely implicated than the trachea. The accompanying fever is of an ataxic or adynamic type.3 It also occurs in the course of several of the exanthemata ; during 1 Rec. Period, de la Soc. de Med. de Paris, April, 1810. a Albers, Comment, de Trach;eatide, p. 69. 8 Med. Obs. and Inq. by Dr. Rush, vol. ii. p. 376. Ferrier, Med. Hist, and Reflections, vol. iii. p. 205. CROUP. 253 the first or eruptive stage of measles, miliary eruption, scarlatina, as I have mentioned, small-pox,1 &c, according to the testimony of many authors. In the latter case, it comes on most frequently during the suppurative stage of confluent small-pox, and, as in diphtherite, the inflammation extends from the pharynx to the larynx. Some cases of erysipelas of the fauces, in which the extension of the inflammation gave rise to croup, are related by Forester, Latour, Stevenson, and Gibson. Dr. Vauthier relates eight cases of secondary croup out of thirty- seven. Three, complicated measles; two, pneumonia and typhoid fever; one, scarlatina; and one, hooping-cough. 397. The morbid changes discoverable after death in secondary croup are of the same character as in the primary affection, but less marked ; there is less redness; the softening or thickening of the mucous membrane is less extensive; the false membranes are yel- lowish, and of smaller extent, thinner, less adherent, and softer than in the disease just described. They seldom occupy the entire larynx, but often the inferior portion of the epiglottis, and the superior part of the larynx, as far as the chorda? vocales, or the ventricles of the larynx. In one case out of eleven only, did Rilliet and Barthez de- tect them at the inferior portion of the trachea, and in another in the bronchial tubes.2 398. The symptoms of the secondary croup are a good deal mo- dified, and resemble more some of the forms of laryngitis. Thus, the cough is sometimes dry, sometimes moist, easy, or painful and hoarse, but it has less of the metallic ringing sound ; the respiration is difficult and hissing, but without the loud sibilant sound of primary croup ; the voice is less changed. Rilliet and Barthez mention that, in five of these cases, it was unaltered; in tw7o others it was nasal, embarrassed, but not extinguished; in three it was muffled, and in one it was ex- tinct ; without any peculiarity in the situation of the false membrane to explain the difference. The expectoration varies; there may be some mucous or muco-puriform matter thrown off, but there are rarely or never any shreds of lymph. On inspecting the fauces, however, in these cases, we shall find there the primary affection in the form of inflammation (and perhaps ulceration) of the tonsils, uvula, and palate, with a gray or yellowish exudation of lymph; the parts are swollen, and of a dark red color, and there is considerable difficulty in swallowing. Dr. Stokes has given a comparative view of the symptoms of pri- mary and secondary croup, which I shall take the liberty of ex- tracting :— "1. In primary croup, the air-passages are primarily engaged ; in secondary croup, the laryngeal affection is secondary to disease of the pharynx and mouth. " 2. In the former, the fever is symptomatic of the local disease ; in the latter, the local disease arises in the course of another affection, which is generally accompanied by fever. 1 Albers, Jurine, Vieussieux, Cheyne, &c. a Mai. des Enfans, vol. i. p. 323. 254 CROUP. " 3. In the former, the fever is inflammatory ; in the latter, typhoid. " 4. In the former, there is necessity for antiphlogistic treatment, and the frequent success of such treatment; in the latter, incapability of bearing antiphlogistic treatment; necessity for the tonic, revulsive, and stimulating modes. "5. The former is spasmodic, and, in certain situations, endemic, but never contagious ; the latter, constantly epidemic and contagious. "6. The former is a disease principally of childhood ; by the latter, adults are commonly affected. "7. In the former, the exudation of lymph spreads to the glottis from below upward ; in the latter, from above downwards. "8. In the former, the pharynx is healthy;, in the latter, it is dis- eased. "9. In the former, dysphagia is either absent or very slight; in the latter, it is constant and severe. "10. In the former, the catarrhal symptoms are often precursory to the laryngeal; in the latter, the laryngeal symptoms supervene, with- out the pre-existence of catarrh. "11. In the former, the complication with acute pulmonary in- flammation is common ; in the latter, rare. "12. In the former, the absence of any characteristic odor of the breath; in the latter, the breath is often characteristically fetid."1 399. Diagnosis.—The pathognomonic symptoms of croup are the hoarse voice, the sibilant breathing, and the rough, metallic-ringing cough; which, in the third stage, become the whispering voice, wheez- ing, hissing respiration, and husky, choking cough. i. It may be distinguished from spasm of the glottis by the ca- tarrhal stage, by the hoarse voice, by the sibilant respiration, and by the ringing cough; in spasm of the glottis there is no catarrh, inspi- ration only is difficult; the crowing sound is quite different from the expiratory noise in croup; there is no cough, and the voice is un- altered.2 ii. In simple laryngitis, the cough and voice are rough and hoarse, but very unlike the ringing, metallic cough of croup; the respiration is sometimes difficult, but rarely, if ever, sibilant; there are fever, ex- pectoration, and no such paroxysms of suffocation as in croup. in. Primary croup differs from secondary croup in the absence of sore throat, inflamed fauces covered with false membrane, the peculiar characters of the original disease, and in the greater intensity of the symptoms; fever, dyspncea, and cough.3 I have already given Dr. Stokes's parallel between the two affections. iv. In pertussis, there is hurry of respiration, but neither the difficulty nor the sibilant sound; the cough, though loud, has not the peculiar metallic sound, and in the intervals there is complete relief, neither hoarseness nor dyspncea. v. If the previous history were obscure, it might be possible to mistake the symptoms resulting from foreign bodies in the trachea 1 Diseases of the Chest, p. 206. * Albers, Comment, de Trachaeatide, &c, p. 50. 8 Pathology of Larynx and Bronchia, p. 16. CROUP. 255 for croup, but a careful inquiry will generally remove the difficulty; and, in addition, the suddenness of the attack, the absence of false membrane and of inflammatory fever, with the results of auscultation, will leave but little doubt. vi. It is, perhaps, impossible to draw the line between croup and the laryngitis resulting from swallowing boiling water, as in the latter case there is an exudation of lymph firmly adherent to the membrane of the larynx; it never, however, extends to the trachea ; and although the swollen membrane impedes respiration, still the spasmodic parox- ysm is wanting. Our best guide will be the previous history of the case. 400. Terminations and Prognosis.—i. Croup may terminate favor- ably in resolution; the fever diminishes, the croup becomes softer, loses its croupy sound, and resembles the cough in a slight attack of laryngitis; the respiration gradually becomes easier, and expectora- tion takes place. "Most commonly," says Dr. Cheyne, " after the disease has arrived at its height, the decline is, as it were, a retro- gression of the attack; the skin is moist, the fever abates; the cough becomes loose, the breathing easy, and the voice gradually recovers its natural tone."1 Sometimes the crisis is marked by the expectoration of false membrane, but this is not always a proof that the disease will subside. ii. The inflammation may subside in the larynx, but extend itself downwards to the large or small bronchial tubes, and the croup will then merge in bronchitis or pneumonia. in. In the majority of cases, croup ends fatally with the symptoms I have already detailed. Marley says that two-thirds die. Vieus- sieux, in 1775, states that, in his early practice, ten cases out of twenty died; Jurine, that one in ten die; Michaelis and Bard, two out of three. In Philadelphia, during the ten years preceding 1845, there occurred 1150 deaths from croup, or 150 per annum. In Paris, in 1838, the deaths were 187; in 1839, 286 ; and in 1840, 326. In London, in 1840, the deaths from croup amounted to 391 ; and in all England, to 4336. Sudden deaths, as I have already stated, may occur from the partial detachment of a valve of false membrane, but ordinarily the cause of death is a deficiency of air, and consequently the patient dies of asphyxia. 401. The prognosis, therefore, in all cases of croup, is very serious; the probabilities are against recovery, but in estimating those proba- bilities we must take into careful consideration the period of the dis- ease at which the child comes under treatment, the intensity of the symptoms, the degree of fever, the complications, and the extent of disease, and the strength of the constitution. If the disease be attacked at the commencement, it will frequently yield; nay, if it be further advanced before we see it, yet if it be a mild case, the symptoms marked but not violent, the inflammation limited, the fever moderate, and no complication, the child may recover under proper care. 1 Pathology of Larynx and Bronchia, p. 16. 256 CROUP. But if the attack be rapid and severe, the cough violent, the dyspnoea intense, and the fever high, and especially if the lungs be affected, there will be but little hope from treatment at any period; none, if the case have been overlooked fbr twenty-four hours. I cannot quite agree with Rilliet and Barthez, that we ought never to despair of the life of the patient in croup, nor do I anticipate as much benefit from tracheotomy, even as a last resource, as those ex- cellent practitioners; but certainly there are some cases of recovery recorded when all hope seemed extinguished, and they appear to have been mainly ow'ing to the strength of the patient's constitution. 402. Treatment.—The indications of cure are: 1. If we are called early, to arrest or subdue the inflammatory action, and to prevent the formation of false membranes, or the albuminous secretion and accu- mulation in the air-passages ; 2. When the time for doing this has passed, to procure the discharge of these matters; 3. To mitigate the spasmodic symptoms ; and, 4. To support the powers of life in the latter stages, so as to enable the system to throw off the matter exuded in the trachea. 403. Our success in the first of these indications depends, I think, upon seeing the child early; if we are present at the very beginning, we may often cut short the disease. My own children, for example, have been attacked five or six times. I always give immediately an emetic of tartarized antimony, and afterwards smaller doses to keep up the nausea for an hour or two. In no instance has bleeding been necessary after this, and the attack has never lasted more than two or three hours. We should, in the first stage, commence by an emetic of ipecacuanha or tartar emetic, and keep up a nausea for some time by smaller doses. "Emetics," says Dr. Cheyne, "appear peculiarly fitted to answer the indications of cure in the first stage of croup. They increase the se- cretion from the mucous membrane of the bronchia, while, at the same time, they lessen the general tone of the arterial system. Hence they are the only true expectorants."1 By most practitioners the tartar emetic is preferred, and I think with reason, because of its peculiar antiphlogistic power; it may be given in doses of a quarter or half a grain every quarter of an hour, until vomiting is excited, and then continued in doses of an eighth or a twelfth of a grain every hour or two. Some German physicians, as Droste, Kerting, and Steinmetz, prefer the sulphate of copper; and Smith, Farre, and Francis, recommend the sulphate of zinc. 404. In the severer cases, or when the emetic fails in changing the character of the disease in an hour or two, we must have recourse to blood-letting. There is no difference of opinion as to the propriety of this practice, but merely as to the mode. Some advise bleeding from the arm or jugular vein, as Marley, Cheyne, Porter; others, as Dr. Merriman, cupping; whilst by the majority leeches are employed 1 Pathology of Larynx and Bronchia, p. 51. CROUP. 257 Whatever method we adopt, the essential point is to take as much blood as will make a decided impression on the disease, and to repeat the bleeding if necessary. I prefer leeches applied to the upper part of the sternum, where the bleeding can be readily arrested by pressure ; and I repeat, that it ought to be arrested when the leeches fall off. _ I quite agree with Dr. Condie, that "there is certainly no disease in which bleeding, when well timed, and carried to a sufficient extent, is calculated to produce more beneficial effects than in croup. The practitioner who, in violent cases, neglects this important measure, and places his hopes in any other remedy, or combination of remedies, will have but little reason to flatter himself upon his success in the manage- ment of the disease."1 The quantity of blood taken must vary according to the intensity of the disease, the strength of the child, and the effects produced. It is not desirable to carry it to excess in any stage, but in the first stage it is less mischievous to take too much than too little. In the eighth volume of the Dublin Medical Journal, and more recently in his Clinical Medicine, my friend Dr. Graves has called attention to the treatment proposed by Dr. Lehman, of Torgau. It consists in the immediate application of hot water in the following manner: "A sponge, about the size of a large fist, dipped in water as hot as the hand can bear, must be gently squeezed half dry, and instantly applied beneath the little sufferer's chin, over the larynx and windpipe; when the sponge has been thus held for a few minutes in contact with the skin, its temperature begins to sink, and it requires to be dipped again in hot water." This is to be continued from ten to twenty minutes, and will produce a vivid redness, as if a sinapism had been applied, accompanied with a general perspiration, and fol- lowed by immediate relief of the cough, hoarseness, and dyspnoea. "Since then," Dr. Graves observes, "I have repeatedly treated the disease on this plan, and with the most uniform success. It is, how- ever, only applicable to those cases which are seen at the very onset of the disease; and you must remember, also, that I do not propose it to the total exclusion of bleeding and tartar emetic, which must be used in the more aggravated cases, or in those which are not seen until the disease is somewhat advanced."2 405. The bleeding may be preceded or followed by a warm bath, which, for a time, relieves the oppression, and certainly gives greater effect to the other remedies; and it is peculiarly beneficial when the disease is yielding to the treatment. These are the principal means at our command during the first stage, and it is necessary to use them promptly and vigorously; for, as Dr. Ferrier observes, the course of genuine croup is very short. If the alarming symptoms I have described are not mitigated during the first six hours, the disease will generally prove fatal. It has happened several times that I have been called early in the day to patients who had become seriously ill only on the preceding evening; and in such 1 Diseases of Children, p. 305. 3 Clinical Med., Lecture xxxix., vol. ii. p. 4. Second Edition. 258 CROUP. cases I have only succeeded once. The proper time for administer- ing relief is when the cough, dyspnoea, and palpitation increase to- wards ten or eleven o'clock in the evening."1 406. In the second stage, it will be well to have recourse to an emetic, and certainly to bleeding, if it has not been practiced before. Dr. Cheyne recommends the employment of tartar emetic in quarter or half grain doses every hour, so as to excite vomiting occasionally. In this practice Dr. Stokes agrees; he dissolves a grain of the salt in an ounce of distilled water, and gives a dessert-spoonful "every quarter of an hour, or every half-hour, as the case may be."2 Mr. Porter rather prefers nauseating doses of this remedy to those which occasion repeated vomiting; and I am inclined to think that after the emetic effect has been at first excited, and kept up for an hour or two, as much good will be derived from the smaller closes. On the other hand, we must not forget that with some children tartar emetic produces a very depressing effect. Dr. Stewart men- tions, that he has known " utter and irrevocable prostration and death quickly ensuing from its use in young children," and in such cases, it may be combined with oxymel of squills, or ipecacuanha may be substituted for it, without danger of similar effects. . 407. Drs. Rush, Hosack, Bard, and other practitioners, have attached great value to calomel, alone, or in combination with Dover's powder. Dr. Cheyne does not think it of much use ; during two seasons, in which he had used it freely during the second stage, all the cases terminated fatally. Dr. Stokes observes, that the mercurial treatment of croup is insufficient and unnecessary. " The uncertainty of the action of calomel, the difficulty of producing ptyalism in violent acute inflammation, the shortness of the period for the exhibition of the remedy, and the various injurious effects of mercurial action on the system at large, are sufficient reasons against the employment of this treatment in the croup of children ; and when we have so valuable a remedy as the tartar emetic, it seems scarcely justifiable to tamper with the case by the attempt to produce mercurial action."3 Certainly, as a substitute for tartar emetic, it would be of feeble and doubtful value ; but I have seen much benefit from it after the vomiting or nausea had been kept up for some time, or when the depressing effects of the latter had been too decided to permit its prolonged use. MM. Bretonneau and Guersent have repeatedly suc- ceeded by the mercurial treatment carried to ptyalism ; but the latter author cautions us against its use in weak or debilitated constitutions. Mr. Porter speaks well of it "in long-protracted and chronic cases, when there is a tendency in the mucous membrane to become thick- ened and changed in structure."4 I have generally given it in com- bination with James's powder, and a minute portion of Dover's powder, say half a grain of each of the former, with a third of a grain of the latter, every three or four hours. Eberle prefers the combina- ' Med. Hist, and Reflections, vol. iii. p. 139. a Diseases of the Chest, p. 217. 3 Diseases of the Chest, p. 218. 4 Surgical Pathology of the Larynx and Trachea, p. 45. CROUP. 259 tion of calomel with tartar emetic, in the proportion of four or six grains of the former with a fourth of a grain of the latter, every fifteen minutes, until vomiting is excited, in tfie case of children from two to five years old. He further states, that he has " administered the lobelia inflata, with a view to its emetic operation, with the happiest effects."1 With the same object, decoction of senega, sulphate of zinc, or copper, have each its advocates. 408. Counter-irritation is certainly of great use, but some difference of opinion exists as to the best course. Some prefer strong liniments to the throat and chest. DewTees recommends turpentine, hartshorn,, or the mustard and vinegar poultice. Others, asJDrs. Ferrier, Under- wood, &c, recommend the application of a blister; but Mr. Porter objects to these, on account of the time required to produce their effects, and on account of the danger of applying them in the imme- diate neighborhood of inflammation; but he admits their value when the lungs are congested.2 Rilliet and Barthez, and Bouchut, dis- approve of them, as rarely useful, and they mention that the denuded surface is sometimes covered with an exudation resembling that in the larynx.3 During the first stage, and the early part of the second, I conceive that blisters are quite inadmissible; but after the employment of bleed- ing and tartar emetic, and the lowering of the system by these means, especially if there be any tendency towards bronchial complication, I have certainly seen benefit from the mustard poultices and blisters. 409. The action of purgatives upon the system generally, and upon the local disease, is beneficial, and should, therefore, never be ne- glected ; but we cannot depend upon them as a main part of the treatment. If neither the tartar emetic nor calomel act upon the bowels, some brisk warm cathartic should be given ; but, on the other hand, should diarrhoea result from the above treatment, it must be controlled by some astringent and cordial medicines. 410. Now if, under this treatment, the disease give way, and the cough become softer, the breathing easier, and the fever less, we may diminish the frequency of the doses and their amount, or we may simply confine ourselves to expectorant remedies, decoction of senega, squills, ammonia, and small doses of ipecacuanha, &c, with an occa- sional warm bath, and a little James's powder, two or three times a-day, so long as the fever lasts, with due attention to the stomach and bowels, and a careful regulation of the diet. 411. But suppose the symptoms continue unmitigated, and there is evidence that they are not entirely spasmodic, we shall have but too much reason to fear that the pseudo-membranous exudation has taken place, and some modification of the treatment will be necessary. It will be of little use to continue the depletion further, as the result will be rather loss of strength than benefit; but we may continue th-* calomel and the expectorants I have already mentioned. 1 Diseases of Children, p. 359. 3 Surgical Pathology of Larynx and. Trachea, p. 45. 3 Mai de l'Enfance, p. 269. 260 CROUP. If the fits of coughing be severe and suffocative, an occasional emetic will be of service in loosening, and, perhaps, expelling the lymphy exudation. The continued use of tartar emetic must depend upon the circumstances of the case. The inhalation of aqueous or medicated vapors has been recommended by high authority, that of Hume, Pearson, Rosen, Pinel, Golis, &c.; they ought to be merely emollient in the first stage and early part of the second, but after- wards, slightly stimulant. It may be useful, also, in the spasmodic form of the disease, but must not impede the employment of anti- spasmodics by the mouth, or in enemata. A warm bath will also be found useful occasionally, but in some cases it seems to aggravate the dyspncea. 412. The use of narcotics in this stage requires great care; they should be given in small doses, and only those should be employed upon whose action we can reckon most certainly, and in the form the most uniform in its operation ; for this reason they had better not be given in clysters. Dover's powrder may be combined with the calo- mel or with camphor, or camphor with James's pow7der and hyoscy- amus; or a drop or twTo of laudanum added to the expectorant mixture will probably answer the purpose best. Dr. Purefoy has related a case of croup in which much benefit was derived from the iodide of potassium, after blood-letting, emetics, and blisters. He gave one grain, combined w7ith a grain of the hyd. c. creta, every two hours.1 Mr. Hird speaks highly of the effects of alkalies in allaying spasm, and promoting the absorption of the exudation; he gives ten or fifteen minims of the liq. potassa? every four hours.2 Dr. Condie recommends a tobacco poultice to the throat, " composed of the moistened leaves of tobacco, mixed with the crumbs of stale bread, or ground flaxseed. The patient must be carefully watched, lest the depressing effects be excessive." The hydro-sulphuret of ammonia, is said by Chamerlat and Condie to be beneficial in this and the next stage. Dr. John Archer, of Maryland, strongly recommends senega root as an almost infallible remedy in cases of croup, and almost all American writers speak favorably of it. I can bear witness to its value, but it is rather as an expectorant, after the first violence of the inflammation has been subdued. It may be advantageously combined with anti- monials, or ipecacuanha, or squills, as in the following formula:— R. Decoct, senega?, §ii; Oxymel scillas, sjii; Vini ipecac, ^i, or liq. antimon. 2[iii. M. Cap. cochl. i, parv. 2ndis vel 3tiis horis. Drs. Maclean and M, Constance speak very highly of tincture of digitalis; the former gentleman tried it in one case, and the latter in two, and all recovered. It may be a useful adjunct in the first, and early part of the second stage, but it would, I think, be unwise to depend upon it to the exclusion of the other remedies. 1 Dublin Journal, May, 1846. 3 Lancet, December 5,1846. CROUP. 261 Should the active measures hitherto recommended cause much depression, it may be necessary to make a cautious use of stimulants or tonics. 413. In the third stage, the three latter indications of cure are to be kept in view. The expectorants must be continued, and occasionally vomiting should be excited.' It is advantageous at this period to com- bine them with antispasmodics or stimulants; such, for instance, as camphor, musk, assafetida, &c. ; or the latter may be given in the form of enema. Inhalation of the vapor of ammonia, camphor, or ether, with aqueous vapor, has often been found useful, and occasionally the fumes of vinegar alone, or mixed with camphor. Tepid baths may be used occasionally, and if there be much col- lapse, a little flour of mustard should be added to them. If we have any evidence of the expectoration of lymph, it may be promoted by emetics; and for the same purpose Sentin and Thilenius recommend sternutatories. Blisters may be applied to the neck or sternum, and during this stage they act as stimulants as well as counter-irritants; or strong rubefacients to the throat, chest, or between the shoulders, may be employed. Stimulants will certainly be necessary as the disease advances, and probably the best we can employ will be camphor, ammonia, or musk. Harden, Schmidt, and Copland, speak well of cold affusion to the head, by way of relieving the congestion of that organ which results from impeded respiration, and so diminishing the chance of convul- sions. The bowels should, of course, be kept free throughout each stage. The persistence of the more active part of the treatment during the third stage is generally undesirable; it must depend upon the cha- racter of the symptoms and the strength of the patient. If the bowels be not too much affected, the calomel may be continued, and an occa- sional emetic exhibited; but, in general, we have to act more indi- rectly, and through the medium of the constitution, aided by counter- irritants. 414. Thus we see the means at our disposal, which offer a proba- bility of success, are not very numerous. Early vomiting, continued nausea, blood-letting, warm baths, counter-irritants, expectorants, tartar emetic, calomel, some few antispasmodics and stimulants, com- pose the whole list; but these, used judiciously, promptly, and vigor- ously at first, and more cautiously afterwards, afford a reasonable hope of success if we are summoned sufficiently early. 415. The modifications of croup will require nearly the same treat- ment. When the attack exhibits more of a spasmodic character, the remedies need not be quite so severe; emetics at the beginning are equally necessary; but in many cases we may dispense with blood- letting, not, however, if any of the croupy character remains. Next to emetics, counter-irritants, expectorants, antispasmodics, and cathar- tics will afford the greatest relief. 262 croup. Dr. Copland recommends the administration of bark; and, no doubt, in the more advanced stage, when there is much sinking, it is calcu- lated to be of use. 416. When croup is complicated with bronchitis, pneumonia, or pleurisy, the same principles of treatment will apply; but, in addition, local remedies will be necessary. Fortunately, tartar-emetic, calomel, counter-irritants, &c, are as effectual in these diseases as in croup. I do not think that children so affected, bear depletion to any great extent; but with regard to this and the rest of the treatment, we must be guided by the intensity of the attack, and the strength of the con- stitution. 417. Secondary croup requires a more skilful modification of treat- ment ; it is seldom that very active means can be employed. In addition to the remedies for the primary disease (to be hereafter men- tioned), we must have recourse to an occasional emetic, to small doses of tartar emetic, expectorants, counter-irritants, stimulants, topical applications, &c. I shall have an opportunity of alluding to this part of my subject in another part of this volume, when speaking of diph- therite, &c. 418. But we have seen that a portion, at least, of the disease con- sists in the mechanical impediment to the passage of air into the lungs, that this obstacle is chiefly in the larynx, and that the fatality of the disease is partly owing to the inefficient aeration of the blood in con- sequence. Now, it is a very natural and plausible question, whe- ther this difficulty might not be avoided by an operation; in other words, whether the operation of tracheotomy, by admitting air freely to the lungs, might not, even in the third stage, prolong life, and in- crease the chances of cure. Accordingly, the question has occupied the attention of most writers, and led to different conclusions. It appears to have been first proposed by Home and Michaelis, and it has been practiced in Spain, Denmark, Germany, America, and in Geneva, Brest, Lyons, Paris, London, Dublin, &c. I shall mention the opinions of some of the principal authorities. Dr. Cheyne is opposed to it because he thinks it would be useless, un- less the membrane could be removed, which, in most cases, would be impossible ; and, in others, superfluous, on account of its rapid repro- duction. He condemns, also, the danger of the operation in young children.1 Dr. Dewees saw the operation performed twice by Dr. Physic, under favorable circumstances, but without success ; and he objects to it as being uncalled for in the earlier stages, and unavailing in the later.2 Dr. S. Merriman seems more favorable to it. He mentions that, " in a case which he attended along with Mr. Lightfoot, this operation was proposed as a last and only remedy; and it was performed by the late Mr. Chevalier, and was perfectly successful."3 1 Pathology of Larynx and Bronchia, p. 41. 3 Diseases of Children, p. 480. 3 Underwood on Diseases of Children, p. 451. CROUP. 263 A successful case is also mentioned in the third volume of the Medico-Chirurgical Transactions. Mr. Porter has investigated the matter with his usual ability, as to the necessity of the operation, the symptoms requiring it, the period at which it ought to be performed, and the amount of success which has attended it; and having had extensive experience of the disease, and, moreover, having performed the operation as a last resource him- self, he has arrived at the conclusion, that "the operation does not afford sufficient prospect of benefit to admit of our having recourse to it."1 Mr. Carmichael has recorded a case, in which he performed the operation with success; and a second, which was unsuccessful.2 Dr. Stokes expresses his decided dissent from the performance of tracheotomy: "Experience has shown that the operation has failed in the great majority of cases; and, it is obvious that, with our pre- sent knowledge of the nature of the disease, we can scarcely hope for good from its performance."3 Dr. Stewart is evidently unfavorably disposed to the operation.4 Dr. Condie admits that, in severe cases, when timely performed, it may save the life of the patient; and he mentions Drs. Hosack and Farre among those favorable to it.5 Dr. Bigger has recently recorded a successful case in the Dublin Medical Press.6 419. On the Continent, however, the operation has found some ad- vocates, and apparently met with somewhat greater success. Caron Marigault, Maslhieurat, Berard, Petit, Rilliet and Barthez, Barrier, Guersent, Bouchut, Thore, &c, are in favor of it; but it has also powerful opponents in Vieussieux, Double, Albers, Jurine, Royer Col- lard, Bricheteau, Becquerel, Boudet, &c. In the cases in which tracheotomy was performed by Guersent and the " internes," in the Hopital des Enfans, at Paris, in 1841, the ope- ration, while it was of no advantage whatever when the pseudo-mem- branous exudation extended to the bronchi, appeared, in many cases, to accelerate the fatal termination, by inducing severe bronchitis, or an excessive secretion of mucus in the bronchi, pneumonia, or con- vulsions; while, in many cases, the patient died immediately after the operation, without any local lesion existing, to which the fatal termi- nation could be referred.7 M. Guersent states, that he has operated in thirty-six cases, and completely succeeded in four. M. Haine has recently recorded, that he has performed tracheotomy in sixty cases of croup, and that eighteen were successful.8 The researches of M. Bretonneau revived the operation in France, and gave hopes of its being more successful. Out of fifty-five cases * Surgical Pathology of Larynx and Trachea, p. 57, et seq. 2 Transactions of Association of Physicians of Ireland, vol. iii. p. 170. 3 Diseases of the Chest, p. 219. < Diseases of Children, p. 85. 5 Diseases of Children, p. 309. 6 Jan. 6, 1847. 7 Condie, Diseases of Children, p. 309. 6 Ranking's Abstract, vol. iv. p. 132. 264 CROUP. of different ages, he found the exudation reaching to the bronchial ramifications in six or seven ; in one-third of the whole number, it reached as far as the bifurcation; and in thirty or thirty-one, it term- inated at different parts of the trachea, so that it was inferred that it was possible to perform the operation below the seat of the dis- ease, and that to these cases the most formidable of the objections would not apply. M. Fourquet mentions five successful operations out of seventeen, by M. Bretonneau, and strongly advocates the ope- ration. It was performed on the child of Dr. Scoutetten, aged three weeks, on the third day of the disease, and under very unfavorable circumstances, and it recovered. More recently, M. Trousseau has reported the result of the ope- ration in 150 cases, of which thirty-nine recovered, and 111 died. He is, of course, favorable to the operation, which he advises as soon as we are sure that false membranes exist in the larynx. He prefers tracheotomy to laryngo-tracheotomy; for, although the latter is the more simple, and the more easily performed, by the former we get more probably below7 the disease, and the canula is more easily tolerated; it occasions less irritation; and after all, he concludes that there is little danger from tracheotomy, as he has performed it 121 times, with only one mischance as far as the operation was concerned. He gives the following summary of the success of croup treated by tracheotomy. M. Bretonneau saved six out of twenty; M. Trousseau saved twenty- seven out of 112; M. Leclerc, of Tours, succeeded in two cases ; M. Velpeau succeeded in two out of ten; M. Petit in three out of six. He mentions that there are also living in Paris about fifteen children saved in croup by tracheotomy, performed by Gerdy, Robert, Guer- sent, Jr., Boniface, Depres, Blandin, &c.; but he is unable to com- municate particulars.1 420. From the slight sketch I have given, the reader will perceive that the weight of authority, especially in Great Britain and America, is against the operation in croup, and also that the results of the cases in which it has been performed, exhibit no very encouraging success. As an argument, this is not worth much, however, to those who re- gard the operation as a " dernier ressort," to be adopted in no case where there is hope from the ordinary method of treatment. The objections to the operation are principally these:— i. That the larynx is not mechanically closed by false membrane; that in all cases, as Dr. Cheyne has remarked, there is sufficient space for the access of air ; that if the larynx be closed, it must be by spasm in addition to the exudation; and that, therefore, to attempt relief by a mechanical operation would be superfluous, to say the least of it. n. That it is extremely difficult to say that exudation has taken place, and still more to fix the limits of it, and pronounce in any case that it has not extended below the larynx; and yet upon this depends the utility of the operation; for, in. If the false membranes have extended below our incision, the ' Rilliet and Barthez, Mai. des Enfans, vol. i. p. 379. CROUP. 265 operation, being purely mechanical, can afford no relief, but may se- riously add to the danger. iv. Bronchitis or pneumonia may exist at the time of the opera- tion, or may very likely arise very soon after, and render it altogether useless. v. The operation itself is not without danger, nor quite so easy as has been stated, especially with young infants. In addition to he- morrhage and escape of blood into the trachea, the patient may be attacked by prolonged syncope, asphyxia, or convulsions, as occurred in M. Trousseau's practice, and occasionally either of them may prove fatal. vi. That the risk of inflammation and other accidents after the ope- ration is very considerable, and materially diminishes its value. vn. That the results of the operation hitherto, although successful to a considerable extent, are not sufficient to justify our having recourse to it under ordinary circumstances. "If," says Mr. Porter, "it were possible to place a host of those cases in which bronchotomy had not proved serviceable, in array against those wherein it had seemed to be useful, it would scarcely be necessary to advance any further argu- ment in proof of its uncertainty."1 421. Still, Mr. Porter admits, very justly, that he cannot say that there are no cases of croup in which tracheotomy would be useful and proper; the great difficulty is, how7 to recognize them with suf- ficient accuracy. If it were possible to ascertain that false membranes had formed in the larynx without extending beyond it, that the lungs were free from disease, the constitution good, and no cerebral symp- toms present, then, the dyspncea being relieved, and the threatened asphyxia postponed, we might hope to gain time for the operation of other remedies; for, as Trousseau remarks, tracheotomy is not a cure, but a means of gaining time for a cure. Mr. Porter has him- self mentioned a case in which it might be employed: "But, if the infant is, to all appearance, dead, and if the practitioner is called to him within any reasonable time, he should then, with the least possi- ble delay, endeavor to inflate the lungs and restore animation by whatever means shall appear to be the speediest; and of these, per- haps, the most preferable will be laryngotomy." 422. This being the case, I shall mention a few of the peculiarities in the mode of performing the operation suggested by MM. Bretonneau and Trousseau. The trachea should be laid open freely, and as quickly as possible; if we can avoid cutting through the veins, it is desirable; but if we cannot, it is unnecessary to apply a ligature, as the bleeding will stop the moment the canula is introduced. Much time is thus saved, and we escape the chances of phlebitis. When the trachea is opened, a dilator is to be introduced into the wound, the child placed upright, and time allowed for the establishment of respiration and the arrest of the hemorrhage. If the child is in a state of asphyxia or syncope, cold water should be dashed in its face, and a feather intro- ' Surgical Pathology of the Larynx and Trachea, p. 64. 266 CROUP. duced into the trachea, so as to excite inspiratory action. In case of orthopncea, a few drops of water may be thrown into the trachea, and that tube cleared of blood and false membrane by means of a small sponge fixed upon a slender stem of whalebone. Generally speaking, the child will itself reject the blood or loose fluid matters which may be in the trachea, but it will require several light spongings to get rid of the false membranes; and when this is done, if the respiration be fairly established, and the child be vigorous, we are advised to inject fifteen or twenty drops of a weak solution of nitrate of silver; or, if the larynx alone be affected w7ith the disease, to apply a stronger solu- tion to it by means of the sponge. M. Trousseau prefers the large-curved canulaof M. Bretonneau, or the bivalve canula of M. Gendrin. It is necessary to have it suffi- ciently long to allow for the subsequent swelling of the parts, and wide enough to allow for the expulsion of mucus. The canula should be withdrawn and cleansed whenever the air does not pass freely through it. At first, the dilator will be necessary for its introduction, after- wards the wound remains open, and the replacement is easy. After the fourth or fifth day, if the case be going on favorably, we may allow the attempt to breathe through the larynx, as " an essential prin- ciple of tracheotomy is to withdraw the canula as soon as possible;" and when the patient has been gradually accustomed to natural res- piration, and it is performed with facility, the canula may be alto- gether withdrawn, and the w7ound closed. But the operation is only a part of the treatment, merely for the relief of the asphyxia, and will probably fail unless topical remedies be applied. Those recommended by Trousseau and Bretonneau are a strong solution of nitrate of silver applied with the sponge to the larynx, and a few drops of a much weaker solution injected into the trachea, four times the first day, three times the second and third, and once or twice the fourth day, followed by a little warm water. A few drops of water may be thrown into the trachea once or twice every hour, and if the breathing be embarrassed by mucus, the sponge must be lightly used after the injection of water. 423. I shall conclude this account of the operation from M. Trous- seau, by quoting his propositions relative to the prognosis:— "1. If the commencement of the attack date several days back, if, consequently, the disease has advanced slowly, whatever may be the extent of the false membranes in the trachea or bronchi, the child will either recover, or, at any rate, live several days. "2. But if the disease have been rapid, even though we ascertain, at the moment of the operation, that the false membranes do not ex- tend beyond the larynx, the patients die quickly. "3. If, before the operation, the false membranes have invaded the nose, if they cover the surface of a blister, if the child be pale and somewhat puffed, without having taken mercury or been bled, or if it have lost much blood, there is little chance of success from the ope- ration. CROUP. 267 "4. If, before the operation, the pulse is moderately frequent, and if, afterwards, it is calm, we may hope. " 5. If, immediately after the operation, respiration becomes very rapid, and the child coughs but little, or not at all, it is a bad sign. "6. More boys than girls are cured. "7. Children under two and above six years are easily cured. "8. C'ceteris paribus, the danger is in proportion to the extent of the false membranes. "9. If the child have been subject to chronic catarrh, and if it had been suffering from cold some time before being attacked by croup, tracheotomy will be more likely to succeed. "10. Even when the progress is favorable, very rapid respiration is a bad sign. "11. The more rapid and more energetic the inflammation which attacks the wound, the better are the chances of cure ; a sudden sinking in of the wound is a fatal sign. " 12. There is nothing to fear so long as the respiration is noise- less, or when the sound is produced by the disturbance of the mucus ; but if the respiratory sound resembles the noise of a saw cutting a stone, death is certain. "13. If pneumonia or pleurisy supervene, it is no ground for de- spairing of the patient. "14. Agitation and sleeplessness are bad signs. " 15. If the wound be covered with false membranes; if, after the removal of the canula, it remains a long time gaping; if, when almost cicatrized, it re-opens freely; we may conclude that the child is in danger. " 16. The sooner the larynx becomes free after the operation, the sooner we can dispense with the canula, the more certain and rapid will be the cure. " 17. If croup have supervened upon measles, scarlatina, small- pox, or hooping-cough, although there is ordinarily no connection between those diseases and cynanche maligna, tracheotomy will not succeed. " 18. If, on the third day after the operation, the expectoration becomes mucous and catarrhal, the infant will recover; if, on the con- trary, there is none, or it is serous, or like half-dried mucilage, the child will die. " 19. If the patients react violently against the injections of water or the sponging, we must not lose hope, how bad soever the other symptoms may be. " 20. Children attacked by convulsions die, and they are the more liable to them in proportion to their youth, and to the quantity of blood lost before, or during the operation. "21. When, after the tenth day, the drink passes from the pharynx into the larynx and trachea, even though easily rejected, the patients most frequently die. "22. Increase of the fever after the fourth day, agitation, collapse of the wound, and dryness of the trachea, rapidity of respiration, and 268 BRONCHITIS. frequency of cough, announce the commencement of pneumonia, which, at first lobular, becomes pseudo-lobular, and must be treated by the usual means, with the exception of blisters, which are apt to be covered with false membrane."1 424. During the attack of croup, the diet should be strictly anti- i phlogistic; but when the child shows indications of exhaustion, we may give light nourishing food, in any form of the disease. Cold water, whey, barley-water, &c, are pleasant drinks, and should be given quite cold. The temperature of the room should be moderate and agreeable, the air kept pure and fresh, and the bed- clothes light yet warm. In favorable cases, when the child is convalescent, the clothing must be carefully arranged, to secure against cold. I should recom- mend that a light, thin flannel waistcoat be worn for some months. The child should go out only during the warm parts of the day, and carefully avoid damp or cold, and during the prevalence of east winds had better remain in the house. 425. Prophylactic Treatment.—W7hen croup appears among the children of a family, our attention should be directed to those not attacked, in order to anticipate and prevent such a seizure; and a patient recovering from the disease must be watched subsequently with more than ordinary care. All predisposing and exciting causes should be removed or neutralized, if possible. If the climate or locality are unfavorable, the children should be removed, at least for a time ; and if that be impossible, other suitable precautions must be taken. Flannel should be worn to guard against vicissitudes of tem- perature or cold winds. The cold or shower ^ath may be used, followed "by smart friction, so as to insure reaction. The bowels should be kept free, and the slightest cough or cold attended to. If an attack"|be threatened, an emetic, followed by expectorants, warm baths, purgatives, and counter-irritation, should be instantly given. CHAPTER V. BRONCHITIS.—CATARRHE BRONCHIQUE.—BRONCHITE. 426. Bronchitis, or bronchial catarrh, is the term applied to in- inflammation of the mucous membrane of the bronchial tubes, accom- panied with increased secretion; and those two elements, the inflam- mation and the secretion, not being necessarily in exact proportion to each other, has led writers to regard the disease either as a simple inflammation or as catarrh, according to the predominance of either, 1 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 380. BRONCHITIS. 269 and occasioned their estimating the disease as more simple than it is in fact. Following the example of M. Barrier, I shall use either term to express the disease, without limiting my meaning to the strict pathological definition of either. In one form or other, it is undoubtedly one of the most frequent diseases of infancy and childhood. From the moment of birth to ex- treme old age, none are altogether exempt from its attacks; but it is at the extremes of life that it is more severely felt, and more serious in its consequences. 427. Bronchitis may be primary or secondary, simple or compli- cated, general or partial, acute or chronic; and these circumstances will require serious consideration in our estimate of the disease, and in determining the treatment. Let us first speak of primary bronchitis, which I shall divide into acute and chronic, and afterwards of second- ary pulmonary catarrh. i. Acute Bronchitis.—The ordinary form of acute bronchitis com- mences generally with a chilliness over the whole body; the child complains of cold, and objects to quit the fire; this is followed by more or less of feverishness. There is a certain amount of cough from the commencement; sometimes it is slight, at others severe, very rarely in paroxysms; it may be moist or dry, but it is rarely a hoarse cough. At first, the child seems to suffer pain from the cough, and, if old enough, complains of soreness on coughing, which disappears as the disease advances. In the commencement, there is no secretion of mucus, which gives a hard character to the cough, but in a day or two there is a more or less profuse secretion, which whilst it relieves the distress in one respect, may increase it in another by impeding respiration, especially with young infants. „ The breathing is generally accelerated, but the amount varies according to the intensity of the disease. So long as the attack is confined to the larger bronchial tubes, and if the child be tolerably healthy, the respiration is not much hurried; it ranges from 28 to 40 per minute, nor is there much increase of respiratory effort; but when the smaller tubes are invaded, it is both accelerated and im- peded, requiring rapid and energetic muscular effort. When the mucous secretion is established, and in proportion to its abundance, there is a wheezing and rattling in the chest very audible at some distance. In proportion to the cough and disturbance of the respiration will in general be the state of the pulse. In slight and partial attacks it may be but little quickened, but when the disease is general, and the respiration much embarrassed, the pulse will be found very rapid, and the fever considerable. The countenance generally expresses distress; at the beginning it is flushed, but in a more advanced stage, and in proportion to the impediment to respiration, it acquires a bluish tinge, as the conse- quence of the imperfect aeration of the blood. 428. The physical signs are simple and easily recognized. On percussion, the chest yields a clear sound, if the disease be uncom- 270 BRONCHITIS. plicated; but in severe cases we find here and there a certain amount of dulness, which is probably owing to a partial complication with pneumonia. If the ear or the stethoscope be applied to the chest, we shall find the sonorous, mucous, or sibilant rales pretty general, the former es- pecially before the mucous is freely secreted, the latter afterwards. Sometimes the respiratory murmur is completely and permanently masked by them; in other cases they are more partial and temporary, and we can still hear the rapid respiratory murmur. In a few cases there is here and there a moist sub-crepitant r&le audible. When the attack is slight, the appetite will be but little impaired, digestion will take place satisfactorily, and the bowels continue reg- ular; but when the fever is considerable, the appetite is lost, there is occasionally vomiting brought on by the cough, and the bowels will be more or less disturbed. 429. Thus, as characteristic of the attack, we have cough, hurried respiration, perhaps dyspncea, mucous secretion, and fever; and these symptoms generally continue stationary for a few7 days; then, in favor- able cases, the fever gradually subsides, the respiration becomes more tranquil, the cough softer and less distressing, and by degrees the child becomes convalescent in the course of a week or two. This, however, must be considered a favorable case; in many in- stances, the disease, instead of diminishing, assumes a more aggravated form; it may either be complicated with pneumonia, or, extending to the capillary tubes, it may assume the characters of suffocative ca- tarrh, which I shall describe immediately. In either case, the cough becomes more troublesome, the respiration more hurried, the fever more intense, and the general distress and constitutional disturbance more severe. Auscultation will generally reveal the form which the disease has assumed; and, as we might expect, the general symptoms will also indicate-the altered character of the disease. The result is much more doubtful than in the first cases; they ge- nerally recover, but when thus aggravated, if the child is much re- duced already, and the attack very severe, the case may terminate unfavorably. 430. The other modification of acute bronchitis to which I have alluded, and which has been called suffocative catarrh, capillary bronchitis, catarrhal fever, is a more severe and more dangerous form of disease. Fortunately, it is not very frequent; Rilliet and Barthez met with but six cases of it as a primary affection, and three as a se- condary. However, in certain epidemics of bronchitis it is much more frequent. As I have already mentioned, it may grow out of or be grafted upon the former slighter catarrh, or it may assume from the commencement its peculiar characteristics. In most cases, the general symptoms precede the local, or at least their greater severity occasions them to occupy most of our attention. The fever is intense; the pulse rapid and full; the skin is hot and BRONCHITIS. 271 dry, with occasional chills; the face is flushed; there is great thirst; the tongue is white and coated, and there is no appetite. The respiration becomes rapid, not exactly difficult at first, but hur- ried; it afterwards becomes difficult, with wheezing, and requiring great muscular effort. The cough, which either did not exist at first, or was too slight to attract much notice, is now developed or increased, for some time dry, and occurring in a kind of paroxysm or kink; it causes great distress, and greatly increases the soreness or pain in the chest, of which the child complains. At first, there is no expectoration; then we have a whitish or yel- lowish mucus, sometimes muco-puriform in its character, and, very rarely, with portions of lymph. 431. The physical signs do not differ much from those in the or- dinary and slighter forms of disease. The chest is generally clear on percussion, with the exception, perhaps, of some spots of small extent towards the base of the lungs. The respiratory murmur is entirely masked by the sibilant and mucous rales, which are heard over the whole lung, mixed, in some parts, with a moist crepitus. The wheezing is audible at some dis- tance from the patient. 432. These symptoms may all be observed very soon after the commencement of the disease, and every hour they seem to increase. The respiration becomes more hurried and embarrassed, and at length unequal, irregular, and panting, with great oppression, and strong muscular efforts, great heaving of the chest, and rapid action of the ala? nasi. The face is pale or livid, especially after coughing, the lips purple, and the expression of the countenance that of intense anxiety and distress. The patient lies on his back, or requires to be raised into a sitting posture, according to the amount of distress in breathing. The mucous rales in the chest increase according to the abund- ance of the mucus secreted, which is occasionally so excessive as to threaten suffocation. The pulse becomes quicker, but smaller, weaker, and unequal; sometimes, towards the end, irregular. If the disease be not quickly terminated, we may sometimes ob- serve occasional remissions, followed by a return of all the symptoms. In unfavorable cases, the disease rapidly gains ground; the symp- toms become aggravated, the cough most distressing and painful, the respiration amazingly rapid and difficult; the pulse very quick, irre- gular, and almost imperceptible; the features changed, and expressive of agony; the face livid, and covered with profuse perspiration, and at length a kind of convulsive agitation or stupor terminates in death. "In some cases," Dr. Watson observes, "in young patients, in whom bronchitis is idiopathic, and not engrafted on any other disease of the chest, in whom the disorder had not appeared severe, extreme difficulty of breathing will sometimes most unexpectedly arise, and rapidly terminate in the extinction of life. This is attributed to the permanent obstruction or plugging up of one of the bronchi. The 272 BRONCHITIS. slightest attack of bronchitis may, in this way, be suddenly trans- formed into a most serious and quickly fatal malady." 433. The course of the disease is often very rapid. Rilliet and Barthez knew it terminate in three days. M. Fauvel found the du- ration of the confirmed attack from six to eight days, although it may last much longer, even twenty or thirty days. But the attack does not always prove fatal; under judicious treat- ment, at an early period, the disease may be checked; the fever then gradually diminishes, the dyspncea and hurried breathing become calmer by degrees, the cough less frequent and distressing, and the child slowly recovers. 434. The description I have just given, is that of ordinary suffoca- tive catarrh, but in practice we find considerable modifications. Dr. Parrish, of Philadelphia, has described one which is worth noticing:1 " This modification of the disease commences with a cough, and the breathing soon becomes laborious and wheezing; the face is very pale, and the whole surface cold, though generally soft and moist. The countenance acquires a peculiar expression of distress and anxiety, and in some cases the cheeks become very cold, even when the other parts of the surface are of a natural temperature. The sto- mach and bowels are generally inactive, and the urine is small in quantity, but, so far as I have observed, of a natural and healthy color. After the disease has continued for some time, a cold per- spiration breaks out on the face and neck. The cough is at first dry, attended with a wheezing sound in the chest, but towards the termi- nation of the complaint it frequently becomes hurried and rattling. The pulse, in violent cases, becomes very small and rapid, and the tendency to sinking is, in all instances, very obvious. There is constantly much difficulty of breathing, but at times the oppression becomes so great as to resemble a violent attack of asthma. * Occa- sionally, considerable remissions occur for a short period, during which the pulse will become fuller and slower, and the countenance brighter and more calm. When the disease is tending to a fatal term- ination, the patient becomes drowsy, insensible, and comatose, and death takes place by suffocation in a paroxysm of convulsions."2 435. Dr. Eberle has described an epidemic which occurred in the Eastern States of America in 1824, which he calls catarrhal fever, and which has very much the appearance of modified capillary bronchitis. "The disease begins with a slight feeling of distress, and with a dis- tinctly formed chill. The hands and feet become cold, the whole surface of the body pale and contracted, and the patient appears lan- guid and drowsy. This state of depression frequently continues for a whole day before the febrile action is fully developed. In many instances, however, the fever supervenes in a very short time after the first feeling of indisposition. The patient complains of aching pain in the extremities and back, the pulse becomes frequent, some- ' North Amer. Med. and Surg. Journ., vol. i. p. 24. a Eberle on Diseases of Children, p. 322. BRONCHITIS. 273 what tense, and generally full, the cheeks flushed, the eyes suffused with tears, and a thin, transparent fluid usually issues from the nose, attended, at the commencement, with frequent sneezing. The skin is dry and husky, though seldom much above the natural temperature. The bowels are torpid, and the urine scanty and high-colored; and, in many instances, the alvine evacuations, during the first few days, manifest a deficiency of secretion, and sometimes an entire absence of bile. In some cases cough, with slight hoarseness, is one of the earliest symptoms; more frequently, however, the cough does not come on until the fever is fully developed, and often not until the dis- ease has continued for two or three days. The breathing is not often much oppressed in the early periods of the disease, though frequently attended with a considerable rattling in the trachea. In severe cases, however, respiration is frequently difficult and wheezing, almost as soon as the fever is developed, owing to the abundant secretion of mucus into the air-cells. This is most apt to be the case in infants, who, from not making any efforts to free the lungs by expectoration, suffer the bronchial secretions to accumulate in the air-passages." "In the ordinary form and course of the disease, the expectoration becomes very abundant after the fever has continued for three or four days; and as the copious secretion of mucus keeps up a constant irri- tation of the bronchia, the cough usually becomes very frequent as the disease advances."1 • 436. The most marked distinction between the symptoms of ordi- nary bronchitis, and the suffocative catarrh or capillary bronchitis, consists in the greater amount of fever in the latter cases, the occur- rence of depression, almost amounting to collapse, the hurried, wheez- ing, and difficult respiration, the cough being more frequent, and occurring in paroxysms or kinks, and the more imperfect aeration of the blood, evidenced by the tumid and livid features, cold, pallid surface, &c. 437. ii. Chronic Bronchitis.—The chronic bronchitis of infants and children, is generally the sequence of an acute attack of the or- dinary disease, or of suffocative catarrh, the symptoms of which lose their acuteness, and, in a great measure, their severity. There is little or no fever during the day. The cough is soft, moist, and sel- dom occurs in kinks; it is still distressing, however, and, in some cases, particularly so at night, or when lying down. The respiration is natural, with occasional paroxysms of dyspncea. On applying the stethoscope, we find mucous rales mixed with a loud sound, as in dilated bronchial tubes, and the chest is clear on percussion. The pulse is quick, weak, and small, with some exacerbation in the evening, and occasional night sweats. Considerable emaciation, also, is the result of the attack. The face is pale, and the eyes hol- low ; the lips are bluish and sometimes cracked or ulcerated ; the edges of the nares are also sore, and kept so by the child picking them. 18 ' Diseases of Children, p. 318. 274 BRONCHITIS. The strength is very much diminished, the appetite deteriorated oi lost, and, in bad cases, there is colliquative diarrhoea. 438. The aspect of cases so severe as these, is really that of phthisis, and in fact they may run on into that disease. MM. Rilliet and Barthez observe, that "chronic bronchitis, simu- lating phthisis, may present itself under a still more unusual form, and last longer. The disease is then accompanied with fits of suffo- cation, followed by the rejection, sometimes, of a large quantity of pus, sometimes of tubes apparently pseudo-membranous; with the general symptoms already mentioned. Thus, in a case communicated to us by M. Legendre, the child, who was seven years and a half old, commenced, at the age of three and a half or four years, to reject, after' fits of coughing, a considerable quantity of matter two or three times a day. There was constantly difficulty of breathing, fever in the evening, and night sweats. There was dulness on the left side posteriorly, and in that spot cavernous respiration, with mucous rales. The child had all the characters of phthisis. The fever increased, and the emaciative diarrhoea came on, then gangrene of the mouth, which, added to the other disease, ended in death. The disease lasted near four years. It was ascertained by a post-mortem exami- nation, that the child had suffered from chronic bronchitis, with con- siderable dilatation of the bronchial tubes."1 The disease ordinarily lasts from thirty to forty days, and may then terminate fatally; or, under the influeuce of judicious treatment, the disease may yield, the symptoms diminish, and the child regain its health gradually. 439. Pathology.—There is some difficulty in ascertaining the pre- sence of inflammation in the smaller bronchial tubes, because their mucous membrane, being very thin, shows the color of the subjacent tissue; and because, as M. Fauvel observes, the mucous membrane has this resemblance to serous membranes, that the redness disappears immediately after death. In slight cases of acute bronchitis, limited to the trachea and large tubes, the mucous membrane will be found red and inflamed, gene- rally, or in patches, with more or less abundant secretion. If the attack involve the middle bronchial tubes, we shall find the redness and abundant secretion, with dilatation of the tubes, in pro- portion as the disease has been of long standing. In the capillary bronchitis, the extremities of the tubes are closed, partly by the swollen state of the mucous membrane, and partly by the accumulation of puriform secretion, notwithstanding the consider- able dilatation which takes place in a few days. Not unfrequently, in this form of the disease, we find evidence of lobular pneumonia. Chronic bronchitis will generally be found to occupy at once the large bronchial tubes, some of the middle size, and more slightly the smaller ones. Its principal pathological characters are, the abundant secre- tion, the hypertrophy of the mucous crypts whose orifices are enlarged, ' Mai. des Enfans, vol. i. p. 43. BRONCHITIS. 275 hypertrophy of the longitudinal fibrous tissue, and of the muscular fibres of the tracha?a and bronchi, and marked dilatation of the middle and terminal bronchial tubes.1 440. A word or two upon some of these details may not be amiss. The redness of the mucous membrane, which is very commonly seen, is not always present, even in very marked cases. It is gene- rally diffused, and as visible where the membrane passes over the cartilaginous rings as in the interspaces; if it appear only in the latter, we may doubt whether it be not rather due to the subjacent tissues. There can be very little doubt that the mucous membrane is thick- ened, as the result of inflammation, although it is not very easy to demonstrate it, nor can we attribute the obstruction of the smaller tubes entirely to this cause. MM. Rilliet and Barthez occasionally met cases of bronchitis in which the mucous membrane was softened, thickened, and rough, but never any in which it was ulcerated. M. Barrier found it ulcerated only in cases in which tubercles also existed. M. Fauvel detected ulceration in one case of pseudo-mem- branous bronchitis. We must be careful not to mistake the enlarge- ment of the orifice of the mucous crypts for small ulcers. 441. Bronchitis rarely continues for any length of time with in- fants, without causing dilatation*of the bronchial tubes, as the direct consequence of inflammation. Sometimes it may be observed in the course of the tubes, in other cases at their extremities. In the latter case, if the lungs be incised, the surface presents a number of rounded areola?, and if pneumonia co-exist, these are surrounded by denser tissue. Some care is necessary to demonstrate the dilatation of the branches of the bronchia?, but it is not difficult to ascertain it. It is easy to understand how much this dilatation, if extensive, must in- crease the difficulty of breathing, by pressure upon other tubes, and if we remember that the quantity of secretion is excessive, we shall cease to be surprised at the amount of dyspnoea in capillary bronchitis. This secretion varies in character according to the extent and duration of the inflammation. At the commencement, there is little., if any; but in the course of a day or two we find a clear, viscid, frothy mucus expectorated, generally white, sometimes yellowish, if the attack be mild. But if it be severe, or of longer standing, the fluid is more puriform, less aerated, and of a yellowish color. Rilliet and Barthez found occasionally shreds of false membrane mixed with the puriform matter, and in some cases false membrane alone. It is seldom that the large tubes are so far filled with it as to impede the entrance of air, but the smaller terminal ones are often completely choked up. M. Barrier has mentioned other accessory pathological phenomena, discoverable upon dissection, as redness, swelling, softening, and ' Barrier, Mai. de l'Enfance, vol. i, p. 343, 276 BRONCHITIS. sometimes suppuration of the lymphatic glands, near the primary di- vision of the bronchia?; an emphysematous condition of the lungs, depending upon a dilated condition of the vesicles.1 I .may add, that the traces of lobular pneumonia are very common, nor is it very rare to find tubercles, and some traces of pleuritis. Rilliet and Barthez have given the following numerical estimate of the occurrence of these morbid changes: In 174, autopsies of patients who died of bronchitis, redness of the mucous membrane existed in 143; and in thirty-four cases this was co-existent with softening and thickening. Out of the 174 cases, there was dilatation of the bron- chial tubes in seventy-four; in sixteen, dilatation of the " vacuoles;" in seventeen, there was vesicular bronchitis; and in ten, false mem- branes were discovered in the bronchia.2 442. Modifications and Complications.—I have already alluded to secondary bronchitis, which is the most important modification of the disease. It is very common in many other diseases, especially the eruptive fevers. We find it very troublesome in hooping-cough, measles, scarlatina, small-pox, infantile remittent, &c. &c. In many cases it proves a serious addition to the primary malady, requiring care, vigilance, and promptitude; in other cases, the attack being slight, it is of no great consequence. Our judgment upon this point must be formed by a careful estimate of its intensity, the effects of the primary disease, and the state of the child's constitution. The symptoms and physical signs do not differ materially from those already described; but they maybe masked, or our attention diverted from them by the importance of the original affection. 443. The most frequent complication of bronchitis is lobular pneu- monia, and that kind of congestion which, if not checked, runs on into pneumonia. A careful examination in such cases will detect dul- ness on percussing some portions of the chest, and a mixture of sub- crepitus with'the mucous and sibilant rales of bronchitis. I need not say that such a complication adds much to the danger; it renders the treatment somewhat more complicated and doubtful also. Again, the disease may give rise to emphysema of the lungs, in consequence of the dilatation of the extreme ends of the bronchial tubes, or of the air-cells; and we shall find the usual physical signs of the disease, enfeebled respiratory murmur, dry crepitus, and rather unusual resonance on percussion, if the tubes be not filled withmueo- puriform secretion. Although it may add to the tediousness of the illness, I do not know that I could say that it adds to the danger. The disease may extend itself upward to the larynx and trachea giving rise, not to croup, but to a modification of laryngitis, with hoarse cough and rough voice, but with no metallic sound. Lastly, it is a doubtful question how7 far bronchitis may be the forerunner of tubercles. M. Fauvel says it is rare to find tubercles in these cases, and Rilliet and Barthez confirm his statement, so far as the rapid, acute form is concerned; but they are not so clear that they ! Mai. de l'Enfance, vol. i. p. 344. 3 Mai. des Enfans, vol. i. p. 27. BRONCHITIS. 277 may not complicate chronic bronchitis—whether as primary or second- ary affection, may, of course, be doubted. Certain it is that, in patients who have died with bronchitis, tubercles, generally in a crude state, have been found. 444. Causes.—Among the predisposing causes we must include other diseases, in the course of which bronchitis occurs as a secondary affection. Thus, of 115 cases of simple bronchitis, Rilliet and Bar- thez found that but twenty-one were primary. It may also result from the suppression of an eruption to which the constitution is ac- customed. Age appears to have an evident influence upon the production of bronchitis, whether primary or secondary. Rilliet and Barthez state that the majority of their cases were before the age of. six years. Dr. Condie mentions, that in Philadelphia, from 1835 to 1845, 1172 deaths occurred from bronchitis, of which 643 were children under one year; 276 were children from one to two years; 201 from two to five years; forty-seven, from five to ten years; and five, from ten to fifteen years of age.1 Of twenty-three cases which occurred to Dr. Meigs, eight were under two years; ten between two and four years; three, between four and six; and two between six and ten years of age.2 M. Barrier explains this by the greater demand for mucous secretion in infants, to protect the membrane from contact with the air; and this normal activity, which is extreme, is on that account easily increased beyond the bounds of health.3 Primary bronchitis occurs most frequently in girls, and secondary in boys; the latter owing, probably, to the greater frequency of the disease in boys, in the course of which bronchitis occurs as a complication. No doubt much depends upon peculiarity of constitution; it is more common among weak and cachectic infants, or those with an hereditary disposition to catarrhal affections. It may be excited by cold, damp clothes, exposure to inclement weather, low, damp habitations, the prevalence of east or north-east winds, smoke or noxious gases, dis- ordered liver, stomach, and bowels, or dentition. 445. Lastly, either primary or secondary bronchitis may occur as an epidemic, and generally with considerable fever; dependent, pro- bably, upon some peculiar atmospheric influence, constituting the formidable complaint which in France has received the name of "la grippe," and in these countries, the influenza. Such was the epidemic of 1557, described by Valleriola ; of 1580, by Sporisch; of 1733, by Storch; and of 1743, by Huxham, in which gre^at numbers of infants perished. In a paper published by M. Petugain, on the epidemic of 1837 in France and Italy, he observes: " Infancy has escaped better than other ages in Paris, at Lyons, at Geneva, at Corbeil, at La Reole, at Milan, at 1 Diseases of Children, p. 88. 3 Diseases of Children, by Mr. Meigs, Junr., p. 106. 3Mai. de l'Enfance, vol.i. p. 317. 278 BRONCHITIS. Padua, and at Leipsic. At Lyons, out of three hundred intern students of the College, about two hundred were attacked, and of these eighty were under fifteen years of age. During the height of the epidemic, infants were most frequently attacked. Sick children as well as old people were seriously compromised by it. "The nasal mucous membrane was the seat of violent congestion, in consequence of which epistaxis was very common (one in ten, accord- ing to Brachet), which sometimes threatened danger by its abundance, in other cases afforded relief. Age exercised great influence upon the mortality. In London, the disease made great ravages among old people, young children, and invalids. In Italy, as in France, it was old persons who chiefly suffered. At Geneva, more elderly people died than all other ages together. Very young infants, under two years, died in great numbers, according to M. Lombard." 446. In the winter of 1846-7, the influenza prevailed very exten- sively in Dublin, though it did not prove very fatal. I shall give the following extract from a paper I published on the subject in the Dublin Journal, as the best description I can give of the epidemic :— " The number of cases that I have seen within the last two months, and from which my remarks are drawn, exceeds sixty; and they em- brace children of all ages, from two months old to twelve or fourteen years. I may add that, in addition to the children, in many cases, the parents or servants were similarly affected. "I think that, without exception, the younger the child the more severe the attack. " The mode of invasion varied a good deal. In some instances, the whole family seemed to submit to the epidemic influence at once, and all were laid up; in others, one or two would present the epidemic character well marked, and the others complain merely of a slight cough, accompanied in a day or two by feverish symptoms; whilst occasionally each child took sick successively, allowing the one first attacked to recover previously. "The characteristic features of the complaint, as in previous epide- mics of influenza, have been affections of the chest, invariably accom- panied by smart fever. Coughs and colds, without fever, are common enough; but I exclude them, as not true cases of influenza. "The fever sometimes precedes the cough, but more frequently comes on about the second, third, or fourth day. The child is heavy, dull, cross, and cold; creeping to the fire, and unwilling to exert itself, or to share in its usual amusements. The skin becomes hot, florid, and the pulse very quick, ranging from 120 to 160. There is, per- haps, rather less thirst than one w*ould expect from the'degree of fever, and the secretion from the kidneys is scanty, and sometimes high- colored. The tongue is always foul, and loaded with white fur; some- times, though but rarely, dry ; the appetite is lost; and occasionally I have seen vomiting or diarrhoea, but generally both stomach and bowels are steady. In almost all cases, the child has been restless and uneasy at night, sleeping little, and in a few instances slightly delirious. BRONCHITIS. 279 "As regards the local affection, I have observed three varieties, often quite distinct, but occasionally two occurring in the same child. "i. In the milder form of the disease, the primary bronchial tubes were the portion of the respiratory system affected, and this was most common among the elder children. The attack began by a frequent cough and a degree of hoarseness, indicating that the larynx and tra- chea were somewhat affected. The hoarseness often subsided, but the cough continued very troublesome, with free expectoration after the first day or two. In two cases of young children (i. e. under four years of age), the larynx was more seriously affected, and the disease began by an attack of well-marked croup, which subsided in one case in ten or twelve hours, and in the other in two days, leaving behind it the form of influenza I am describing. "The cough gives a good deal of pain, and the elder children de- scribe it as scraping the chest. After a day or two the fever is de- veloped, and the cough not less troublesome, and for some days the child suffers great distress; until the fever subsides, the cough dimi- nishes, and the expectoration becomes more abundant. "If the lungs be examined with a stethoscope, they will be found generally free from abnormal sounds, and the respiration vesicular and natural; but the respiration through the large bronchial tubes gives a rough and slightly sonorous sound. Percussion yields a clear and perfectly natural sound. "ii. The second form of the disease affected children of all ages, and consisted of more or less intense bronchitis of one or both lungs, with great congestion of those organs. In these cases respiration was much more rapid, and performed with some difficulty, a wheezing being audible at some distance. The imperfect aeration of the blood showed itself in the dusky red color of the cheeks, which, in some severe cases, were nearly livid. The cough was incessant, the mucus abundant; but, as little children do not expectorate, this rather added to the distress. The fever set in nearly as soon as the bronchitis, and in some cases ran very high. In some instances, the attack was so severe that suffocation was imminent; but these, with some difficulty and delay, recovered. "When the chest was examined, its movements indicated consider- able difficulty of respiration, and the respiratory murmur was lost in a variety of bronchitic rales, mucous, sibilous, and sonorous, varying according to the extent and intensity of the attack. Mixed with these is frequently heard a crepitus—not the small, distinct crepitus of pneumonia, but larger and more moist. Percussion yielded a pretty clear sound generally, with a diminution of tone occasionally in dif- ferent parts; mainly, I think, in those where the crepitus occurred. "In the progress towards convalescence, the crepitus first disap- peared ; then the movements of the chest became less labored, and the respirations less frequent; the distress diminished, and the fever subsided gradually. The bronchitic rales continued in a minor de- gree for a considerable time; and, what was very remarkable, in a 280 BRONCHITIS. great number of cases, as the general bronchitis diminished, I found the primary tubes, and even the larynx, become affected. "in. The.third form which I observed the affection of the chest to assume, was either simple pneumonia, or mixed with a moderate amount of bronchitis; and, I believe, this form occurred only in young children ; I do not remember any case of it in children above five years old. Its commencement, in most cases, was very obscure. The child labored under high fever, with very rapid breathing, but very little cough. It looked very like a case of remittent fever, and in one or tw*o cases I believed at the first moment it was so, and exa- mined the chest as a matter of duty, to make sure, rather than with any expectation of detecting serious disease. In these cases, double pneumonia existed. The respiration in all wras, as I have said, ex- tremely rapid, with great action of the ala? nasi, but without the labored movements of the chest which occurred in the last variety; the face was flushed, with the centre of the cheek of a florid red color; the pulse very frequent; the thirst considerable, with great restlessness. The usual crepitant rale of pneumonia, clear, small, and distinct, was present, mixed in a few cases with mucous or sibi- lant rales. The part of the chest affected was dull on percussion. Under the treatment adopted, the signs of pneumonia gradually dis- appeared, and, in proportion, the fever subsided, the cough generally increasing for a time, the chest became clear, and the little patient slowly recovered. " Of course, this form of disease involved the greater danger ; and of some of the patients I had but slender hopes, as they were children of weak constitution. "As to the treatment, it has been simple and successful. On the accession of fever, in all the varieties of local affection, I found it most advantageous to give an emetic of ipecacuanha in the first two, and of tartar emetic in the last, and to prolong the nausea for an hour or two. In the second and third varieties, I found leeches necessary when the attack was severe, the respiration hurried and difficult, the pulse quick and strong, and the child able to bear them. "In most cases, after these preliminaries, I ordered a mixture of ipecacuanha wine, paregoric elixir, and almond milk, to be given at short intervals ; but, when pneumonia exists, the tartar emetic mixture is better, and if it should produce great depression, this may be cor- rected by ammonia. A small quantity of ammonia, in the former mixture, was advised by Dr. Stokes, in some of the cases, and with immediate benefit; it seems to relieve the congested state of the bronchial mucous membrane as much as anything I have tried ; or, if it do not answer, from two to five drops of spirits of turpentine, in mucilage and water, every three or four hours, may be given ; in several cases it was very beneficial. If these mixtures disagree with the stomach, or after they have produced their effect, or at the same time that they are exhibited, small doses of calomel, ipecacuanha, and James's powder, may be given with advantage. "As to external applications, I found it necessary, in some cases. BRONCHITIS. 281 to have recourse to blisters, but not very frequently; partly on account of the annoyance they are to young children, but principally because I found a very good substitute in poultices, which I think worthy of a more extensive use than they obtain. They are best made of lin- seed-meal, and should be applied directly to the surface, warm, and very moist, changing them every two hours, or oftener. If irritation be desired,'a dessert-spoonful of the flour of mustard may be mixed with the meal. "Warm baths are exceedingly useful, and may be used every night, provided the child do not cry much ; if it do, it will be better to bathe or foment the feet." 447. Diagnosis.—There is seldom much difficulty in the diagnosis: the physical signs are generally sufficiently clear; the chest is sono- rous on percussion, and there are abundant mucous and sibilant rales to be heard. i. The absence of crepitating rale and of dulness will ordinarily distinguish the case from lobular pneumonia ; but as the two diseases may be co-existent, of course we cannot come to so decided a con- clusion in every case. ii. The cough in capillary bronchitis occurs in paroxysms, like the kink in pertussis, and for some little time the absence of the whoop may not be conclusive; but if this continue, and if the physical signs of suffocative catarrh predominate, we cannot have much doubt. in. It is more easy to mistake a case of chronic bronchitis for one of phthisis, inasmuch as we find cough, emaciation, evening exacer- bations, and night swreats, in both; but a very careful examination of the chest will show that many of the physical signs of tubercles are absent, and that those of chronic bronchitis already noticed, which are present, differ considerably from those of phthisis. 448. Prognosis.—The simple form of bronchitis is not in general very serious, unless it be secondary, and then its importance will rather be owing to the original disease. When the entire mucous membrane is affected, the case is, of course, very serious, and will often prove fatal. Suffocative catarrh is certainly the most fatal form of the disease in these countries. The increase of the dyspncea, the severity of the cough, the feeble- ness and irregularity of the pulse; the oppression, anxiety, and rapid breathing, indicate a fatal termination to the attack; while a gradual mitigation of the symptoms, diminished dyspncea, a firmer, slower pulse, &c, are favorable. 449. Treatment.—There is an important distinction between ca- tarrh in the adult and in infants. When the first stage is passed with the former, and profuse secretion takes place, the disease is essen- tially overcome, and the patient rapidly becomes convalescent; but in the infant, although a certain amelioration takes place when the second stage is established, we cannot always be sure of a favorable termination; for if the bronchial secretion be prolonged, and if it oc- cupy the smaller tubes, there is considerable danger of lobular pneu- monia, unless the treatment be continued. 282 BRONCHITIS. The indications we should have in view are: 1. To diminish the inflammation; 2. To remove or lessen the secretion; 3. To support the strength; and, 4. To relieve certain symptoms when it is impos- sible to do more. 450. When the attack of simple bronchitis is slight, it will often be sufficient to exhibit demulcents and expectorants, with the use of a stimulating liniment to the chest. Almond milk, with ipecacuanha wine and syrup of squills, answrers the purpose very well. Should the secretion be abundant, an emetic will be very useful; and as the disease advances, the addition of a little paregoric will both relieve the cough, and, to a certain extent, control the secretion. A poultice of bread and milk, or of linseed-meal, is very soothing, and if it be desirable to excite irritation, a little flour of mustard may be added; or the compound camphor liniment used. 451. But when the attack is more severe, it will be necessary to commence with more active measures. An emetic, followed by a warm bath, will generally afford some relief; or it may be advisable to apply leeches to the chest, or to cup, regulating the amount of blood abstracted by the age and strength of the child. This will be particularly necessary when the breathing is much hurried, the pulse quick, and the skin hot, whether the affection be of the large tubes or the smaller. All authorities are agreed upon the propriety of blood-letting, and generally that it should be carried so far as to make an impression upon the disease, provided we see the child at the commencement of the attack. It is far less efficacious, and should be more cautiously used, at a later period. After the bleeding is stopped (which should be instantly the leeches fall off), the child should be put into a warm bath, and then returned to a warmed bed. A little calomel and. James's powder may be given once or twice a day, with a purgative when necessary. The ' demulcent and expectorant mixture should be continued, but unless the secretion be very abundant, there is no object in repeating the vomiting. When the fever is lessened, and the pulse reduced in frequency, great benefit will be derived from counter-irritation, either by blisters or a strong liniment. Upon the whole, I think the blisters answer best; but if we wish merely to irritate the skin, compound camphor liniment, or a linseed-meal and mustard poultice (one-third of the latter to two-thirds of the former), will be sufficient. This may be followed by an ordinary poultice, of the soothing, beneficial effects of which upon the lungs, practitioners seem scarcely sufficiently aware. The best proof of this is, that the children like it, and ask for a second application. It should be applied to the surface with nothing inter- vening, and should be warm and moist. When it cools, it should be exchanged for a fresh one. 452. In suffocativecatarrh,vre must have recourse to similar reme- dies, but there are others which will be necessary. The decoction of senega root has been highly extolled, and I think with reason, espe- BRONCHITIS. 283 cially when combined with ammonia and ipecacuanha wine. The two remedies I have found most efficacious in relieving the smaller bronchial tubes, are ammonia, with ipecacuanha or tartar emetic, or spirits of turpentine. The formula? I generally employ, are the following:— R. Mist, amygdal. gii; Vini ipecacuan. £i; Carbon, ammoniae, gr. vi or gr. x. M. A teaspoonful may be given to a child of a year old every three or four hours, and the quantity of ammonia may be increased or dimin- ished according to the age. Or, Mucil. acacke. Syr. simpl. aa 3H; Spts. tereb. rectif. gtt. xx to gtt. xxx; Aquas carui, §ii. M. A teaspoonful to be given every two, three, or four hours. From these medicines I have found great benefit, after bleeding, warm baths, &c. I quite agree with M. Barrier and others, that active blood-letting is essential in severe cases of capillary bronchitis, and that it should be followed by other evacuants, as emetics, pur- gatives, &C.1 Benefit will also be derived from small doses of Dover's powder, or the addition of a drop of laudanum to the expectorant mixture. Counter-irritation is of great value in capillary bronchitis, and cer- tainly blisters answer the purpose better than milder irritants. I have found more benefit with young children from a succession of small blis- ters than from a large one, with far less distress and exhaustion. 453. In that form of the disease described by Dr. Parrish, he or- dered " a warm bath, sinapisms to the feet, a large blister over the breast, and laxative injections, containing assafetida. But the remedy upon which I chiefly relied was assafetida, rubbed up with mint water, given frequently and in large doses." However, as other remedies were employed, they may have had as much influence as the assafetida. Dr. Parrish ordered a drachm of the gum to be rubbed up with an ounce of mint water, and a teaspoonful to be given every two hours. For the catarrhal fever, described by Dr. Eberle, he first freely evacuated the bowels, and then, if the pulse were full and quick, leeches or the lancet were freely used; after which, antimonials, calo- mel, and ipecacuanha, with a mixture containing small doses of tartar emetic, were employed. When the febrile action had been moderated, small doses of Dover's powder were found beneficial. He found an occasional emetic very useful, and an expectorant mixture, composed of equal parts of paregoric, syrup of squills, and sweet spirits of nitre, with water.2 454. Chronic bronchitis will require a somewhat modified treat- ment; we cannot here use blood-letting very freely, nor in every ' Mai. de l'Enfance, vol. i. p. 364. a Diseases of Children, p. 321. 284 INFLAMMATION OF THE LUNGS. — PNEUMONIA. case. I do not mean to say that there are no cases in which it may be necessary, but as a general rule it should be avoided. We must content ourselves with free evacuations from the bowels, an occasional emetic, repeated counter-irritation, diuretics, and expectorant mix- tures, containing the stimulating balsams. Decoction of senega, with carbonate of ammonia, balsam of tolu, Peruvian balsam, &c, will be found very useful. If, as is commonly the case, the disease be complicated, it will be of great importance to relieve the complication; indeed, we shall scarcely overcome the chronic bronchitis without previously effecting this. In most cases tonics will be necessary ; anrlof these, perhaps, some of the vegetable bitters, as quinine, infusion of cascarilla, gentian, &c, will be found the best. It may also be necessary to allow a better diet than in acute cases. 455. In either form of the attack, but especially in the acute, it will be necessary that the air of the room the child inhabits should be fresh, and the temperature equable and warm. It is much better, even when the disease is slight, to confine the child to two rooms, and not to allow it to run about the house, as the frequent change of air irritates the delicate mucous membrane, and keeps up the cough. In capillary bronchitis, it will be still more necessary to keep the infant in a warm temperature, and this course must be continued during convalescence. For some years past, I have been in the habit of recommending a very slight flannel waistcoat next the skin after these attacks, with the best effects. In fact, this climate is so variable, that it is an excellent pre- caution to adopt at the beginning of winter, before the child takes cold; and children who can walk are so apt to stand still after heating them- selves, that it is next to impossible to escape a chill without some such precaution. The diet of the child should at first be very moderate; in most cases the appetite is lost, and no child will eat without one, so that there is no danger of over-feeding. As convalescence proceeds, we must gradually increase the quantity of the food, taking care to keep up the strength without overloading the stomach. CHAPTER VI. INFLAMMATION OF THE LUNGS.--PNEUMONIA. 456. Inflammation of the substance of the lungs is a disease rarely, or incompletely noticed by older writers, and often passed over very superficially by more modern authorities. We are more indebted to the researches of continental physicians, than to those of our own countries, for the information we at present possess. MM. Duges1 ' Recherches sur les Mai. les plus import, et les moins connues des Enf. nouveaux-nes. INFLAMMATION OF THE LUNGS.—PNEUMONIA. 285 and Guersent1 were the first to investigate the subject, and they were followed by Leger,2 Denis,3 Brunet,4 Gerhard,5 Cumming,6 Valleix,7 Billard,8 &c.; but probably the most valuable contribution to the his- tory of the disease is to be found in the works of Rilliet and Barthez,9 Barrier,10 and Dr. West,11 of London. Notwithstanding that the disease has been so often slightly treated, it is sufficiently frequent in children of all ages, and in different cir- cumstances. For example, the registered deaths in Great Britain for 1839, show that 18,151 children—10,000 males, and 8151 females —died of pneumonia ; and in Philadelphia, during the ten years pre- ceding 1845, of 26,510 deaths, there were 1592 cases of this disease. In the appendix to the Registrar-General's Report for 1841, we find that of 1,000,000 children living in the country, 905 died of pneumonia, and 2028 out of the same number of children living in towns. M. Guersent states that three-fifths of the children dying in Paris before the completion of dentition, die of this disease. This is sufficient to prove the frequency of the disease, and to show that it deserves our most careful and minute consideration. 457. Recent researches have established a distinction betwreen pneumonia affecting an entire lobe of the lung, and pneumonia affect- ing the lobules. The former, lobar pneumonia, resembles the disease in the adult; the latter, lobular pneumonia, is peculiar to children. According to Rilliet and Barthez, and Barrier, the latter is much more common than the former; Rilliet and Barthez give the results of eighty-four cases of the former, and 203 autopsies of the latter. Of eighty-one cases of pneumonia, M. Barrier found twenty of lobar, and sixty-one of lobular pneumonia. Dr. West considers this disproportion exaggerated, and that lobar pneumonia, both primary and secondary, is more frequent than our continental neighbors would • lead us to believe; and from my own experience, I am very much inclined to agree with him! But, what is of more practical importance, either form may be pri- mary or secondary, although, as Barrier observes, lobular pneumonia more frequently constitutes the secondary attack. I shall endeavor to lay before the reader a short sketch of the cha- racteristic symptoms of each variety, and then notice the difference to be observed, according as the disease is primary or secondary. 458. Symptoms.—i. Lobar Pneumonia.—This form of the disease, at least when primary, is rarely preceded by catarrh ; the child ex- hibits a degree of fever, with a hot skin, quick pulse, thirst, &c, for a few days, during which time a short cough may be observed, less 'Dictionaire de Medecine. 2Essai sur la Pneumonie des Enfans. 3 Recherches Anat. et Phys. sur quelques Mai. des Enfans. 4 Mem. sur la Pneumonie lobulaire. 5 American Journal of Med. Science, vols. xiii. xiv. 6 Trans, of Assoc, of College of Physicians in Ireland, vol. v. p. 28. 7 Clinique des Mai. des Enfans nouveaux-nes. 8 Traite de Mai. des Enfans. 9 Traite Clinique et Pratique des Mai. des Enfans., vol. i. p. 60. 10 Traite pratique des Mai. de l'Enfance, vol. i. p. 45. " Lectures on the Diseases of Infancy and Childhood, p. 175. 286 INFLAMMATION OF THE LUNGS. — PNEUMONIA. * strong and frequent than in adults, dry at first, and with little or no effort at expectoration. This cough continues, and increases in fre- quency in most cases, but we have not the advantage of the peculiar expectoration of adults, for very young infants swallow the expecto- ration, if there be any; and, in general, up to five years of age, it is not peculiar; from five to fifteen, although the pneumonic sputa may frequently be observed, they are absent in many cases. Very often, the cough is not accompanied with pain in the chest; but, in some cases, when the child is old enough to complain, we find pain circumscribed to the seat of the disease ; in others, it is diffused and obscure; sometimes at the epigastrium, and radiating to the ab- domen ; sometimes near the base of the lung. Dr. Gerhard observed it most frequently at the anterior edge of the axilla. The dyspncea, Barrier remarks, is greater tfyan in adults ; " thus, it is not rare to find a pneumonia occupying the lower half of one lung cause from forty to sixty respirations per minute, whilst in the adult, it would require very extensive disease to produce the same effects."1 And from a careful register of nine patients, he finds that the frequency of the movements of the thorax, compared to those of the heart, were as 1 to 2.69. 459. The respiration, then, is short and rapid ; from 40 to 60 or 80 per minute. Nay, Dr. Cumming2 mentions a case, in which they amounted to 118 ; but, although the frequency may in part be owing to the amount of disease, it appears to be partly an involuntary pre- caution to avoid the irritation and cough consequent on a full inspi- ration. Sometimes, this hurried respiration intermits, and for a short time the respiration seems natural, but very speedily the rapid move- ment is resumed. This acceleration of the respiration and pulse is said to be at its height on the fourth or fifth day; and by the seventh or ninth, if the case progress favorably, the pulse diminishes in fre- quency, and the respiration becomes more calm and deliberate. If the disease increase, the respiration becomes more labored, not less rapid, but with greater muscular effort; the chest heaves, the ala? nasi dilate, and even the momentary interruption caused by speak- ing seems to add to the distress of the lungs. There is an effort now and then to fill the lungs by gaping, sighing, &c, but it appears to be ineffectual; the congestion is so great, that it impedes both the circu- lation in the lungs and the respiration. Rilliet and Barthez have remarked that the irregular, abrupt respira- tion occurred almost exclusively when the summit of the lung was principally affected. When the disease proves rapidly fatal, the frequency of respiration goes on increasing until death; but when the disease is prolonged, we may observe a diminution during the last few days, not from any amelioration, but probably from a degree of organic insensibility. The pulse is very quick from the beginning, seldom under 120, even in cases where the distress does not appear very great; but it 1 Mai. de l'Enfance, vol. i.p. 193. 2 Trans, of Association, vol. v. * INFLAMMATION OF THE LUNGS.---PNEUMONIA. 287 often exceeds this, and may reach 140, 160, or even 180, especially with young children. At the commencement it is generally full, strong, and regular, and in favorable cases, it gradually becomes softer and slower; but in unfavorable, whilst it preserves its fre- quency, it becomes extremely small, irregular, and at length insensi- ble. The-heat of skin bears a relation to the rapidity of the circula- tion : during the first part of the attack, the skin is dry and very hot; towards the end, in unfavorable cases, although the pulse is equally, or even more rapid, the skin becomes cooler, and moistened with clammy perspiration. The decubitus is sometimes dorsal, sometimes on one side or the other, apparently owing to the effect upon the thoracic pain or uneasi^ ness. The expression of the face is that of great distress; sometimes flushed, sometimes pale, or more frequently, with a patch of vivid red on one or both cheeks. The ala? nasi are in active operation, dilating just before or with each inspiration, and the nares are dry, for young infants rarely breathe through the mouth. Rilliet and Barthez have noticed the blue circle which appears beneath the eyes, and which increases with the progress of the disease, especially when there is much emaciation. 460. The physicaljigns of lobar pneumonia are of great import- ance, from the frequent absence of the characteristic sputa of pneu- monia. They, however, do not differ much from those observed in the adult, and therefore I need not dwrell at length upon them. Per- cussion yields a distinct dulness of sound in the affected part, com- pared with those portions of the lungs which are free; but, we must be on our guard against making the opposite side a standard of com- parison, as both lungs are frequently involved; different portions of the lungs, as well as both sides, must be carefully percussed, and it will rarely be difficult to satisfy ourselves. The crepitant or sub-crepitant rale will be heard in those parts of the lungs still in the first stage of inflammation; but when the respi- ration is very quick and short, it is less characteristic, and will require that we make the child cough, or take a deep inspiration. With in- fants who cannot comprehend our directions, the best way is to stop the breath for a moment; the effort to resume it will insure a deep inspiration. The rale may occupy a small portion, or nearly the whole of the lung; it may be heard at the superior, middle, or inferior portions. Not unfrequently, when one lung only is affected, we shall find puerile respiration in the other. When extensive hepatization has taken place, little or no crepitus will be audible, except around the diseased portion; but, instead, we may find bronchial respiration, and something resembling broncho- phony, with extreme dulness. ** The auscultatory signs of the third stage of pneumonia are, in the main, those of the second stage, except that the bronchial breathing usually becomes more distinct and more extensive, occupying situa- tions where either the sub-crepitant rale, or even large crepitation, 288 INFLAMMATION OF THE LUNGS. — PNEUMONIA. ' had previously been heard. As it extends, it becomes audible in front, as well as behind, and both it and dulness on percussion may be perceived in the infra-mammary as well as in the infra-scapular region, to which at first they are almost always limited. This bron- chial breathing is generally much more extensive on one side than on the other, and sometimes it is heard throughout the whole posterior part of one side of the chest; but I never found bronchial breathing confined to the upper part of one lung, except in cases where there existed previous tubercular disease of the organ; and then the pul- monary tissue may become solidified under the influence of an amount of disease which otherwise would be inadequate to produce this result."1 Dr. West observes, that bronchial respiration must always be con- sidered of serious import; in eleven out of twenty cases of pneumo- nia, where it existed, the disease terminated fatally. 461. The appetite is lost from the beginning in severe cases; the tongue is white and loaded, sometimes moist, but generally dry, pro- bably from the endeavor to breathe through the mouth; and the thirst is considerable. In very young children, Dr. WTest has noticed a peculiarity of sucking. Vomiting occurs occasionally at the commencement of the disease, and more frequently than with adults; subsequently, it is generally the consequence of medicine. Diarrhoea, on the other hand, is rare, ex- cept towards the termination, or when caused by the remedies. The secretions are irregularly and variously affected; the urine is high-colored at the beginning, and occasionally scanty, but in many cases but little altered. The liver is less affected than in adults ; nevertheless, jaundice does sometimes, though rarely occur; and in such cases, MM. Chomel and Bouillaud2 conceive the base of the right lung to be the seat of the disease, and the jaundice to be the result of its proximity to the liver; but M. Grisolle has adduced evidence to show that this can scarcely be the reason.3 Others have asserted that the jaundice is not the result of the peculiar condition of the liver, but of the incomplete ha?matosis caused by the pneumo- nia, and that it is analogous to the jaundice determined by purulent infection. It is unnecessary to state, that the strength of the patient is greatly depressed, and that, in a very few days, it is in every way alarmingly reduced. The nervous system does not escape; there is generally a good deal of anxiety and agitation, especially at night. In other cases, there are headache, and a degree of stupor; in a few cases, delirium or con- vulsions.4 In some cases, as M. Tonnelierhas remarked, these nervous symp- toms may be the result of sympathetic irritation, but in others they appear to depend upon coincident meningitis. ' West's Lectures on Diseases of Infancy and Childhood, p. 197. 3 Clinique, vol. ii. p. 138. 3 Traite de la Pneumonie, p. 384. * Barrier, Mai. de l'Enfance, vol. i. p. 200. INFLAMMATION OF THE LUNGS. — PNEUMONIA. 289 462. Duration and Termination.—Lobar pneumonia in children, like the same disease in adults, commences, as we have seen, by rigors, heat, cough, pain in the chest, hurried respiration, dyspncea, and quick pulse; these symptoms continue, and perhaps increase, for a time ; but, when the treatment is successful, they gradually diminish. The pulse becomes slower, the respiration calmer and less labored, the pain disappears, and the cough is softer; then the appetite returns, the tongue becomes clean, and the strength is gradually regained. Unfavorable cases, on the other hand, are marked by an increase of the symptoms ; the respiration becomes more hurried and labored, the ala? nasi moving incessantly; the cough short, frequent, and dis- tressing; the pulse small, weak, quick, and at length irregular or in- termitting; the face livid; the eyes sunken; the lips purple, and the surface cold and clammy. Upon the whole, in primary lobar pneumonia, the result is favorable; only one in twenty of M. Barrier's patients died. The duration of the disease varies somewhat: it is seldom less than from six to twelve days, generally from twelve to eighteen, and fre- quently longer. Dr. Gerhard states the mean duration to be fifteen days. Of fifteen uncomplicated cases, M. Barrier mentions that the disease lasted ten days in four cases; eleven in two; twelve intone; thirteen in one; fourteen in three; and sixteen, eighteen, twenty, and twenty- five, in one case each.1 463. Lobular Pneumonia.—We will now enumerate the symptoms of lobular pneumonia, which differ, in some particulars, from those just described, and which, in many cases at least, may be chiefly owing to the disease being secondary, or occurring in the course of some other malady. In almost all cases, it is preceded by pulmonary catarrh; either the latter is the primary disease, upon which pneumonia supervenes, or, being secondary to some other primary disease (as measles, for in- stance), it runs on into pneumonia. It occurs, also, more generally in infants and young children than lobar pneumonia. Of sixty-one cases related by M. Barrier, twenty occurred from two to three years, and twenty more under five years of age, which will account also for some obscurity in' those symptoms which depend upon the patient's description. For example, we have reason to believe that there is pain or uneasiness in the chest, but with young infants this can only be suspected from their crying when the cough comes on. In older children, it does not appear to be acute and circumscribed, but diffused, and principally in the region of the dia- phragm, not troublesome ordinarily, but excited by coughing. The cough is an important symptom; no doubt, it exists before the pneumonia sets in, in secondary attacks; but even then its increase will mark the accession of the more serious disease. It continues short and troublesome, dry or moist, until the decline of the disease; but in fatal cases it often disappears for two or three days before death. ' Mai. de l'Enfance, vol. i. p. 24. 19 290 INFLAMMATION OF THE LUNGS.—PNEUMONIA. In some rare cases of latent pneumonia, the cough is nearly absent, and these occur generally in weak, cachectic children. The cough does not occur in kinks, neither is it hoarse, unless the disease be complicated. We can derive but little assistance from the expectoration, for, in many cases, there is but little secreted, and by infants and young children it is always swallowed; but, from some observations he made, M. Barrier is of opinion that, if it occurred, the sputa, in many cases, would exhibit the pneumonic character. The dyspnoea and hurry of respiration are in proportion to the ex- tent of the bronchitis and pneumonia, and fully as much owing to the former, when severe, as to the latter. Thus, with intense catarrh and a pneumonia of moderate extent, the respirations will occasionally amount to fifty or sixty per minute. On the other hand, when the pneumonia is extensive, and the bronchitis slight, the respiration will be found very rapid and short, with free motion of the ala? nasi, and ultimately of the chest and ab- domen. "Moreover," M. Barrier observes, "it is not merely by the number of respirations per minute that we must judge of the extent and gra- vity of the lesions of the lungs. We must also observe whether the respiration be superficial or profound ; if it be easy, or painful and anxious ; costal or abdominal; regular or irregular. In general, the more frequent, deep, and anxious it is, the more serious is the attack. But we must not forget that, occasionally, we find the respiration in- creased in infants for a few minutes, without apparent cause, and that it soon subsides again."1 464. The physical signs are of great importance, even though they may not be quite so definite and certain as in adults. Dr. Gerhard lays great stress upon the dulness on percussion; he conceives it in many cases of more use than auscultation. M. Vernois found the dulness very marked in twenty out of twenty-two cases, and slight in the remaining two. M. Valleix found dulness in twelve out of six- teen cases; seven times on the right side, and five times on both sides.2 Rilliet and Barthez found but little deviation from the normal sound in partial or mamellonated pneumonia, but decided dulness in the generalized form. M. Barrier states that, in "disseminated lobular pneumonia," the results of percussion are completely negative, and that there is no dulness unless from some complication; but that, when the disease has gradually spread and coalesced in " generalized lobular pneumonia, the sound is dull on percussion."3 My own experience coincides with Dr. West's, who remarks: "Per- cussion sometimes yields a very manifest dulness on the affected side • and this dulness is usually most evident in the infra-scapular region. At other times, however, no such marked results are afforded; but the lower parts of the chest yield a somewhat duller sound than the upper, ' Mai. de l'Enfance, vol. i. p. 103. 2 Clinique des Mai. des Enfans, vol. ii. p. 132. 3 Mai. de l'Enfance, vol. i. pp. 105-7. INFLAMMATION OF THE LUNGS.—PNEUMONIA. 291 and the impression communicated to the finger is that of greater solidity below than above the scapula?. This last sign is very valuable, since it may be perceived at a time when the ear cannot clearly detect any actual dulness on percussion."1 In the disseminated or partial form of the disease, we find the sub- crepitating and mucous rales, with an occasional mixture of the sibi- lant. Rilliet and Barthez lay great stress upon the subcrepitant rale, as being often the only sound to be heard throughout the course of the disease. It is generally audible at the back of the chest, some- times in front, and at different points, according as the lobules affected may be distant or near. The true crepitant rale is much rarer in infants than in adults, although it is occasionally audible for a few moments. If one lung only be affected, we shall find the sub-crepitant rale on one side and puerile respiration on the other; but if both be affected, as Dr. West remarks, we may overlook the disease, owing to the absence of con- trast, unless the disease of one lung be so far advanced as to give rise to bronchial breathing, whilst in others nothing but the sub-crepitus can be detected. At a more advanced period, or, what is much the same thing, in the " generalized lobular pneumonia," we have present more or less of the preceding phenomena, but with certain modifications. The diseased portions having coalesced, and the lung having become more generally solid, we find bronchial breathing, both in expiration and inspiration, in one or both lungs posteriorly, and even bronchial rales and bron- chophony. The sub-crepitant rale has changed a good deal, the bubbles are smaller, and the crackling much finer; in fact, in many cases we find the pure crepitating rale of lobular pneumonia, as in the adult, especially when the disease is superficial. Occasionally, these more defined phenomena of pneumonia are masked by the great amount of moist rales; but even these have a sort of metallic sound in this disease, which, taken along with the vocal resonance and the dulness on percussion, may prevent an error in our diagnosis.2 With regard to the vocal sounds, Dr. West observes: "In the child, we lose all the evidence which in the adult is afforded by the different modifications of the voice sound; for the shrill or querulous tone of a suffering child, and the words, often uttered in very differ- ent keys, yield, even when the child is old enough to talk well, results far too uncertain to be trustworthy."3 465. The external appearance of the infant is not characteristic; it will show that the chest is affected, but not the peculiar form of disease. Thus, the face may be pale or colored, swollen and puffy, or red; very often, while the rest of the face is pale, there is a bright spot of red on one or both cheeks. The ala? nasi will be found in 1 Lectures on Diseases of Children, p. i95. a Rilliet and Barthez, Mai. des Enfans, vol. i. p. 80. 3 Lectures on Diseases of Infancy and Childhood, p. 195. 292 INFLAMMATION OF THE LUNGS. — PNEUMONIA. action in proportion to the hurry and difficulty of respiration, and the eyes appear sunken. The patient lies generally on his back, but is not more distressed by lying on one side than the other, which may be because the pneu- monia is frequently double. The pulse varies very much, of course, but it is generally in pro- portion to the extent of the inflammation; it may range from 100 to 110, with but little heat of skin, in weak, delicate children; to 140, 160, or 180, with high fever in others. Towards the termination, it either gradually becomes slower and more natural; or quicker, weaker, and irregular, according as the result is favorable or unfavorable. The usual relation between the respiration and circulation is destroyed; in the adult, suffering from pneumonia, it is as 1 to 4; in infants, it is as one to 2 or 3. The digestive system is more or less deranged; vomiting is fre- quent at the commencement of the disease, but rare subsequently. Intestinal catarrh, according to M. Barrier's experience, precedes the attack' of pneumonia in many cases, and in others we often have diarrhoea in the course of the disease, especially when it is secondary to measles; and in these cases, if the pneumonia be extensive and advanced, it will be a very unfavorable addition; but, if the result of calomel or tartar emetic, it is not of so much consequence. Besides this diarrhoea, however, we have no symptoms of intestinal inflamma- tion ; there is neither pain, tenderness, nor tympanitis. As in lobar pneumonia, we may have a certain degree of sleepi- ness, indifference, or cloudiness of intellect; nay, even some more marked nervous affections, as anxiety, agitation, contractions or con- vulsions, and delirium. 466. i. Termination and Duration.—As I have described it, lobu- lar pneumonia may continue steadily advancing, the symptoms in- creasing in gravity, and the constitution suffering more severely, until death. Or, the disease having arrived at its maximum of intensity, the symptoms may gradually diminish; and, if the termination is to be favorable, this amelioration will affect both the general and local symptoms. In some cases, we have an improvement in some one or two symptoms for a time, and then a return; such cases generally terminate fatally. It is more difficult to fix the duration of lobular than lobar pneu- monia, because, the former being most frequently secondary, and stealing on more or less insidiously, we cannot ascertain the exact period of invasion. Rilliet and Barthez give the following duration in eighty-three cases : in twenty, it lasted from one to five days; in nineteen, from six to ten days; in sixteen, from eleven to fifteen days ; in twenty, from sixteen to twenty-five days ; and in eight, from twenty-six days upwards. M. Barrier remarks, that those cases which are cured are of the longest duration; the fatal cases he has never known to last longer than from twenty-five to thirty days. The others may run on for a month or two. INFLAMMATION OF THE LUNGS. — PNEUMONIA. 293 467. n. Lobular pneumonia may result in abscess of the lung, as a termination; but, probably, in most cases, it will escape detection, unless purulent matter be expectorated. This, and a large mucous rale, approaching to a gurgle, may enable us to suspect the existence of an abscess, when the bronchial tubes communicate with it. In other cases, it may be impossible to decide. Moreover, as these ab- scesses tend to the surface, and occasionally open into the pleura, the very sudden occurrence of pleurisy may lead us to suspect a per- foration. 468. m. In some rare cases, pneumonia terminates in gangrene; the symptoms are those of pneumonia, with extreme depression of strength, profound constitutional suffering, and a rapid course. It seems more apt to attack children during exanthematous fevers, whose constitution has been much deteriorated; and, it is not uncommon to find, at the same time, gangrene of some other parts. Of eighteen cases of gangrene, mentioned by Rilliet and Barthez, three had gan- grene of the mouth ; one, of the pharynx; two, of the oesophagus ; one, of the larynx and pharynx; one, of the bronchial glands and spleen; one of the glands, pleura, and oesophagus; and one of the pleura alone. In Dr. West's case, there was gangrene of the mouth. From all the circumstances, Dr. West infers, and I think with great proba- bility, that the gangrene is due rather to some peculiar morbid altera- tion of the circulating fluid than to the violence of the inflammatory action. 469. Such are the characteristics of lobar and lobular pneumonia; either may be primary or secondary; but the lobar is more frequently primary, the lobular secondary. The principal differences are in the mode in which each commences, in the greater amount of fever, the dulness on percussion, the crepi- tating rale, and the quicker termination of the former; the insidious approach, the greater obscurity of the physical signs, the slight dul- ness on percussion in the first stage, the diffused subcrepitant rale, the different points at which it is heard, and the changes which it undergoes subsequently, the greater duration, and greater fatality, of the latter. 470. Now7 let us examine the different characters of primary and secondary pneumonia, wdiether lobar or lobular. Primary pneumonia commences by intense fever, with occasionally a slight bronchitis preceding, in very young children. The respiration is always rapid, with thoracic pain occasionally, and a short, dry cough. Auscultation reveals the existence of crepitant or subcrepitant rales on one side of the chest, and especially towards the base of the lung. Vomiting occurs at the beginning, and, occasionally, diarrhoea. There are anxiety, agitation, and sighing. As the disease advances, some of these symptoms disappear, and new ones appear. The fever rather increases, as do the dyspncea and hurry of respiration ; the ala? nasi are observed to move extensively, and more effort is required to breathe ; the cough is very troublesome, short, and painful; ex- pectoration makes its appearance, except in young subjects; the 294 INFLAMMATION OF THE LUNGS. — PNEUMONIA. pulse is very quick ; the crepitating or subcrepitating rale gives place in some portions to bronchial respiration and bronchophony, and the chest yields a dull sound on percussion. These symptoms attain their height about the fifth or sixth day; but, after the eighth or ninth day, in favorable cases, they begin to subside, the fever diminishes, the pulse and respiration become slower, the ala? nasi are quiescent, the heat of skin subsides, the large subcrepitant rale is freely heard, with bronchial breathing more rarely, and chiefly in expiration. The sound of the voice is diffused, and the dulness less marked. By degrees, the appetite returns, the spirits and strength of the child are recovered, the cough diminishes, the fever altogether disappears, and the patient becomes convalescent. 471. When pneumonia supervenes upon another disease, or is secondary, it presents very different characters; and the difference is greater, according to Rilliet and Barthez, the earlier the secondary affection supervenes upon the primary disease. Secondary pneumonia (most frequently lobular) is apt to steal upon us very insidiously; the pulse, respiration, and countenance, affected by the primary disease, undergoing but little change. The cough may be troublesome; but there is little thoracic pain, and no expec- toration. If no cough existed previously, we shall be induced, pro- bably, to examine the lungs, and thus the complication will be detected. The subcrepitant rale will be heard on one or both sides posteriorly. As the disease advances, the fever will increase, the pulse become quicker, the respiration more hurried, the cough more constant; the strength diminishes, and the face will have a worn, anxious, and distressed expression. The chest will gradually become dull on percussion, and with the subcrepitant rales we may also hear bronchial respiration and bronchophony, increasing in intensity and extent. The primary disease will generally be found to have under- gone an unfavorable change, and with these unfavorable symptoms will at length be found others, such as feeble and irregular pulse, violet color of the face, great dyspncea, coldness of extremities, &c, which denote the approach of death. We can readily understand that the secondary must be more fatal than the primary, because the child has to combat a second most for- midable disease at a time when his strength is reduced, and his con- stitution shaken, by a previous one. Of sixty-one cases noted by M. Barrier, forty-one died. 472. Complications.—When we recollect the anatomy of the lungs, and consider their contiguity with the tissues which line or surround them, we cannot be surprised at other affections supervening in the course of pneumonia. i. Bronchitis.—In a great majority of fatal cases, evidences of in- flammation of the bronchial mucous membrane are found after death and in a very large number we can ascertain its existence during life, either as a primary or secondary affection. Barrier has proved that lobular pneumonia is preceded, in a very large proportion of instances INFLAMMATION OF THE LUNGS. — PNEUMONIA. 295 by pulmonary catarrh, and that it is, probably, an extension of this latter affection. Rilliet and Barthez have drawn the following con- clusions from their experience :— " 1. That the bronchitis, which coincides with pneumonia, is almost always an affection of the small tubes. 2. That, in a great majority of cases, it co-exists with lobular, mamellonated, partial, and gene- ralized pneumonia; more rarely with lobar pneumonia. 3. That bronchitis, with dilatation, is found almost exclusively in infants who have died of partial or generalized (lobular) pneumonia; almost none in those who have suffered from lobar pneumonia. 4. That bronchitis exists almost always either in the centre of the part hepatized, or in the portions surrounding it, but that it may occur elsewhere. 5. That dilatation of the bronchi is frequent in the carnified tissue."1 473. ii. Pleuritis is a frequent complication of pneumonia, and so intense is it occasionally, that the disease may well be called, as it is by some, pleuro-pneumonia. About one-fourth of Rilliet and Barthez's patients, attacked with lobular pneumonia, exhibited traces of recent pleurisy. The proportion of those suffering from lobar pneumonia, who had secondary pleurisy, was even higher; it amounted to one- half. I do not think that the complication is so frequent in this country, or in private practice ; but still it does occur, and adds much to the danger. In most cases, it is extremely difficult to detect the presence of pleurisy, the symptoms, and even the physical signs, being masked by those of the existing pneumonia; but now and then we may arrive at a just conclusion. 474. in. When we consider the extreme difficulty of the respiration in some cases, and the violent efforts made by the child, we shall not be surprised that the disease is occasionally complicated by emphy- sema, which is, in general, in proportion to the extent of the pneumo- nia and bronchitis, to the acuteness of the disease, and to the amount of dyspnoea which is present. 475. iv. I have already mentioned that lobular pneumonia is occa- sionally complicated with convulsions and other cerebral affections of minor degree. Six of M. Barrier's cases were thus attacked, and died. In three, there were proofs of meningitis. 476. But in many cases, the pneumonia, whether lobar or lobular, but far more frequently the latter, is secondary, and occurs as a com- plication in the course of other diseases. It occurs most frequently in the course of measles, but we find it complicating scarlatina and other febrile eruptions, hooping-cough, croup, pleurisy, bronchitis, cancrum oris, intestinal catarrh, typhoid fever, &c. 477. Morbid Anatomy.—i. Lobar Pneumonia.—I need not enter at length upon the post-mortem appearances found in lobar pneu- monia, as they are identical with those in the adult, and will be found laid down in all the modern books on the subject. We find, in in- fants, evidences of congestion, red and gray hepatization, extending ' Mai. des Enfans, vol. i. p. 75. 296 INFLAMMATION OF THE LUNGS. — PNEUMONIA. from the base of the lung towards the summit, but very rarely termi- nating in abscess. Dr. West has stated the result of forty-seven cases carefully noted: in five, the first and second stages of pneumonia co- existed ; and in four, the first and third ; in thirteen, the second and third ; in eleven, all three stages; in three, the first stage only; in six, the second stage ; and in five, the first stage only ;*• and this, as he observes, agrees very closely with the results obtained by M. Gri- solle in the adult. In forty cases, he found that the first and second stage co-existed in four; the first and third, in three ; the second and third, in sixteen ; all these stages in two cases; the second stage only in seven ; and the third stage only in eight.2 It resembles the pneumonia of adults, also, in being more frequently single than double, and more common in the right lung than the left. Of 1430 cases in the adult, M. Grisolle states that 742 were on the right side, 426 on the left, and 262 double. Of eighty-four cases in children, given by Rilliet and Barthez, forty-eight were of the right lung, twenty-seven of the left, and nine double.3 Of M. Barrier's twenty cases, ten were of the right lung; six of the left; and four were double.4 In cases of double pneumonia, both lungs are pretty equally affected. Of seventy-five cases in which a single lung was affected, Rilliet and Barthez found forty-eight in which the base, and twenty-seven in which the summit, of the lung was diseased; and of the latter, twenty- three -were of the right, and four of the left lung. M. Barrier, in twenty cases, found the entire lung affected in three cases; the inferior lobe in twelve ; the superior in four; and the su- perior lobe with the upper part of the inferior in one case. Observation has also proved that the posterior portion of the lung is more frequently affected than the anterior; and even when the post- mortem examination shows both to be involved, the history of the case would lead us to the conclusion that the disease commenced pos- teriorly. 478. ii. Lobular Pneumonia.—The credit of more accurately de- scribing this form of the disease is certainly due to Rilliet and Bar- thez; and they have been succeeded by observers in no way inferior, whose views differ slightly from them. Their opportunities have been so great, that I shall be excused, I trust, for borrowing freely from their description. Anatomically speaking, lobular pneumonia is so called from its occupying one or more lobules; and it has been divid- ed into several varieties, mamellonated, disseminated, partial, gene- ralized, with an additional species, by M. Barrier, which he calls pseudo-lobar. "When we examine," observe Rilliet and Barthez, "the lungs of subjects who have died from this disease, we find them extremely soft and flaccid, of a grayish rose color, with patches of violet red here and there, generally circumscribed, prominent, solid under the ' Lectures on Diseases of Infancy and Childhood, p. 176. 5 Traite de la Pneumonie, p. 18. * Mai. des Enfans, vol.i. p. 72, note. * Mai. de l'Enfance, vol. i. p. 185. INFLAMMATION OF THE LUNGS. — PNEUMONIA. 297 finger, and not collapsing when the chest is opened, as the surrounding pulmonary tissue does. These patches, ordinarily circular, but some- times elongated from above downwards, are most frequent at the posterior edge of the lung, but are to be found on other portions. Oc- casionally, they are not visible; but nodosities, more or less deep, can be felt in the substance of the organ." When cut, the lung presents a marbled appearance, of a grayish-red color, mixed with violet red, the latter corresponding to the external red patches; and we see that these patches and the deeper nodosities are centres of congestion and hepatization, whose characters resemble those of pneumonia generally; i. e., the surface cuts smoothly, is gra- nular when torn, easily penetrated by the finger, and sinks when placed in water. On pressure, these portions of the lung crepitate very little, or not at all; but asanious, frothy fluid escapes: from the central por- tion, if pressed, we obtain a red, serous fluid, without air, as in lobar pneumonia. " The three degrees of pneumonia maybe observed; the first with the tissue marbled, of a rose and gray color; the red portions, irre- gularly limited, somewhat less resisting than the neighboring parts, floating in water; when pressed, giving forth a frothy fluid, and cre- pitating under the finger. This is the first degree; the second has just been described. " The third degree is characterized by a gray, yellow, or yellowish- gray color, owing to the infiltration of pus in the pulmonary paren- chyma. The tissue is very friable, and pressure expresses a purulent fluid. When the tissue is chiefly gray, it is possible to mistake the disease, unless care be used, inasmuch as it presents a resemblance to the surrounding healthy tissue."1 The same authors have entered into more special detail, however, and have described three varieties: the mamellonated, the partial, and the generalized. 479. i. The mamellonated lobular pneumonia consists of a small nodule (noyau) of hepatization, quite distinct from the surrounding tissue; it is an isolated point of disease, in the midst of healthy or nearly healthy tissue, with its limits clearly defined. The limits are occasionally marked by a white resisting circle or space, like a fibrous capsule; and ordinarily we can define the extent of the diseased por- tion from its prominence, which results from the shrinking of the surrounding parts, when cut through. The volume of these nodules varies from that of a hemp-seed to a pigeon's egg; their shape is generally regular and spherical, or some analogous form ; varying in number from one to twenty or thirty in the same lung. They result, it is clear, from the inflammation being limited to one or more lobules, without extending to the neighboring tissue; but in some few cases they are surrounded by a portion, in the first stage of pneumonia, just as we see in the case of tubercles. 480. In these nodules of hepatization, it is not rare to find the dis- ' Mai. des Enfans, vol. i. p. 62. 298 INFLAMMATION OF THE LUNGS. — PNEUMONIA. ease attain the third degree, and form an abscess. The pus primarily deposited in the pulmonary tissue is collected in the centre of the inflamed lobule, surrounded by two concentric zones, the inner one of a yellow color, the third degree of inflammation, and the outer one of a red color, inflammation of the second degree, or hepatization. By degrees, the suppuration is increased, at the expense of the inner circle and of the outer, and the centre is surrounded by a layer of false mem- brane. If several lobules close to each other have been attached, the abscess may be multilocular, and each cavity separated from its neigh- bor by a thin layer of hepatized tissue; or, this being broken through, they will communicate with each other. These abscesses maybe situated in any part of the lungs; but they have rather a tendency towards the surface, and we occasionally find an adhesion between the two pleura? at this point. If this adhesion do not take place, the abscess may open there, and a pneumothorax be the result. Rilliet and Barthez met one case in which adhesion took place between the pleura of the base of the left lung and the dia- phragm, and through this adhesion the abscess opened into the peri- toneal cavity. 481. M. Barrier differs from the view taken, by Rilliet and Barthez, of these abscesses; but as I have not entered very minutely into their description, I shall avoid the controversy altogether, and simply quote M. Barrier's conclusions: "Lobular pneumonia may terminate by suppuration in three ways: 1. Gray hepatization, when the pus is combined with, and infiltrated into, the parenchyma, constituting the most frequent and least advanced form. 2. Purulent collection in the lobule, with direct, free communication with the corresponding lobular bronchus, which is dilated but not interrupted in its continuity, and which seems to widen in order to form the purulent cavity (va- cuole). This is far from being rare, and is intimately connected with capillary bronchitis. 3. Abscess, properly so called, or collections of pus, primitively isolated, and closed completely, communicating at a later period with the bronchial tubes, by rupture of its walls. This form is really very rare."1 The number of abscesses varies very much; sometimes there is but one, in other cases a great number. They are rarely found in both lungs, and most commonly in the left. Of twenty-six cases, Rilliet and Barthez found abscesses in seven cases in the right lung; in fifteen cases in the left lung; and in four in both lungs. Eight of these cases occurred in infants from one year to two and a half years old ; ten, from three to five and a half; three, from six to ten and a half; and four, from eleven to fifteen years of age. 482. ii. The partial lobular pneumonia is less defined than the mamellonated; its circumference is confounded insensibly with the surrounding tissue, without our being able to decide upon its limits from the color or prominence. The volume of the diseased portion is often considerable, and its form irregular. The whole may be 1 Mai. de l'Enfance, vol. i. p. 60. INFLAxMMATION OF THE LUNGS. — PNEUMONIA. 299 hepatized, or the outer portion congested, and the centre hepatized ; and, by the extension of the inflammation, many separate points of disease may be united, so as to involve nearly the entire lobe, and so constitute the generalized partial pneumonia. When the latter passes into the third degree of inflammation, it becomes, to all purposes, lobar pneumonia, and yet there is a considerable pathological differ- ence. The three degrees of inflammation are evident in both, but they are disposed differently; in the latter, commencing most gene- rally at the base, and ascending, we shall find the lower portions the most advanced, and the superior less so; whereas, in generalized lobular pneumonia, the most advanced portions will be those of longest standing ; and, as the disease begins at different points, we may find gray hepatization in any part, and congestion or red hepatization occupying the spaces between. Abscess may be the result of this species of pneumonia, but less frequently than of the former. Still more rarely is it found with the lobar pneumonia, although such cases are on record. Out of 203 autopsies of lobular pneumonia, Rilliet and Barthez met with seventy of the mamellonated, 140 of the partial, and 104 of the generalized pneumonia. Thus it seems quite possible that capillary bronchitis (443) may run on into lobular pneumonia, and lobular pneumonia, by becoming generalized, into lobar pneumonia; but it is far from being a neces- sary transition. 483. Carnification.—There is another morbid condition which de- mands our attention. It has not been described by authors generally, although sufficiently frequent; its existence was first noticed by M. Rufz, in his memoir. He states : "I have observed an alteration of the pulmonary tissue, which is certainly not hepatization, although I am quite ignorant of its symptomatic value. This condition is ordi- narily found along the inferior border of the superior lobe; it may also occupy all the middle lobe, or the circumference of the base of the inferior lobe, to the extent of from a line to half an inch in thick- ness. In these parts, the pulmonary tissue is collapsed, of a violet color, but with whitish patches, which circumscribe the lobules. There is no crepitation; the air appears entirely expelled ; one would say that it was a portion of lung which had not as yet been expanded by respiration. When detached, it does not float; it is firm, and, when hepatization co-exists, it is not easy to perceive the difference at the first glance."1 When cut into, we find a red, smooth, resisting tissue, on pressure furnishing a sero-sanguineous fluid, free from air; resembling a divided muscle in appearance ; hence the name. Thus, as to situation and form, it resembles each variety of hepa- tization. This peculiar condition is nearly as frequent in the right as in the left lung, and more frequently single than double; the most common situation for it is on the left side, near the heart, and on the right side, in the middle lobe. ' Journ. des Connois. Med.-Chir., 1835, 404. 300 INFLAMMATION OF THE LUNGS. — PNEUMONIA. Rilliet and Barthez observed forty-two cases of carnification: six- teen double ; seventeen on the right side only; and nine on the left.1 484. Gangrene of the Lung.—This termination of inflammation is very rare in children. Rilliet and Barthez met with eleven cases ; Barrier does not mention the subject; and Dr. West has seen but one case. I shall quote Dr. West's description of the post-mortem ap- pearances, as being as concise and accurate, and more vivid, than any I could give: "The right lung, which consisted only of two lobes, was universally solid, and not crepitant, with the exception of about a fourth of the upper and inner edge of the upper lobe, which was emphysematous. The two lobes were connected together by a layer of yellow lymph. The exterior of the lung generally was of a dark, reddish-gray color, with irregular patches of yellow deposit beneath the pleura, some of which were nearly half an inch in length and a quarter in breadth; besides which, many small, purulent deposits were contained within the pulmonary vesicles, as in vesicular bron- chitis. The upper part of the upper lobe, and a small portion near the diaphragmatic surface of the low7er lobe, felt soft and boggy to the touch. On cutting into the upper lobe, a. cavity was opened as large as a hen's egg, very irregular in form, intersected in various directions by the tubes and vessels that crossed it, from which, as well as from the walls of the cavity, portions of the lung hung in shreds. The cavity contained a small quantity of dirty, grayish- yellow putrilage, which exhaled a most fetid odor. The substance of the lung in the immediate neighborhood was in a far advanced stage of purulent infiltration, and other parts of the lobe were in an earlier stage of the same condition; besides which, small collections of puriform fluid, not bigger than a split pea, were found in various parts of its substance. The state of the lower lobe on the whole resembled that of the upper, but the cavity in its lower part was not larger than a marble, and contained a small quantity of yellow pus, of a less fetid character than that in the upper lobe. The bronchial glands were swollen, soft, of a homogeneous aspect, and a gray color ; but neither in them nor in either lung, nor in any organ of the body, was there the least trace of tubercular deposit."2 485. So much for the principal lesions of the lung resulting from, or connected with, pneumonia. I must just notice one or two others more or less frequently observed. i. Bronchitis.—Inflammation of the mucous membrane of the bronchi may be detected, in the great majority of fatal cases of pneu- monia, and especially of lobular pneumonia, from the earliest slio-ht congestion, with increased secretion, up to entire vascularity, thick- ening, and softening of the mucous membrane, and dilatation of the tubes, with purulent or pseudo-membranous matter contained in them. Although the tubes connected with the diseased lobules are almost always affected, yet they are not invariably so, nor is the inflamma- ' Mai. des Enfans, vol. i. p. 74. a Lectures on Diseases of Infancy and Childhood, p. 209. INFLAMMATION OF THE LUNGS. — PNEUMONIA. 301 tion limited to these tubes. I have already given Rilliet and Barthez's conclusions from their experience. ii. The pleura not unfrequently exhibits evidence of ancient or re- cent inflammation, more frequently the latter. Adhesions, false mem- branes, vascularity, and effusion may, one or all, be observed in these cases of secondary pleuritis. M. Valleix met with them in twenty cases out of 123. in. The bronchial glands are often quite healthy; in other cases, they are enlarged, softened, and red, or they may contain tubercular matter. Their alterations, however, are of no practical importance. iv. According to M. Barrier, in a small number of cases, compli- cated with convulsions, traces of inflammation of the membranes of the brain were detected; in other similar cases, no such evidences were found. v. The intestinal canal may occasionally exhibit marks of irrita- tion ; but, although diarrhoea is a very common complication of se- condary lobular pneumonia, it rarely, if ever, appears to be owing to inflammation of the mucous membrane, except in cases complicated with muguet or tubercles.1 486. These, I believe, are all the morbid phenomena to be learned by a post-mortem investigation; the inquiry still remains as to what relation they bear to each other. Whether they are, in truth, a chain beginning with bronchitis and terminating at gangrene, or whether there is some difference in kind? Whether bronchitis invariably pre- cedes lobular pneumonia? Whether every form of bronchitis may originate pneumonia, or what form has this peculiar consequence? And why, if this be the result of any species, such an effect should be confined to the period of infancy? -> M. Barrier has entered at length into these interesting questions, and has, I think, shown that all varieties of bronchitis do not equally give rise to pneumonia, but only the vesicular or capillary bronchitis; that lobular pneumonia is almost invariably preceded by it, and that capillary bronchitis is more frequent from one to six years than at any other age; and that, at this period, the anatomical and physiological conditions of the respiratory organs are more favorable for the exten- sion of inflammation to the substance of the lungs. But I will give his conclusions in his own words: "1. The influence of age upon the production of lobular pneumonia is circumscribed within the pe- riod of from one to six years. Before and after that age, the disease is rare. 2. The anatomical and physiological conditions of the lung at that age are but secondary in the production of the lobular form of pneumonia. 3. Observation proves that the disease, in its develop- ment, is intimately connected with preceding bronchitis. 4. The species of bronchitis which has most influence is that which occupies the smaller tubes, and in which the catarrhal element is the most marked; it might be called catarrh of the small bronchi. 5. Lobular pneumonia is more frequent from one to six years, because this ca- 1 Valleix, Clinique des Mai. des Enfans, p. 70. 302 INFLAMMATION OF THE LUNGS.—PNEUMONIA. tarrh of the small tubes is most frequent during the same period, and because it calls into action those anatomical and physiological pecu- liarities which diminish after that age. 6. Inflammation attacks the lobules, either because it is propagated from the bronchi to the lobules by continuity of tissue, or from the stagnation of the mucus in the most dependent bronchial tubes. The obstacle, resulting from this, to the penetration of air into the lobules, favors the sanguineous en- gorgement, as by a species of partial asphyxia. 7. MM. Rilliet and Barthez have not understood all the importance of the bronchitic affec- tion ; the opinion of MM. Burnet and De la Berge appears better founded, but it wanted the demonstration into which we have entered. 8. To pretend that it is not demonstrated, that bronchitis always pre- cedes pneumonia, and not the contrary, is to put forth a slightly founded objection, and one easily refuted. 9. If lobular pneumonia , is rare from one to six years, it is because the causes of this form are rarely in action at this age."1 Thus, then, it would appear that capillary bronchitis may become the first step towards pneumonia; congestion follows, then hepatiza- tion, red and gray, abscess, and gangrene. So far, the chain seems quite complete; the disease may run through all its stages, or it may, of course, stop at any of them; and experience shows us that the limit between capillary bronchitis and the first stage of pneumonia is very often intact. 487. But in this series of morbid phenomena, what place is held by that condition of the lung which has been termed carnification 9 Is it the product of inflammation, a modification of hepatization ? or is it a quasi-normal condition, as if that portion of lung had been exempt from respiration? Rilliet and Barthez seem inclined to regard it as a kind of termination of pneumonia, or as a chronic pneumonia; and they mention the case of a child who for a long time presented the signs of pneumonia of the right lung, yet afterwards died of pneumonia of the left lung. On making the autopsy, a considerable carnification of the right lung was found occupying the situation of the auscultatory evidences of pneu- monia during life.2 M. Barrier admits that it is not quite understood, but that it is pro- bably the consequence of acute inflammation, and " may be considered as a termination of induration."3 Hasse, in his Pathological Anatomy, regards it as a persistence of the foetal state of the lungs after birth, and distinguishes between this condition and inflammation. Dr. Joerg has described it under the name of atelectasis pulmonum; and Dr. West, in his paper on pneu- monia, and in his work, agrees with these authors. More recently, MM. Legendre and Bailly have described this state ■ and, regarding it as passive and asthenic, and not active, and not pathological—a physical modification of the organ, analogous to the condition of the foetal lungs—they have founded upon this opinion an ' Mai. de l'Enfance, vol. i. p. 98. 2 Mai. des Enfans, vol. i. p. 74. 3 Mai. de l'Enfance, vol. i. p. 62. INFLAMMATION OF THE LUNGS. — PNEUMONIA. 303 entirely new view of the disease termed lobular pneumonia. I must, however, content myself by referring to their ingenious essay,1 as their theory is by no means established, and it would require more space to develop it than I can afford. 488. Causes.—Among the predisposing causes, age appears to exer- cise a considerable influence. It has been said that primary pneumo- nia never attacks infants under five years; but Rilliet and Barthez have shown that this is not true: Out of 245 cases, fifty-eight were primary, and of these twenty-four were under five years, ire. five from one to two years, and nineteen from three to five; and thirty- four were beyond five years. Of these fifty-eight cases, fifty-five were lobar pneumonia. M. Valleix mentions that the ages of his patients were, of simple pneumonia, from seven to twelve days; of pneumonia with oedema, from twro to eight days; and of pneumonia with muguet, from nine to twenty days.2 M. Hache, out of 108 autopsies, found pneumonia in seventy-one between the ages of two and five, and in thirty-seven from five to fifteen years of age.3 M. Barrier, out of twenty cases of lobar pneumonia, met with three before the age of five years; six from five to eight; seven from eight to eleven; and four from eleven to fifteen.4 Of sixty-one cases of lobular pneumonia, forty-five were between two and five years, and sixteen from five to sixteen. In 203 cases, Rilliet and Barthez found lobular pneumonia between the ages of one and five and a half in 160, and from six to fifteen in forty-three cases. Thus, both primary and secondary, both lobar and lobular pneumo- nia, may occur from birth up to fifteen years; both are more frequent before five than after, but especially lobular pneumonia. 489. The predominance of the male sex is more marked in lobar than in lobular, in primary than in secondary, pneumonia. Of twenty- four cases of primary lobar pneumonia, referred to by Rilliet and Bar- thez, nineteen were males and five females; and of forty-five of secondary pneumonia (generally lobular), twenty-seven were males and eighteen females. Of sixteen cases of lobar pneumonia, related by Dr. Gerhard and M. Rufz, twelve were males and four females; ten out of fifteen of M. Valleix's cases were males. Of M. Vernon's 114 cases, there was an equal number of males and females. Of 104 cases mentioned by Dr. Condie, sixty were boys and forty-four girls. Of 1615 deaths from pneumonia, occurring in Philadelphia during the ten years preceding 1845, 872 were in boys and 743 in girls.5 According to M. Barrier, sex exerts but little influence upon lobular pneumonia. Temperament and constitution, doubtless, exercise great influence in the production of the disease; those of a lymphatic temperament, and ' Archives Gen.de Med., Jan. and Feb., 1844. 3 Clinique des Mai. des Enfans, p. 173. » Mai. des Enfans, p. 478. * Mai. de l'Enfance, vol. i. p. 187. 6 Diseases of Children, p. 284. 304 INFLAMMATION OF THE LUNGS. — PNEUMONIA. of an enfeebled and broken-down constitution, being peculiarly liable to secondary and especially lobular pneumonia. Of 245 cases related by Rilliet and Barthez, only fifty-eight were stout and well when attacked; and in fifty-five of these fifty-eight, the form of disease was lobar pneumonia; in a great majority of the remainder, it was lobular pneumonia. Dr. Stewart mentions an hereditary predisposition, in some families, to the disease.1 M. De la Berge and M. Leger state that the disease is more fre- quent in spring and autumn; Dr. Gerhard, that primary pneumonia prevails in the months of April and May; Rilliet and Barthez mention that, from April to September, 1837, only six cases of primary pneu- monia were received into hospital; whereas, in the same months of 1840, twenty-two were admitted. During the six summer months of the year referred to by M. Bar- rier, fifty-six cases of pneumonia occurred. So that we cannot regard the summer as conferring immunity from this disease; nevertheless, I have no doubt that, in this country, it will be found far more frequent during the winter. In this city, I have generally met w-ith more cases from December to the end of March than at any other period of the year. This is confirmed by the opinion of Dr. Stewart and others; and Dr. Hood has quoted from Mr. Chadwick the following details: In winter, there were 3,326 cases of pneumonia; in spring, 2,454; in summer, 1,827; and in autumn, 3,600. 490. No doubt that cold is the most frequent exciting cause among children; it can hardly affect young infants so much; but yet they are often exposed. Change of room, change of garment, exposure to draughts of air, going out in unsuitable weather, the prevalence of damp, and certain winds, all may excite the disease even in the most healthy—how much more in those already weakened by disease! By certain French writers, much stress has been laid upon the effect of a prolonged dorsal decubitus in the production of the disease among the children in the Hopital des Enfans at Paris. MM. Billard, Denis, De Commercy, Leger, Rilliet and Barthez, all attribute more or less influence to this cause; but it seems probable that, at least, as much is owing to other causes acting at the same time. Pneumonia may also prevail epidemically; or, what is more frequent in this country, it may form part, as it were, of the epidemic influenza, sometimes the bronchitic; at others, of the pneumonic element pre- vailing, as I noticed in the last chapter. 491. Dr. West has given definite numbers for a fact which all must have experienced with regard to pneumonia ; I mean the great liability of those who have once suffered from it to be again attacked. Of seventy-eight cases which came under Dr. WTest's care for inflam- mation of the lungs, " thirty-one were stated to have had previous attacks of the disease; twenty-one, once; four, twice; two, four ' Piseases of Children, p. 50. INFLAMMATION OF THE LUNGS.—PNEUMONIA. 305 times; and four were said to have had it several times, though the exact number of seizures was not mentioned. Of these thirty-one, ten were under two years of age; ten, between two and three; and the remaining eleven, between three and six."1 492. We must now examine as to what diseases predispose to pneumonia, as a secondary affection, and I shall avail myself of a table drawn up by my friend Dr. West. It concerns 166 cases; and, of these— " In sixty-five cases, the respiratory organs presented no sign of recent inflammation, the children having died of the following dis- eases: Of trismus, three; meningeal apoplexy, two; cerebral con- gestion, one; inflammation of the brain, one; acute hydrocephalus, twenty-five; cerebro-spinal arachnitis, three; chronic hydrocephalus, one; tubercle of the brain, three; cancer of the brain, one; croup, two; laryngismus stridulus, two; phthisis, five; anasarca, one; anasarca after scarlet fever, one; diarrhoea, four; atrophy, three; congenital syphilis, one; cancrum oris, two; lumbar abscess, one: scrofulous disease of the vertebra?, one; fungus ha?matodes of the liver, one ; of the kidney, one. " In fourteen cases, though there was no sign of inflammation, yet a more or less considerable portion of the lung was collapsed, but restored by inflation to its natural condition, or presented the physical characters of collapsed lung in so marked a degree as to preclude the possibility of error. The causes of death in these fourteen cases were: congenital atelectasis, one; induration of the cellular tissue, one; convulsions, one ; meningitis of the convexity of the brain, one; congestion of the brain occurring in the course of hooping-cough, one; tubercle of the brain, one; autopsy of one hemisphere of the cere- bellum, one; atrophy, five; laryngismus stridulus, one; fungusha?ma- todes of the kidney, one. " In forty-seven of the above seventy-nine cases, the pulmonary tissue was quite free from tubercle. In twenty-two, the lungs con- tained crude'tubercle only; in three, some softened tubercles. " In the remaining eighty-seven cases, either the pulmonary sub- stance, the bronchi, or the pleura, showed signs of recent inflamma- tion. " The pleura was mainly affected in twelve of these cases, its in- flammation having been idiopathic only in four. In six of these cases, the lung was inflamed ; in the other six, merely compressed. " In nineteen cases, the inflammation wa*s chiefly or entirely con- fined to the bronchi; and in six of these the inflammation was idio- pathic. " In fifty-six cases, pneumonia prevailed, which was idiopathic in seventeen, and secondary in forty-five instances. " In the fifty-nine cases of acute secondary inflammation of the lungs or bronchi, the patients had suffered from the following dis- eases: Hooping-cough, sixteen ; phthisis, seven; acute pleurisy, six; 1 Lectures on Diseases of Children, p. 180, note. 20 306 INFLAMMATION OF THE LUNGS. — PNEUMONIA. measles, five; croup, three; scarlatina, three; diarrhoea, three; acute hydrocephalus, three; croup, consequent on measles, two; remittent fever, two; acute meningitis, two; chronic bronchitis, one; coryza, one; anasarca after scarlatina, one; cancrum oris after remittent fever, one; acute rheumatism, one; convulsions, one. " Of the whole eighty-seven cases : in sixty-nine, the pulmonary tissue was free from tubercle; in ten, it contained tubercle unsoftened ; in five, tubercle softened; in three, tubercular cavities."1 This valuable summary affords both negative and positive informa- tion ; negative as to the diseases of which pneumonia is not a frequent complication, and positive as to those in the course of wdrich it occurs as a secondary attack. However, as Dr. West observes, it would require a larger number of cases to enable us to draw any stringent conclusions. So far as it goes, it confirms pretty exactly what I have said previously. 493. According to M. Barrier, of sixteen cases, thirteen were con- nected with acute catarrh, and three w7ith chronic catarrh, occurring in the course of measles; in two, with scarlatina ; in three, but obscurely, with small-pox; in ten, with bronchial catarrh ; in twelve, with bronchial and intestinal catarrh; in nine, with hooping-cough ; in one, with typhoid fever. There can be little doubt that lobular pneumonia arises most fre- quently in the course of the eruptive fevers, bronchitis, and hooping- cough; and, knowing this, it is our duty to be constantly on the watch, that we may detect the earliest symptom. 494. Diagnosis.—The diagnosis of the lobar form is less difficult than of lobular pneumonia ; we have the short cough, pain in the chest, hurried breathing, dulness on percussion, crepitant rale, and fever. In lobular pneumonia, the cough, dyspncea, and fever are much the same, the pain is less, and the dulness on percussion not so perceptible in the mamellonated form of the disease. In the gene- ralized form, we shall have less difficulty, as the dulness is marked, and the crepitant or subcrepitant rale very evident. i. The differential diagnosis between this disease and bronchitis will depend very much upon the clearness on percussion, the presence of mucous and sibilant rales, the absence of the crepitating or sub- crepitating rales. In the latter disease, the face has generally a purplish tinge, the cough has more of a kink, the respiration is more labored, and perhaps less hurried. n. From pleurisy. In both, of course, there is dulness on percus- sion, spreading rapidly; but in general there is less constitutional and local disturbance in pleurisy, the cough is not so frequent, the pulse not so quick, nor is there the same hurry of breathing. The pain in pleurisy, also, is more distinct, severe, and occupies a different situ- ation. The distinguishing characteristic rales of pneumonia are, of course, altogether absent, and the vocal sound may be different. in. There may be great difficulty in distinguishing pneumonia 1 Lectures on Diseases of Infancy and Childhood, p. 181. INFLAMMATION OF THE LUNGS. — PNEUMONIA. 307 from a sudden infiltration of tubercles. M. Grisolle remarks : " A child has a hot skin, violent fever, dulness, with bronchial respiration under one of the clavicles, and we have no information as to its pre- vious history. Is it certain, then, as Rilliet and Barthez ask, that the child has pneumonia? These physicians have often seen this question answered in the affirmative, and treated accordingly, and yet the autopsy has proved that these symptoms depended upon a tuber- cular infiltration of the lung. 'In such cases,' they remark, 'we must observe the intensity of the fever, and especially the cause of the disease; if the stethoscopic phenomena persist, notwithstanding the diminution of the general symptoms, it is probable that this persist- ence is the consequence of the tubercles.' I am completely of the opinion, but this does not prove, that the feverand bronchial respira- tion may not have been owing to a kind of pneumonia."1 495. Prognosis.—Primary pneumonia, whether lobar or lobular, is much less fatal than the secondary disease. Lobar pneumonia (perhaps because more frequently primary) is less fatal than lobular, and uncomplicated much less fatal than when complicated. Second- ary lobular pneumonia is, of course, frequently fatal, partly owing to the disease itself, but much more to the effects of the primary malady, and the inability of the child's constitution to resist the in- roads of a new disease. Of twenty-one cases of primary pneumonia, Rilliet and Barthez state that twenty-one were cured. Of twenty cases of lobar pneu- monia, according to M. Barrier, but one died; whilst, of sixty-one cases of lobular pneumonia, forty-eight died, eight were completely, and five incompletely, cured. 496. Treatment.—Before entering upon the treatment of any case of pneumonia, we should carefully satisfy ourselves whether it be primary or secondary, whether simple or complicated ; and of the exact state of any other existing malady, whether primary or secondary ; and of the state of the patient's constitution, its strength or weakness, the injury already done to it, and the probable powers of endurance remaining. This done, we may select and apportion the remedies at our command, which, although few and simple, do yet require judg- ment in their application. The principal remedies are bleeding, tar- tar emetic, calomel, counter-irritation, and stimulants. It will be also essential to remove all existing causes of irritation, and amongst these the most influential is probably that arising from dentition. Whether it may give rise to pneumonia or not, certain it is that it will increase and perpetuate the inflammatory action. In all children, therefore, at the age of teething, the gums should be ex- amined, and if the gums be at all swollen or inflamed, they should be divided thoroughly. 497. i. Bleeding, either generally or locally, is one of our most powerful means for arresting inflammation of the lungs. Some of the continental writers object to it, as weakening the patient; but, as Dr. ' Traite de la Pneumonie, p. 513. 308 INFLAMMATION OF THE LUNGS. — PNEUMONIA. West observes, this opinion, being formed from the cases of secondary pneumonia met with in the hospitals, cannot be a guide to us in general practice. The great majority-of British and American practitioners agree in recommending that, at the commencement of pneumonia, blood should be freely abstracted, according to the age and strength of the patient; and that, if it be necessary, owing to the severity and obstinacy of the disease, it should be repeated once or twice. The blood may be taken from the arm of the child, if it be old enough, or by cupping or leeches to the chest, hand, or foot. I prefer leeches to the chest in infants, because they are more manageable, and less likely to frighten a young child, than cupping; and I think they produce greater effect when applied to the chest than to more distant parts. Both lobar and lobular pneumonia may be thus treated freely when primary; but, when secondary, it will be necessary in all cases to modify the amount taken ; and, in some cases, when the child is much broken down and exhausted, it would be very imprudent to take blood at all. In such cases, we must have recourse to counter-irritation, calomel, or perhaps tartar emetic. "When an abundant effusion has taken place into the bronchia," Dr. Cuming observes, in his excellent paper, "and when, as generally happens, this state is combined with more or less of collapse of the system, the abstraction of even a very trifling quantity of blood might be attended with a fatal prostration."1 When the leeches have ceased bleeding, a large, soft, warm poultice of bread and milk, or linseed-meal, should be constantly applied to the part affected. I have found nothing afford such immediate comfort and relief to infants and children. It maybe removed when counter- irritants are to be applied, and then replaced. It soothes the sensa- tions, relieves the aching pain, quickens the action of the counter- irritants, and promotes expectoration. 498. ii. Tartar Emetic.—No physician is ignorant of the extreme value of tartarized antimony in the treatment of pneumonia in the adult. It is not less valuable with children, but it requires a little more watchfulness and caution, as it sometimes produces very alarm- ing depression. After bleeding, in all primary cases, it will be right to give it a fair trial, and, if it acts kindly, to continue it as long as we find necessary. The dose must be graduated according to the age of the child, the object being rather to produce nausea than vomiting. It will often be found, however, that a child will bear a larger dose than we might suppose, and that, although the first dose may cause vomiting, the subsequent ones will not. Or, we may commence by producing vo- miting, and then diminish the dose, so as to occasion nausea merely. Dr. West recommends "one-eighth of a grain every ten minutes, till vomiting is produced, in the case of a child two years old, and con- tinued every hour or two afterwards, for twenty-four or thirty-six hours." ' Trans, of Association, vol. v. p. 49. INFLAMMATION OF THE LUNGS. — PNEUMONIA. 309 One grain of the salt to two ounces of fluid, for a child under two years, and two grains for a child of four or five, will form a mixture of which a teaspoonful may be taken every two, three, or four hours. The following mixture answers the purpose, and, besides being very palatable, will probably check the tendency of the tartar emetic to act on the bowels:— R. Mist, amygdal. ^ii; Antim. tartarizati gr. i. vel. ii; Syr. papav. alb. gii. M. A teaspoonful to be given every three or four hours. But, in secondary pneumonia, when the patient is much reduced especially, or when the stomach and intestinal canal have been affect- ed, we must be very cautious how we give tartar emetic. If used at all, it must be given in much smaller doses, at the same or longer intervals, or we may seriously aggravate the patient's weak- ness, or add to the intestinal irritation. If we cannot give it, our great reliance must then be upon calomel, counter-irritation, and stimulants. 499. in. Calomel.—It is rarely advisable or necessary to give calomel so long as we are employing tartar emetic; but, when a change be- comes desirable, or, if for any reason, we are afraid to give the latter medicine, we must have recourse to calomel. Of less immediate value, perhaps, than tartar emetic, it is still of great importance, and possesses great control over inflammatory action. It may be given in doses varying from one-fourth or one-third of a grain to a grain, every three, four, or six hours, guarded by a little Dover's powder, or the powder of chalk with opium. In secondary pneumonia, it will still be found of great use, provided there be no diarrhoea, or provided we can so guard it as to prevent it acting upon the bowels. Sometimes the hyd. c. creta is better borne than calomel, though less effective. If we cannot give it, on account of the state of the bowels, we may use mercurial inunction, which has more effect with children than adults, from the greater sensitiveness of their skin. Although salivation and ulceration of the gums are very rare in chil- dren under five years of age, yet, as they do occasionally occur, it is necessary to watch the child, and to stop the mercury on the first sign of tenderness of these parts. 500. iv. Counter-irritation.—I have always derived great benefit from blisters in pneumonia, provided they were not applied too soon. We ought not to apply them during the height of the fever, until after having recourse to bleeding and tartar emetic, except in cases in which these remedies have not been suitable. But, after bleeding and tartar emetic have lowered the febrile ex- citement, even though the pulse still remains quicker than natural, a moderate-sized blister, applied, for a few hours only, over the seat of the disease, will seldom fail to afford relief. It is better to apply it for a short time, and allow it to heal, and then apply another near to the former, than to cover the chest with one at once. 310 INFLAMMATION OF THE LUNGS. — PNEUMONIA. In cases where more active measures are inadmissible, a succession of blisters must be substituted, care being taken that they are not ap- plied too long, so as to give rise to ulceration. Dr. West speaks highly of stimulating liniments, others of mustard plasters; but, though useful, they are far less efficacious than blisters; and, if the blister be carefully attended, I have not found any mischief result. WThen we do not give tartar emetic, or after we discontinue it, it will be necessary to give some cough mixture, and I have found one composed of equal parts of decoction of senega and water, with syrup of smilax, and a little ipecacuanha wine, of great use, to which we may add the carbonate of ammonia towards the end of the disease; as thus:— R. Decoct, senegas ^ii; Carb. ammon. Qi to gi; Vini ipecac, gss; Syr. smilac asp. ^iv. M. AqufE t*5ii. A teaspoonful every three or four hours. 501. v. Stimulants.—These are only required in cachectic cases, when the constitution has been broken down, or towards the termina- tion of the disease, when the pulse has become slower, and the patient is weak. Ammonia is probably the best we can employ, and it may be given in almond milk, in doses of from half a grain to two grains, every three or four hours, or it may be combined with the expectorant mix- ture. Under similar circumstances, it may be necessary to give wine whey, or plain wine and water. A warm bath at the beginning of the disease, with fomentations to the feet occasionally, will be both soothing to the patient and bene- ficial. The diet, in primary pneumonia, must be low and spare, but, to- wards the termination, and in all cases of secondary pneumonia, we shall find it necessary to support the strength by chicken broth, beef tea, &c. The bowels must be kept free, and it is well not to place the child always in one position in bed. 502. During convalescence, the utmost caution and care must be exercised. The child should be confined to one room, or to two of the same temperature. For some time the clothing should be warm, with a light flannel waistcoat next the skin. For the treatment of the complications, I must refer the reader to the chapter on those diseases, merely observing that, although they much increase the danger, they often diminish our power of active treatment, and in some cases (as intestinal irritation) exclude some of the most valuable remedies for pneumonia. PLEURISY. — PLEURITIS. 311 CHAPTER VII. PLEURISY.--PLEURITIS. 503. Inflammation of the pleura, or pleuritis, may attack children of all ages, although its comparative frequency varies a good deal. Of 4012 patients treated at the London Infirmary for Children, dur- ing the year 1846, only three cases of pleurisy1 were noted; but out of 4158 admitted in 1845 to the Royal Institution for Diseases of Children in the district of Wieden, Vienna, there were seventy-six cases of the disease.2 "In London, during the year 1843-44, the deaths from pleurisy, in children under fifteen years of age, amounted to one-sixth of the whole number of deaths from the same cause ;3 and of twenty-five deaths at all ages, from pleurisy, registered in the month of January, 1847,4 eleven occurred under the age of fifteen years."5 M. Billard6 states that he has found it more common than one would have expected; and, on the other hand, M. Valleix considers it rather rare.7 Of 3392 autopsies of children under two years old, M. Baron found pleurisy in 205, or six per cent. ; and of 181 autopsies of children from two to fifteen, the pleura of 158, or eighty-seven per cent., was affected.8 Dr. Eberle regards it as more common than is supposed. Mr. Crisp met with six cases of pleurisy in forty-one autopsies of children under two years of age.9 Dr. Battersby has recorded six cases of simple or complicated pleurisy.10 MM. Rilliet and Barthez have recorded eighty-five cases of pleurisy under fifteen years of age. M. Hache states that he has met traces of pleurisy in eighty-one cases out of 194 post-mortem examinations ; and M. Barrier has given fourteen cases. From these facts we may infer that pleurisy is not so rare a disease in children as many have supposed. Perhaps, indeed, this supposi- tion may be the cause why so little attention was paid to the subject until lately. It is only recently that any very accurate researches have been undertaken into the distinction between pneumonia and 1 Report of the Royal Infirmary for the year 1846. 2 Jahrbericht iiber die Leistungen des Unentzeldlischen Kinderkranken Instituts, &c. 3 Sixth Annual Report of Registrar-General. * Weekly Tables of Births, &c, January, 1847. 6 Dr. Battersby, Dublin Journal, Nov. 1847, p. 349. 6 Mai. des Enfans Nouveaux-nes, p. 529. 7 Clinique des Mai. des Enfans, p. 198. 8 De la Pleurisie dans l'Enfance. 9 London Medical Gazette, Dec. 25, 1846. 10 Dublin Journal, November, 1847.' 312 PLEURISY.—PLEURITIS. pleurisy in children. We are indebted to Meissner, Henke, and Heyfelder,1 in Germany; to Billard, Constant,2 Baron,3 Berton,4 Rilliet and Barthez, and Barrier, in France ; to Crisp,5 West, and Battersby,6 in these countries ; and to Stewart, Eberle, Condie, and Meigs, in America, for the principal information we possess. 504. Symptoms.—Pleurisy may be either primary or secondary, simple or complicated, acute or chronic. It will be found to be mo- dified somewhat in early infancy. Rilliet and Barthez have also described the disease occurring in children of a broken-down consti- tution, under the name cachectic pleurisy. 505. Primary Acute Pleurisy commences generally with depres- sion and loss of appetite, occasional vomiting, weakness, slight cough, and a degree of fever, which subsides after a time. In some cases, there are rigors ; in all, the child seems ill, uneasy, and cross. In other cases, the symptoms which usher in the disease are more alarm- ing, and point rather to the head than the chest. " The child is seized with vomiting, attended with fever and intense headache ; it either cries aloud, or is delirious at night, or screams much in its sleep; and, when morning comes, complains much of its head, but denies having any pain whatever in its chest, while the short cough and hurried breathing may be thought to be merely the result of the cerebral disturbance."7 Early in the complaint, the child complains of pain in the side, if it be old enough ; in young children, it is not always easy to ascertain this, except, perhaps, by the cry, when the side is percussed. The cough soon becomes troublesome ; it is short, dry, and inter- rupted, the respiration hurried and short, especially on lying down, because of the pain caused by deep breathing. Rilliet and Barthez consider the dyspnoea to be less than in pneumonia. "Respiration," says Dr. Condie, "is performed chiefly by the action of the abdominal muscles and diaphragm, the motions of the chest being instinctively restrained by the patient, in consequence of the pain attendant upon the elevation of the ribs; sometimes each inspiration gives rise to a sharp cry or moan, and an expression of countenance indicative of suffering."8 In the majority of cases, there is no expectoration, and when pre- sent, it is not peculiar. Mr. Crisp has noticed the throwing back of the head, and fixing it steadily there, as a peculiarity in pleuritis, and the distress'occasioned by an attempt to straighten it.9 Dr. Battersby states that he has long observed it, and he thinks it arises " from an instinctive effort to avoid painful motion of the chest, by fixing the ribs, and giving full play to the abdominal respiration. 1 Archives, third series, vol. v. p. 59. 2 Gazette Med., 1836, p. 265. Lancette, 1837, p. 146. 3 Thesis, 1841. 4 Traite des Mai. des Enfans. 6 London Medical Gazette, Dec. 25, 1846. 6 Dublin Journal, Nov. 1847, p. 348. 7 Dr. West's Lectures, p. 213. 8 Diseases of Children, p. 290. B London Medical Gazette, Dec. 25, 1846, p. 1104. PLEURISY. — PLEURITIS. 313 This position of the head in pleuritis may be distinguished from that attending cerebro-spinal arachnitis, or other affections of the nervous centres, by all change of posture being followed by great uneasiness and screaming, wdiile in the latter the infant is not so restless, nor crying so constantly, especially when moved or held erect, as in pleu- ritis."1 This fixing of the head backward occurs in pericarditis also, and in other affections, and I must confess I have hitherto been unable to satisfy myself of its exact value as a symptom. The face is generally pale and anxious, with considerable contrac- tion of the respiratory muscles of the face, and action of the ala? nasi, especially at the commencement. The tongue is moist, white, and loaded; the appetite impaired or lost; vomiting occasionally occurs; and the bowels, at first unaffected, are often subsequently attacked by diarrhoea. The decubitus is of little or no value in young children, as they generally lie as they are placed in bed. In older children, one side or the other will afford more ease. Dr. Stokes says, on the healthy side in the beginning, and the diseased side towards the end. The pulse is very quick at first, from 110 to 120, but it frequently subsides after a time to somewhat above the natural standard. At first, too, there is smart fever, with heat of skin, thirst, &c:; but this very commonly diminishes. 506. Now let us examine into the physical signs of pleurisy. At an early stage of the disease, we find the respiratory murmur enfee- bled, and gradually retreating upwards as the effusion increases; then we may detect bronchial respiration, generally constant, but occa- sionally disappearing and returning at intervals, owing, M. Bouchut thinks, either to the short inspirations, or the interruption to the pas- sage of air offered by the accumulation of mucus. MM. Rilliet and Barthez class this among the earliest symptoms of pleurisy ; they found it present on the first, second, or third day. The sound in pleurisy is peculiar and metallic in its tone, differing in that and in its progress and duration from the bronchial souffle of pneumonia. Generally speaking, it is heard posteriorly, and, at an early period, over the whole upper portion; at a later period, chiefly about the in- ferior angle of the scapula or the inter-scapular space. It lasts for some little time, and then disappears in the course of one, two, or three days; or it may persist longer, and be audible either during inspira- tion or during both inspiration and expiration. When the case is simple, and the termination fatal, it may be heard until the end; Rilliet and Barthez heard it after the twenty- seventh day in a child who died on the twenty-eighth; but, when the disease subsides, the bronchial souffle is superseded by feeble re- spiratory murmur, more rarely by frottement, and sometimes by- pure respiration. In some few cases, this peculiar characteristic is absent. ' Dublin Journal, Nov. 1847, p. 371. 314 PLEURISY.—PLEURITIS. Rilliet and Barthez explain the frequency of the bronchial souffle by: 1. The comparatively greater narrowness of the chest in children than in adults; 2. The greater number of respiratory movements; and 3. In certain cases, the small amount of effusion.1 Frottement, which is so characteristic a symptom of the early stage of pleurisy in adults, is comparatively rare in children. Both MM. Baron and Rilliet and Barthez agree that, though rare at the beginning, it is often present during the resorption of the effused fluid. The latter authors have never heard it in children under five years of age. Mr. Crisp, however, speaks of its occurrence in all his cases. Bronchophony and egophony occasionally accompany the pleurisy of children; the latter generally in the early stage in acute cases; it is heard ordinarily at the posterior and inferior part of the chest. It is more distinct in older children, though audible at all ages. When it is not present in very young children, there is generally a peculiar resonance of the voice. Percussion affords evidence of great value at the commencement of the disease. The dulness may be somewhat obscure; but, as the disease advances, it becomes more marked, keeping pace with the feebleness of respiration and the bronchial souffle, until at length the side of the chest becomes absolutely dull. This lasts until the disease begins to subside, and marks not only the locality, but the duration, according to its persistence. By degrees, as the bronchial respiration is replaced by the feeble or pure respiration, the chest becomes more sonorous, and at length perfectly clear. As in the adult, change of position will modify the results of per- cussion as well as of auscultation. Taupin,2 Baron, Rilliet and Barthez, Trousseau, and Bouchut lay great stress on the absence of vibration when the effusion is consider- able, as was first noticed by Reynaud, Hudson, and Stokes. M. Bouchut conceives that this sign alone distinguishes it from all other inflammations. If the hand be placed on the chest of a healthy person, we feel a remarkable vibration both of the respiration and voice; but, if there be effusion, there will be no vibration perceptible, either from the respiration or the voice; and this is exactly the opposite of what is perceptible in pneumonia. Dr. Stokes, however, mentions that it is inapplicable to many cases of boys and girls, before the change of voice, on account of the na- tural feebleness of the vocal vibrations.3 Dr. Battersby thinks it im- possible to detect this vibration before the eighth year. On inspection of the chest, the affected side appears immovable during respiration; there is no expansion, no movement of the ribs. The measurement of the chest is by no means easy with infants and young children, nor does it yield much information early in the complaint, nor when it runs its course rapidly. When the attack is prolonged several weeks, there is a notable difference in the tw7o sides 1 Mai. des Enfans, vol. i. p. 149. 2 Recherches sur le Diaguostique des Mai. de Poitrine chez les Enfans. 3 Diseases of the Chest, p. 498. PLEURISY. — PLEURITIS. 315 of the chest, in proportion to the effusion. The affected side is en- larged, the intercostal spaces are raised to the level of the ribs, or even protruded, so that the ribs are not quite visible, and neither the sternum nor spine occupies the centre of the chest. When the fluid is absorbed, the affected side is contracted, but not to any great extent. It is very remarkable that neither Baron, Rilliet and Barthez, nor Barrier, have met with effusion so considerable as to displace the heart. M. Heyfelder has observed in chronic pleurisy considerable deformity, with curvature of the spine, and a displacement of the heart from its ordinary position ; and my very intelligent friend, Dr. Battersby, has related four such cases.1 Thus, although the rational signs of pleurisy are not very clear, we can hardly mistake the physical signs. In the earlier stage, feeble- ness of respiration, succeeded by the bronchial souffle, with marked and increasing dulness on percussion, absence of vibration in the side affected, perhaps egophony or vocal resonance, and, at a later period, if the effusion be great, dilatation of the chest, and dislocation of the heart. 507. When pleurisy attacks an infant at the breast, the symptoms are necessarily more obscure, and the physical signs less readily ascertained; there are fever, quick breathing, and cough; but whether pain or not, it is not easy to determine, unless we infer it from the child crying when the cough is troublesome. The infant is evidently very ill; it sucks less eagerly, is fretful and heavy, and, as the dis- ease advances, it loses its appetite ; is sometimes attacked by diarrhoea; the fever is occasionally remittent, with nocturnal exacerbations; the respiration is quick, hurried, and panting, and the cough frequent. The usual physical signs are present; feeble respiration, bronchial respiration, dulness on percussion, except just at the beginning, and the absence of vibration when the hand is placed on the affected side. 508.' Acute Secondary Pleurisy may occur in the course of any other disease; but it seems peculiarly apt to develop itself in the pro- gress of pneumonia, either from contiguity of structure, or in conse- quence of the opening of an abscess (480) into the pleural cavity. The symptoms which mark its commencement vary a good deal; it may begin in young children by convulsions or by sudden ortho- pncea. More frequently, it commences with sudden and severe pain, with increased difficulty of breathing, and cough. The hurry of breathing and the rapidity of the pulse are often very great. The physical signs are somewhat modified, and, in the case of pleu- risy supervening on pneumonia, have been thus stated by Rilliet and Barthez: "When effusion is superadded to pneumonia, it happens occasionally, but very rarely, that there is a complete absence of the respiratory murmur instead of bronchial respiration. Ordinarily, the souffle is considerably increased in intensity; sometimes, it has even a cavernous tone; and, if there be any mucus agitated by the rush of air, giving rise to a rale, one might mistake so far as to fancy that a cavity 1 Dublin Journal, November, 1847, p. 353. 316 PLEURISY. — PLEURITIS. had been formed in the lung. At the same time, the voice sounds so shrill that it is literally painful to the ear. If we percuss the chest, the dulness is absolute, whereas, a short time before, it was but rela- tively dull. We lay it down, then, as a principle, that, when a pleu- ritic effusion supervenes in a child laboring under hepatization of the posterior part of the lung, all the abnormal sounds, which were percep- tible in the diseased part, are considerably exaggerated, and the reso- nance on percussion lost."1 This peculiarity, however, is not observable in all cases; it requires for its production that the hepatization should be sufficient to prevent the compression of the lung; so that, if a complete, absence of the respiratory murmur succeeds to the symptoms of pneumonia, we may infer that the hepatization is neither extensive nor profound; but, on the other hand, if the souffle, the resonance of the voice, and the dul- ness are suddenly exaggerated, it is an evidence that the pneumo- nia was deep and extensive. 509. Very frequently, the progress of the disease is much more rapid than in simple pleurisy; in other cases, the duration may be more or less prolonged. In favorable cases, the symptoms gradually diminish, both locally and generally; but in fatal cases they increase, and the smallness and feebleness of the pulse, the coldness of the ex- tremities, paleness of face, and general sinking of the powers of life, warn us of the final result. But either primary or secondary pleurisy may pass into the chronic form. 510. Chronic Pleurisy may either be the issue of an acute attack, or the disease may assume this form from the beginning. In the former case, the symrJtoms gradually diminish to a certain point, but not beyond, the fever continuing more or less, but especially in the evening. In the second, the symptoms are much more indefinite, and steal on insidiously. There may be little or no fever, the pain is uncertain, and not limited to one particular spot, or there may be none at all. The cough is slight, and at first there is but little distress in respira- tion ; the effusion, however, increases, the respiratory murmur is feeble or absent; there is, occasionally, the bronchial souffle, with marked dulness on percussion, and absence of vibration. On inspecting the chest when the effusion is considerable, we may perceive the enlargement of the side and the consequent deformity, the protrusion of the intercostal spaces, and perhaps the displacement of the heart. Heyfelder has remarked that the child lies on the affected side, which is slightly cedematous, with its knees drawn up, in a crouching position. The child, meantime, becomes emaciated and pale; the evening ex- acerbations are marked, followed by sweating during the night; the appetite is lost, and, at the end of some weeks or months, the child sinks, quite worn out. ' Mai. des Enfans, vol. i. p. 152. PLEURISY. — PLEURITIS. 317 It is quite possible, however, that the child may be saved, either by the absorption of the effusion, its removal by expectoration, or by a surgical operation. 511. Complications.—These are not frequent; Rilliet and Barthez have rarely seen any that could be fairly connected with the pleuritic inflammation. Convulsions sometimes usher in the attack, and occasionally there are some irregular cerebral symptoms connected with secondary pleurisy. Rilliet and Barthez mention a case of meningitis which occurred in the progress of pleurisy, which itself was developed during the existence of Bright's disease, but upon which of the two the me- ningitis depended it w7ould be hard to say. Pneumonia may itself complicate primary pleuritis; it is not very uncommon to find a thin layer of the pulmonary tissue inflamed be- neath the serous membrane. 512. Terminations.—Acute primary or secondary pleurisy may terminate: 1. In resolution, with gradual subsidence of the inflamma- tion, and re-absorption of the effusion; 2. In absorption of the fluid by the lungs, and its vicarious expectoration from those organs; 3. In chronic pleurisy; 4. Chronic pleurisy may terminate by re-absorp- tion of the fluid; 5. By its vicarious expectoration; and 6. By a spontaneous opening through the parietes of the chest, "empyema of necessity." 513. Morbid Anatomy.—In the majority of cases, the pleura of the side affected is found smooth, pale, and semi-transparent; in others, regularly and finely injected, or exhibiting patches of ecchymosis, especially underneath the false membranes. In one case, Rilliet and Barthez found the pleura beneath the false membrane very vascular and softened, and in another case thickened. The sub-serous tissue is occasionally vascular. More or less fluid is found in the pleural sac ; sometimes simple or bloody serum, with flocculi of lymph; sometimes the fluid is thick, yellow, and puriform, or of an intermediate character. The colorless, viscid, stringy fluid which we find occasionally is regarded by Rilliet and Barthez as the result of inflammation. When there is a communication with the external air, the effusion may acquire a fetid odor. In most cases, the effusion naturally occupies the most depending position, rising in the serous sac according to its amount; in other cases, as in adults, it is contained in sacs formed either by old adhe- sions or recent false membranes. The pleura costalis and pleura pulmonalis are frequently covered with false membranes of varying size and thickness. Sometimes they are soft, and deposited in small patches; or they may be extensive, but very thin; or several of their lamina? may be superimposed, form- ing a thick, solid layer. They are generally of a whitish-yellow color, but near the surface of the lung we find a tinge of red. Their free surface is irregular, unequal, occasionally nodulated, and sometimes connected with the opposite pseudo-membranous layer by bands. 318 PLEURISY. — PLEURITIS. When the disease is of old standing, the fluid portion becomes ab- sorbed, the false membranes become dry and thin, forming adhesions, intimate or loose, between different portions of the opposite surfaces. Laennec has admirably described the change from false membranes to adhesions, and to his work I must refer the reader, as the process is essentially the same in adults and children. 514. When the pleurisy is simple, the lung is pressed back either totally or partially to the vertebral column, its volume is diminished, and its substance is flaccid, smooth when cut, impenetrable to the finger, presenting that condition which has received the name of car- nification. The extent of this change will, of course, correspond to the amount of the effusion. But in other cases the lower lobe of the lung is solid, heavy, and but slightly pressed back to the vertebral column. Its substance re- sembles the lung in a state of hepatization, but is firmer and less penetrable by the finger, and on pressure less sanguinolent fluid es- capes. In such cases, it is pretty certain that the hepatization pre- ceded the effusion; the lung, having become more solid, could not be compressed by the fluid beyond a certain point, but still it is more condensed by the pressure than it would otherwise have been. Rilliet and Barthez have attempted to point out the anatomical characters when the pneumonia succeeds to the effusion, but without much suc- cess. In the case they mention, the superior lobe was carnified and compressed, the inferior exhibited the different stages of pneumonia, was friable, sank in water, and on pressure no sanious fluid escaped. 515. The same authors observe that simple pleurisy is more fre- quently unilateral than double, and rather more common on the right side than the left; and that, when complicated with pneumonia, it is still more frequently unilateral, but that the left side is more com- monly affected. Taking all the cases, they found that pleurisy, complicated or simple, was more frequently unilateral than double, and more common on the left side than the right. Thus, in eighty-five cases, the disease affected the right lung only in thirty ; the left, in thirty-eight, and both, in seventeen: but of twenty-one cases of simple pleurisy, the right side alone was affected in eleven ; the left, in eight; and both sides, in two cases. M. Baron has arrived at nearly the same conclusion. All M. Barrier's fourteen cases were unilateral, except two; in twelve, it was seven times on the right, and five times on the left side. In six simple cases, it was five times on the right, and once on the left; in six cases, complicated with pneumonia, it was four times on the left, and twice on the right. Dr. Battersby rather agrees with Dr. Copland, that " pleurisy in every form, in children as well as in adults, is much more frequent in the left than in the right side of the chest." The most frequent morbid lesion is the false membrane ; the next, the turbid serum ; and least common, pus. The former is often the only lesion. The quantity of these products of inflammation varies ; PLEURISY.—PLEURITIS. 319 but it is seldom great. Rilliet and Barthez, Baron, and Barrier state that the effusion is generally very inconsiderable, and in none of their cases was it sufficient to cause displacement of the heart. M. Hey- felder mentions cases from which six pints (chopins) of pus were removed by operation. Dr. Battersby has related several cases in which the effusion was sufficient to dislocate the heart from its usual situation. As to the adhesions, Rilliet and Barthez remark that, in the great majority of cases, they are parieto-pulmonary ; next, costo-pulmonary; and lastly, interlobular. They met with costal false membranes alone in one case, interlobular in four, pulmonary in seventeen, parietal and pulmonary in fifty-six, parietal, pulmonary, and interlobular in one case. Of 137 cases in which adhesions existed, sixty were of the right pleura only, thirty-one of the left only, and forty-six of both. In ninety-three cases, adhesions were the sole inflammatory product. 516. Causes.—The age of the child appears to afford no exemption from the disease; but how far it enters fairly into the list of causes, it is not so easy to say. It may certainly occur at any age, from a day old upwards. Billard and Berton believe that simple pleurisy is more common among infants than is generally believed, but that it is much more so after five years ; and M. Barrier's researches confirm this opinion. Rilliet and Barthez state that, of twenty-one cases of simple pleu- risy, eight occurred from one to five years ; and thirteen, from six to fifteen; and of sixty-one cases, complicated with pneumonia, forty- four were from one to five years old; and seventeen, from six to fifteen. Dr. Stewart thinks that, at the age of three years, pleurisy is as common as among adults ; M. Barrier, that it is rare before the sixth year. Dr. Battersby thinks that Dr. Stewart is nearest the truth, judging by his experience. Secondary pleuritis, or pleuritis combined with pulmonary diseases, is more frequent among young children. In 3392 autopsies of children from one to two years old, M. Baron found pleurisy in 205, or six per cent.; and in 181 autopsies from two to fifteen years old, the pleura presented evidences of inflammation in 158, or eighty-seven percent.; that pulmonary complications existed in twro-thirds from one day to one month old; in four-fifths, from one month to one year; and in eight-ninths, from one to fifteen years. M. Hache found the pleura inflamed in eighty-one out of 194 autopsies; and in none was it the simple disease. M. Valleix mentions that, of ninety-two cases under two and a half months, examined by M. Vernois, fourteen only showed signs of pleurisy; and, of the whole number, one-sixth had been so affected. Mr. Crisp, in forty-one autopsies of children under two years old, discovered pleuritis in six: in one, simple; in five, com- bined with pneumonia. M. Barrier observed no case of pleuritis in- dependent of pneumonia before the sixth year; very few between the 320 PLEURISY. — PLEURITIS. sixth and tenth ; but from the tenth to the fifteenth, it was nearly as common as with adults. 517. From the researches of Rilliet and Barthez, it would appear that simple pleurisy is more common among boys than girls; in twenty-one cases, twenty were boys, and one a girl. Secondary pleurisy is equally common in both; but what they call cachectic pleurisy prevails more among girls than boys. In eighty-two autopsies of boys, M. Hache found traces of pleurisy in forty-two ; and only in forty out of 112 autopsies of girls. Children of a weak, scrofulous constitution seem to be more liable to the disease than those of a more healthy habit. M. Baron considers the disease more prevalent in w'inter; Rilliet and Barthez in the month of April. Impure air, insufficient food, inadequate clothing, a prolonged so- journ in a hospital, lying too long on the back, seem to exercise as much influence on the production of pleurisy as upon pneumonia. Exposure to cold is, perhaps, the principal exciting cause; but Ril- liet and Barthez have seen it result from external violence. 518. Simple pleurisy may occur secondarily in the course of rheu- matism, scarlatina, Bright's disease, &c; it is rare in the course of measles, although it may occur as secondary to the pneumonia which so often attacks children in measles. Secondary pleurisy more frequently complicates pneumonia than, perhaps, any other disease, either from contiguity of tissue, or by the rupture of a small abscess (480). It occurs, also, in tubercular disease of the lungs, in like manner, either by extension, or by the softening and evacuation of a tubercular mass. Bouchut mentions that he found pleuritis in twenty-three out of sixty-eight autopsies; i. e., it was combined with acute pneumoniain nine ; with tubercular pneumonia in six ; with entero-colitis in five, and with different other diseases in three cases.1 519. Diagnosis.—The characteristic signs of simple pleurisy are the feeble respiration, gradually diminishing from below upwards, bronchial respiration, dulness on percussion, vocal resonance on ego- phony, and the absence of vibration. When the effusion is great, we may observe the prominence of the intercostal spaces, the deformity of the chest, and the displacement of the heart. In pleuro-pneumonia, as we have seen, the sounds increase in in- tensity, the dulness is absolute, the bronchial souffle almost cavernous, and the voice painfully resonant. No doubt, the diagnosis in the commencement of the illness is often difficult, but yet I agree with Dr. West, who, after mentioning the difficulties, remarks: "But even then, and in spite of all the circum- stances which have been enumerated as tending to mislead, you will seldom be wrong if you regard as an instance of pleurisy any case in which, symptoms like those of pneumonia having set in suddenly and ' Mai. des Nouv.-Nes, p. 345. PLEURISY. — PLEURITIS. 321 severely, auscultation fails to detect the crepitus of pneumonia, and discovers only feebleness of the respiratory murmur on one side, with or without a more or less marked bronchial character in the breathing.1 520. Prognosis.—The prognosis in pleurisy will vary according to the age of the patient and the circumstances of the case. Simple primary pleuritis, in children above five years of age, Rilliet and Barthez found to be a benign disease, and to terminate favorably when acute. Out of twenty-one cases to which they refer, none died. Hache, Constant,2 Baudelocque,3 Barrier, and Battersby,4 concur in this opinion. Of seventy-six cases treated at the Institution for Diseases of Chil- dren at Vienna, but tw*o died. Mr. Crisp and Dr. Copland, however, give a different opinion; the former considers it a disease of great danger; and the latter, that "its effects are more to be dreaded, the younger the child which becomes the subject of it." The combination of pleurisy with pneumonia appears more serious than either disease existing alone; for of five such cases, related by Rilliet and Barthez, two died, and five out of six in M. Barrier's ex- perience. Chronic pleurisy, Rilliet and Barthez consider as still more unfavorable, contrary to the opinion expressed by M. Barrier, who found acute pleurisy more fatal than chronic; and Dr. Battersby re- marks, there are many cases on record of recovery from uncompli- cated empyema, after the occurrence of deformity of the chest, and even after the evacuation of the fluid by a natural or artificial opening. Dr. Hughes performed paracentesis in four children between seven and nine years of age, and all recovered ;5 and Heyfelder in three cases, between six and seven years old, with perfect success.6 521. Treatment.—The treatment of acute pleurisy does not differ very much from that of pneumonia. If the disease be primary, and the child strong, we must have recourse to liberal blood-letting, either from the arm, or by leeches to the side, or both. It. may, very likely, be advisable to repeat this if the attack be severe, and the first attempt be only partially successful; but in this we must be guided very much by the intensity of the disease, and the strength of constitution pos- sessed by the child. In secondary pleuritis, it will probably be necessary, likewise; but we must carefully estimate the importance and results of the primary disease, as it is possible that this may preclude very active remedies for the secondary affection. After the proper treatment for acute pneumonia, for instance, and the exhaustion and weakness produced by that affection, it is evident that, should pleuritis suddenly arise, our treatment of the latter must be very much modified. As a general rule, in chronic pleurisy, blood-letting is rarely called 1 Lectures on Diseases of Infancy and Childhood, p. 214. 3 Gazette Med. de Paris, 1837, p. 265. 3 Lancette Francaise, 1837, p. 146. 4 Dublin Journal, November, 1847, p. 365. 6 Guy's Hospital Reports, Nos. 3 and 4, 1844. 6 Arch. Gen. de Med., third series, vol. v. p. 59. 21 322 PLEURISY. — PLEURITIS. for; certainly, if we detected the commencement of the disease, it would be advisable, but this is seldom the case ; and at the period when we are called to see the child, the mildness of the symptoms, the absence of fever, &c, rather indicate another line of treatment. 522. If there be much fever, with a quick, firm pulse, and, above all, if pneumonia exist, we shall derive great benefit from the employ- ment of tartar emetic for a few hours, given so as to produce slight nausea, but not vomiting. Dr. Condie speaks very highly of a combination of tartar emetic and calomel given in the following form:— R. Nitr. potassae £i; Antim. tartar, gr. ii; Sacch. alb. gii; Aquas ^iv. A teaspoonful to be given every two or three hours, according to the age of the patient. 523. Calomel, either alone or combined with James's pow7der, ipe- cacuanha, or tartar emetic, is a most valuable remedy. Small doses may be given two or three times a day from the commencement, and continued until the violence of the disease abates, unless diarrhoea should occur, or the gums become tender. If the state of the bowels forbid the continuance of the calomel, even though guarded by the pulv. creta? cum opio, or Dover's powder, we may substitute the hydr. cum creta. I have before remarked, that mercurial diarrhoea in chil- dren is nearly as good a sign of the constitution being under the in- fluence of the mineral, as ptyalism in the adult. The treatment by calomel, when it can be borne, is well suited to those cases of secondary pleuritis in which bleeding and tartar emetic are counter-indicated ; and in chronic pleurisy, where they are unne- cessary and unsuited. 524. I need hardly state, that the bowels should be kept free through- out the attack; at the commencement, a brisk purgative will be found very beneficial; but in repeating it, we must be careful not to occa- sion diarrhoea, if we wish to persist in the use of mercury. When diarrhoea exists, a little compound powder of chalk, with the powder of chalk and opium, may be given; or chalk mixture, with aromatic confection, and a few drops of laudanum. 525. After the first acuteness of the disease has subsided, when the pulse is quieter, and the fever nearly gone, very great benefit will be derived from blisters; small ones, and repeated, over the side affected. They are peculiarly applicable to secondary and chronic pleuritis, in connection with calomel and diuretics. In some cases, a sharp liniment will be sufficient, applied alter- nately to the back and front of the chest. 526. The majority of writers are agreed upon the benefits to be derived from diuretics, given, not in the very early stage of the dis- ease, but after the fever has somewhat subsided; and continued for some time. In secondary and chronic pleurisy they are also of great value, not PLEURISY.—PLEURITIS. 323 merely as a derivative, but as probably promoting the absorption and evacuation of the fluid effused into the chest. Squills, digitalis, and nitre, may be combined with the calomel, or formed into a mixture with mucilage, syrup and w7ater, or combined with an expectorant. Some mixture should be ordered to soothe the cough, and with this the diuretic may very well be combined. Dr. Eberle speaks highly of the tinctura sanguinaria? canadensis. Warm baths at the beginning are very soothing, but at a more ad- vanced period of the disease they may exhaust the patient too much. As in bronchitis and pneumonia, I have found the patient derive benefit from a constant poultice of bread and water, or linseed meal, applied to the chest; over the dressing, if a blister have been applied ; if otherwise, next to the skin. The diet must be low and simple until the acute stage be past, but then it may be gradually improved. The utmost care will be neces- sary during convalescence. 527. I have already alluded to the operation of paracentesis in chronic pleurisy. The success of the operation seems to have varied in different hands. Dr. Henry Bennett, in his paper,1 states that Boyer had performed the operation several times, but without success; that Dupuytren had seen only two successful cases out of fifty; Sir A. Cooper only one ; Gendrin not one out of twenty on which he operated; Dr. Bennett himself has seen three unsuccessful cases. On the other hand, he has recorded six successful cases out of nine by Dr. Davies, and several by Dr. Hamilton Roe. Herpin succeeded in one case, and Heyfelder in three. Dr. Hughes mentions that, within the last four or five years, the operation must have been performed from twenty to thirty times in Guy's Hospital. 528. As to the place and mode of operating, Mr. Cocks observes: "Auscultation and percussion are the best and surest means to detect the presence and the situation of the fluid; and on this and this alone we must place dependence. In the great majority of instances, the existence of the fluid will be most clearly indicated at the lateral and posterior part of the chest, in a position somewhat central between the upper and lower boundaries ; and in every case which has come under my own hands, I have had occasion to tap below the angle of the scapula, between either the seventh and eighth, or the eighth and ninth ribs, and at a point distant from one to three inches from the angles of the bones." "Our incapability of judging of the exact positions of the diaphragm, and the alterations which are liable to occur about the floor of the chest, from recent or old adhesions between that muscle and the base of the lungs, would lead me to deprecate the practice of making a low puncture. WThen we have the choice of two or three intercostal spaces, I would select the upper, or at any rate the middle one, as the least obnoxious to those casualties which may induce a failure in our object. Any advantage supposed to result from a de- pending opening can readily be obtained, as I shall presently show, by adapting the position of the patient to our purpose."2 1 Lancet, December 30, 1843. 3 Guy's Hospital Reports, 1844, No. 3, p. 67. 324 PLEURISY. — PLEURITIS. Previous to the operation, Mr. Cocks always employs Dr. Babing- ton's exploring needle, of which he speaks most highly, and deservedly. The instruments he employs for evacuating the fluid are, of course, the trochar and canula, but of a smaller size than usual. He prefers them of one-twelfth of an inch in diameter, and about two inches in length, and of a circular rather than an oval shape. In some cases of oedema of the subcutaneous tissue, a longer instrument may be re- quired. Mr. Cocks thus describes the operation itself, which inflicts very little pain: " It will be found most convenient to let the patient sit across the bed, so as to admit of his body being readily lowered and supported over the edge. The spot having been determined upon, it is advisable to make a small puncture in the skin, just at the upper edge of the rib, with a narrow-bladed lancet, through which opening the exploring needle, and subsequently the trochar, may be inserted. This preliminary step is not absolutely necessary, but as the skin is by far the most impenetrable and resisting of the tissues to be tra- versed, its previous division will render the introduction and with- drawal of the canula more easy, less forcible, and attended with a minor degree of pain and alarm to the patient. The exploring needle having been first introduced, and the presence of fluid ascer- tained, the trochar and canula may then be carried into the chest through the same track, giving the instrument a slight obliquity up- wards, which will, enable it to clear the edge of the rib. The depth to which the trochar must be passed, will, of course, depend much on the thickness of the parietes, the presence of fat, muscle, or oedema, for which due allowance should be made; and in most instances the penetration of the pleura will be appreciated by the sensation conveyed to the fingers of the operator, especially if the integument has been previously incised, so as to diminish materially the friction. " The remainder of the operation consists in getting rid of as much fluid as the strength and condition of the patient will bear, and care- fully avoiding the admission of air into the cavity. On withdrawing the trochar, the fluid will at first be found to flow in a steady and equable stream, slightly augmented in force at each expiration. After the lapse of a shorter or longer period, the flow will become checked at each inspiration, and then the body of the patient should be gently lowered into a horizontal posture, and turned slightly over to the af- fected side, so as to bring the cavity directly over the opening; and, in this position, he should be duly supported by assistants. The fluid will now recommence flowing in an uninterrupted stream; and when it again begins to flag, a still further quantity may be obtained, if the state of the patient permit it, by directing an assistant to make steady and continuous pressure on the lower part of the chest, by grasping it on either side with the hand. This may be kept up for a period varying from a few seconds to a minute, until a continuous stream can no longer be obtained, when the canula should be imme- diately withdrawn. The greatest care should be taken to remove the tube, and thus close the opening, while the chest of the patient is yet PLEURISY. — PLEURITIS. 325 in the grasp of the assistant; but if he relax the pressure, while the communication with the pleural cavity be still open, air will infallibly rush in. " During the whole process of evacuation, the unremitted attention of the operator should be directed to the stream of fluid, which he should never allow to become completely interrupted during the effort of inspiration. The admission of the slightest quantity of air is im- mediately indicated by a peculiar sucking noise, which cannot be mistaken, and which should be the signal for the withdrawal of the canula. The wound requires nothing but the application of a small dossil of lint and a strip of plaster, and the patient may then be laid down on the bed. If he complain of faintness during the operation, some wine or ammonia may be given."1 Dr. Hughes and Mr. Cocks have given the following resume, of twenty-five cases, in which the operation was performed: " Of these twenty-five cases, in which paracentesis thoracis was once or several times performed, thirteen may be fairly stated to have recovered, so far as regards the effusion into the pleural cavity. Twto may be justly mentioned as having at least partially recovered. One of these has, after seven years, a fistulous opening into the pleura; and the other has still some, though comparatively a very small quantity of fluid in the right pleura, but feels so much better as to be actually in search of employment in his profession. Ten have ultimately died of other diseases, generally connected with that for which the operation was performed, but entirely independent of its performance. Of these ten cases, ultimately fatal, six have died of phthisis; one of gangren- ous pulmonary abscess of the opposite side; one, after three months, of chronic pneumonia; one rather suddenly, with hydrothorax in the other pleura; and one, a case of pneumothorax with effusion (in which the operation was performed, simply with the hope of affording tem- porary relief), of pneumonia and pericarditis."2 1 Guy's Hospital Reports, 1844, No. 3, p. 74. 1 Ibid., No. 4, p. 366. SECTION III. DISEASES OF THE HEART. 529. Before entering upon the consideration of the malformations or diseases of the heart, it appears to me that I shall be doing good service to my readers by extracting from the valuable work of Rilliet and Barthez their conclusions as to the normal state of the heart, and the results of auscultation and percussion in infants. They are based upon the examination of 193 cases, from fifteen months to fifteen years, and are as follows:— " 1. The circumference of the heart does not increase in proportion to the age; it is nearly the same from fifteen months to five years and a half; from this time it increases irregularly up to puberty ; but, at the age of five years, the limit is more marked when we measure the heart filled with coagula; as, when empty, its progression appears less irregularly increasing. " 2. The distance from the base to the point, anteriorly, is nearly the half of the entire circumference at the base of the ventricles. " 3. The maximum thickness of the walls of the right ventricle varies little according to age; it is generally two millemetres up to six years, after which it is ordinarily three or four. " 4. The maximum thickness of the left ventricle is less than one centimetre up to six years old; after which it is one centimetre, or a little more. " 5. The relative thickness of the two ventricles is generally, as pointed out by M. Guersent, as 3 to 1, or as 4 to 1, rather more than less. " 6. The maximum thickness of the septum is nearly the same as the left ventricle; rather more than less. " 7. We will add a remark, the result of our notes, that the thickest part of the right ventricle is quite at the base, near the auricular opening; of the left ventricle, one or two centimetres from the base; and of the septum, from two to three centimetres. It follows, that the more considerable the thickness, the nearer it is to the middle of the height. " 8. The size of the right auriculo-ventricular orifice continues much the same up to the fifth year; it scarcely increases up to the tenth; but from this age its increase is marked. " 9. The left auriculo-ventricular opening, always smaller than the DISEASES OF THE HEART. 327 right, increases somewhat more regularly, and presents often the same dimensions as the distance from the base of the heart to its apex. " 10. The aortic orifice shows but very slight increase between fifteen months and thirteen years. " 11. The pulmonary orifice, on the other hand, increases notably from the age of six or eight years; so that, whilst previously it is about equal to the orifice of the aorta, afterwards it is much more considerable." x Rilliet and Barthez found no perceptible difference in their mea- surement between the two sexes. 530. I shall now extract their account of the results of auscultation of the heart and percussion:— " The precordial region presents ordinarily a diminished resonance, though rarely absolute dulness, in a portion of its extent between the nipple and the sternum, and is from four to seven centimetres ver- tically, and from four to eight transversely. This comparative dulness, therefore, occupies a space, circular or elliptical, whose greater trans- verse diameter runs from the nipple to the sternum, and sometimes to the xyphoid cartilage, so that the nipple is central as to the height, and at the left extremity of this diameter. With children above six years, the nipple will sometimes be found above this centre. " The ear, applied to this elliptical space, perceives easily the two sounds of the heart; the first is almost always duller (sourd) than the second. Around this central space the heart's action is weaker, according to the distance, although we can generally perceive the sounds, or at all events the second sound, all over the thorax an- teriorly. " Ordinarily, they are as audible, if not more so, beneath the right clavicle as at the right nipple, owing, doubtless, to their being con- veyed by the aorta superiorly; but in a small number of cases the pulsations of the heart are transmitted more plainly to our ears in the region of the liver than superiorly. " In the normal state, we have never heard the pulsations of the heart posteriorly. " In the great majority of cases, the sounds of the heart succeed each other with regularity, and the interval between them is always the same in the same child; some transient irregularities w7ere merely exceptional, and without value. Lastly, the radial pulse was always felt by the finger; just as the ear, applied to the precordial region, perceived the end of the first sound ; or, more correctly, the pulse cor- responded to the commencement of the interval which separates the two sounds."2 1 Mai. des Enfans, vol. iii. Appendix, p. 662. 2 Ibid., vol. iii. p. 265. 328 MALFORMATIONS. CHAPTER I. MALFORMATIONS.—INTRA-UTERINE DISEASES.—CYANOSIS. 531. It will be sufficient to enumerate very briefly the principal malformations to which the heart is subject, referring the reader for minute details to the elaborate works of Meckel,1 Geoffroi St. Hilaire,2 and to M. P. H. Berard's excellent article in the Diet, de Medecini, in thirty volumes. These malformations may be divided into— i. Anomalies as to JVumber.—There are examples of children born without hearts, but of course this is incompatible with extra-uterine life ; and, as a general rule, such cases occur only in acephalous foetuses. Double hearts only occur in instances of diplogenesis. n. Anomalies of Position and Situation.—Instances have occurred of the apex of the heart being directed laterally to the right or left; and it is said to have been placed vertically. WThen the heart is displaced, it may still remain on a level with the chest, as in those cases where, the parietes not being closed, it is projected externally. M. Vaubonais relates a case in which " the heart was external, hung to the neck like a medal." Other cases are related by Buttner, Martinez, Haller, &c. Or the heart may be found elevated to the neighborhood of the head (eciopie cephalique of M. Breschet), as in the case related by MM. Breschet, Beclard, and Bonfils, where it was found in one between the bones of the jaw7, and adhering to the tongue ; in another, attached by its apex to the vault of the palate ; and in a third, adhering, on the one hand, to the placenta, and on the other to the head. Or, lastly, the heart may be depressed into the abdominal cavity, in consequence either of an opening through the diaphragm, or from the absence of that muscle. In the former case, if the abdominal parietes are complete, the individual may live for years, as in the cases related by Ramel3 and Deschamps.4 WThen the abdominal parietes are incomplete, life cannot be prolonged, even if the child be born alive, as in Mr. Wilson's cases.5 in. Malformations which do not permit the Mixture of Arterial and Venous Blood.—These cases are rare, and of little importance, in- cluding examples of bifurcation of the apex, multiplication of the cavities, &c.6 iv. Malformations which permit the Mixture of Arterial and Venous 1 Manuel d'Anatomie Generate, &c. * Hist, des Anomalies de l'Organization. 3 Journ. de Med. de Chir. et de Pharmacie, 1778, vol. xlix. p. 423. 4 Journ. de Med., vol. xxvi. p. 275. 5 Philosophical Trans., 1789. 6 Paget on the Congenital Malformations of the Heart. CYANOSIS. 329 Blood.—These are, of course, of much greater importance, and some of them will involve a more lengthened consideration. According to M. Berard, the following are the principal instances: 1. When the heart forms but a single cavity, into which the vessels open at once.1 2. When it consists of two cavities, an auricle and a ventricle, as in the cases of Wilson,2 Standen,3 Faure, Mayer, Ramsbotham,4 Mau- ran,s and Breschet. 3. Wliere the foramen ovale remains open. I shall return to the consideration of this latter case and its conse- quences presently. 4. M. Billard has included, among the malforma- tions of the heart, a narrowing of its orifices, which, however, may possibly have been the result of intra-uterine disease. He attributes it to a disproportionate growth in the heart and the orifices; i. e., the latter do not increase as fast as the former, and thence result various disturbances of the circulation, and certain asthenic affections.6 532. Let us add here, that, during the intra-uterine life, the serous membrane of the heart and pericardium may be the seat of inflam- mation. I examined a foetus recently in which I discovered intense pleuritis and pericarditis. Organic diseases, also, are occasionally observed. Billard mentions a case of scirrhus ; Denis, of hypersar- cosis; Cruveilhier, of aneurism of the aorta; and Billard, of aneurism of the ductus arteriosus, &c.7 CYANOSIS. 533. Before entering upon the examination of this disease, which appears to be the consequence of a communication between the right and left sides of the heart, through the open foramen ovale, it is necessary to inquire as to the period when this foramen is ordinarily closed, and the mode by which it is effected, as we shall be then better able to judge of the results of its non-obliteration. I must here avail myself of the minute and interesting observations of M. Billard.8 He states that, "out of nineteen infants of a day old, the foramen ovale was completely open in fourteen; in two, partially closed; and in two others, quite closed. In the same infants, the ductus arteriosus was free and full of blood in thirteen ; partially obliterated in thirteen; completely so in one. In the same infants, the umbilical arteries were open near their insertion into the iliacs, but their calibre was dimi- nished by a remarkable thickening of their parietes. " Infants of two Days old.—Of twenty-two, there wTere fifteen of whom the foramen ovale was very free; three in whom it was almost obliterated; and in four, entirely closed. In thirteen, the ductus arteriosus was free; in six, partially obliterated; and in three, com- pletely so. In all, the umbilical arteries were more or less closed, but the umbilical vein pervious. ' Manuel d'Anat, vol. ii. p. 305. a Philos. Trans., 1798, p. 346. 3 Ibid., 1805, p. 228. * London Medical and Physical Journal, June, 1829. 6 Philadelphia Med. Journ., Aug. 1827. 6 Mai. des Enfans, p. 605. 7 Graetzer, Krankheiten des Fcetus, p. 160. 8 Mai. des Enfans, p. 605. 330 CYANOSIS. " Infants of three Days old.—Of twenty-two, there were fourteen , in whom the foramen ovale was quite open; in five, its obliteration had commenced ; and in three, it was completely closed. The ductus arteriosus was free in fifteen ; its obliteration had commenced in five, and was complete in two only; but in these two the foramen was closed. The umbilical vessels were empty, and even obliterated in all. " Infants of four Days old.—Out of twenty-seven cases, in seventeen the foramen was open, and in six of them the opening was large, and distended with blood; and in the remaining eleven, it was simply free; its obliteration was commenced in eight, and was complete in two. The ductus arteriosus was permeable in seventeen, partially closed in seven, and completely so in three. The umbilical arteries were obliterated near the umbilicus, but still dilatable near their iliac insertions. The umbilical vein and ductus venosus were empty and contracted. "Infants of five Days old.—Out of twenty-nine cases, thirteen had the foramen ovale open, but not equally so; it was nearly closed in ten, and effectively so in six others. The ductus arteriosus was open in fifteen ; largely so in ten of them ; partially obliterated in five; nearly completely in seven ; and quite so in seven others. The um- bilical vessels closed in all. "Infants of eight Days old.—Of twenty cases, the foramen ovale was free in five only; it w7as incompletely closed in four; and Com- pletely so in eleven. The ductus arteriosus was obliterated in all except three; the umbilical vessels in all. "We find, from this last examination, that the foetal openings are generally obliterated in eight days, but that we may find them free at that age, or even at twelve or fifteen days, without the child suffering in consequence. " From the facts laid down before us, it follows that the foetal open- ings are not obliterated immediately after birth; that the period when this takes place is very variable; but that in eight or ten days the fora- men ovale and the ductus arteriosus are generally closed. " From our examination, we find that the umbilical arteries are first obliterated, then the umbilical veins, next the ductus arteriosus, and, lastly, the foramen ovale. The persistence of those communications for some days after birth should not be regarded as a disease, seeing that it is very common, -that it produces no ill effect, and that it is owing to the mode of obliteration." 534. I shall next present to the reader M. Billard's account of the mode in which this obliteration is effected, merely premising that his observations have been confirmed by M. Berndt, of Vienna. If any apology be necessary for such long extracts, it will, I trust, be found in their importance, and in the fact that they are unique. " If we examine the disposition gradually assumed by the foramen ovale from a short time after conception up to birth, we perceive that the form of this opening, the arrangement of the surrounding parts, and especially of the Eustachian valves, become such, that the blood, CYANOSIS. 331 which at first flowed freely from one auricle into the other, meets by degrees with more difficulty in doing so. Sabatier has strongly insisted upon this point. Thus, then, a modification in the organization of the heart has forced the blood to modify its course; this fluid, inert by itself, is in immediate dependence upon the motor power which pro- jects it, and directs it into the channels in which it ought'to flow. If so, it follows that other changes will equally take place in those parts which the blood ought to forsake; anatomical changes which, altering the form and modifying the action of the organs, will impress a new direction upon this fluid. Now, if we examine the umbilical arteries and the ductus arteriosus, we shall find that, in progress of obliteration, their coats become thickened. This thickening of the umbilical arte- ries is especially remarkable at their insertion into the umbilicus; at that spot they often present, after birth, a fusiform contraction, which diminishes the calibre of the arteries, and is able to resist the force of the column of blood projected by the iliac arteries." .... "Thus two causes force the blood, after birth, to abandon the course it took during intra-uterine life: 1. The establishment of respiration and the pulmonary circulation. 2. The modification of structure which the umbilical arteries undergo. Moreover, there is an experiment which proves that the contractility of the umbilical vessels can sus- pend the flow of blood through them. If we divide the cord, after birth, at some distance from the navel, the jet of blood is at first very strong, then it becomes slower, and afterwards stops altogether; and if w7e cut off another portion, the same phenomenon occurs. It is owing, of course, to the contraction of the arteries upon the blood; and if this contractility exists near the umbilicus and within the abdo- men in a greater degree, on account of the greater amount of elastic tissue, one can understand the resistance they will be able to offer to the.course of the blood, in its more tranquil flow after birth. By de- grees, as the infant grows older, the vascular tube is converted into a ligament. "That which happens with the umbilical arteries is observed also in the ductus arteriosus. In the embryo, it is as yielding as other arteries, easily dilated by the column of blood which flows through it, without resistance, to the aorta. But at birth, and afterwards, its parietes become by degrees thicker by a sort of concentric hypertrophy which diminishes the calibre without apparently diminishing the size of the vessel, and, in consequence of this resistance, the blood which is obstructed passes into the pulmonary arteries. At this period, the duct presents the appearance of a pipe whose walls are very thick and perforation very moderate." . . . "If it be necessary that the foramen ovale and the ductus arteriosus should undergo organic changes wdiich prepare and lead to their obliteration, one can easily perceive that the modifications may sometimes be effected prematurely, in others very tardily; so that, on the one hand, we find the foramen ovale closed soon after birth, in some infants, or for a long time patent in others, and, in most instances, requiring some considerable but un- certain time for the completion of these changes. Thus we may ex- 332 CYANOSIS. plain the irregularity observed in the time at which an independent circulation is established, without considering it as the cause or effect of disease of the heart or lungs. "However, the result will, no doubt, be an incomplete oxygenation of the blood, since all that the heart projects to the different parts of the body has not previously traversed the lungs, nor is in contact with the blood so renewed. " But, after all, is it necessary that the blood of a new-born infant should be as highly oxygenated as that of an adult ? Is it not suit- able that the recently completed and tender tissues of its organs should not receive blood too active ? that the materials of nutrition should not be charged with principles too exciting, whose action upon the infantile organs might prove injurious to health, and even impede the progressive establishment of independent life? I think so, and see no reason for rejecting the opinions which result from the examination of the circulating system in new-born infants. These conclusions are supported by another consideration, viz., that the lungs might be ex- posed to fatal congestions, if all the blood sent from the heart were conveyed to these organs by the pulmonary arteries. The ductus arteriosus, by allowing the superabundant blood to escape by it, relieves the respiratory organ, and permits a freer entrance of air into it than would take place if it were in a state of congestion, thus favoring the establishment of independent life by the persistence of those arrange- ments which were necessary during foetal life. Thus all is connected in a chain, the disposition of parts and the exercise of their functions; everything progresses in order, and by transitions foreseen and pro- vided for, so that no sudden and unexpected change disturbs the har- mony of the vital phenomena. "If those openings persist much beyond the period already indi- cated, then, indeed, disease may be the result."1 After reading the valuable researches of M. Billard, we shall be better prepared to consider the disease in question, properly called "the blue disease," "morbus ceruleus," or cyanosis. 535. Cyanosis consists in a blue, violet, or purple color of the sur- face of the body, and especially of those parts which are usually of a fresh or rose color, as the lips and other mucous surfaces, cheeks, &c.2 The color is very marked in the face, hands, feet, and genitals, and less deep in other parts of the body, presenting the aspect of extreme venous congestion. The color deepens during excitement or exertion, giving a very distressing appearance to the patient. The extraordinary color, however, would be of little consequence, were it not that it is attended with other disturbances of a more seri- ous character. The action of the heart is very subject to derangement upon the slightest excitement or exertion; the patient suffers from palpitation, fainting, &c, accompanied by bruit de soufflet, or the purring- sound ; and there is, as we should expect, a marked disposition to serous effusion. * Mai. des. Enfans, p. 605. J Copland's Dictionary, p. 199. "Blue disease." CYANOSIS. 333 The respiration* is consequently and equally disturbed; hurried breathing, panting, dyspncea, with a sense of suffocation, follow the least exertion, or occur in paroxysms without any cause. In fact, as Dr. Copland remarks, "it may be said that the disorder is made up of a succession of paroxysms and remissions. In the paroxysms alone, we observe those frequent faintings, that tumultuous palpitation of the heart, and suffocation, which endanger the life of the patients. No rule can be relied on as to the recurrence of these paroxysms; in fact, if it be certain that they are brought on by over-exertion, fatigue, and violent mental agitation, it is equally certain that they occur without any assignable cause, and are more frequent in winter than in summer. "The length of the paroxysm varies; it sometimes lasts several hours, and generally abates gradually. " The termination of cyanosis is fatal to most patients; but some appear to recover entirely; others live for many years."1 536. Pathology.—One circumstance is common to almost all these cases, and is discoverable in making a post-mortem examination; I mean some mode of communication between the two sides of the heart. This may be affected in various ways:— 1. The foramen ovale may remain open or may have been re- opened ; and M. Gintrac2 remarks that, along with this patency, there is generally an obstacle to the passage of the blood from the right auri- cle into the right ventricle, or more frequently from the right ventricle into the pulmonary artery. This obstacle he found in twenty-seven out of fifty-three cases; in twenty-six of the twenty-seven the im- pediment was in the pulmonary artery. 2. The inter-ventricular septum may be perforated, as in some of M. Louis's cases.3 3. The ductus arteriosus may remain open, and, according to Louis, this is often coincident with the patency of the foramen ovale. 4. The two auricles may open into the right ventricle, as in MM. Gintrac's and Breschet's4 cases, with perforation of the inter- ventricular septum, or, as Haller5 mentions, with one auricle for the two ventricles. In one of M. Gintrac's cases, the two auricles opened into the right ventricle, between which and the left ventricle there was a considerable opening. The aorta took its origin from the left ventricle. 5. The pulmonary artery and the aorta may arise from the left ven- tricle, the right being almost obliterated, with a communication by means of the persistent foramen ovale, or perforation of the inter- ventricular septum. Hoist, of Christiana, and Gintrac, have related a case of this kind. 6. The insertion of one or all the pulmonary veins into the vena cava superior. 1 Diet, of Pract. Med., part i. p. 200. 2 Observations et Recherches sur la Cyanose, 1824. Paris. 3 Memoires et Recherches Anatomico-pathologiques, p. 328. 4 Repertoire Gen. d'Anatom., vol. ii. * De Monstris, vol. i. 334 CYANOSIS. 7. The presence of a second pulmonary artery arising from the right ventricle, and opening into the aorta; or supplying the place of the aorta, which was obliterated after giving off the cephalic and brachial trunks. 8. The transposition of arterial or venous trunks; as, for example, the implantation of the pulmonary artery upon the left ventricle, and the aorta upon the right, whilst the veins remain in their normal situation; or the opening of the veins into the left ventricle, the pul- monary veins, or even into the aorta. 9. The pulmonary artery may be completely obliterated. 10. The heart may consist of one auricle and one ventricle, as in the batrachia?. 11. There may be two superior vena? cava?, one opening into each auricle. 537. M. Louis has remarked the rarity of narrowing of the auriculo- ventricular, or the ventriculo-aortic orifices of the left side, he having met one case only, and that a slight one, in his twenty cases; whereas, in the same cases, there were ten examples of narrowing of the orifices of the pulmonary artery, and one of occlusion of the auriculo-ventri- cular communication by ossification of the tricuspid valves, which were perforated in many places. The narrowing of the pulmonary artery may be owTing to the ossification of the sigmqid valves, united by their free edge, or to a species of diaphragm pierced in the centre, or by an approximation of the parietes of the artery to the correspond- ing ventricle. M. Louis conceives the changes to have been either malformations, or the result of intra-uterine disease. 538. The condition of the heart itself is worth notice in these cases. M. Louis observes that, with one exception, his tw7enty cases were all examples of aneurism of one or more of the cavities of the heart. Dilatation of the right auricle occurred in nineteen cases, with hyper- trophy in six, and thinning of the walls in two. The right ventricle was dilated in ten cases, hypertrophied in eleven, and in five, the hypertrophy and dilatation were coincident. But the left auricle was dilated only in three cases, hypertrophied in two, and the left ventricle dilated in four, and hypertrophied in three cases.1 M. Bouillaud states that the volume of the heart was augmented in eleven out of fifteen cases, and that, in the majority of cases, it was owing both to hypertrophy and dilatation of the right cavities. In ten cases the right auricle was dilated, in five of them it was hyper- trophied also; in five others, it is not stated; in five, there was hyper- trophy; in five others, it is not stated. In ten cases, the right ventricle was hypertrophied, and the hypertrophy was concentric.2 M. Bouillaud has also mentioned that, in four of his cases, the peri- cardium contained from three ounces to a pint of serum ; in two cases, it was mixed with flocculi of albumen, and, in one case, there was false membrane with granulations on the surface of the rio-ht auricle. 539. There is some difference of opinion as to whether the com- munication between the two sides of the heart are congenital malfor- ' Mem. et Recherches Anatomico-pathologiques, p. 334. * Traite des Mai. du Cceur, p. 685. CYANOSIS. 335 mations, or the result of accident or disease. M. Louis, who has examined the question with his usual minute care, has arrived at the conclusion that they are original malformations; but M. Bouillaud thinks that the perforation of the inter-auricular or inter-ventricular septum may have taken place from causes which have left no traces. M. Ferrus1 also objects to attributing all the cases to original mal- formations, because of the sudden development of the consequences; which, he thinks, could not have been so long postponed if the cause had been longer in existence. M. Fabre,2 howrever, very justly re- plied to this, that he has often dissected children in whom these mal- formations existed, but in whom the symptoms never occurred. He differs from M. Louis, in thinking the absence of any traces of dis- ease about the opening a conclusive proof that it is a malformation ; and he concludes that, in the majority of cases, the communication is congenital, especially between the auricles, but that the perforation of the inter-ventricular septum is sometimes accidental. 540. The effect of this inter-communication one would suppose to be the immediate mixture of red and black blood, or the reduction of the heart to the condition of a single one; but such is not invariably, nor necessarily, the case. There will, probably, be no mixture of blood, although the foramen ovale be open, unless there be hyper- trophy and dilatation of the right side of the heart, wTith narrowing of the auriculo-ventricular opening; and, in like manner, it will require a narrowing of the arterial orifices to occasion a mixture of blood where the ventricles communicate. And the coincidence of these changes is not unfrequent. M. Jules Cloquet and M. Bouillaud agree pretty nearly with this view of M. Louis, that, when the foramen ovale remains open, the ductus arteriosus is pervious, the aorta springs from both ventricles jointly; and when to the communication between the right and left side of the heart, there is superadded an obstacle to the free current of blood in the former, a considerable quantity of black blood must, of necessity, mix with the red. The endocardial murmurs which are occasionally present, are, no doubt, due to the narrowing of the auriculo-ventricular or arterial orifices, or to regurgitation. 541. But are we to conclude that the discoloration of the skin is owing to the mixture of arterial and venous blood? M. Louis says: " It is, then, impossible to maintain, either from reason or experience, that the blue color is due to a mixture of black and red blood ; and the more, that it appears that this mixture occurred in almost every case, whereas, the blue color was by no means constant. Let us add, with M. Fouquier, that the skin of the foetus, in which black blood circulates, is not blue." He adds : " Morgagni seems to have given the true explanation in the case which we have quoted from him. To account for the livid color, he remarks, that the constric- tion of the orifice of the pulmonary artery, in consequence of ossifica- tion, must have caused great embarrassment of the circulation ; that 1 Diet, de Med., en 30 vols., vol. ix. p. 536. 8 Bibliotheque de Med. Prat., vol. v. p. 379. 336 PERICARDITIS. the blood stagnated in the right ventricle, right auricle, and conse- quently in the entire venous system."1 Corvisart seems to doubt whether the blue color Is owing to this admixture of blood. M. Billard states, that cyanosis is not the invariable result of the persistence of the foramen ovale, or the passage of the venous blood into the arterial system, inasmuch as there are many cases in which this took place without such results; but it is probably due, either to this mixture, or to deficient oxygenation of the blood, whether there be intercommunication, or whether the blood be incompletely changed in the lungs. M. Bouillaud expresses a similar opinion ; he regards cyanosis as essentially due to a deficient oxygenation of the blood, whether the structure of the heart be perfect or not. The prolongation of life, according to M. Louis, bears no relation to the symptoms, nor to the supposed condition of the blood. The subjects of this disease may die in infancy, or may live to twenty, thirty, or fifty years of age. Neither is it incompatible with the due development of the intellectual faculties. 542. Treatment.—As far as the disease depends upon organic im- perfection of the heart, so far it is evidently beyond the reach of our means of cure, although some alleviation may be afforded. We are not, however, to conclude that no reparation is possible, because we cannot effect it, or discover how it is to be done. It is for us to assist the efforts of nature by securing the conditions most favorable to the present comfort, and permanent benefit of our patient; such as bodily and mental repose, a pure, mild air, with careful attention to the stomach and bowels. M. Bouillaud recommends blood-letting during a paroxysm ; but Dr. Copland objects to this, as seldom relieving the paroxysms, and naturally increasing the disease. Counter-irritation to the chest, by dry cupping, mustard poultices, or blisters, may be of use. "I have derived," says Dr. Copland, "more advantage from stimu- lating pediluvia, frictions of the surface of the body and lower extre- mities, and the administration of gentle antispasmodics and stimu- lants. In one or two instances, I conceived that some advantage was derived from the preparations of iron, combined with the fixed alkaline carbonates."1 CHAPTER II. INFLAMMATION OF THE PERICARDIUM.—PERICARDITIS. 543. The only diseases of the heart of which I shall treat, are in- flammation of the investing and lining membrane, i. e., pericarditis, 1 Recherches sur plusieurs Mai., pp. 336, 344. "Dictionary of Practical Medicine, part i. p. 201. PERICARDITIS. 337 and endocarditis, with a slight notice of their consequences. It is only since Laennec's brilliant discovery of the pbwTer of auscultation in detecting disease that we have had the means of acquiripg infor- mation about these affections during life; but it is within a few years that our knowledge has acquired any degree of certainty. Previously, dissection had proved the occurrence of pericarditis in childhood, but such was its obscurity, that it was generally passed over in works on diseases of children. Cases were published by Lieutaud, Schmidel, and Koppel. Krukenbergius1 and Roux2 detailed some which occurred during the course of scarlatina and measles, and Vieussieux, Davis, and Wells, others which occurred during an attack of rheumatism. Puchelt collected most of the scattered cases, and published them in a memoir, with others he had observed himself; but it was not until the labors of Stokes, Watson, and others, in Great Britain, and Bouillaud in France, that much light was thrown upon the disease, either in the adult or in children. Since then, it has been noticed by Billard, Rilliet and Barthez, Condie, West, &c, in children. 544. Pericarditis, or inflammation of the serous membrane which lines the pericardium and covers the heart, is not a very common dis- ease of infancy and childhood, but neither, on the other hand, is it extremely rare. In 700 autopsies made by Billard at the Hopital des Enfans Trouves, he found seven presenting evidences of pericarditis.3 Dr. West states, "in six out of 170 cases in which the state of the thoracic viscera was carefully examined, he discovered evidences of inflammation of the pericardium, or endocardium, or both."4 At a meeting of the South London Medical Society, in the debate on Mr. Crisp's paper on pleurisy in children, Dr. Todd stated it to be his opinion that the pericardium was oftener the seat of inflamma- tion in young than in older persons, and by no means rarely so in in- fants.5 The acute may either be acute or chronic; of the latter, however, we know but very little, as it is the acute symptoms which generally attract attention. The disease may be either primary or secondary, the former being exceedingly rare. It is seldom met with in adults, according to Dr. Latham, and still more rarely in children. Our chief knowledge of the disease in the living subject is drawn from those cases in which it occurs in the course of other diseases, such as rheumatism, the erup- tive fevers, pleurisy, &c. 545. Dr. West has given a case of idiopathic, or primary pericar- ditis, which I may be excused for copying, on account of its rarity and interest. The subject of it was " a healthy boy, eleven years old, who, on May 8, 1843, complained of feeling cold, and began to cough. 1 Jahrbucher d. Ambulatorischen Klinik, vol. i. Halle. a De Carditide exsudativa, p. 47. s Mai. des Enfans, p. 623. 4 Lectures on Diseases of Infancy and Childhood, p. 314. s Medical Gazette, Dec. 25, 1S46. 22 338 PERICARDITIS. The chilliness was succeeded by fever, and he continued gradually getting worse till the 13th, when I visited him for the first time. He had had, no other medicine than a purgative powder. On May 13th, I found him lying in bed; his face dusky and rather anxious; his eyes heavy, and his respiration slightly accelerated; coughing fre- quently, but without expectoration; skin burning hot, and pulse fre- quent and hard. He made no complaint, except of slight uneasiness about the left breast. On examining the chest, there was found to be very extended dulness over the heart, with slight tenderness on pres- sure. A very loud and prolonged rasping sound was heard in the place of the first sound, loudest a little below the nipple, though very audible over the whole left side of the chest, and also distinguishable, though less clearly, for a considerable distance to the right of the sternum. The second sound was heard clearly just over the aortic valves, but was not distinct elsewhere, being obscured by the loudness of the bruit. Respiration was good in both lungs. "The child was cupped to ^vi between the left scapula and the spine, and gr. i of calomel, with the same quantity of Dover's powder, was given every four hours. "On the following day, it was found that the sense of discomfort in the chest had been relieved by the cupping, and that the child had slept well in the night. He looked less anxious, though his eyes wrere still heavy and suffused, and his skin was less hot and less dusky. His pulse was 114, thrilling, but not full. There was now slight prominence of the cardiac region, and the heart's sounds were ob- scurer and more distant than on the previous day. The bruit was now manifestly a friction sound, louder at the base than at the apex of the heart, and altogether obscuring the first sound, while the second sound could be heard over the aortic valves. Six more leeches were applied over the heart, and the hemorrhage from their bites was so profuse as to occasion some faintness. Mercurial inunction was now superadded to the treatment previously employed; and the child's con- dition continued through the 15th to be much the same as it had been on the previous day. On May 16th, there was some improvement in the general symptoms, and the pulse was softer. The friction sound was now no longer audible; but a loud, rasping sound was heard in the place of the first sound. The second sound was now distinguishable at the apex of the heart, as well as over the aortic valves, and its character was quite natural. On the 17th, the mouth was slightly sore, and the dose of the remedies diminished. On the 22d, the soreness of the mouth was considerable, and all active treatment was discontinued on that day. The child gradually regained his strength, but the bruit accompanying the. first sound continued, and was heard a month afterwards, with no other change than being rather softer, and more prolonged. Four years afterwards, I saw him ao-ain. He had continued well in the interval, and had never suffered from pal- pitation of the heart, nor from any other ailment referable to the chest; but his pulse was small, jerking, and not always equal in PERICARDITIS. 339 force, and the natural character of the first sound was altogether lost in a loud, prolonged bruit."1 This case is of great value, both on account of the accurate picture of the disease it presents, and from its simple character and history. The characteristics of the heart disease are pretty much the same, whether as a primary or secondary affection. 546. Symptoms.—The symptoms of pericarditis are not very strik- ing, and in infants are necessarily more obscure than in adults, because a very young child's expression of pain or uneasiness is always more or less confused. When it occurs in the course of other diseases, also, our attention may be so fixed upon the important primary affection, that we may overlook the slight but essential changes which mark the incursion of a new disease. No better illus- tration could be given of the value of a rule which I have adopted for many years, and which I strongly recommend to my readers, viz.: when first called to see a child, no matter for what disease, to examine every organ of the body, and to repeat this examination at intervals of a few days. By so doing, we shall often ascertain the commence- ment of secondary affections before they give rise to any complaint of distress. Probably, the earliest symptom we shall notice of the disease in question will be uneasiness or pain in the left side of the chest, in the precordial region, near the left mamma; this pain will be ex- pressed, if the child be old enough; or, if not, we may detect it by the position in bed, the restrained inspiration, the suffering on percussion, or on being moved. In Constant's, Mayne's, and Billard's2 cases, it was pretty severe ; inp Puchelt's, not very acute; and in Rilliet and Barthez's cases it occurred but rarely, and w7as not severe. It will be less marked, or at least less pathognomonic, when the primary disease is pleurisy or pneumonia ; but in fever or rheumatism any uneasiness in the left side of the chest ought at once to excite our suspicions, and direct our most careful attention to the state of the heart. The respiration, too, has a peculiar character in general; it is not the dyspnoea of obstructed lungs, nor is it any form of cerebral re- spiration, but it is high, rapid, yet restrained and suffocating, with quick movement of the ala? nasi, and a difficulty of speaking sen- tences, as though the interruption to the short, quick inspirations, necessary in speaking, wrere intolerable. This, again, will be masked, if there exist any pulmonary disease, but in other cases it is very striking. If there be no disease of the lungs, there will be but little cough, if any; but when these organs are affected, we may be at a loss to sepa- rate and distinguish the symptoms peculiar to each disease. Palpitation, owing to irregular action of the heart, is seldom trou- blesome, but the violent action of the organ is sometimes felt in a distressing manner. 1 Lectures on Diseases of Infancy and Childhood, p. 317. a Mai. des Enfans, p. 570. 340 PERICARDITIS. The pulse is very quick, strong, and wiry. The face has an anxious, drawn, distressed, almost frightened expression; in two cases, Billard observed spasmodic movements of the limbs; the child cries often, as if suffering extremely, and generally objects to lying flat down in bed. 547. But all these signs would only excite our suspicions that some grave lesion existed ; they afford us no precise information as to its nature. This we can only obtain by a careful estimate of the phy- sical signs; but then it is satisfactory to know that these are amply sufficient. The natural sounds of the heart are dull or muffled, though gene- rally distinguishable. This obscurity increases for some days, occa- sionally varying; its maximum is just beneath the mamma, and it appears to depend either upon the effusion of fluid, or upon the exo- cardial murmurs occasioned by the disease. In eight out of nine cases, related by Rilliet and Barthez, both sounds were obscure ; in one, one of the sounds only. Although the sounds are muffled, they are not weakened, but, on the contrary, may even be louder than natural, with increased impulse. The exocardial murmurs are thus described by Dr. Williams: "Those of pericarditis are various sounds of superficial friction, which are quite characteristic. At first, this sound is soft and rustling, like the rubbing together of two pieces of paper or silk stuff; and it may accompany only part of the natural sounds, from which, however, it is obviously distinct, in being much more superficial. It is generally heard first about the middle of the sternum, or to the left of it, corresponding with the base of the heart or the attachment of the auricles ; it afterwards increases in loudness and duration, being heard beyond the immediate region of the heart, and accompanying not only the periods of the natural sounds, which it disguises, but also the interval between them. It thus gets a sort of continuous jogging rhythm, corresponding with the movements of the heart, which is like that of the saddle when one rides on horse- back ; and when, as it generally happens, the friction sound becomes harder, and more like the creaking of leather, its resemblance to the noise of a new saddle is quite ridiculous. In some cases the noise is crackling, like that of crumbled, dried membrane or parchment." "These friction sounds are certainly caused by the rubbing of lymph on the pericardium proper, and on its sac."1 WThen effusion takes place, so as to separate the opposing surfaces of the pericardium, these friction sounds are, of course, impossible, so that they are heard chiefly during the early stage of the disease, and again, when the process of absorption has removed the principal por- tion of the fluid, except in those cases where there is little effusion. The sounds are generally audible in whatever position the child may be placed; but, in tw7o cases, Rilliet and Barthez found them more evident in a sitting posture. Along with these exocardial murmurs, we occasionally hear a bruit 1 Diseases of the Lungs, p. 235. PERICARDITIS. 341 de soufflet accompanying the first or second sound of the heart, but this does not result from pericarditis, but from coincident endocarditis, of which I shall speak presently. If the effusion be small, the respiratory murmur will be audible in the pericardial region, but if large, the lungs will be, to a certain extent, displaced. Dulness on percussion is another sign of considerable value ; it* is almost always more absolute than usual in the precordial region, but its extent will depend upon the amount of effusion. When this is considerable, the dulness will be proportionally extensive, and not only so, but the precordial region acquires a degree of prominence ; the intercostal spaces are protruded, and subside as the effusion is absorbed. Thus, the physical signs of pericarditis are muffled sounds and increased force of the heart, exocardial murmurs, dulness on percus- sion, and fulness or prominence of the precordial region. 548. I have already mentioned that the pulse is quick, the skin is hot and feverish, the tongue loaded or white, the appetite lost, and the bowels often disordered. In other words, the entire constitution sympathizes with, and suffers from, the diseased condition of its central and most important organ. 549. Cases, however, occur in which the symptoms are much more obscure, nay, which may hardly indicate the region affected. My dear friend, the late Dr. Hunt, gave me the notes of the following case, which strikingly illustrates the fact: "George M'Donnell, a?t. seven months, a large, healthy child, awoke screaming from sleep, about 6 A. M., on Monday morning. He was bathed and fomented without relief. On Monday, Dr. Hunt saw him, and found the state of the skin, abdomen, and his general appearance, natural. He drank freely, but not greedily, and without pain or difficulty; pulsation of the fontanelle regular; respiration high, apparently painful, but not diffi- cult ; the ala? nasi were not in movement, nor was there any heaving of the chest. After crying continuously for some minutes, he would then give two or three screams. This state continued until 8 A M. of Wednesday, he having never slept more than a few minutes the whole time. At this time, the pulse was scarcely to be felt, the body was cold, and the side on which he was lying was dark red, like the appearance of cadaveric congestion. This appearance, and the sink- ing of the pulse, were said to have existed from an early hour the pre- ceding night. He died at 11 A. M., without convulsion or struggle. Dr. Hunt was for some time inclined to regard it as a case of cerebral disease; but, on making a post-mortem examination, the pericardium was found universally adherent to the heart by fresh lymph, except in one small space which was filled with milky fluid. The lungs and pleura were healthy." This case is very valuable as showing the occasional obscurity of these cases, and also as another instance of idiopathic pericarditis. 550. In cases which terminate favorably, the symptoms, after con- tinuing a certain time, gradually diminish, the abnormal sounds be- 342 PERICARDITIS. come less and less audible, or the dulness becomes more limited and less absolute, and the child recovers its usual health. These are the most fortunate cases, and their duration varies from one week to a month and more. The course of the fatal cases is much more rapid, terminating often in three or four days. Rilliet and Barthez mention one case of small- pox, which proved fatal in twenty-four hours after pericarditis set in. But there is an intermediate class of cases, and perhaps more nu- merous than either, viz., where life is saved, but a certain amount of injury to the heart remains permanent, requiring a long time to re- pair, even if the normal condition be ever restored. There may or may not be much evidence of its existence—some increase of impulse, and a liability to palpitate from exertion or mental emotion. Or it may give rise to remote consequences of more or less importance, and requiring great attention. Let us inquire into some of these conditions and consequences. 551. i. In the process of cure, the fluid may be entirely absorbed, allowing the two surfaces of serous membrane, covered by a layer of lymph, to come into contact, and between them adhesions may be formed, so complete, that the pericardial cavity shall be entirely ob- literated. This is almost complete reparation, as Dr. Latham remarks, but still it is unsound, and may lead to further evil, although this is a point not quite understood as yet. Dr. Latham observes: "I have, indeed, often met with 'this almost complete reparation, and this least degree of unsoundness,' appertaining to the pericardium after death, where inflammation had been formerly suffered. But it has been ac- companied with unsoundness of the endocardium also; and further disorganization, in the shape of a threatened muscular structure and a dilated ventricle, has been superadded, and all have been notified by symptoms during life."1 It is, however, very doubtful, in these cases, what share in the production of the mischief is due to the dis- ease of the pericardium, and what to the endocardium. ii. But, instead of a close and universal adhesion of the serous sur- faces, we may have part adherent and part free, or there may be several adhesions and several perforations or cavities. At first sight, this would seem to be of no consequence, or of rather less importance than the former case; but this is not so, for these loose spaces are very liable to fresh attacks of inflammation and its results. "After death from secondary pericarditis, the heart has been found apparently surrounded with many little separate abscesses, which have turned out to be collections of purulent matter between the folds of the peri- cardium, where it had here and there failed to contract adhesion after a former inflammation."2 "Thus, the thought of a healthy child first seized with acute rheu- 1 Lectures, &c, comprising Diseases of the Heart, vol. ii. p. 111. I cannot refer to Dr. Latham's work without expressing my sense of its great value. I know no book which contains more sound medical philosophy, or more judicious practical suggestions con- veyed in a manner more simple and intelligible. 2 Ibid., p. 112. PERICARDITIS. 343 matism is full of sorrowful forebodings. Its heart is very likely to be inflamed, and it may die; but whether it die or not, its heart is very likely to be damaged for life. Having had acute rheumatism once, though it may perfectly recover, it is very likely to have it again; and whenever it again has acute rheumatism, it is very likely again to have inflammation of the heart as its accompaniment."1 552. The symptoms which indicate partial or complete adhesion of the pericardium are by no means definite. Wlien the adhesions are loose and mobile, they do not interfere with the heart's actions or sounds, and afford no sign. When closely adherent, the heart's ac- tion is generally exaggerated, and Dr. Hope speaks of a "jogging, or trembling motion;" but Dr. Williams does not regard this as proving an adherent pericardium. He has specified one condition in which he thinks the diagnosis plain, i. e., when the folds of the pericardium are adherent to each other, and the outer one also to the walls of the chest, to the left of the sternum. In such a case, he says, "there will be, proportionally to the adhesion and size of the heart, a space in which the pulsations are always felt, and the sound on percussion is always dull in every stage of respiration, and in every position of the body."2 553. The symptoms which mark the accession of a fresh attack of inflammation are likewise vague in character, though affording suf- ficient evidence that the heart is the seat. "In the first inflammation of the pericardium, there is the exocardial murmur, made by the moving of its roughened surfaces upon each other. But in after in- flammation of the pericardium, exocardial murmur there is none, and none can there be if its surfaces adhere completely; and if they ad- here partially, and there be a murmur, it will not have the proper attrition in it, and so will want the proper exocardial character."3 We must, therefore, infer the secondary attack from the local symp- toms, without pretending to much exactness. Dr. Latham has given a case illustrating this, from which I shall make an extract, as it is too long to quote. "William Bean, a?t. 12, was admitted into the hospital December 16th, 1833, and died on the evening of the 19th. His symptoms on admission were these: Skin hot and dry; tongue moist and white; pulse 140, and jerking; swelling, and slight red- ness, and pain of the right wrist and hand, but of no other part of the body; breathing hurried and short, with a slight cough; pain in the precordial region, increased by pressure between the ribs, and by deep inspiration; excessive impulse of the heart; inability to lie on the left side. Auscultation found the lungs admitting air freely in every part, and at a circumscribed part beneath the cartilages of the third and fourth ribs on the left side, the systole of the heart was heard, accompanied by an unnatural sound of an indefinite kind. The sound was lost when the stethoscope was removed from this spot ' Latham on Diseases of the Heart, vol. ii. p. 29. 2 On Diseases of the Chest, p. 240. 3 Latham on Diseases of the Heart, p. 33. 344 PERICARDITIS. in the least degree."1 The boy had had an attack of rheumatism a year and a half before, with inflammation of the pericardium; and after death there was found evidence of two distinct inflammations occurring at distant periods; certain old, firm, close adhesions, and, in other parts, recent lymph deposited on the surface. 554. in. Lastly, we may have not merely a difference in the ex- tent of adhesions, but in the quantity of uniting medium. Sometimes we find a thin, slight tissue interposed; in other cases, one of half an inch in thickness; and every intermediate degree. Now this must be an impediment, and an incurable one, to the accurate performance of the heart's functions, though compatible with life; and, moreover, the pericardium in this condition is peculiarly exposed to the perils of secondary inflammations. 555. iv. So much for the organic changes, the consequences of pericarditis, with their dangers; but in pericarditis we have irritations of other organs complicating the primary disease. For example, vari- ous and severe nervous symptoms sometimes arise. "Wild delirium, epileptic or tetanic convulsions, chorea, coma, fatuity, are the greatest and the rarest; and muttering, reveries,transitions from torpor to ex- citement, subsultus, are the least and most frequent. But they are all akin to one another. The least may mount up to the greatest, and the greatest run down to the least."2 556. Morbid Anatomy.—The morbid changes discovered by dis- section resemble closely those of other serous membranes; the pleura, for example. The membrane is found occasionally injected, either generally, giving it a pale rose color; or in patches, or resembling ecchymoses. Its surface is generally polished and smooth, but in one case Rilliet and Barthez found it thickened and rough. The increase of thickness generally described is probably due to the layer of false membrane deposited upon the serous surface, and the erosions or ulceration, as in Schmidel's case, to depressions in this adventitious layer. A quantity of serum is almost alw7ays the result of inflammation. The amount varies a good deal; in general, it is not very abundant; in children, from two or three to six or seven spoonfuls. When the inflammation is very intense, it will be more abundant: generally yellowish, sometimes greenish yellow, like whey mixed with flocculi of lymph. But besides serum, there is generally a layer of false membrane on one or both serous surfaces, of varying thickness and tenacity, but more firm and dense the longer the standing of the disease. It may, however, be limited to one serous fold, or it may occur in patches, granules, or filaments, connecting the two surfaces. When the disease becomes chronic, the fluid is absorbed, leaving the false membrane as the only evidence of the pericarditis. Ultimately, as I have already stated, more or less intimate and ex- tensive adhesion takes place between the opposite surfaces of the 1 Latham on Diseases of the Heart, p. 41. 2 u^ p jg. PERICARDITIS. 345 pericardium; but as this is rather a reparative process, we do not generally observe it in those who have died of pericarditis, but in those who, having recovered from the attack, either become victims of a second or of some other disease. In secondary attacks of pericarditis, we find the old, firm, close ad- hesions in some parts, whilst in others there are patches of recent lymph, or small collections of puriform matter. The irregular white patches, which are so commonly observed upon the pericardium of children as well as of adults, have been proved by Dr. Paget to be the result of circumscribed chronic inflammation. Rilliet and Barthez mention having once found the interposed false membrane of a semi-cartilaginous character. 557. Causes.—Pericarditis is more common, according to Rilliet and Barthez, in children above six years of age; all their cases, with one exception, were from seven to fifteen years, and more above than below eleven years. Puchelt, however, quotes cases of one, two, three, and four years. I have seen the disease in an infant under a year old; and we have had Dr. Todd's testimony that it is not unfre- quent in infants. Whether sex does really influence the predisposition to the disease it is difficult to say; but of Rilliet and Barthez's twenty-four cases, twenty-one wrere boys and three girls. Puchelt attributes much influence to hereditary predisposition, and among direct causes he enumerates blows, falls, cold, &c. Billard conceives that its occurrence in young infants may be owing to the extra activity of the heart on assuming an independent life.1 558. But a much more important point for our investigation is the diseases during whose course pericarditis is most apt to occur; in other words, the primary diseases to which the present affection is secondary. This is of unusual importance, because we find that secondary pericarditis is by far the most frequent, and if we know the diseases in the course of which we may expect it, wTe shall be pre- pared to detect, and to treat it in its earliest stage. i. Bouillaud considers pericarditis and endocarditis to be essentially a part of rheumatism in the adult; and though Dr. Williams does not go so far, he states that he has found signs of one or other in three- fourths of the cases of severe rheumatism he has examined in the last six years. Dr. Latham's experience is also to the same effect, and such appears to be pretty much the case with rheumatism in children. Rilliet and Barthez found pericarditis in four cases out of eleven of acute rheumatism; and Dr. West mentions it as the most frequent ac- companiment of this disease. He adds also the following very im- portant practical observations: "It is of importance, however, to bear in mind, that the risk of cardiac mischief supervening in any case of acute rheumatism increases in direct proportion to the youth of the patient, and that the mildness of the general symptoms, the small amount of pain in the limbs, and the almost complete absence of 1 Mai. des Enfans, p. 570. 346 PERICARDITIS. swelling of the joints, afford no guarantee that the heart may not become the seat of the most serious disease. It happens, too, less rarely in the case of children than of the adult, that the general indi- cations of rheumatism follow instead of preceding the heart affection; so that fever, with hurried circulation and distinct endocardial murmur, may exist for two or three days, before the occurrence of pain and the appearance of swelling of the joints show that the disease of the heart is only a part of the great malady which has attacked the whole system."1 ii. It may also occur in the course of infantile remittent, although, as in rheumatism, it is more frequently endocarditis than pericarditis. in. The eruptive fevers occasionally give rise to it; thus, it may arise in the course of scarlatina, as first noticed by Vieussieux and Wells, or measles. iv. We sometimes find it apparently the result of other diseases of the chest, from which it may probably have extended, owing to the contiguity of the tissues affected. Thus, it is not very rare to find it complicating pneumonia and pleuritis. Dr. West mentions three such cases, and I have seen similar ones. v. It sometimes appears to be the result of morbid changes in the blood, caused by other and more distant diseases, as, for instance, Bright's disease of the kidney; and in such cases it may arise only shortly before death, as in a case related by Dr. Latham.2 vi. I have already mentioned (129) that in chorea the heart often becomes the seat of secondary inflammation. This cursory enumeration of diseases which may be complicated by inflammation of the membrane of the heart may well impress us with the necessity of watchfulness, and of repeatedly examining into its condition in all such cases. Much of our success will depend upon the early detection of the disease, and we may often overlook it if we wait until the symptoms force it upon our attention. 559. Diagnosis.—If we trusted to symptoms alone, our diagnosis would be often inexact, although even then we could have no doubt of the existence of a very serious thoracic affection; but when, in ad- dition, we are able to examine the chest with the stethoscope, we shall generally make out the disease correctly. The distress referable to the region of the heart, the hurried respiration, the difficulty of lying down, the exocardial murmurs, the dulness on percussion, and the increased impulse of the heart, are the characteristic signs and symptoms of the disease. The only diseases with which there is much danger of our confound- ing it are pleuritis and endocarditis. i. From the former it is distinguishable by the limited extent of the dulness, the locality of the friction sounds, and the free permeable condition of the lungs, and the resonance of all parts of the chest except the precordial region. When complicated with pleuritis, we shall have all the signs of each disease present. 1 Lectures on Diseases of Infancy and Childhood, p. 314. 8 Lectures, &c, on Diseases of the Heart, vol. i. p. 358. PERICARDITIS. 347 ii. In endocarditis, the symptoms are very similar, but the endo- cardial murmurs are essentially different, and indicate some obstruction to the current of the blood. But the two diseases are frequently com- bined, and then, in addition to the friction or crackling sound of peri- carditis, wre have the souffle of a narrow valvular orifice. In simple endocarditis, there is no increase of dulness on percussion. 5o0. Prognosis.—Although a very serious disease, yet pericarditis is not as frequently fatal as we might a priori suppose; nay, a con- siderable number recover when the disease is partial. When the inflammation is acute and general, of course the danger is very much greater, and is aggravated by the existence of the pri- mary disease; yet even of such cases a proportion recover. Rilliet and Barthez saved their four cases of rheumatic pericarditis. In forming our prognosis, we must take into careful consideration the age, strength, constitution, and previous history of the patient, with a due estimate of the primary disease and its effects. Dr. Latham has so strikingly shown the danger dependent upon the constitution of the child in such diseases as the present, that I need make no apology for extracting some of his observations: "It goes hard with weak, scrofulous children, and with men and women whose habitual health is no better than an habitual infirmity, when they come to suffer inflammation of any vital organ; but it often goes still harder with them after the inflammation has ceased, if much be left for reparation. Subjects of this unhappy constitution will struggle through a combined attack of inflammation of the heart and lungs, and hold out well until it has come to an end, and will afterwards die during the halting, ineffectual efforts of reparation, or, only after a very long time and many vicissitudes, will reach the point of safety at last. Their constitution has given all that it could to the disease without dying, and it has now not enough, or scarcely enough left to give for reparation, or rather for that degree of reparation which is needed for present safety."1 561. Treatment.—Fortunately, the treatment of pericarditis is simple and intelligible, so that, having ascertained the nature and stage of the injury, wTe have only to bring our remedies to bear upon it promptly. The indications of cure are to abate the inflammation, to moderate the violent action of the heart, and at a more advanced stage to promote absorption. Each remedy I shall mention will, if successful, accom- plish more than one of these objects. When called to a case of acute pericarditis, whether primary or se- condary, the first thing is to take away some blood, either from the arm or by cupping or leeching, if the child will bear it, and in proportion to its strength. If the heart disease be primary, it will bear it well, and not only once, but twice or three times, if necessary. If the disease be second- ary, and the primary disease have not much reduced the child, blood must be taken; in almost all cases of rheumatism, for instance, there will be no counter indication. 1 Diseases of the Heart, vol. ii. p. 14. 348 PERICARDITIS. But when the child has been run down by measles, scarlatina, pleu- risy, &c, or was originally of a wTeak, scrofulous constitution, we must be more cautious; perhapsthreeor four leeches may be borne, applied to the pra?cordium, or, if not, we must then depend upon calomel and opium, with counter-irritants. 562. Calomel alone, or in combination with a small quantity of opium, squills, or digitalis, is next in value to bleeding. We should commence its exhibition in all cases immediately, and proportioning our dose to the age of the child, the state of the bowels, &c, and guarding against diarrhoea, we should endeavor to bring the child as quickly as possible under its influence. Mercurial inunction may be used at the same time that calomel is given internally, and both should, if possible, be continued until either soreness of the gums or mercurial diarrhoea gives proof that the constitution is affected. In the first instance, the mercury is employed for its antiphlogistic properties, but afterwards it may be continued in smaller doses, or resumed, for the purpose of removing the fluid effused into the peri- cardium. Dr. Latham has some valuable observations upon this sub- ject, to which I gladly refer the reader.1 As an adjunct to these remedies, and especially for the purpose of quieting the inordinate action of the heart, digitalis has been recom- mended, and it has the additional advantage of acting as a diuretic. It may be given either in powder, infusion, or in tincture, but its effects must be carefully watched, and, if necessary, the medicine suspended. It is better to commence with small doses at first, say a drop or two, three times a day, for a child of a year old, and gradually increasing it according to the effects. The German writers recommend its combination with the calomel, or we may add a little squills to it by way of securing the action upon the kidneys. If digitalis cannot be borne, Rilliet and Barthez recommend the nitrate of potash, to which Puchelt adds Glauber's salts and cream of tartar, with absolute repose, low diet, and moderate warmth. 563. Counter-irritation is of considerable value when the first acute- ness of the disease is subdued after bleeding, &c, and also subsequently to promote absorption of the fluid ; and the best mode is to apply a small blister for a short time, and repeat it near to the former. The bowels must be kept free ; but severe purgation should be avoided. Let the child be kept perfectly quiet, both mentally and corporeally; there should be no attempt to enforce discipline; and those who are in health may patiently bear with and humor the caprices of a child suffering under so distressing an affection. The child must be kept in bed, comfortably clothed, and in the position it finds most comfortable. The diet must be antiphlogistic, with some modification in the case of children who are much worn down, or of weak constitution. 1 Diseases of the Heart, vol. i. p. 260, et seq. ENDOCARDITIS. 349 CHAPTER III. INFLAMMATION OF THE LINING MEMBRANE OF THE HEART.--ENDO- CARDITIS. 564. Endocarditis, or inflammation of the membrane lining the heart, seems more common than pericarditis, both in adults and children, though they are frequently combined. Rilliet and Barthez record sixteen cases, and in two others the disease existed, but was only discovered after death. The attack may be either acute or chronic, the latter fully as fre- quent as the former; and either primary or secondary, the latter being, as in the case of pericarditis, much more common than the fornfer, and more frequent than primary pericarditis, according to Dr. West. 565. Symptoms.—The phenomena which indicate the commence- ment of endocarditis are very slight and obscure: a slight febrile movement, which subsides in a little time; the respiration somewhat accelerated, and possessing the peculiar character I noticed in peri- carditis; obscure pain in the precordial region ; and some difficulty in lying upon the left side, may be all the symptoms developed;1 on which account, it becomes of great moment to watch those diseases in which it is apt to occur, that we may detect its commencement. " In cases of acute rheumatism," says Dr. West, " you are aware of this danger; you do not wait till the patient's sufferings inform you that the mischief has been done, but you are on the watch against the first threatenings of its approach; and your sense of hearing gives you earlier information and surer information concerning this than all the other signs together. But if the same evil, against which you guard thus sedulously in cases of rheumatism, may occur inde- pendently of it, and may scarcely give warning of its approach until it is almost, or altogether, too late to cure, a measure, at least, of the same precaution, should be observed at all times; and in no instance of febrile disturbance in early life, how simple soever the case may seem, should you consider the examination of the patient complete without auscultation. With all your care, there will, probably, still be cases in which the commencement of the heart affection will escape your notice ; in which you will accidentally make the discovery of its existence, when auscultating the chest for some other purpose, or in which the gradual supervention of the signs of valvular dis- ease will call your attention to it long after the ailment has become chronic.2 566. The physical signs are pretty decided and characteristic. The 1 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 232. a Lectures on Diseases of Infancy and Childhood p. 318. 350 ENDOCARDITIS. sounds of the heart are energetic and regular, though hardly so clear as usual, and with the first sound there is a bruit de soufflet, either distinct from the contraction, or more or less masking it. It is heard generally in the mammary region, sometimes clearer at the apex, and in other cases at the base, and extending upwrards, according as the tricuspid or mitral valves may be the principal seat of the disease. This endocardial murmur may be heard at the commencement of the attack ; and, unless in those rare cases where the return to health is complete, the souffle will remain for a long time as evidence of an injured heart. As pericarditis often co-exists, exocardial murmurs may accompany the bruit de soufflet, indicating the complex character of the disease, but ceasing long before the sounds from the diseased valves disap- pear. In simple endocarditis, the precordial region is not more dull on percussion than usual. 567. But, from the obscurity of the symptoms, and the slight consti- tutional disturbance, the disease may run on into the chronic form before we are consulted, and then we shall be at once presented with the phenomena of the disease, and of some at least of its consequences, mixed, very likely, with the symptoms of the primary disease, whether bronchitis, pneumonia, pleurisy, or fever. There is generally more or less cough, sometimes dry, in other cases with expectoration ; the respiration is also accelerated, partly owing to the primary disease, but principally to the affection of the heart. The breathing is panting, hurried, and as if a moment's interruption would be followed by suffocation. The pulse is always quick, small, and thread-like ; sometimes, though by no means always, the patient complains of pain or uneasi- ness in the region of the heart. The surface is seldom hot, although, in some cases, there are abundant perspirations. Rilliet and Barthez have not found the face so characteristic as in adults ; sometimes the ala? nasi were in action ; and in all, the countenance expressed anxiety and suffering.1 In some cases, the child can lie on either side ; but in most, I think it requires to be propped up by pillows. A large proportion of cases suffer from anasarca, partial or general. Rilliet and Barthez met with it in nine out of twelve cases. Other and more distant consequences of the condition of the heart I shall describe presently. The physical signs are those which indicate injury of the valves of the heart, and the results of such injury, dilatation or hypertrophy, or both. The heart's action is more extensively heard than usual; sometimes dull, but energetic; in others, and perhaps more frequently, clear and superficial. Ordinarily, they are distinct, but sometimes confused, and running into each other. Mental emotion or sudden movement occasions \iolent palpitations. 1 Mai. des Enfans, vol. i. p. 235. ENDOCARDITIS. 351 In all cases, a bruit de soufflet accompanies, or immediately follows the first sound of the heart. Heard from the beginning, it persists after the patient has apparently recovered, or until death, if the disease prove fatal. 568. Unlike acute endocarditis, when the chronic form has con- tinued for some time, there is a diminution of resonance on percussion, amounting, in many cases, to absolute dulness, and much more ex- tensive than natural. The following case, given by Dr. West, affords an excellent pic- ture of this form of disease : " Nothing could be more gradual than the advances of the early stages of the disease of the heart in the case of a little girl, eleven years old, who came under my notice in the month of March, some years ago. Her mother stated that, though not robust, she had never had any definite illness, but that for the last year she had been growing thinner, and had suffered from palpitation of the heart, which had, by degrees, become more and more distress- ing ; and that, for the past three months, she had suffered likewise from cough. The child, when brought to me, was greatly emaciated; her face wras anxious and distressed ; her breath short, so that it was with difficulty that she walked even a short distance. She had fre- quent, short cough, without expectoration, and she suffered much from palpitation of the heart, and a sense of discomfort at the chest. The heart's action was violent; dulness in the precordial region was ex- tended ; a very loud, harsh, rasping sound accompanied the first sound of the heart, loudest towards and to the left of the nipple ; but heard over the whole of the chest, both before and behind. Various remedies brought slight but temporary relief to her sufferings, and she grew7 worse every month. She became more and more emaciated ; the distress at the chest, and the palpitation of the heart, increased ; her cough became more violent, and once she had an attack of he- moptysis. For about a month before her death, the cough altogether ceased ; but she was now altogether unable to leave her bed from in- creasing weakness; the palpitation continued unmitigated, and her extremities became slightly anasarcous. During the last week of her life, her respiration was extremely difficult, and became increasingly so till she died, on the 10th of October. " The lungs wrere very emphysematous, and much congested, but not otherwise diseased. The heart was extremely large, but its right cavities did not exceed the natural size. The pulmonary valves were healthy ; the edges of the tricuspid valve were slightly thickened; the left auricle was enormously dilated, but its walls were not at all attenu- ated ; the pulmonary veins were much dilated ; the left ventricle was dilated, its walls wrere thickened ; the chorda? tendinea? of the mitral valve were greatly shortened, so that the valve could not close ; the valve itself was shrunken, thickened, and cartilaginous ; and there existed likewise a slight thickening of the edges of the semilunar valves of the aorta."1 ' Lectures on Diseases of Infancy and Childhood, p. 319. 352 ENDOCARDITIS. 569. Such, or such like, is the history of those cases of endocarditis which, giving rise to injury of the valve, and consequent hypertrophy, run a fatal course within the space of some months: incipient ob- struction to the circulation, constant dyspncea, palpitation, exhaustion, emaciation, and death. But all do not necessarily thus terminate. The patient may recover, i. e., her life may be saved, with an injured heart, and in this exact condition it may remain for five or six years, neither improving nor getting wrorse, suffering from palpitation, dys- pnoea, and some pain on exertion or mental emotion. " The child who has had the precordial murmur ever since it suffered a certain rheuma- tic attack is just the same child it was before, except that it cannot join in any pastime requiring rapid movement, for then its heart pal- pitates, it loses its breath, and is obliged to sit down."1 Dr. Latham adds: " I have lately seen a young lady, thirteen years of age, whom I attended three years and a half ago, under an attack of acute rheu- matism, attended by endocarditis. The symptoms during the attack, referable to the heart, were completely characteristic of the disease, and carried to such extremity as to keep life in peril for several days. It was, perhaps, the severest case I ever saw recover. She did reco- ver, however, but never lost the murmur and occasional palpitation. At present, she has the appearance of perfect health; she even bears the marks of premature womanhood. She goes to school, plays about like other girls, but cannot run so fast or so far as the rest, or use bodily exertion beyond a certain amount, without dyspnoea and pal- pitation, and some pain in the region of the heart. For all other purposes, she is absolutely well. In examining the state of her heart when she is quite free from all excitement, I find no extraordinary impulse either of extent or of degree. It is felt only at the apex. Neither do I find any extraordinary extent of dulness on percussion. A systolic murmur is audible everywhere within the precordial re- gion, most audible at the apex, more faintly at the base. From the basis upwards, towards the right clavicle, in the course of the aorta and subclavian artery, it is entirely lost; towards the left clavicle, and in the course of the pulmonary artery, it is very loud, but not at all heard in the carotids. From the apex, the murmur extends far round towards the left axilla and the back. Here, I presume that the rheumatic inflammation has done a permanent injury to the endo- cardium on both sides of the heart, and that the mitral valve, and the semilunar valves of the pulmonary artery, have undergone change of structure."2 The same author mentions the case of two young ladies, in whom similar evidence of valvular injury had existed from childhood, but whose health has never suffered in consequence, and he asks: " Do not these facts give intimation of a certain protective power, probably in- herent in the growing heart, whereby it can accommodate its form and manner of increase to material accidents, and so repress or counteract their evil tendencies?" 1 Latham on Diseases of the Heart, vol. ii. p. 89. 2 On Diseases of the Heart, vol. ii. p. 90. ENDOCARDITIS. 353 I have a little patient in whom I accidentally detected a bruit de soufflet with the first sound of the heart some years ago, without being able to trace the disease to its commencement. Like Dr. Latham's case, his health does not appear to suffer, and the heart disease remains stationary. 570. Consequences.—But this is far from being the general result of such cases. There are certain consequences which seem to be the necessary effect of permanent disease of the valves, from endocarditis. i. I should first mention, however, that the lining membrane of the heart, once having been the seat of inflammation, seems as liable as the pericardium to a repetition of the attack; with this difference, however, that the signs indicating it, the palpitation, dyspncea, impossibility of lying down, strong impulse, and loud murmur, are much more charac- teristic and definite than those of secondary attacks of pericarditis. Both Dr. Latham and Dr. West mention cases of this kind, with a melancholy foreboding of the future history of such cases. " The valvular disease, and the heart's efforts to overcome its consequences, have already led to a considerable degree of hypertrophy of the organ ; the danger of each acute attack will be aggravated by the old disease, and every fresh inflammatory seizure will add to the chronic mischief, until, in the course of time, the disorganization of the heart will have advanced so far as to render it unable to perform its office sufficiently well to maintain existence any longer, and a life of suffering will then be closed by a painful death."1 n. Attenuation and softening of the left ventricle, either alone or combined, may be the result of valvular disease, giving rise to a feeble impulse, but loud-sounding action of the heart, and to other and deeper derangements of the circulation, near or distant, and of a passive cha- racter, such as effusions of serum or blood, congestions, &c. hi. But a more common result, with children at least, is the pro- duction of hypertrophy with dilatation, i. e., when the substance and size of the heart are both increased, the cavities, or some of them, are larger than natural, and the wralls are thicker. The left ventricle and auricle are most frequently the seat of this morbid change. There can be no doubt that it is the result of valvular injury, and that it is a kind of reparation at the same time; an obstacle existing to the passage of the blood, an increase of force is required by the heart to overcome it, and to prevent the consequences of such inter- ruption. "A loud, systolic, endocardial murmur, and an excessive impulse of the heart, and a larger space of precordial dulness than naturalthere, are the sure and authentic signs of an injured valve, and hypertrophy of the left ventricle."2 But the rhythm of the heart's action may be perfectly regular, and the pulse betray no sign of the existing mischief. The general circulation, too, may be perfect, and the color and heat of surface quite natural. But although in itself, and to a certain extent, a process of repara- 1 West's Lectures on Diseases of Infancy and Childhood, p. 321. * Latham on Diseases of the Heart, vol. ii. p. 296. 23 354 ENDOCARDITIS. tion, this augmentation of size and force may become a deadly evil in its result. The most common effect of this state of the heart is the effusion of serum into the cellular membrane, first of the lower extremities, then of the body, upper extremities, and face. In some cases, similar effusion may take place into the serous cavities with alarming results. Again, a child laboring under hypertrophy of the heart is liable to congestion, hemorrhage, or inflammation of different and distant or- gans, of an active character, and attended by very serious conse- quences. The same diseases, apparently, as those from attenuation, but of an opposite character, and requiring a different treatment, they seem upon the whole more manageable. 571. Morbid Anatomy.—The morbid changes from endocarditis are not so numerous, nor so marked, as in other serous membranes, for the very obvious reason that the current of blood must sweep away with it all the serum which may be effused, and a great portion of the lymph; still enough remains to afford evidence of the disease, now that we know what to seek for. On opening a heart which has suffered from this disease, we find the lining membrane vascular, and of a red color generally, or in parts when the inflammation is recent. A certain amount of coagulable lymph is deposited upon the valves, either in patches or like small beads. The mitral valve is the most frequent seat of these depositions; then the tricuspid. At a later period, there may be no vascularity, nor any traces of recent lymph ; but the valves are thickened, irregular, retracted, or incom- plete ; sometimes cartilaginous, and occasionally, but rarely, osseous; now and then, there are vegetations upon them, or the chorda? tendi- nea? may be shortened. Whatever be the peculiar modification of the lesion, the effect is to render the valves less pliable, less capable of closing the orifice, or of yielding to the current of the blood ; hence, the endocardial murmur, and the remote consequences of obstructed circulation. When the valvular disease is of old standing, we may find hyper- trophy and dilatation about equally frequent, according to Rilliet and Barthez, who also mention that they have found the hypertrophy limited to the inter-ventricular septum, and to the columna? carnea?, in connec- tion with diseased valves.1 The tissue of the heart is almost always in its normal condition, red and firm. In one case only Rilliet and Barthez found it soft, flaccid, and of a yellowish-red. 572. Causes.—It is extremely difficult to specify the causes of en- docarditis, except in general terms, inasmuch as we see so little of the disease, except as a secondary affection. It does not appear that either age or sex has much, if any, predisposing influence. Of eighteen patients mentioned by Rilliet and Barthez, affected with acute or chronic endocarditis, the numbers of boys and girls were equal. It is as a secondary disease, however, that its principal interest con- • Mai. des Enfans, vol. i. p. 220. Dr. Hope on Diseases of the Heart, 3d ed., p. 203, tt seq. ENDOCARDITIS. 355 sists, and the primary affections in which it occurs are the same as those enumerated when speaking of pericarditis, with which it is very often combined. i. The most common primary disease is acute rheumatism, at any stage of which the heart may become affected. We may easily detect its invasion, if we are on the watch ; the increase of the heart's action, the hurried respiration, the anxiety of countenance, and the endocar- dial murmur will at once indicate the new and formidable enemy with which we have to grapple. ii. I have seen it come, in the course of infantile remittent, quite suddenly. A few hours before, the child was going on very well, without any local affection, when suddenly dyspnoea, very quick pulse, pain in the chest, and bruit de soufflet made their appearance. in. In like manner, we may find it complicating any of the erup- tive fevers, especially scarlatina and measles, when we least expect it, and without any warning. On this account, let me repeat the advice already given, to look carefully to the heart at each visit in all these diseases. The hypertrophy and dilatation result naturally, and, to a certain extent, as a reparative process, from the obstruction offered to the cir- culation, and the necessity of an increase of force to overcome it. Rilliet and Barthez mention that deformity of the chest (from rachitis) may give rise to hypertrophy, as it certainly may to considerable con- fusion in the heart's sounds. 573. Diagnosis.—There is perhaps less difficulty in the diagnosis of endocarditis than of pericarditis, and there is not much danger of their being confounded. We may certainly overlook either when both are combined, but practically this would not be of much conse- quence. The general symptoms are much the same, but the presence of en- docardial murmurs, the bruit de soufflet, " de scie," and "de rape," with the first chiefly, or with both sounds of the heart, and the absence of the friction sound, will render" the diagnosis clear. At an early stage, the dulness is less absolute and less extensive in endocarditis, and the patient suffers more from palpitation. In the chronic stage, we have the murmurs, an increase of dulness, cedema or anasarca, with palpitation upon the least exertion. There is a class of cases among adults which seems a little puz- zling at first. I allude to those in which bruit de soufflet and other murmurs are heard in the heart and large vessels, not from valvular disease, but from some change in the component parts of the blood, e. g., in patients in a state of ana?mia. This I have often found in women laboring under amenorrhoea ; but we have the satisfactory tes- timony of Dr. West that it is not the case with children under seven years of age, and that at a later period it is very rare. 574. Prognosis.—The prospects of the patient are always very seri- ous and doubtful. They may recover from immediate danger, and life may be safe for the present, and, even in some rare cases, for years ; but, sooner or later, it is to be feared that some of the consequences I 356 ENDOCARDITIS. have enumerated will either terminate life or render its continuance a burden. 575. Treatment.—The treatment of endocarditis is almost identical with that of pericarditis. When acute, bleeding, general or local, Calomel, digitalis, and diuretics, with counter-irritation subsequently, are all the means at our disposal. As I have entered fully upon their employment in pericarditis, there is no occasion to do so now, as what was then said applies to the present disease just as well. The necessity for absolute quiet is even greater, or, at least, more obvious, in endocarditis; for mental emotion, disturbance, or exertion increases the dyspncea and palpitation to a most distressing degree. 576. A second attack of inflammation must be met in the same way, but, perhaps, less actively, according to the condition of the patient, and certainly with less hope of being successful. Whether any means at our command are sufficient to arrest or con- trol the hypertrophy and dilatation is at least doubtful; but by judicious regimen we may often prevent inconvenience, and by timely and well- considered treatment may relieve some of the consequences, such as anasarca, local congestions, &c. Diuretics for the removal of effu- sions, calmants for tranquillizing the action of the heart, and local antiphlogistics in moderate degree, will, at least, afford a chance of relief, and of the prolongation of life. SECTION IV. DISEASES OF THE DIGESTIVE SYSTEM. CHAPTER I. INTRA-UTERINE DISEASES.—CONGENITAL MALFORMATIONS. 577. A considerable variety of intra-uterine diseases of the digest- ive system have been observed and recorded. Thus Orfila, Veron,1 Cruveilhier,2 Billard, and others speak of muguet observed at birth, and evidently existing during intra-uterine life. Cases of oesophagitis have been mentioned by Billard3 and Orfila; of gastritis by Siebold,4 Billard, and Orfila; of peritonitis and enteritis by Weisberg,5 Chaus- sier,6 Veron,7 Duges,8 Billard, Canes, Cruveilhier,9 Simpson,10 and others. Numerous cases of infants born jaundiced are on record. Some of the mothers had jaundice ; others bowel complaints, &c. Panarola," Kerkring,12 Schurig, Schultz,13 Wrisberg,14 Sentin,15 Billard, and others have described such cases. Billard16 has seen tubercular granulations, and Orfila mentions that the liver is occasionally hypertrophied, fatty, tuberculous, transposed, softened, or indurated.17 It is enough for my purpose thus slightly to prove the existence of morbid actions in utero, analogous to those observed in after life, thus completing the circle of disease. With those whose effects continue after birth, and with certain malformations or arrests of development, affecting, as they do, the comfort or even the life of the child, I must enter more into detail. I shall, in the remainder of the chapter, notice hare-lip and cleft palate, which are arrests of development, and imper- 1 Seance de l'Acad. Roy. de Med., June 28, 1825. 3 Anat. Pathol., liv. 15, p. 13. 3 Mai. des Enfans, p. 274. * Journal fur Geburtshulfe, vol. v. s Dissertatio de prEeturnaturali et raro intestini recti cum vesicae urinaria? coalitu, &c. 1779. e Bull, de la Faculte de Med, 1821, vol. 10. 7 Recherches des Mai. des Nouveaux-nes, 1821. 8 Gynaecologie, vol. ii. p. 251. 9 Anat. Pathol., liv. 15, pp. 2, 3. '0 Edin. Med. and Surg. Journal. " Obs. Med. Pentecost, p. 137. a Spicilegium Anat. Obs., 57. " M. N. C. Dec. 1. An. 6, 7, p. 355. l* Descriptio Anat. Embryon., 1764, Obs. 1. 15 Beitrage zur ausiibenden Arzneivvissenschaft, vol. i. p. 29. 16 Mai. des Enfans, p. 421. " Graetzer, Krankheiten des Fotus, p. 155. 358 INTRA-UTERINE DISEASES. forate anus, which is a malformation. These are of too much import- ance to be omitted, although the reader will find them fully treated in every systematic work on surgery. For most of the information, I have been indebted to Mr. Cooper's invaluable Dictionary. 578. Hare-lip.—This congenital deformity consists of a perpen- dicular or oblique division of the upper lip, either directly below the septum of the nose or one of the nostrils. The upper lip, thus divided, is generally movable; but, in some cases, the two portions are closely attached to the alveolar process. The space between the divided por- tion varies; sometimes it is considerable, in other cases but slight. But the cleft is occasionally double, constituting what is called "dou- ble hare-lip," and in such cases we find a small portion of the lip in front between the fissures. In a great many cases, the arrest of development is confined to the lip; in other cases, it extends along the soft parts of the palate, even to the uvula; and in others, the bones of the palate are incomplete. Again, the jaw may be incompletely ossified in front, leaving a cleft between ; or one portion may project more than the other. The lower lip may also be affected; but this is a very rare malformation. Everyone, probably, has witnessed the deformity occasioned by the simplest form of hare-lip, which is much aggravated when it is double. But there is more than deformity resulting; for it often hinders an infant from sucking, and, at a later period, interferes with the facility and perfection of speech. All these evils are greatly worse when the lower lip is fissured, and even the health may suffer. 579. Treatment.—It is evident that this deformity can only be remedied by a surgical operation ; and, as all mothers are naturally anxious to have it relieved as soon as possible, the first question re- lates to the age at which the operation should be undertaken. The earlier the age at which it can be done safely, the better; but then it must be remembered that very young infants are very liable to convulsions, and on this account it is generally deferred until the child is about two years old. Sir Astley Cooper sanctioned this, having known a fatal result from operating earlier. Mr. Cooper mentions having successfully operated upon a child five months old, and upon another a year old. Le Dran, B. Bell, and others operated upon infants even at earlier ages; and Dupuytren has fixed upon three months as the most favorable age.1 My friend, Surgeon Smyly, who has had great experience in this operation, has favored me with the following note, illustrating the point in question:— " The infant on whom you saw me operate for hare-lip was tw7o months old. I removed the needles the third day; I, however, ap- plied adhesive plaster, to prevent accidents. The child has been able to suck well since. In cases of single hare-lip, I always prefer ope- rating early; the operation is much easier of performance, as the child can make no resistance, the wound heals faster, and deformities of the 1 Clin. Chirur., vol. iv. p. 90. HARE-LIP. 359 nose and palate are more easily redressed when the patient is very young, and before teething has commenced. I have looked over the notes of some cases; one, the youngest I ever operated upon, was only a fortnight old; the others, from one to four months. In none of them have I seen any unpleasant symptom to deter from operating early. " I never saw convulsions follow in any case operated upon for hare- lip, and hemorrhage is as easily controlled in the young infant as in an older child. I generally take the precaution of compressing the coronary arteries with Dieffenbach's forceps. In looking over my notes, I was surprised to see so many cases in which the cleft was on the left side, i. e., in three-fourths of the cases." Other surgeons of this city, I am informed, prefer a later period. 580. Whatever be the time chosen for operating, all surgeons are agreed that the object is to reduce the fissure to the condition of an incised wound, by removing the edges of the divided portions, and keeping them in contact until adhesion takes place. There has been some difference of opinion as to whether this approximation should be effected by sutures or by adhesive plaster and bandages. M. Louis offered a weighty opposition to the sutures; but, notwithstanding, the twisted suture is now generally used. "No modern surgeons doubt that a hare-lip maybe cured by means of adhesive plaster and uniting bandages quite as perfectly as with a suture; and all readily allow that the first of these methods, as being more simple and less painful, would be preferable to the latter, if it were equally sure of succeed- ing. But it is considered far more uncertain in its effect. To ac- complish a complete cure, the parts to be united must be maintained in perfect contact until they have contracted the necessary adhesion; and how can we always depend upon a bandage for keeping them from being displaced? What other means, besides a suture, afford in this respect perfect security?"1 When about to perform the operation with the twisted suture, we should first examine whether the lip be adherent to the gum, and if so, they must be separated by the knife. When the frenulum is in the way of the operation, it must be divided. " In the operation for single hare-lip," says Mr. Cooper," the grand object is to make as smooth and even a cut as possible, in order that it may more certainly unite by the first intention, and of such a shape that the cicatrix may form only one narrow line. Hence, in this country, the edges of the fissure are cut off with a sharp knife. One plan is to place any flat instrument, such as a piece of horn, wood, or pasteboard, underneath one portion of the lip, and then, holding the parts stretched and supported on it, to cut away the whole of the callous edge. Another, is to hold the part with a pair of forceps, the under blade of which is much broader than the upper one; the first serves to support the lip, the other con- tributes also to this effect, and at the same time serves as a sort of ruler for guiding the knife in an accurately straight line. When 1 Cooper's Surgical Dictionary, p. 656. 360 CONGENITAL MALFORMATIONS. the forceps are preferred, the surgeon must of course leave out of the upper blade just as much of the edge of the fissure as is to be re- moved, so that it can be cut off with one sweep of the knife. This is to be done on each side of the cleft, observing the rule to make the new wound in straight lines, because the sides of it can never be made to correspond without this caution." In University College Hospital, the margins of the fissure are usually removed by transfix- ing the lip with a long, sharp-pointed, narrow bistoury, just above the upper end of the cleft, and then cutting towards the red portion of the lip, while the part is held and stretched out by the surgeon himself, or his assistant. One side of the cleft is thus pared off, and then the other, particular care being taken to remote a small piece of the red part of the lip on each side, lest an ugly notch should be left in that situation. This is the plan ordinarily followed by Mr. Liston. In France, the edges of the fissure are always taken off with a pair of strong, sharp, long-handled scissors, invented for that purpose by M. Dubois. Two silver pins, made with steel points, which admit of an easy removal, are next to be introduced through the edges of the wound, so as to keep them accurately in contact, the lowest pin being intro- duced the first, near the inferior termination of the wound, and the upper pin afterwards, about a quarter of an inch higher up. A piece of thread is then to be repeatedly wound round the ends of the pins, from one side of the division to the other, first transversely, then ob- liquely, from the right or left end of one pin above to the opposite end of the lower one, &c. Thus the thread is made to cross as many points of the wound as possible, which greatly contributes to main- taining its edges in even apposition. Lastly, the steel points of the pins are to be taken off, or, if not made to slide off, they are to be supported by small dossils of lint, placed betwTeen them and the skin. In the University College Hospital, Mr. Liston employs largish com- mon needles, the heads of which have been dipped in sealing wax, and after they have transfixed the lip, he takes off their points with a pair of cutting forceps. "Instead of pins made with steel points, Dr. Barton, of Philadelphia, prefers using apiece of iron wire, with a point made by simply cutting it with a pair of scissors. Thus he avoids the risk of the steel point slipping off the pin and remaining within the lip." " It is obvious that a great deal of exactness is requisite in introducing the pins, in order that the edges of the incision may afterwards be precisely applied to each other. For this purpose, some surgeons previously place the sides of the wound in the best position, and mark with a pen the points at which the pins should enter and come out again. The pins ought never to extend more deeply than about two-thirds through the substance of the lip, and it would be a great improvement always to have them of a flat instead of a round shape, and a little curved, as this is the course which they naturally ought to take when introduced. The steel points should also admit of being easily taken off when the pins have been applied, and per- haps having them to screw off and on is the best mode, as removing HARE-LIP. 361 them in this way is not so likely to be attended with any sudden jerk, which might be injurious to the wound, as if they were made to pull off. In general, the pins may be safely removed in about four days, when the support of sticking plaster will be quite sufficient. After the operation, compresses and a bandage for keeping forward the cheeks are sometimes employed, but they may in general be dispensed with, because irksome to children, and the occasion of restlessness." This is what is called the twisted suture, and is the most generally used for hare-lip ; but there are other circumstances and other modes of operating which require a moment's notice. 581. It occasionally happens that there is a considerable projection of the upper jaw (especially when the hard palate is divided), sufficient to offer a serious obstacle to the union of the two portions of the lip. The ordinary practice has been to remove this portion; but, as that destroys the harmony of the upper and lower jaw, it has been proposed and practised successfully by Dessault, Dunn, and others, to employ compression first, so as to reduce the prominence to its proper level, and then operate for the hare-lip. M. Gensoul, in a case, seized the projection with a strong pair of forceps, and brought it down into its place by main force. " M. Dupuytren had a peculiar method of operating in some cases of complicated hare-lip. He observed that, when the labial tubercle was inserted very close to the point of the nose, its union to the lateral parts drew7 the lip upwards, and exposed the gums and teeth, while the nose itself was pulled down and flattened in a most ugly manner. Hence, he conceived that it would be better to employ the labial tuber- cle in forming the lower part of the partition of the nose, and to unite at once the lateral portions of the lip. He first divided with a bis- toury the fold of mucous membrane uniting the labial tubercle to the osseous one, and then, with a pair of cutting forceps, removed all such portions of the latter as projected beyond the anterior level of the jaws. He next pared off the sides of the cutaneous tubercle and its lower edge. These things having been done, the vertical margin of the fissure on each side was cut off with a pair of scissors. The two lateral portions of the lip were now brought together, and united with two pins; and the fresh cut, bleeding, middle tubercle was laid over the bony partition of the nostrils, of which it was to form the lower portion. A third pin was applied, so as to include at once the upper end of each part of the lip, and the loose extremity of the reflected tubercle. Lastly, two interrupted sutures united the angles of this tubercle to the lateral portions of the lip. The sutures were assisted with straps of adhesive plaster, and a bandage that made pressure on the apex of the nose, so as to keep the flaps from being too much stretched."1 Instead of the twisted suture, Sir Astley Cooper preferred the com- mon interrupted suture, on account of the danger of separating the new adhesions, when withdrawing the pins. The threads of the com- 1 Cooper's Dictionary, p. 657. 362 CONGENITAL MALFORMATIONS. mon suture can be cut and easily removed. When the hare-lip is double, the operation is the same in principle, and had better be com- pleted at once, instead of making two operations, as the older surgeons advised. Occasionally, hare-lip is complicated with cleft palate, and now and then, after the hare-lip is cured, this fissure closes; in other cases, there must be some artificial substitute contrived. This brings us to the second of the malformations. 582. Cleft Palate.—There are three degrees or forms of this con- genital malformation: first, when the fissure is simple, and confined to the soft palate; secondly, when there is a partial division of the bony palate; and thirdly, when this division involves a greater or less in- terspace between the lateral portions, and almost always a fissure in the alveolar process and the upper lip. The operation for each, re- spectively, has been termed staphyloraphe, staphyloplasty, and urano- plasties 583. i. Staphyloraphe.—Mr. Cooper describes MM. Roux's and Berard's, Mr. Smith's, and Mr. Liston's method of performing this operation.1 In M. Roux's plan, the apparatus required consists: 1. Of three broad, flattish ligatures, composed of three or four strong threads. 2. Of six small, curved, flat needles, two for each ligature. 3. A porte- aiguille. 4. A pair of dressing forceps. 5. A probe-pointed bistoury. 6. Scissors, with long handles and short blades, bent laterally to an obtuse angle. " The patient being seated opposite the light, and the mouth kept open, the surgeon takes hold of the right edge of the fissure with the forceps held in his left hand, while, with the right, he conveys into the pharynx the porte-aiguille armed with a needle,, the point of which is of course turned forwards. The point of the needle is then carried back to the posterior surface of the velum, and passed through it from behind forward, near the lower end of it, and about three or four lines from the margin of the slit. The point of the needle is to be passed out as far as practicable, and then taken hold of with the forceps. The porte-aiguille being now removed, the needle is drawn into the mouth with the forceps, and along with it the ligature with which it is thread- ed. After the patient has recovered his tranquillity, and washed out his mouth, the other end of the ligature is to be passed in a similar way through the left side of the velum, and the two ends are to be brought out at the commissures of the lips. Then a second ligature is to be applied near the angle where the two sides of the velum meet, and a third at the middle point between the other two ligatures. The left side of the fissure is then seized, depressed, and rendered tense with the ring-handled forceps, and the excision of its margin begun with the curved scissors, and completed with a straight probe-bistoury, ap- plied on the outer side of the forceps, and with its back directed towards the root of the tongue. Thus, a slip is to be removed about half a line * Surgical Dictionary, p. 1077. CLEFT PALATE. 363 in breadth. Particular care must be taken to let the slip extend a little above the front angle of the fissure. The same proceedings are to be followed on the opposite side, the two incisions being made to join at an acute angle above the point just now specified. It only remains to tie the ligatures. The surgeon begins with the lowermost one, wdiich is first to be tied in a simple knot. As soon as this has been duly tightened with the forefinger, it is to be taken hold of with the ring- handled forceps, and kept from slipping until another knot is made. The same plan is to be adopted with the two upper ligatures. Finally, the ends of each ligature are to be cut off as useless." No other dressing is requisite; the patient must avoid all exertion of the part, such as laughing, talking, sneezing, and even swallowing, as much as possible. The upper ligatures may be removed on the third or fourth day; the lower ones should remain a day or two longer. If the union be not complete, the edges may be touched with the nitrate of silver. 584. M. Berard's method is apparently more simple. With the left hand he seizes the left border of the fissure, with a tenaculum, and with the right he passes a curved needle, held by the forceps, and armed with a ligature, from before backwards, on a level with the upper angle, until its point can be seized with the forceps, when it is draw7n through. Another ligature is passed, in like manner, through the opposite edge, and as many ligatures are thus inserted as the fis- sure requires, and then the edges of the fissure are removed and the ligatures tied. 585. Mr. N. R. Smith, of the United States, employs a curved needle, mounted on a handle, and armed with a ligature. The front of the needle is passed from behind forward, until the ligature appears, and can be seized with a tenaculum and drawn through. The needle is then withdrawn, and passed through the other side of the fissure. After a sufficient number of ligatures have been inserted, the sides of the velum are to be tightened by means of them, and the edges removed by scissors or knife. The ligatures are then to be tied. 586. Mr. Liston's method is as follows: "A narrow, sharp-pointed knife, held by the further end of the handle, is introduced through the edge of the fissure at its anterior margin, and run back to the apex of the one-half of the uvula. This may be laid hold of, and made tense by means of the sharp-pointed forceps. The same proceeding is re- peated on the other side." The ligatures are introduced with needles fixed in handles, and of different sizes and curvatures, the eyes being near their points. They are passed through the velum about a quarter of an inch from its free edge, and towards it, and through two-thirds of its thickness. Each needle carries a double ligature, the noose of which is caught by a blunt hook and pulled out into the mouth, while the instrument is withdrawn. A second and smaller ligature is carried through, opposite to the first, and by means of this second thread the first and double one is brought through. By a repetition of this plan two, three, or more points of interrupted suture are made. After the edges have been brought together by one or two points, no difficulty 364 CONGENITAL MALFORMATIONS. will be experienced in carrying others through both edges, by means of a more curved instrument in a handle, or by the use of a small needle, carried in the points of a pair of strong and well-fitted forceps. Before the ligatures are finally secured, the parts being put upon the stretch, an incision should be made on each side towards the alveolar ridge, through the anterior surface of the velum. By this method, Mr. Liston finds that the edges may be more easily brought together, and the strain is taken off the threads, so that there is less risk of their making their way out by ulceration. Mr. Liston deems the operation very liable to failure."1 In two cases, upon which Sir Philip Crampton operated, in the year 1842, that distinguished surgeon deviated from the ordinary mode of securing the ligatures, and from the usual treatment, subse- quently. Mr. Hamilton, who relates the cases, observes: " The dif- ficulty of tying the second knot on the ligature without suffering the first to become opened by the strong retraction of the edges of the fissure, effected by the muscles of the palate, has always been ac- knowledged. This difficulty, however, was effectually removed by an ingenious suggestion of Mr. M'Clean's, of Stephen's-green. After the ligatures had been passed through the palate at the distance of one-quarter of an inch from the cut edge of the fissure, and brought out at the mouth, their ends were passed through a small, perforated metallic bead, such as are used in making purses. The bead was then pushed down along the ligatures, closing them as it descended, until it touched the approximated edge of the wound ; it was then compressed by a pair of strong, blunt-pointed forceps, and the liga- tures were thus firmly secured, without a knot, at the required degree of tension. The other, and most important peculiarity in the treat- ment, consisted in allowing the patient an ample supply of soft food during the whole period of the treatment. Boiled bread and milk, custard, soup, and jelly, were given twice or thrice a day, and the patients were not confined to their beds."2 587. Professor Ferguson, of King's College, London, has proposed a modification of this operation, founded upon a more careful investi- gation of the anatomy of the parts.3 He regards the action of the levatores palati, and the palato-pharyngei muscles as an obstacle to the closure of the fissure, and he proposes to obviate this retraction by dividing these muscles. " As a preliminary step to trie ordinary operation, I suggested the division of the levator palati on each side, and also, if it seemed needful, of the posterior portion of the fauces, whereby large portions of the palato-pharyngei might be cut across. I also then thought that the anterior pillars, each containing the palato- glossus, might possibly require division. To effect these different incisions, I used a small, peculiarly curved blade for the levator muscle, and common curved scissors for the others."4 Mr. Ferguson 1 Cooper's Surg. Dictionary, p. 1078. Liston's Practical Surgery, p. 472. 'Dublin Journal, Jan. 1843, p. 324. * Trans, of Royal Med. and Sura;. Society, vol. 27. Practical Surgery, p. 530. * London Journal of Medicine, No. 1, p. 21. IMPERFORATE ANUS. 365 prefers a free incision through both mucous membrane and muscle. " I still retain the opinion, that there is no better mode of introducing the stitches, than by means of a slightly curved needle set in a handle. The point of the instrument, armed with a smooth, round, waxed silk thread, is passed from below upwards, about a quarter of an inch from the cut margin of the fissure, and made to appear in the middle of the gap, when the thread is seized with the forceps, drawn three or four inches out of the mouth, and then the needle is withdrawn. A similar manoeuvre is followed on the opposite side; the two threads are then tied together by the ends which have been thus drawn out of the mouth, and by withdrawing one of them, the other will be car- ried through the aperture opposite to that where it was first intro- duced. Hitherto, the thread has been double ; now one end must be drawn through the apertures and out at the mouth, and so the thread is ready to be tied. Two, three, four, or five threads are introduced in this way, and then, after the cut margins of the flaps are sponged free of blood and mucus, the various threads are fastened." Mr. Ferguson prefers "a moderate degree of tightness, rather than that the edges should be kept asunder by saliva or mucus." He also agrees with Sir Philip Crampton, in allowing the patients the use of fluid food. In Roux's experience, two-thirds of the simple cases, and one-third of the complicated, derived benefit from the operation. Dr. Mutter, of Philadelphia, succeeded in nineteen out of twenty-one operations ; Dr. J. M. Warren, of Boston, in thirteen out of fourteen ; Mr. Fer- guson has given a notice of twenty-four cases, in which the operation was performed according to his suggestions, in twenty-one of which it was successful.1 588. Staphyloplastic.—Dieffenbach's method of performing this operation, consists in making an incision along the palate on each side of the fissure, and afterwards drawing the edges together by ligatures. " The Indian staphyloplastic consists in raising up a flap of soft parts from the roof of the mouth, and twisting its pedicle round, so that the flap may be adapted, by means of suture, to the loss of sub- stance in the palate." I must refer my readers to the different writers on surgery, for the various attempts which have been made to remedy this defect, by the substitution of an artificial palate. If it be necessary at all, it is, at least, desirable to wait until after the age of puberty, and therefore the subject hardly comes within the scope of a treatise on diseases of children. 589. Imperforate Anus. In this malformation, the lowrer portion of the intestine terminates in different ways, which materially affect the operation for its relief, and the results. 1. The anus may be closed by a thin membrane, the rectum being perfect; in such cases, the membrane generally projects, the blue color of the meconium is dis- cernible, and there is a feeling of fluctuation or something very like it 1 London Journal of Medicine, No. 2, p. 117. 366 CONGENITAL MALFORMATIONS. to the touch. 2. The rectum may terminate an inch or so above the anus; and there will then be no projection, the skin will retain its natural color, and the parts will feel firm and solid. 3. Sometimes the intestine does not descend lower than the upper part of the sacrum. " Dr. Palmer dissected a case where the colon, after reaching the vicinity of the left kidney, began, as it descended, to form a sigmoid flexure; but, previously to its arrival at the concavity of the left ilium, made a sudden turn to the right, and, crossing the psoas muscle, reached the projection of the sacrum, where it terminated without entering the sacrum at all. With this malformation was combined an imperforate meatus urinarius, and other considerable deviations of the genital organs from the natural structure."1 4. Occasionally, the colon terminates in a cul-de-sac, the rectum being entirely wanting. 5. Although the anus may be perfect, yet if there be a closure of the rectum by membrane higher up,- as sometimes happens, the result will be the same. 6. In any of these cases, there may be an attempt to afford relief naturally by an opening into the bladder, as in a case lately under my care, or into the urethra, in the male, or vagina in the female. 590. We can easily understand that this malformation must speedily be attended with very serious or fatal consequences. If relief be not afforded, the infant perishes with symptoms of strangulated hernia. Mr. A. C. Hutchison recommends that the operation should be de- ferred until from twenty-four to sixty hours after birth, the advantage being that the intestine, being distended by the meconium, will be a guide to the operator in making an incision. At all events, within a moderate time after birth, an attempt must be made to afford relief by evacuating the contents of the intestine. 591. WThen the anus is merely closed by a membrane projected downwards by the meconium, whose color is discernible, the opera- tion is simple, and consists in making a crucial incision through the centre of the prominence and removing the corners. After the rectum is emptied, the wound must be kept open by a portion of a bougie, elastic gum catheter, or, what I found answer equally well, a small glyster-pipe. It is little matter, what means are used, if the end be attained. 592. But when no external appearance denotes where the anus ought to be, and when the touch gives us no information, the case is much more difficult, inasmuch as we know not how far distant the intestine may be from the surface, and consequently are ignorant how far we may have to penetrate before relief be afforded. " However," as Mr. Cooper observes, "it is the surgeon's duty to do everything in his power to afford relief. For this purpose, an incision an inch long, or rather more, is to be made in the situation where the anus ought to be, and the wound is to be carried more and more deeply in the natural direction of the rectum. The cuts are not to be made directly 1 Med -Chir. Journal, 1816, vol. i. Cooper's Dictionary, p. 208. IMPERFORATE ANUS. 367 upwards, nor in the axis of the pelvis, for the vagina or bladder might thus be wounded. On the contrary, the operator should cut back- wards along the centre of the concavity of the os coccygis, where there is no danger of wounding any part of importance. In all cases of this kind, the surgeon's finger is the best director. The operator, guided by the index finger of his left hand, introduced within the os coccygis, is to dissect in the direction above recommended, until he reaches the fa?ces, or has cut as far as he can safely reach with his finger. If he should fail in finding the meconium, as death must unavoidably follow, one more attempt ought to be made by introduc- ing upon the finger a middle-sized trocar in the direction, but calcu- lated to reach the rectum, without danger to other parts, viz., upwards and backwards in the median line. The canula may be left in the puncture, and secured there with tapes, so as to afford an outlet for the fa?ces. In some observations on this subject, addressed to the Medical and Chirurgical Society by Mr. A. Copland Hutchinson, he recommends an elastic gum catheter to be substituted for the canula, after a week; and, when the tube can be dispensed with, a sponge tent, or a piece of bougie, to be w7orn twelve out of the twenty-four hours."1 M. Wolff, after cutting to the depth of two inches without finding the gut, was enabled to reach it by means of a pharyngotomus, and the child recovered. The great difficulty appears to be to prevent the wound closing. Mr. Bell states that it was only by most assiduous attention, for eight or ten months, that he obviated the necessity for another operation. Mr. Miller, of Newhaven, had to repeat the operation ten times before the child wTas eight months old. In the case under my care, I had to repeat the operation once, and by great care it has perfectly recovered. A portion of a catheter, or bougie, a short glyster-pipe, or in short any matter which can be maintained in the wound, and which reaches into the intestine, will answer the purpose. 593. If the obstacle should be high up, the anus being perforate, we must endeavor to ascertain its nature and extent; if it can be relieved by dilatation, well and good; if not, it must be divided either with a blunt-pointed bistoury or a pharyngotomus, and the opening maintained by a bougie. When, in addition to an imperfect or imperforate anus, there is an opening into the bladder, vagina, or urethra, the best remedy for the latter is making the former more free; the more fa?ces pass through the anus, the less will escape by the supplementary passage : it is rarely necessary to do more. In my case, the fa?ces passed by the urethra before and a few days after the operation; but, as the one passage became more free, the other ceased to be used altogether. 594. But suppose that we cannot reach the intestine in the way already pointed out, and that we must conclude that there is some extraordinary malformation, as in Dr. Palmer's case—what is to be ' Surgical Dictionary, p. 209. 368 DENTITION. done? If wre do nothing, the child's death is certain ; therefore, some risk may very properly be incurred. In 1720, M. Litere proposed to make an artificial anus by opening into the sigmoid flexure of the colon, above the left groin. M. Dumas tried this plan in 1788 ; but the infant died. In 1793, it was practised with complete success by M. Duret, of Brest, and M. Pilore, of Rouen. Dessault, Ouvrard, and Roux lost the cases in which they tried it.1 " The operation consists in making an incision a little above Pou- part's ligament, about two inches in length, and on the outer side of the curve of the epigastric artery: the skin, superficial fascia, apo- neurosis of the external oblique muscle, the lower fibres of the internal oblique and transverse muscles, the fascia transversalis, and the peri- toneum, are to be divided in succession. As soon as the peritoneum has had a small puncture cautiously made in it, a director is to be in- troduced into the opening, which is to be enlarged w'ith a probe-pointed bistoury. The distended bowel, of a livid or greenish color, presents itself in the wound; and, being opened in the same direction as the wound, a tent, or piece of full-sized, elastic, gum catheter, should be placed in the new passage. The introduction of a ligature through the mesentery is sometimes advised; but, as my observations apply only to opening the sigmoid flexure of the colon, such expedient is out of the question."2 Though we may be justified in having recourse to the operation as a dernier ressort, the results do not seem to afford much hope of success. CHAPTER II. DENTITION. 595. Before we proceed to examine into the consequences of severe dentition, it may be as well to lay before the reader the ordinary course of dental development, in which medical interference is rarely necessary. Meckel, Sims, and others agree that the formation of the teeth com- mences, at a very early period of embryonic life, by an ossific deposit upon the pulp, which is extended and developed from without inwards, so that the grinding surface and shell of the tooth are first formed, with a central cavity, which gradually diminishes as the osseous mat- ter increases, to form the body: last of all, the roots are formed. The teeth are enclosed in a capsule consisting of two lamella?, from the union of which the pulp is developed; and the entire at birth, are en- closed in and covered by a considerable thickness of gum. " The membrane which secretes the enamel invests the course of the ' Velpeau, Nouv. Elem. de Med. Operat., vol. iii. p. 983. 3 Cooper's Surgical Dictionary, p. 211. DENTITION. 369 tooth, and adheres firmly to its neck. As ossification advances, the crown of the tooth rises, and the membrane of course accompanies it. On the tubercles and cutting edge of the tooth the crystallization of the enamel is first completed, and the process continues until the neck is reached ; the membrane covering it, becoming gradually thinner and less vascular, is at last quite absorbed. The absorptive process goes on in the gum covering the tooth, which at last presses through, and is said to have cut the gum."1 596. The period of the first dentition is subject to some variation, but as a general rule we may say that it occupies from the seventh month to the twentieth or thirtieth. The teeth commonly appear in each jaw in couples; thus, about the seventh month, we find the two central incisors of the lower jaw appear; then, after a short time, those of the upper jaw, followed after an interval by the lower lateral incisors, and then by the upper lateral incisors. From the twelfth to the four- teenth month the first four molar teeth appear, and from the sixteenth to the twentieth the lower and upper canine teeth ; last of all, the last four molars. The succession here stated has been observed, by Serres and De la Barre, to be the general order in which the teeth become ossified, and Dr. Ashburner's experience agrees with theirs. But although this sketch may indicate sufficiently well the usual process of teething, it is a rule to which there are many exceptions, a law from which there are many deviations. Children are occasionally born with teeth, or cut them shortly after birth. I knew a child, who was found to have three well-developed teeth at birth, and another who cut two the first fortnight of its life. Haller has noted nineteen cases of the precocious appearance of the first teeth. Denman mentions a child born with teeth, and Ashburner one of a child who cut the two incisor teeth of the lowrer jaw before three months old. Louis XIV. of France, Richard III. of England, and Mirabeau, were said to have been born with teeth. Neither do they always appear in pairs. I have a little patient in whom the right lateral incisor of the upper jaw did not make its ap- pearance before three years old, although she possessed all the other incisors, canine teeth, and some of the molars. Occasionally, the lateral incisors appear before the central ones, or the canine teeth before the incisors. On the other hand, there is often great delay before the teeth ap- pear. Van Swieten mentions a healthy child that did not cut a tooth until it w7as nineteen months old ; Underwood, one at twenty-two months; Dumas, one beyond seventeen months; and Serres quotes a case from Lanzoni, of a little boy who did not cut his first tooth until he was seven years old. Dr. Ashburner saw " a child, twenty-two months old, beginning to cut its first tooth, which was an incisor in the upper jaw." Fouchard gives an instance in which, at six years old, the child had but the front teeth, and Rayer one in which the four canine teeth did not appear till thirteen years of age. ' Ashburner on Dentition, p. 39. 24 370 DENTITION. Very frequently this order of succession is violated ; the upper in- cisors may appear before the lower, the molars before the canine teeth, or even before the lateral incisors, and, perhaps, all the upper teeth taking precedence of the lower. Dr. Hamilton observes: "In some rare cases, the grinders come out before the cutting teeth, and the usual order of succession is changed. It is not uncommon, too, for several pairs to succeed each other rapidly, and then for a considera- ble period to elapse before the rest advance. In general, the later the commencement of teething, the shorter are the intervals between the several pairs."1 For further examples of abnormal variations in teething, I must refer the reader to Meckel's Anatomy, and to the special works on the teeth. 597. Let us now consider the second dentition. " The germs of the second set of teeth," says Dr. Ashburner, in his excellent little essay, "have long existed in the jaws. It has been remarked, that the germs of the first dentition are attached, in the foetus, immediately to the membranous folds which, at this period, constitute the gums; and that those of the second dentition are suspended from them by means of small pedicles. When the capsules of the first dentition were advancing towards their development, and were approaching the upper part of the gum, those of the second appeared to retreat into the depths of the jaw, and hung to the gums by their pedicles. The pedicle in the process of growth is destined to perform an im- portant part. It becomes a fibrous canal, communicating between the alveolar margin and the cell in which the capsule is lodged; it is apparently periosteum ; but, whatever maybe its real nature, it leads to the tooth, and becomes continuous with the external layer of the dental membrane." "The gums grow, they enlarge ; as their volume increases, the germs of the permanent teeth continue to develop the organs they have to form. These germs are enclosed in cells in the bony substance of the jaws. Up to the age of five, six, or seven years, the jaws of a child may be said to contain two sets of sockets,"2 which are kept distinct by a bony lamina. But whilst this process of growth and development of the jaw and second set of teeth is going on, another commences, having reference to the first set. The root is gradually absorbed, so that, if we remove a. loose primary incisor, we shall find it more or less deprived of root, according to the time absorption has been going on, and apparently seated on the gum rather than inserted into it. When the absorption is far advanced, the tooth becomes dead and loose, and when com- pleted it falls out or is removed by the child itself. Previous, however, to the decadence of the first incisors, we generally find a molar tooth of the permanent set make its appearance behind the last molar of the first set, the jaw having expanded so as to afford sufficient space. The age at which these first appear is stated differently; by Soemmering, at seven or eight years; by De la Barre, at five or six; by ' Diseases of Infants, p. 73. 3 On Dentition, p. 62. DENTITION. 371 Bell, at six and a half; and by Ashburner, at about six years, although he saw them cut through in one case at three and a half years. The incisors are sometimes shed before the molars appear. This condition, of course, increases the total number of teeth. The first set consists of twenty, and then four permanent molars make the number twenty-four. Soon after the appearance of these molars (or sometimes before), at the age of five, six, or seven years, I have said that the central incisors loosen and fall out; and the same process of absorption ex- tending to the roots of the other deciduous teeth, they are likewise shed successively, and, as a rule, pretty much in the order in which they appeared, but with uncertain and considerable intervals between each pair. The temporary incisor and canine teeth are thus replaced by permanent incisor and canine teeth, and the four deciduous molars in each jaw (two on each side), by four bicuspid teeth, making twenty- four; which, with eight more (four molar and four wise teeth), make the full set of thirty-two. Now7, " let us inquire into the epochs for the appearance of all these teeth. We have seen that the two deciduous central incisors of the lower jaw, belonging to the first set, fall away about the age of seven years. The vacant spaces are soon to be occupied by a couple of incisor teeth, which cut through the gums with edges that are ser- rated—an appearance that time takes away. When these teeth are half up, the two superior central incisors fall away, and are succeeded by two much larger teeth. In consequence of the want of a perfectly normal instance of healthy growth, it is very difficult, in London, to fix the time when the next two incisors, the lateral of the lower jaw, should fall out. Irregularities in this respect are very numerous, for the perfect consent between the growth of the teeth and that of the jaws is wanting. The common occurrence is that of a pressure, from deficient growth of the jaw, turning the newly-arrived central incisors out of their line for a time, producing an angle at the median line, instead of a continuous arc; and their backs appear to be pushed to- wards each other. In most cases, the jaw increases in time, and the teeth assume their proper stations. About a year is occupied in shed- ding the four central incisors, and another year in that of the four lateral incisors. The anterior bicuspid teeth of the lower, then those of the upper jaw, are next to be shed; these occupy another year. The posterior bicuspids go next, and then comes the turn of the cus- pidati or canine teeth, but very often the canine teeth take precedence of the posterior bicuspid. The falling out of the posterior deciduous molars and canine, and replacing by these teeth, is a process that lasts from about 9| till 12. In the mean time, the jaws manifestly enlarge, particularly at the posterior part. Spaces are found behind the first permanent molars; these teeth appeared at six years of age, and before 13£, four new molars are cut. " The individual has now completed the development of twenty-eight teeth, and is nearly ready to encounter the further unfolding of the frame which is implied by the changes attendant on puberty. Three 372 DENTITION. or four years seem to be required for a due perfection in the growth of the organs of reproduction; and during the remainder of this septe- nary period, the system adds accretion to the body, while four new molar teeth are put forth, completing the full number of thirty-two teeth in the mouth. These last four, cut between seventeen and twenty-one years of age, are the wise teeth, or dentes sapientice." Deviations from the ordinary rule are just as common with the second dentition as with the first, and all we can attempt is an ap- proximative estimate. 598. From what has been said, it will be perceived that the resist- ance to the first set of teeth arises, first, from the fibrous capsule; and, secondly, from the gum, which is tolerably thick over the teeth, and of a dense texture. Through these structures the tooth must force its way by pressure, and consequent absorption, as it ascends. As the tooth rises, the anterior and posterior walls of the gum appear to se- parate, and the edge spreads out and becomes broad ; the gum swells, its texture is less dense and more vascular, and it rises on either side the central line or ridge, until this appears rather as a depression. As absorption proceeds, the gum immediately over the tooth becomes thinner and paler, until we can distinctly trace the edge of the tooth through it. At length the gum is pierced and slightly retracted, and the tooth is said to be cut. Occasionally, I have noticed a drop of straw-colored fluid between the tooth and the surface of the gum, giving it the appearance of a vesicle. The second dentition gives much less trouble, and for obvious rea- sons. The teeth which supply the place of the first set, have little more than the resistance of their own capsules to overcome; the va- cancy left by the first is merely healed over, and easily opened by the second, which so soon succeed. The additional molar and wisdom teeth, of course, meet with as much or more resistance than the first set. 599. If the child be healthy, and the process of dentition favorable, the suffering is not great, and the distress is almost entirely local. For some time before, the gums are much swollen; there is an abund- ant flow of saliva from the mouth ; the child dribbles, as it is called, incessantly, and thrusts its finger, or anything it can seize, into its mouth; and if we put our finger into its mouth, instead of sucking as heretofore, it attempts to relieve the irritation of the gums by biting. Up to this time, the mouth is quite cool. As the teeth advance in the gums, the latter swell, and become softer and tender, but with a feel- ing of tension and itching, which makes the infant anxious to close them upon something, or to press something against them, even though this be accompanied with some degree of soreness. There are occasional stings of pain, as we know by the sudden cry of the child; and if there be several teeth coming forward, or if the gums appear inflamed, the mouth will feel hot to the finger. The child now bites vigorously, its mother does not escape with impunity, and it carries everything it can seize to its mouth. It is fretful and uneasy, does not sleep as quietly as usual, and the bowels maybe rather more free than at other times. The dribbling continues until the tooth is DENTITION. 373 cut through. The irritation may extend to the lining membrane of the nose, or to its nerves, and the child be observed to sneeze fre- quently, and to rub its nose. It would seem that dentition is commonly more severe in the win- ter than in the Summer, and certainly more so in large cities than in the country; and its consequences are more serious in badly nurtured children, of delicate constitution, and among the poor. This, I think, is a pretty accurate description of a case of easy den- tition, in which the local distress is not excessive, and there is neither fever nor sympathetic irritation. So long as this is the case, inter- ference is unnecessary; there is no reason for lancing the gums, and the slight diarrhoea is beneficial. Ivory, caoutchouc, or gutta-percha rings, for the child to bite, are useful. Davies prefers a flat, ivory ring; but, in my opinion, by far the best thing is a finger-shaped crust of bread, or a biscuit, if care be taken that the infant do not break or bite off a piece. 600. Now let us turn to the cases of severe dentition, in which we find the local symptoms considerably aggravated. The mouth is hot, and in some cases dry; the gums are of a bright or deep red color, much swollen and very tender; the child is not now inclined to bite, on account of their tenderness, and, in some cases, even sucking gives pain. The suffering is very considerable ; the child is restless, cross, and uneasy, crying bitterly without any cause, and refusing to be comforted and amused by its usual playthings. Its sleep is disturbed ; some- times it cannot settle to sleep ; at others, after sleeping for a while, it awakes up crying. Its thirst is great, and it takes cold drinks with avidity. The flow of saliva may be nearly arrested, or it may be excessive, and occasionally the submaxillary glands are enlarged and tender. The cheeks are flushed, especially after sleep. If the local inflammation continue to increase, we may find the appearance of muguet on the inside of the lips or cheek, or the gums, may ulcerate. The local treatment is simple enough. The distress results from inflammation of the gums, excited and kept up by the pressure of the teeth, and it will be almost instantly relieved by dividing the gums freely with a gum lancet. 601. There are one or tw7o points, as regards lancing the gums, which I should wish to impress upon my junior readers. First, that, in order to perform the operation effectually, the gum lancet should have a back spring like a knife, and not an open back like a bistoury; for it is almost impossible to lay open the gums thoroughly with an instrument that is not firm and steady, and still less with a common lancet, although that has been recommended. Secondly, that a slight scarification of the gums for the relief of teething, is of no use whatever; they must be cut down until we feel the lancet touch the tooth, and to the full extent of the swollen gum, and a little further. I have often seen the irritation continue as severe as ever, after an incision over the central incisors, because the ope- 374 DENTITION. rator had not noticed that the lateral ones were pressing forward, and so of the other teeth. Moreover, when the suffering is very great, or in the case of the molars, or with the canine teeth, which commonly make their appear- ance between (because after) the lateral incisors and first molars, it is quite necessary to make a crucial incision down to the tooth, so as to free it completely. And I would beg to impress on the student that, owing to the fright of the mother or nurse, and the cries and resistance of the child, to lance the gums effectually is, by no means, an easy operation, but one that requires both firmness and deliberation to avoid, on the one hand, cutting too superficially or too limitedly ; and, on the other, wounding the mouth or tongue. Lastly, in severe cases, the operation will have to be repeated. It is a very good plan when the sympathetic irritations (of which I shall speak presently) do not speedily subside, to run the lancet along the old incisions every three or four days; it gives no pain, and prevents the wound from closing over. It is a mistake to suppose that the gum, when healed, is more re- sisting to the tooth, than if it had not been lanced, upless a very long time have elapsed ; and it is to be presumed that ordinarily no such early lancing will be necessary ; but when it is so, the gum must, of course, be reopened. The repetition maybe necessary, either because the gum has healed, or because the first operation was ineffectual, or as a precaution, if the sympathetic irritation continue. In very severe cases, when the ordinary lancing does not seem to afford adequate relief, we have been advised to shave off the entire edge of the gum over the tooth with a bistoury. I have never found this necessary; but I had a case lately, in which I was obliged to use the lancet thirty or forty times, each tooth requiring several operations, and the suffer- ing continuing until all were cut. From this case, and some others like it, I am inclined to believe that there is an irritation of growth, as well as that arising from the resistance of the gum ; for the latter, I took care to remove or prevent. In very rare cases, the bleeding from the wound has been excessive; but it may be arrested by pres- sure, astringents, or caustics. 602. Besides lancing the gums freely, it is desirable that the bowels should be more free than at ordinary times ; and, even if they are some- what purged, it will not signify, as this is by far the safest local irri- tation a child can experience during dentition. If, however, they should be too much moved, and with griping pain, we may easily moderate by chalk mixture with aromatic confection, and a drop or two of laudanum to the ounce, according to the age of the child, tak- ing care only to moderate, and not to arrest the action of the bowels. If the gums are disposed to ulcerate, it will be well to apply a little borax and honey to them occasionally, or a little acid and water ; but, in general, they are so much relieved by the lancing, that they recover their healthy state without any application. 603. But the suffering, occasioned by dentition, is not confined to DENTITION. 375 the mouth ; if it exceed a certain amount, or in children of an irri- table constitution, the irritation is reflected by the nervous system to some other organ or system of organs. The sympathetic irritations occur pretty much in the following order: — i. The most common disturbance, is irritation of the bowels, as I have already mentioned ; diarrhoea, with griping pain, and sometimes tenesmus. If it be not excessive, it seems rather a relief; and, as it is the least injurious of all the irritations resulting from dentition, we should rather moderate than altogether arrest it. The child will cer- tainly become weaker, thinner, and its flesh soft and flabby; but this will rapidly be remedied, when the teeth are through. When it is excessive, and the quantity and frequency of the dis- charge are great, we shall find it necessary to interfere with a mixture of chalk and laudanum, as just recommended; increasing the lau- danum, if necessary, or adding tincture of kino or catechu. If there be much pain and flatulence, an occasional warm bath, and the use of a liniment composed of half a drachm of laudanum to two ounces of compound camphor liniment, will be found of great service. If this fail, a mustard and linseed-meal poultice (one-third of the former to two-thirds of the latter), or a blister to the epigastrium for an hour or two, may answer the purpose. Vomiting does not always co-exist with the diarrhoea of dentition, but it does sometimes, and may prove very troublesome; especially because it deprives the patient of food, and renders the administration of remedies difficult, so long as it continues. As a general rule, it is the consequence of irritation, and not of inflammation; and will be relieved by the division of the gums, and the exhibition of half a drop or a drop of laudanum, or counter-irritatiqn to the epigastrium. M. Cruveilhier has described an affection, apparently caused by den- tition, under the title "maladie gastro-intestinale des enfans avec des- organization gelatiniforme," in which thirst, vomiting, and purging, with collapse, are the leading symptoms. This disease, however, is so much more serious than the ordinary vomiting and purging of den- tition, as to deserve a distinct notice; and the same may be said of the disorder noticed by M. Guersent. In all these affections of the digestive tube, warm baths, emollient fomentations, poultices, and slight counter-irritants to the abdomen, are exceedingly useful; but we must also regulate the diet carefully. If possible, the child should have its natural food, and but little besides, if it agree with him; but if it be already weaned, the diet should be of the simplest kind—boiled milk, or milk and water, rice milk, thin arrowroot made with milk, bread jelly, &c. 604. n. Next to the stomach and intestinal canal, and often co- incident, the most frequent seat of irritation is the skin. Patches of papular eruption appear on different parts of the body, particularly the face, and disappear after a time; or the child may be attacked by some more permanent eruption, such as crusta lactea, prurigo, ec- zema, &c, especially of the scalp; which, while it affords relief for the time, becomes itself a very troublesome disease, requiring special treat- 376 DENTITION. ment, and which, unlike many other irritations, is not necessarily cured by the liberation of the teeth. If any disease of the skin should exist previous to dentition, it will be found much more difficult, if not impos- sible, to cure it, until that process is completed. Even when appa- rently cured, the irritation of teething will cause the eruption to re- appear. The relief of the gums is then an essential part of the treatment of the cutaneous affection. We often find that, during dentition, the parts behind the ears be- come soft, tender, and inflamed, with a discharge which keeps these parts excoriated and sore. Among the poor, this is regarded as a matter of course, and little or no efforts are made to cure it until after the teeth are through ; but if we relieve the gums, the ears may be also restored to their natural condition by a little black wash and gentle purgatives. As it is a natural derivation, it might be unwise to stop it unless other means were adopted for the relief of the original irritation. 605. in. Probably the next sympathetic irritation, in point of fre- quency, is some irritation of the nervous system. This may develop itself in different localities, and with different degrees of intensity. I saw the other day a single attack of spasm of the glottis, resulting from teething, and relieved by lancing the gums. Or the spasm may return frequently in the course of the day, and continue for weeks, alternating with convulsions. Lancing the gums is absolutely necessary, and generally relieves the child; but as the attack is apt to return with each tooth, further measures must be adopted. The bowels should be kept rather more free than usual, warm baths given occasionally, the gums freely di- vided at the first sign of dental irritation, and, if necessary, a blister applied behind the ear, or to the back of the neck; or, if more perma- nent counter-irritation be desired, a seton of three threads of silk in- serted into the arm. Fresh air is very desirable, and, if possible, a change of air from the town to the country. For further details, I must refer my readers to the chapter on spasm of the glottis. But, instead of spasm of the glottis, the child may have a fit of con- vulsions, partial or general, limited to the muscles of the face or one extremity, or involving the whole body. The symptoms and treat- ment have already been described; the most important point to re- member is, that, although dentition may be the sole cause, lancing the gums, warm baths, and purgatives, may not be all that is necessary for the cure, but w7e may be obliged to have recourse to blood-letting or leeching, with subsequent counter-irritation. 606. iv. Affections of the chest, bronchitis, pneumonia, &c, are often attributed to the irritation of teething; and, without calling in question the possibility, I am inclined to think that in many of these cases it is merely a coincidence. The child takes cold when teething, and as undoubtedly it will be difficult to cure the pulmonary affection until the gums are relieved, the two are connected as cause and effect. In addition to the proper remedies for the disease, we should always STOMATITIS. 377 lay open the gums, whenever we have reason to suspect the slightest irritation from the teeth. 607. Many other diseases are enumerated as resulting from denti- tion ; but those I have named are the principal ones. The list has, no doubt, been lengthened by including coincident affections arising from other causes, just as the mortality attributed to dentition embraces many cases in which death resulted from the secondary or synchronous disorder. At the same time, I differ from those who go to the opposite extreme, and deny all secondary diseases, and nearly all fatality arising from dentition. Formerly, it was extremely difficult to comprehend the mode in which the secondary affections occur; but since my friend Dr. Mar- shall Hall's brilliant discovery of the reflex action of the nerves, we understand so far that the irritation of the gums, conveyed to the nervous centres, is thence reflected, or rather projected to some other organ; but of the laws which determine the particular organ or sys- tem thus affected, we know7 as yet but little. In conclusion, I would beg my junior readers to bear in mind that many diseases which prove obstinate in infancy and childhood, but which originated quite independent of dentition, may owe their per- sistence to an access of teething arising during their course, and that we shall fail in curing them, unless we first relieve the gums. In fact, the diseases which are easily cured at other times become excessively obstinate during dentition, and it will be w7ell always to ascertain the state of the teeth, whenever w7e find such diseases do not yield to our treatment. This applies equally to most of the diseases of infancy, and especially to diseases of the skin, during both the first and second dentition. With the exception of diseases of the skin and the bowels, the second dentition rarely excites any sympathetic affection, nor is the local irritation great. The posterior molars and the wisdom teeth give a good deal of pain, which may be relieved by a touch with the lancet. CHAPTER III. INFLAMMATION OF THE MOUTH.--STOMATITIS. 608. Inflammation of the mouth is sufficiently common among children of all ages, from birth to ten or twelve years old, and we find it varying in extent and intensity, constituting the simple or erythe- matous stomatitis, muguet or pseudo-membranous stomatitis, aphtha? or ulcerated stomatitis, and gangrene or cancrum oris, described by authors. In simple or erythematous stomatitis, the mucous membrane is ob- 378 STOMATITIS. served to be unusually red, either generally, in points, or in patches. The entire surface of the mouth may be involved, or only the mucous membrane lining the cheek, or merely the gums; and in the latter case we find them spongy, with their edges rounded, swollen, and somewhat loosened from the teeth. The mucous membrane thus affected, is, as I have said, of a deeper or brighter color than usual, puffy, and extremely tender to the touch. The mouth is very hot, and, except at the beginning, there is a profuse secretion of a colorless, bland saliva. The child is extremely uneasy, restless, and fretful, and, when suck- ing or eating, is evidently in great pain. In addition to these local symptoms, in many cases we shall find the bowels disordered, with flatulence and griping. Very little fever accompanies this affection, except in those cases where the child is, in addition, suffering from dentition. 609. Causes.—The causes to which the disease may generally be attributed are either a disordered condition of the intestinal canal, or dentition. Both give rise to irritation at the commencement of the digestive tube; and, in the latter case, if the patient have already teeth in one jaw, their pressure upon the opposite gum, already swoll- en by the teeth approaching the surface, very frequently converts irritation into positive inflammation and slight ulceration, which may spread to the neighboring parts. Any irritating matters taken into the mouth may give rise to stomatitis, and it not unfrequently occurs in the course of certain eruptive fevers, as measles and scarlatina. 610. Treatment.—In its simple form, the disease involves no dan- ger, and is easy of cure. The bowels should be freed by a brisk purgative, if they be at all confined ; but, if there be irritation and diarrhoea, wre shall do better to quiet that before clearing the intestinal canal. If the child be teething, the gums must be freely lanced ; and, these sources of irritation being removed, very simple local treatment will be sufficient. Cool, emollient drinks, which the child will eagerly take, are the best application in the acute stage; and, when this is past, we may gently apply a little honey, then a little borax and honey, in such proportions as the patient can bear. If this fail, we may try a mixture of honey, alum, and water, in the proportion of one part of alum to fifteen of honey, and seven of water, as recommended by M. Bouchut. But the great point is to restore the stomach and bow7els to their healthy condition. Generally speaking, the attack subsides easily, but if neglected, or badly treated, or if more than usually severe, it may give rise to muguet, aphtha?, or ulceration. MUGUET. 379 CHAPTER IV. MUGUET.--STOMATITE PSEUDO-MEMBRANEUSE. 611. This common affection of infancy and childhood has long been known to practitioners under various names, as aphtha lactan- tium, aphtha lactamen, aphtha infantilis, although its true nature and seat are a modern discovery, due chiefly to the labors of Guersent,1 Lelut,2 Billard,3 Valleix,4 &c. By many, it has been and still is confounded with the vesicular aphtha, or thrush, though no two diseases can be more distinct, mu- guet being an abnormal secretion upon the mucous membrane of the mouth, and thrush consisting of a vesicle or pustule formed beneath the epithelium. Muguet may be either idiopathic or symptomatic, either a primary or a secondary affection. 612. Symptoms.—After inflammation of the mouth has continued for a longer or shorter time without yielding to treatment, or without our being aw7are of any previous inflammation, we may observe in different parts of the mouth small points or patches of a curdy matter, at first, if the child be sucking, probably mistaken for the remains of milk. This matter, however, is adherent to the subjacent membrane, although by a little trouble it may be removed. These points or patches sometimes disappear in a few hours, if the attack be very slight; but, if severe, they increase and coalesce, so as to cover more or less of the mouth and fauces, as by a false membrane; or, after disappearing for a short time, they may return and increase. This pellicle is of a white color when unstained; but it is occasion- ally tinged yellow or reddish, as Billard has observed, by bile, or blood exuding from the mucous membrane, and this particularly in severe and fatal cases. It may occur at any period of infantile life (or at a later period), but it is more frequent during the first year, as the result of derange- ment of the stomach and bowels; but, when children of this age are crowded together, badly tended, and insufficiently nourished, then the disease displays itself in its severest form. If the mouth be carefully examined before it is entirely covered by the white pellicle, the intervening mucous membrane will generally be found more vascular than natural, dryer, of a brighter or deeper 1 Diet, de Med., Art. Muguet, Stomatite. * Arch. Gen. de Med., vol. xiii. p. 335, 1827. 3 Traite des Mai. des Enfans, p. 199. 4 Clinique des Mai. des Enfans Nouv.-nes, p. 202. 380 MUGUET. red color; and, if we detach a portion of the pellicle, the surface un- derneath will be seen to be highly inflamed. In addition to the local condition of the mouth, there are few con- stitutional symptoms; the child is uneasy, and may find it difficult or painful to suck ; and, although very thirsty, the effort of drinking occa- sionally gives great pain; nay, in some cases, I have seen it impos- sible. This, perhaps, may be owing to the extension of the disease to the oesophagus, of which I shall speak presently. The skin is hot and dry, although the pulse does not seem to be much quickened. M. Billard "counted the pulse and beatings of the heart in forty children, aged from one to twenty days, affected with it, and found fifty, sixty, sixty-four, eighty, and, in one instance, 100 pulsations in the minute." The conclusions to which M. Bouchut has arrived are : " That there are two varieties of muguet, idiopathic and symptomatic ; that both depend upon the general condition of the individual; the first upon a bad state of the constitution, and the second upon deranged health from organic disease ; that the only proper symptoms are the local ones, i. e., the condition of the mouth ; that the general symp- toms depend upon the disease in the course of which muguet occurs; that ordinarily they are those of enteritis, but that they may be those of pneumonia, tubercular phthisis, hydrocephalus, &c." The local phenomena, then, which characterize the disease are precisely the same, whether the latter be primary or secondary. 613. Pathology. — Careful and repeated investigation has esta- blished, beyond dispute, essential difference between muguet and aphtha. Muguet is not seated beneath the mucous membrane gene- rally, nor does it involve the destruction or disorganization of that tissue. It is a curdy matter, deposited upon the surface, quite re- movable, and which, in fact, is constantly thrown off, leaving an un- broken surface beneath. What, then, is this matter, and how does it originate ? Opinions differ upon this point. M. Auvity and others have regarded muguet as a disease of the mucous follicles; but the minute researches of M. Lelut seem to have refuted this opinion, inasmuch as he never could detect any prolongation of the false membrane into these follicles, but found it perforated at their orifices; and this observation upon the living was abundantly confirmed by careful examination after death. 614. M. Lelut describes two varieties of muguet: one creamy, in patches, of a creamy consistence, easily removed by lotions or slight friction, and which is seated upon the mucous membrane; the other in flocculi, irregularly filamentous, yellow, and either under the epi- thelium, or at least so adherent to the mucous membrane that the latter may be removed with the deposit. Further, he concludes that this false membrane is analogous to other false membranes which are found internally or externally, to the secretions of the mucous mem- branes, and to the epithelium itself; and this conclusion was attained by submitting each to the same chemical tests, with the same results. M. Lelut's researches would seem to prove that, on the edges and MUGUET. 381 inside of the lips and cheeks, and on the central portion of the pala- tine vault, the false membrane is beneath the epithelium; but that, on the other parts of the mouth and in the oesophagus, it is either upon the epithelium, or, if originally beneath it, it rapidly so transformed it as to render it undistinguishable.1 M. Billard regards the deposition as coagulated mucus, and Guyot as mucus modified by excess of fibrine. 615. M. Bouchut rejects the opinion of Lelut that muguet is analo- gous to other false membranes secreted by the mucous membrane, and adopts that of M. Gruby, viz., that it is a vegetable parasite, formed according to the laws of spontaneous generation ; and he gives the following extract from the report of the Academie des Sciences, the exactness of which he states he has many times proved: "A por- tion of muguet being placed under the microscope, it is seen to be composed of a mass of cryptogamic plants. It consists of conical elevations of twenty-five millimetres in diameter, each cone consist- ing of separate portions, provided with roots, branches, and sporules. " The roots are implanted in the cells of the epithelium ; they are cylindrical and transparent, of 1.400 of a millimetre in diameter ; and in their development they perforate each series of cells composing the epithelium, to arrive at the surface of the mucous membrane. The trunks or stems which grow from the surface of the epithelium are equally transparent, interrupted at distances by divisions, and en- closing in their cavities corpuscles. Like the roots, they are cylin- drical and rectilinear, 1.4 of a millimetre in length, and 1.400 of a millimetre in thickness. These stems are divided into branches, which again subdivide, bifurcating at a very acute angle. The branches are composed of oblong, distinct cells, enclosing in their in- terior, one, two or three transparent knots (noyaux); their sides here and there exhibit sporules, of which there is a great number at their extremity. The diameter of these sporules is from 1.200 to 1.400 of a millimetre. These cryptogamia have considerable analogy with the mycodermia of the porrigo favosa, and resemble the genus sporo- trichium of botanists."2 M. Bouchut agrees with M. Lelut as to the red and dry condition of the mucous membrane underneath the muguet, but differs from him in regarding the muguet as a growth upon the epithelium everywhere. He describes the mode of extension from the mouth to the pharynx, oesophagus, and stomach; and he mentions distinctly having seen the disease in the large intestine, and around the anus, thus confirming the observations of Lediberder, Billard, and Valleix. Dr. West observes: "I cannot pretend to decide, from personal observation, the point at issue between the supporters of these two conflicting theories, but my opinion decidedly leans to the adoption, as generally correct, of that view which sees, in the deposit of aphtha? and muguet, the result of an inflammatory process ending in the ' Archives Gen. de Med., vol. xiii. p. 360. 3 Manuel Prat, des Mai. des Nouv.-nes, p. 174. 382 MUGUET. formation of false membrane, wherein a parasitic growth may become developed." "The frequency of the parasitic growth in the false membrane is possibly dependent on the actual transplantation of its sporules from one patient to another, by means of the cups, spoons, &c. used by them in common, and generally without sufficient attention being paid to insure their perfect cleanliness. Whether, in any case, the deposit of these sporules upon the surface of the healthy mucous membrane is followed by the development of the conferva? and the alteration of the epithelium of the mouth, is a question to which it is not possible at present to give a satisfactory reply. For my ow?n part, I should greatly hesitate to answer it in the negative."1 It is very pleasant to recollect that we may recognize and cure the disease, may, in fact, understand all about it practically, and control it, notwithstanding these microscopic difficulties and doubts. The im- portant facts we know are, that, as the result of an inflammation of the mucous membrane of the mouth or digestive tube, a deposition of curdy matter may take place in the mouth, or in other parts of the digestive canal, and that generally this matter is upon the epithelium, and does not involve the destruction of the subjacent membrane. 616. Causes.—I have already alluded to the greater prevalence of this disease in the early months of life, at a period when the constitu- tion is peculiarly tender, the digestive tube scarcely reconciled to its new functions, and when mismanagement is so immediately and seriously injurious. Even under careful treatment, we meet with it, but much more frequently when the infant is exposed to bad food, impure air, or insufficient clothing. I quite agree with the opinion of MM. Baron and Billard that the disease is not contagious in the ordinary sense; but, that it may be communicated by contact under certain circumstances, e. g., to the nipples of the nurse, I have no doubt, because I have seen it, and this agrees with the experience of MM. Guersent and Marlay. It may also prevail either epidemically or endemically. In places where many infants are congregated, I may say it prevails at all times. According to Billard, "it prevails with almost equal intensity, and at all times at the Hospice des Enfans Trouves. In the quarter ending in March, 1826, out of 290 patients, there were thirty-four cases of it. In the quarter ending in June, out of 235 patients, there were thirty-five. In the quarter ending in September, out of 213, there were 101 cases; and forty-eight, in the quarter ending in December, among 189 patients. M. Baron has seen it prevail among a number of individuals at certain periods, without being able to assign for its cause any influence from temperature."2 617. But, no doubt, the most frequent cause is to be found in the primary affection to which muguet is secondary, and we shall now in- quire into these complications, and, for this purpose, I shall avail my- self of the minute researches of M. Valleix. I am tempted, however, 1 Diseases of Children, p. 342. 3 Mai. des Enfans, p. 167. MUGUET. 383 as a prelude, to give a short summary of his experience of the disease in twenty-four cases in the Infirmary of the Hospice des Enfans Trouves. All the infants were less than a month old, and were strong and vigor- ous. Most of them had been sent to the infirmary on account of pemphigus or pustules. In one only did muguet exist at that time, and there were no grounds for suspecting its communication to the others by contagion; the less so, indeed, as one-fourth of the infants sent to the infirmary are so attacked. The appearance of the false membrane was preceded some days by an attack of erythema of the thighs. After the erythema had con- tinued for four or five days, diarrhoea supervened, at first moderate, but increasing rapidly, the evacuations being yellow at the beginning. At the same time, the pulse was accelerated from 80 or 90 to 116, 130, or even 140; the face became pale, and of a dull yellow color. To these symptoms were added most frequently (in nineteen out of twenty cases) a marked swelling of the papilla? at the extremity of the tongue, and, shortly after, a vivid redness of that organ, which soon spread to the rest of the mouth. In eight cases, ulceration of the palate occurred about the same time. The redness and swelling of the tongue indicated the invasion of muguet, the grains of which, in twenty cases, appeared on the first day. In seven cases, they were developed at the same time on the inside of the cheeks, but commonly the tongue was the part first affected. At first, a few grains were observed on the tongue, then irregular masses on the inside of the cheeks, and strips on the vault of the palate, and coalescing they formed a layer more or less thick. This morbid production was always white at first, and only became yellow towards the termination in five cases. It w7as at first adherent, and any attempt to detach it made the mucous membrane bleed, but afterwards it could easily be removed. During the deve- lopment of the false membrane, the former symptoms (erythema and diarrhoea) persisted, and new ones were added. The stools almost always became green, but in no case could any portions of false mem- brane be detected in them. The heat of the mouth was rarely increased, but the tongue was dry in thirteen cases. When the muguet was very abundant, it occasioned considerable distress, which the infant evidenced by rolling about the tongue and moving the jaws, as though to remove some unpleasant substance. At the same time, it refused the breast, and cried if the fingers were introduced into the mouth. Meteorism of the abdomen supervened in twenty cases; in four, previous to the appearance of the muguet; in the remainder, during the greatest intensity of the disease ; and was attended by symptoms of colic, and in some cases by tenderness. Vomiting occurred in only five cases, and the matter ejected was sometimes yellow, sometimes colorless. After the diarrhoea had continued for some time, ulceration of the ankles or heels took place, the patient became agitated, inter- mittingly at first, but afterwards constantly, and the pulse became rapid. The heat of skin was in proportion to the quickness of pulse. 384 MUGUET. "Towards the end of the disease all the symptoms seemed to dimi- nish, but it was only to give place to collapse. The erythema became less vivid ; the ulcerations were covered with crusts; the diarrhoea diminished or ceased entirely; the infant refused the breast, and would scarcely drink ; the muguet diminished, and ordinarily consisted only of a few grains on the tongue. The pulse fell to 80, 70, or even 60 in a minute; the heat was succeeded by chilliness, at first of the ex- tremities, and afterwards of the whole body; the agitation gave place to almost complete insensibility ; the cries were changed into groans ; the emaciation and pallor became extreme, and the face acquired the appearance of decrepitude. "About this period were developed in certain cases inflammations, not very acute, characterized by oedematous swelling, obscure redness and pain; they occurred in the nose, lower lip, and neck. At this time also abscesses, occasionally numerous, were formed in different parts of the subcutaneous cellular tissue, and in one case gangrene of the integuments of the limb occurred. At last, death closed the scene without pain."1 The mean duration of the disease was 17£ days in the fatal cases, and 16^ in those who recovered. Three distinct periods were re- marked. The first, from the commencement to the appearance of the muguet; the second, from this time to the termination of the febrile stage ; and the third, the period of collapse. "Autopsy revealed various lesions. In nineteen cases, false mem- brane was found in the mouth ; in ten, the palate was ulcerated. The oesophagus was almost always occupied by false membrane, and in all the cases there were lesions of the gastro-intestinal mucous membrane, the result of inflammation. In a small number, ulcerations were found. The liver, the spleen, the kidney, the bladder, the larynx, trachea, and bronchi, presented nothing abnormal, but in eight cases there was he- patization of the lungs. The circulating system was unchanged, except in one case. The skin and cellular tissue exhibited evidences of the lesions with which they had been affected." I shall add M. Valleix's resume of the special condition of the gastro-intestinal canal in twrenty-two cases; merely premising that, as far as the stomach was concerned, the localities of these morbid changes were as follows:— At the larger extremity, in . . .13 cases. On the anterior parietes, in . . . 12 " On the posterior parietes, in . . . . 11 " At the greater curvature, in . . . 11 " At the smaller curvature, in . . . . 8 " i. As to the lining membrane of the stomach, there was found :— 1. Softening of the mucous membrane, with thick- ening and redness, or some other alteration of color, in 6 cases, i. e.: ' Clinique des Mai. des Enfans, &c, pp. 209, 210. MUGUET. 385 Occupying almost the entire stomach, with red- ness, in . . . . . .3 cases Occupying a limited portion of the surface, with redness, in......2 " \ 6 Occupying a limited portion, with brown disco- loration, and softening of the other coats of the stomach, in . .... 1 case. 2. Softening, with redness, without thickening, oc- } cupying the entire extent of the stomach, in 3 cases. >■ 5 Occupying a limited portion, in . . 2 " ) 3. Softening, with neither redness nor thickening, oc- } cupying the entire extent of the stomach, in 2 " v3 Occupying a limited portion, in . .1 case. ) 4. Alterations of color, without thickening or softening, i. e.: General rose color, in . . . .5 cases. } General brown color, in . . . .1 case, v 7 Deep red color, punctated, in . . . 1 " ) No change in ...... . 1 No data in ....... . 1 ii. As to the mucous membrane of the small intestines, there ex- isted— 1. Extreme softening, with thickening and redness, in 3 cases. 2. Considerable softening, with thickening and redness, in 5 " Considerable softening, with thickening, but without redness, in . . . . . . . 3 " Considerable softening, with redness, but without thickening, in . . . . . . .1 case. Considerable softening, with neither redness nor thick- ening, in . . . . . ... 2 cases. 3. Slight softening, with thickening, but without red- ness, in . . . . . . . .1 case. Slight softening, with redness, but without thick- ening, in . . . . . . . . 1 " Slight softening, with neither redness nor thicken- ing, in . . . . . . .4 cases. 4. The natural color and consistence, in . . 2 " m. The condition of the mucous membrane of the large intestine is thus stated :— 1. Extreme softening, with thickening, and Of a punc- tated brown color, in ..... 1 case. Extreme softening, without thickening, and of a bright red color, in . . . . . . 1 " 2. Considerable softening, with thickening and redness, in . . . . . . . .2 cases. Considerable softening, with thickening, but without redness, in . . . . . . . 4 " Considerable softening, with redness, but without thickening, in.......2 " 25 386 MUGUET. Considerable softening, with neither redness nor thick- ening, in ....... 2 cases. 3. Slight softening, with thickening, but without red- ness, in . . . . . . .1 case. Slight softening, with redness, but without thicken- ing, in . . . . . . .2 cases. Slight softening, with neither redness nor thickening, in.........3 " 4. The natural color, consistence, and thickness, in .3 " J It does not appear that M. Valleix was able to trace the false mem- brane further than the stomach in more than one or two cases; Veron, Davies, Eberle, and Condie have not been able to trace it beyond the oesophagus, whilst Guyot and Billard have found it through the en- tire alimentary canal. I have seen a similar false membrane around the anus, at the same time that it appeared in the mouth; and, though I have not traced it through the alimentary canal, I feel scarcely a doubt that it occasionally extends throughout. It would appear, from these researches, that muguet is chiefly secondary to a diseased condition of the mucous membrane of the digestive tube, and that softening of the mucous membrane is the principal form of this disease. We have seen that children attacked by muguet may also suffer from pneumonia, as a complication, and occasionally they are attacked by bronchitis. 618. Diagnosis.—There is no difficulty in the diagnosis w7hen once the false membrane is formed, inasmuch as the only disease with which it can easily be confounded is aphtha?; and from this it is distinguished by the integrity of the mucous membrane underneath the creamy deposition, and by the fact that the latter is seated upon the mem- brane generally; whereas in aphtha? we have small grayish ulcers or pustules in the mucous membrane. Previous to the appearance of the muguet, the disease of the mu- cous membrane resembles some forms of gastro-enterite; nor is it of consequence to make a very nice distinction, if it were possible, for in most cases the muguet is secondary to such an affection. 619. Prognosis.—Idiopathic muguet, in tolerably healthy children, and uncomplicated with organic disease, is of short duration, and of comparatively little consequence. After a few days, the false mem- brane becomes thinner and less continuous, resembling in appearance the patches or points by which it commenced; by degrees, it peels off, leaving the mucous membrane moist, and somewhat smoother and redder than natural; and the little patient, relieved from the soreness and distress in swallowing, appears quite recovered. In this simple form of the disease, we do not meet with fatal cases. But it is not so when muguet occurs in dilapidated constitutions, or with extensive disorder of the alimentary canal, or in the course of chronic diseases; the mortality is then considerable, resulting, how- 1 Clinique des Mai. des Enfans, &c, p. 267. MUGUET. 387 ever, not so much from the muguet as from the primary disease, or from the complications. The affection of the mouth is important, as indicating the state of the constitution; but it is to the primary affec- tion that our attention should be directed. M. Baron had 109 fatal cases out of 140; M. Valleix, twenty-two out of twenty-four, all of which labored under entero-colitis, and, in addition, eight of them had pneumonia, and one meningitis. M. Bouchut observed forty-two cases in the Hopital Necker, fourteen of which were idiopathic, and of these none died: in the remaining twenty-eight, the muguet was symptomatic of visceral disease; and of these twenty died, fourteen of chronic entero-colitis, complicated in five cases with pneumonia; four of acute entero-colitis; three of pneumonia; and one of hydrocephalus. The remaining eight were affected with entero-colitis or phthisis, and left the hospital suffering from muguet. 620. Treatment.—The two forms of muguet are so far different that the one is a local affection, dependent, no doubt, to a limited extent, upon the general condition of the child; whilst the other is secondary to some pre-existing disease—an additional symptom, in short, and little more; and of course the treatment will vary accordingly. In primary or idiopathic muguet, if the disease be slight, some mucilaginous w7ash, slightly acidulated, and applied with a brush, or a little honey placed on the tongue, with a gentle purgative now and then, a warm bath, pure air, and wholesome nourishment, will be all that is necessary. If the child have been too early deprived of its natural food, or if the suck appear to disagree with it, it will be quite necessary to pro- vide a healthy nurse for it. In some cases, we must add to the w7ash or to the honey either chloride of soda (one-fourth part), as Guersent and Darling recom- mend, or a small portion of alum, as Billard advises, or a little borax. M. Trousseau, at the Hopital Necker, uses equal parts of borax and honey with great success. I have found this extremely useful; but I prefer commencing with a smaller proportion of borax. Dr. Hecker recommends a solution of the sulphate of zinc; M. Duges, a lotion containing the vegetable acids; and M. Bretonneau, the application of a powder, consisting of half a grain of calomel tri- turated with a few grains of sugar, three or four times a day. Dr. Condie prefers borax rubbed up with white sugar. In some obstinate and severe instances, it may be necessary to apply stronger remedies, such as nitrate of silver in solution (gr. x or gr. xx to si), or muriatic acid and water or honey (3i of the former to 3*i of the latter). 621. In all these cases, it will be advisable to give small doses of the hyd. c. creta, with rhubarb, two or three times a day, so as to act gently upon the bowels, unless diarrhoea should be present, in which case chalk mixture, or mucilage and water, with a drop or two of laudanum to the ounce, and a few grains of aromatic confection, will form a useful mixture, of which a teaspoonful may be given three or 388 APHTHA. four times a day. When the looseness of the bowels is corrected, we may then commence with the mercury and chalk. In the cases where the constitution of the child is much deteriorated, I have found great benefit from small doses of quinine, say one-third of a grain, three times a day; and it may be combined with the powders already mentioned, or given separately. The diet must be carefully superintended; in many cases, the infant cannot suck; it must, therefore, be fed with a spoon. Milk, alone or with water, arrowrroot, gruel, with a little wine whey occasionally, will be their best food. Older children will require that their food should be nourishing and soft, so as not to irritate the inflamed mucous membrane. As the false membrane is only an accidental accompaniment in secondary muguet, our first care must be directed to the primary dis- ease ; and the local affection of the mouth will follow its course, dimin- ishing or increasing, according to its state. The local remedies just named may be used, but success with the mouth will mainly depend on our curing the primary complaint. Of that I shall speak hereafter. CHAPTER V. APHTHA.--THRUSH.--STOMATITE FOLLICULEUSE. 622. Aphtha, or thrush, is a very common disease of infancy and childhood, and has been noticed by most writers from very early times; for instance, it is mentioned by Hippocrates, Galen, Areta?us, and Celsus, and, in our own country, by Harris,1 Moss,2 Rosenstein,3 and since then, by all writers on diseases of children. The earlier descriptions, however, were so far inaccurate, that they confounded muguet with aphtha?, and simple thrush with ulceration, or even gangrene of the mouth. Like muguet, aphtha? of the mouth may occur at any period of in- fantile life from birth, or it may attack adults, but certainly it is more frequent in children under four or five years of age; and this we should expect, because it appears to be dependent upon some derangement of the digestive system, and the stomach and bowels are more apt to be disturbed in early life than subsequently. Denis4 and Billard5 re- gard muguet as more common with young infants, and aphtha? about the period of the first dentition. * De Morhis Infantum, p. 81. 3 On the Management and Nursing of Children, &c, p. 185. 3 On the Diseases of Children, p. 27. 4 Recherches des Mai. des Nouv.-nes, p. 109. 6 Traite des Mai. des Enfans, p. 213. APHTHA. 389 623. Symptoms.—The symptoms will naturally vary, according to the extent of the disease, which may be confined to the mouth, and exhibit either few and distinct or numerous and confluent aphtha?, and also according as the affection is primary or secondary. Take, for example, the case of a child in pretty good general health, whose mouth has become thus affected; we shall find a few vesicles or small ulcers, if the top have been rubbed off; and the mother is sure to direct our attention to the prominent fact that the infant does not like to be fed, that it cries, and resists sucking still more, or, perhaps, that it positively refuses to suck at all. This is not to be wondered at, for nothing could be better calculated to give the child pain, except, perhaps, the scouring the nurses give the mouth, by way of cure. The mouth is extremely hot, the lips often swollen, and the saliva constantly dribbling, partly from its excessive secretion, and partly from the difficulty of swallowing; the breath is often very disagree- able, and the bowels will generally be found to be out of order. In the milder cases, however, there is no fever or constitutional disturb- ance. 624. But, when the aphtha? are numerous and confluent; when they extend into the oesophagus; and when, as generally happens in such cases, the primary disease is severe, and has broken down the health of the child, then the case presents another aspect altogether. The appearance of the patient changes; it becomes pale and anx- ious, with a restless, fretful, and distressed expression, irritable and w7hining, unable to suck or to sw7allow without great pain, if at all. It becomes greatly emaciated; the stomach and bowels show signs of great disorder, partly from irritation, and partly from want of pro- per nutrition; vomiting is frequent, and diarrhoea almost constant, with watery or green-colored stools. The skin is hot and dry, the mouth hot, swollen, red, and covered with aphtha?, the dribbling is excessive, and the pulse quick, but feeble. When the disease extends to the pharynx, the glands are apt to enlarge, and the irritation or inflammation may extend to the trachea, altering the character of the voice, and rendering it harsh or hissing. WThen the thrush is secondary, or when complicated with other or- ganic affections, the symptoms of the primary or secondary disease may predominate, so that the thrush will appear merely as an aggra- vation. 625. Pathology.—I have already stated that muguet and aphtha? differ essentially, in that the former is a secretion deposited upon the surface, and the latter an ulcerative process beneath the epi- thelium. Dr. Bateman defines the disease thus: " The aphtha? are small, whitish or pearl-colored vesicles, appearing on the tongue, the lips, and the interior surface of the mouth and throat, generally in con- siderable numbers, proceeding to superficial ulceration, and terminat- ing by an exfoliation of white crusts." l 1 On Cutaneous Diseases, p. 263. 390 APHTHA. Some writers have classed them as pustules, others as ulcers, with- out investigating their seat. Bichat, with his usual acuteness, started the question as to whether they were an affection of the chorion of the mucous membrane, or of the papilla?, or of the follicles; a question which Gardien hesitated to answer, but upon which the researches of Billard have thrown much light. He regards the disease as an in- flammation of the muciparous follicles of the mucous membrane. In an early stage of the inflammation, " they appear on the internal sur- face of the lips and cheeks, on the pillars of the velum, and the palatine arch, and the inferior surface and lateral parts of the base of the tongue, under the form of small white points, sometimes exhibiting a colored spot in their centre, slightly prominent, and often surrounded by a slightly inflammatory circle." " The follicular points enlarge, preserving also their circular, primitive form, and from their central aperture there soon issues a white matter, which is at first compressed by the epithelium, but which escapes on that membrane becoming ul- cerated. The follicle, when ruptured, is no longer a prominence, but a superficial ulcer with rounded edges, sometimes sharply defined, more or less tumefied, and almost always surrounded by an inflamed circle of a fiery red. The border and centre of this slight ulcer often secrete a white, pultaceous matter, like a slight scab, which is separated and expelled with the saliva." *• The vesicular or pustular character of the aphtha?, then, appears to be owing to the limitation by the epithelium of the space occupied by the white matter issuing from the follicular orifice, and certainly the appearance is sufficiently exact to justify Bateman's description. The distinctive character, which is practically important, appears to be the small ulcer with its inflamed base. These aphtha? appear first on the edges of the tongue, the angles or inside of the lips, from whence they spread with more or less rapidity over the tongue and inside of the cheeks to the fauces; and, as they will be found in different stages, the mouth acquires the appearance of irregular, superficial ulceration, with white, cream-colored sloughs. 626. That the oesophagus, and even the stomach, may be thus affected, is admitted by most writers; but they are not agreed as to whether the disease may extend lower. Moss2 and Underwood3 notice the appearance of aphtha? at the anus, and assume this as a proof that the disease extends through the bowels; and Bateman mentions that such extension of the disease is supposed to take place, but very pro- perly observes that the redness and partial excoriation about the anus, so frequently observed in the complaint, may be owing to the acrid nature of the discharges from the bowels. Armstrong4 states that, from the oesophagus, "it is continued quite through the stomach and intestinal canal to the anus, at least it makes its appearance very plainly at this part." Marley observes: "I saw a case, some time since, where I had little doubt but that the disease 1 Mai. des Enfans, p. 209. 1 On the Management and Nursing of Children, p. 188. 3 Diseases of Children, p. 155. « Ibid., p. 24. APHTHA. 391 ran its course to the verge of the anus;"1 and Gardien mentions this extension as a fact well known. Dr. Bateman notices that the trachea is occasionally affected with aphtha?, but that they very rarely extend to the nose. When the aphtha? are numerous, and coalesce, covered by the white sloughs, they resemble and may be mistaken for muguet; but a little care will avoid this error, for in the latter no ulceration can be dis- covered, and it is plain enough in the former, notwithstanding the crusts; and, moreover, we shall be able in some part of the mouth to detect the enlarged follicle before exudation has taken place. 627. These small, aphthous ulcers may assume a more extended and formidable state of ulceration, and even become gangrenous ; but there is an appearance which has been mistaken for gangrene, against which we should be on our guard. Billard thus describes it: " Some- times, when the follicular points are ulcerated, the borders of the ulcers, instead of being covered with a slight creamy exudation, exhale a small quantity of blood, which concretes under the form of a slight brown scab, mistaken by some authors, as in malignant sore throat, for a gangrenous eschar." "Before pronouncing these eschars to be gangrenous, the nature and causes of the brown scabs covering the aphthous ulcerations should be examined with the greatest care. This mistake might produce very serious consequences, for we might be led to treat with stimulants and tonics a disease which it would be more rational to treat by simple antiphlogistic remedies."2 628. Causes.—We find the disease most common in pale, delicate, and unhealthy children, whose constitutions have been injured by neglect, bad food, vitiated air, want of cleanliness, and over-crowded habitations. It is not unfrequent with spoon-fed infants, and, as we might expect, it prevails very extensively in hospitals for children and foundling hospitals. Dr. Hamilton is of opinion that thrush is induced by " specific con- tagion," and Marley and others speak of the disease being excited in infants who had sucked from a breast previously used by a child so affected. It is said to have prevailed epidemically in some parts of Holland. But, though occasionally a primary affection, it is by far more fre- quently secondary to an affection of the alimentary canal, similar to that in muguet, or it is the result of deteriorated health and constitu- tion resulting from various diseases. 629. Prognosis.—From what has been said, it is pretty clear that, when aphtha? are a purely local complaint, occurring in a tolerably healthy subject, few in number and distinct, there is no danger to the child. With proper treatment, the white crust will fall off, and the little ulcer heal in a few days. This is not the case in the severe form of the disease. The child is in great danger from the suffering, the want of food, the vomiting, and diarrhoea; if these be not checked, it will run down rapidly beyond the 1 Diseases of Children, p. 52. » Mai. des Enfans, p. 211. 392 APHTHA. reach of assistance. Add to this the danger arising from the primary disease, or from subsequent complications, and it is evident that the case is a very serious one. The extension and coalescence of the aphtha?, the dark color of the crusts, the unhealthy appearance of the small ulcers, the emaciation, the small quick pulse, &c, are very unfavorable symptoms. 630. Treatment.—Dr. Bateman observes, very truly, that, " in the milder degrees of aphtha? lactantium, slight remedies are sufficient to alleviate or remove the disease. The acidity in the first passages is often readily corrected by some testaceous powder, which, if the bowels be not irritable, may be joined with a little rhubarb or magnesia, or by the pulv. contrayerva? co., if they are in the opposite state, and weakly. At the same time, the nutriment of the patient should be regulated by attending to the diet and general health of the nurse ; or, if the child be not suckled, by procuring a wet nurse, when that is practicable, which often speedily cures the complaint."1 If the surface of the mouth be very irritable and tender, the first local applications should be of a bland and soothing character: a little cream, or the yolk of eggs mixed with a little syrup of poppies, as recommended by Van Swieten; or the lips and tongue may be lightly covered with pure almond oil. By degrees, and in proportion to the decrease of the soreness, astring- ents may be applied, and of these perhaps the best is the borate of soda mixed with powdered sugar or honey. Dr. Armstrong speaks very highly of a " solution of white vitriol in barley-water," in the proportion of half a scruple of the former to eight ounces of the latter at first, and gradually increasing its strength. For very young infants, the juice of boiled turnips sweetened with sugar or honey. Ettmuller and Dr. Shaw advise honey of roses and spirit of vitriol or sea salt, but Underwood thinks no application superior to borax and honey. 631. In severe cases of the disease, the same astringents maybe used locally, or we may wash the mouth with a weak solution of the nitrate of silver, which I have found beneficial; but, unless we can change the state of the constitution, we shall do but little good. For this purpose, if the child be still at the breast, the nurse should be changed; or the food, if the child be weaned. In addition to milk, barley, bread jelly, or arrowroot, we may give wine whey or wine and milk pretty freely. For older children, we may order chicken broth. If the stomach do not reject medicine, we may prescribe the hyd. c. creta with rhubarb, if the bowels be costive; or with the pulv. creta? co. c. opio, if diarrhoea be present. A drop of laudanum in milk, once or twice a day, will often quiet the bowels when more bulky medicine only irritates. If there be much vomiting, it will be better to administer these or analogous medicines by the rectum, and employ the stomach for nutriment only. Dr. Armstrong and others recommend us to commence by an emetic followed by a brisk purgative, but this will entirely depend upon the ' On Cutaneous Diseases, p. 267. ULCERATED SORE MOUTH. 393 condition, of the child when we first see it. If the stomach be loaded and the bowels confined, it may do very well; but, in the majority of cases, especially if at all advanced, it would be somewhat hazardous. The following case, related by Marley,1 is a good illustration of the value of Dr. Armstrong's suggestion in certain cases : "It occurred in a child about two years and a half old. The aphtha? were, from the commencement, of a brownish hue, and, in the course of a day or two, became nearly black; the teeth were loaded with a brownish fur; there was a copious flow of saliva ; the breath was remarkably offensive, resembling much that of a person in a state of salivation; the pulse was of a quick and jerking nature; no appetite whatever; in fact, the mere appearance of food produced a sensation of nausea. There was universal lassitude. In this case, I commenced with a dose of castor oil, which was retained on the stomach and operated well. This was followed the next day by an emeticj which brought away an almost incredible quantity of bilious matter for so young a child, after which I treated the case with bark and ammonia. The only local applica- tion used was a lotion composed of decoction of bark and muriatic acid. The case got well." " When the aphtha? assume a brown hue, or appear in a state of debility consequent on acute diseases, the general strength must be supported by light tonics and cordials, with proper diet, such as a weak decoction of cinchona or cascarilla, or the solution of the tartrate of iron with rhubarb, light animal broths, and preparations of milk w7ith the vegetable starches."2 Dr. Hamilton very properly lays great stress upon cleanliness, ad- vising that the child should be washed all over, and a clean dress put on every twelve hours. If the anus should become excoriated, as often happens, it should be washed, four or five times a day, with w7arm water, and, after being dried, may be bathed with lead lotion or black wash, or pow'dered with lapis calaminaris, or anointed with zinc cream. CHAPTER VI. ULCERATED SORE MOUTH.--STOMATITE ULCERO-MEMBRANEUSE. 632. At first sight, there appears a similarity almost amounting to identity between this disease and aphtha?; but in the latter the disease is limited to the muciparous follicles, the ulceration commencing around their orifices ; in the former, the inflammation of the mucous membrane may run on into ulceration at any part, and in an irregular manner. Aphtha? occur also in young infants ; but Rilliet and Barthez have found ulcerated sore mouth more common after five years. 1 Diseases of Children, p. 53. 2 Bateman on Cutaneous Diseases, p. 268. 394 ULCERATED SORE MOUTH. 633. Symptoms. — According to M. Taupin,1 the disease com- mences in the gums, which are swollen, red, or violet, bleeding, and soon covered with a soft layer of grayish matter. From the gums, the inflammation and ulceration spread to the corresponding portion of the mucous membrane lining the mouth and lips, the small whitish spots by which it commences enlarge and coalesce, until they form the large gray patches covering the erosion or ulceration. Generally speaking, the lesion is of small extent, affecting the gums, and exhibiting a few patches inside the cheeks or lips, more frequently one side than both, according to M. Taupin, and oftener the left than the right, according to Rilliet and Barthez ; but in some rare cases it is much more extensive, involving the vault of the palate as well as the other parts of the mouth. If the treatment fail, and the inflammation persist, the patches increase in thickness by the secretion of additional layers, and the ulceration deepens; the layers of false membrane are detached and quickly renewed, and thus the disease is perpetuated. If, on the contrary, the inflammation diminish, the patches are thrown off, the ulcers become cleaner and fill up, and their raised borders subside. Then the epithelium is reformed, and there remains only a deeper redness, marking the situation of the ulceration.2 M. Taupin states that the mucous membrane in these places re- mains thickened and somewhat hard; but Rilliet and Barthez regard the submucous tissue as the seat of this thickening. The submaxillary glands are swollen, and, if the attack be severe, they become hard and painful ; but the surrounding cellular tissue does not participate in the inflammation. The breath is generally offensive; and, when the disease is extensive, the odor is not unlike, or much inferior to, what we observe in gangrene. In severe cases, we find, externally, considerable swelling, corre- sponding to the ulcerations, and when pressed it feels soft, quite unlike the hard, resisting, circumscribed swelling in gangrene; the skin is neither smooth, nor shining, nor hot. More or less salivation attends the complaint. If severe, the mouth is kept open, the lips protruding, and the saliva dribbling over the swollen and ulcerated surface. This appearance is very characteristic of the disease. 634. The suffering is very considerable ; the child is restless and uneasy, moaning, and putting its fingers to its mouth, and finding it more or less difficult to eat or drink. In severe cases, with infants, sucking is out of the question, and the child can only be nourished by the spoon. There is almost invariably some derangement of the stomach and bowels, often preceding, always following, the affection of the mouth. Occasionally, the symptoms of entero-colitis are very marked, and such complications, whether primary or secondary, not only augment the ' Journ. des Connois. Med.-Chir, No. 10, April, 1839. 3 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 262. ULCERATED SORE MOUTH. 395 distress and suffering of the patient, but materially influence his con- dition, and add to the danger. When the inflammation is moderate, the heat of skin will be natu- ral, and the pulse unaltered; but, when of considerable extent and intensity, we shall find more or less fever, with a quick and rather weak pulse, loss of appetite, disordered bowels, emaciation, &c. The disease may be prolonged for some time, although, generally speaking, it is not very tedious. Much will depend upon the consti- tutional condition of the child, upon the primary or secondary compli- cations, and upon the extent and depth of the ulcerations, the deeper ones requiring more time to fill up: moreover, the child is very liable to relapse. 635. Pathology.—The disease commences as stomatitis, as already described. The mucous membrane of the mouth is swollen, inflamed, and hot; sometimes of an equally diffused redness, sometimes in patches; the gums are also swollen, red, and spongy. After the in- flammation has continued for some time, we find a number of small whitish, or yellowish patches, slightly prominent. Beneath the epi- thelium, which is thicker than natural, we find these whitish points to consist of a pseudo-membranous secretion, similar to that found in the pustules of small-pox on the eighth or ninth day. This concretion is pretty firmly adherent to the subjacent parts, and covers a small ulcer with irregular borders, which bleed when touched, and of uncertain form, sometimes round, sometimes longitudinal.1 If the disease increase, this false membrane forms a yellow, broad, and thick layer, underneath which we find a co-extensive superficial erosion of the mucous membrane. This is the milder form of the complaint. If not checked, the ulcer- ation deepens, the edges are red, or of a violet color, and the surface covered with a reddish-gray layer. When the gums are mainly af- fected, they appear red or violet, swollen, softened, bleeding, and covered with a pultaceous secretion. The ulceration spreads trans- versely, and is rather narrow, and by the destruction of the gingival tissue, the teeth are loosened, and sometimes fall out. The ulcerations of the tongue and inside of the cheeks are of a rounded form ; those of the lips and their commissure are longitudinal, and spread rapidly. 636. Causes.—Although an infant may be the subject of ulcerated sore mouth, yet both M. Taupin and MM. Rilliet and Barthez state that they have found it more frequent in children from five to ten years of age than at any other period, and in boys than in girls. Like other kindred affections of the mouth, it may appear at the time, and connected with dentition, and it may be dependent upon a disordered state of the stomach and bowels, or a deteriorated consti- tution, which in children so certainly results from insufficient or im- proper food, want of cleanliness, vitiated air, damp or unwholesome dwellings, or the crowding together too many individuals in too small a space. 1 Taupin, Journ. des Connois. Med.-Chir., No. 10, April, 1839. 396 ULCERATED SORE MOUTH. It may also occur in the course of other acute or chronic disorders, as pneumonia, eruptive fevers, &c, which entail constitutional injury. It is endemic in certain wards of the Hopital des Enfans Trouves, according to M. Taupin, who also believes it to be contagious, i. e. to be communicable by using the same spoon for feeding, &c. And occasionally, also, it appears to prevail as an epidemic. 637. Treatment.—The first indication is to remove the predisposing and exciting causes, if possible. Thus, if the child be young, and have been spoon-fed, we ought to procure a wet-nurse for it, if it be not too old to suck; and if already weaned, the food should be changed. If it occur at the period of dentition, the gums should be freely scarified, and the child removed away from its companions to a dry, airy apart- ment, and kept scrupulously clean. Even if the teeth,are complete, we shall often derive benefit from slightly scarifying the gums ; or, if the inflammation be severe, apply- ing a leech or twro to other parts of the mouth. If this be not necessary, or, after it have been done, the mouth should be carefully washed by means of a syringe and warm water, or a piece of lint dipped in water, we shall then be able to judge accurately of the state and extent of the ulcerations. In slight cases, it will be sufficient to wash the mouth with emollient or mucilaginous, or slightly acidulated lotions, or to apply powdered sugar, or a weak mixture of borax, with honey or sugar. If these milder remedies fail, we may try M. Bonneau's plan, and apply the dry chloride of lime, or powdered alum. The end of the fin- ger, or the end of a small roll of linen, should be moistened and dipped in the powder, and gently rubbed over the ulcers twice a day, and this application must be continued until the surface is healthy, and begin- ning to heal. The mouth should be cleansed with a syringe and water, a few minutes after each application. In ordinary cases, I have found the borax and honey, in the usual proportions, answer the pur- pose exceedingly well. 638. But in very severe cases, before applying the borax and honey, or alum, it will be necessary to touch the surface of the ulcers with nitrate of silver, or even muriatic acid, or the acid nitrate of mercury, and, after the slough has separated, then to have recourse to the milder applications. It sometimes happens that a carious tooth, though it may not have originated the inflammation, will certainly augment and perpetuate it. In such cases, it will be advisable to have it removed, as a preliminary to other treatment. Very great attention must be paid to the state of the stomach and bowels. If disease exist there, it will be in vain that we treat the mouth judiciously if that be neglected. Purgative medicine may be necessary, or diarrhoea may require to be checked; and if there be evidences of more serious disturbance, for example, of entero-colitis, it must at once be treated in the way we shall mention hereafter. The same may be said of every other complication, whether primary or secondary. GANGRENE OF THE MOUTH. 397 The diet must depend a good deal upon the state of the constitu- tion. If the child be exhausted, or broken dowrn, broths may be given freely, and wine whey maybe necessary; but, if it be a local affection merely, and the child otherwise robust and healthy, moderate or even low diet will be advisable. CHAPTER VII. GANGRENE OF THE MOUTH.--CANCRUM ORIS.--STOMATITE GANGRENEUSE. 639. This very formidable disease has been noted more or less cursorily by the older writers: for instance, by Butter, in the sixteenth century; Van der Voorde, who called it waterkanker; Van Swieten, who gave it the name of gangrene; Boot, Berthe, Dease, &c.; but we are indebted for our more accurate knowledge of the disease to the researches of Baron, Isnard, Guersent, Constant, Taupin, Richter, Cuming, Duncan, Hueter, Rilliet and Barthez, &c. It has been described under various names, as water-canker, noma, gangrene of the mouth, cancrum oris, stomacace, necrosis infantilis, cancer agneux des enfans, &c. I have preferred the old appellation of cancrum oris, as involving no hypothesis. 640. Symptoms.—Mr. Cooper gives the following definition of the disease: "A deep, foul, irregular, fetid ulcer, with jagged edges, on the inside of the lips and cheeks, attended with a copious flow of offensive saliva. It is a perfect specimen of phagedenic ulceration, and in its worst forms not unlike hospital gangrene, as I have seen in several deplorable instances. It also resembles the ulceration and sloughing in the mouth produced by mercury."1 There appear to be several phases of the disease, differing in degree, if not more essentially. One variety is described by Dr. Cuming, of Armagh, as occurring in children between twenty months and seven years of age. "The ulceration commences generally in the gums, from whence it extends to the lips or cheeks. Sometimes it is of an acute, sometimes of a chronic nature, and as it approaches to one state or the other, it is more or less attended by sloughing. In the very wrorst cases, however, though the sloughing is considerable, the ulcer- ation is always predominant, and by its means the destruction of parts is principally effected. This form of the disease, which seems to answer to the affection described as cancrum oris by authors, bears a resemblance, in some respects, to the ulceration and inflammation of the mouth produced by mercury."2 ' Surgical Dictionary, p. 332. 3 Dublin Hospital Reports, vol. iv. p. 341. 398 GANGRENE OF THE MOUTH. Another variety has been described byRichter and others, in which we find spots of gangrene, limited in extent, at the angles of the lips, or upon the cheeks, occurring suddenly and with little general dis- turbance. In some instances, there is a red spot for a few days pre- ceding the gangrene. When the sloughs separate, we see that the gangrene was but superficial, there being very little loss of substance. Such cases are apt to occur after acute affections of the skin, as mea- sles, scarlatina, small-pox, &c, and generally heal without trouble. Dr. Marshall Hall has published six cases, in five of which, the disease commenced externally in the lip or cheek: " In one case, the patient did not survive the extreme irritation of the system in general which attends the commencement of this affection; in four others, life was prolonged until a considerable portion of the soft part of the face and mouth was destroyed by mortification, and the latter patients died from exhaustion. In a sixth, the patient survived the affection alto- gether, after experiencing an extensive sphacelation of each cheek, of a part of the tongue, and of the contiguous gums, and even of a por- tion of the jaw-bone." "In this disease, frequently, when the little patient has appeared to be convalescent from the previous indisposi- tion, some part of the face has been affected with pain, induration, swelling, and erythema, and the child has become cross, irritable, feverish, and restless. At no distant period, usually on the succeed- ing day, a dark purple or livid spot has appeared, which has soon assumed a dark brown color, losing its purple hue, and, at the same time, its vitality. W7hen the patient survives, the sphacelated part enlarges and becomes black, separated, loose, and extremely fetid; the living part retains an erythematous redness, bordered by a ring of a livid hue. The internal mouth is soon involved in the affection, the sphacelus spreading into this cavity; the teeth become loose and eventually fall out, and the breath is shockingly offensive. The child, from being restless, becomes more tranquil and patient; it seems fre- quently conscious of the disgusting appearance of the affection, and dislikes to be noticed ; but there is often eventually dozing or coma. In the latter stages, there is not much heat .of skin, but the pulse is frequent."1 My friend, Dr. Duncan, of this city, has more recently published a very interesting account of an epidemic of this disease which occurred in the North Union Workhouse:— " The age of the patients varied from about a year and a half to five years. I have no reason to believe it infectious; but, in more than one instance, it attacked a second member of the same family. Generally speaking, the attack was preceded, for some days, by diar- rhoea; but, from the period of life corresponding often with the occur- rence of dentition, this feature was not always sufficient to attract the attention of the mother, and little was done to arrest its progress till the condition of the mouth was observed. The children at first did not seem to suffer pain in the bowels, and would bear the usual pres- sure of manual examination without inconvenience. The alvine 1 Edinburgh Medical and Surgical Journal, vol. xv. pp. 547-8. GANGRENE OF THE MOUTH. 399 evacuations were usually unhealthy, but they differed in appearance in different cases. Sometimes, they were thin and watery, but not deficient in bile; more generally, they were whitish and exceedingly offensive; and, in almost all of them, blood was discharged, either in a fluid state, or mixed with a jelly-like mucus. When this diarrhoea had continued a week or ten days, the mother would mention that the child had a sore mouth, and, on examination, it would be found that the gums were ulcerated, and the fangs of the teeth exposed, and covered with a yellowish-white sordes. According as the disease ad- vanced, the gums lost their pale flesh color, and became red, swelled, and spongy, and the margins exhibited a tendency to bleed, both spontaneously and on being touched." " The breath gradually be- came offensive, and the secretion of the salivary glands increased, so that the saliva used, at times, to flow from the mouth, and even to wet the pillow on which the patient lay. Partly from the attending fever, but principally from the tender and inflamed state of the gums, the children were unable to take food ; but their thirst was often ex- cessive. In no instance did I observe the teeth to fall out, probably because, in fatal cases, death took place from the constitutional irri- tation running so high before the local affection had time to produce its legitimate effects." " At first, the disease did not appear urgent; but, as soon as ulceration of the gums took place, and especially if appropriate means to arrest its progress were not adopted, it advanced with considerable rapidity to a fatal termination. When this event occurred, it seemed due rather to the violence of the attending fever, or the intractable persistence of the diarrhoea, than to any peculiar changes effected in the condition of the mouth. In some of the cases, the disease seemed to be arrested for a time, the diarrhoea being com- pletely checked, the alvine evacuations improved, the appetite restored, and every symptom of permanent convalescence being visible, when, after a time, the former symptoms would return in a severer form, and, resisting all measures of a remedial nature, hurry the victim to the grave."1 641. In the severe form, the disease always commences in the mucous membrane, preceded by stomatitis, aphtha?, or ulceration of the gums, lips, or inside of the cheeks, and occasionally with slight oedema. This state may persist for several days, or gangrene may set in the first day. Then the bottom of the ulcer becomes covered with a layer of gray matter evidently gangrenous, and the subjacent tissues are swollen and hard. WThen this tumefaction takes place in the cheek, it may be felt like a kernel; and the skin outside is tense, shining, and white in the centre. From this moment, the ulcerations extend rapidly ; at first of a gray- ish color, they shortly become brown and black, covered with " pu- trilage," of a fetid odor, and bleeding when touched. The edges are sometimes regular, sometimes irregular, and raised or level according to the progress of the ulceration, which, in a few hours, changes their appearance. The portions of the mucous membrane of the mouth in 1 Dublin Journal, vol. xxviii. p. 3. 400 GANGRENE OF THE MOUTH. contact with the gangrenous spots become likewise affected, and run the same destructive course. In all directions, the disease extends fearfully, laying bare and destroying the bones. In a short time, a livid spot is perceived in the cheek, in the centre of the kernel just mentioned ; this spot is surrounded by an inflamed base, and is soon perforated by ulceration, which from thence spreads rapidly, and in some cases destroys the entire cheek. The gums struck by gangrene are destroyed, leaving the teeth bare and loose; the bones of the jaws are affected with necrosis, and exfoliate if life be sufficiently prolonged. "The parts," says Mr. Dease, "were con- tinually soaked in a cold, putrid, offensive ichor, until often the whole side of the face was eat away, particularly the lips, so that the jaw- bone and inside of the mouth were exposed to view." "In this situation, I have known children to live until the entire jaw-bone had fallen down on the breast, and the whole side of the face become a mass of putrefaction."1 642. As already stated, the primary disease of the mouth is inflam- mation and ulceration, upon which gangrene supervenes, and the early symptoms are those I mentioned when describing that form of disease. The superaddition of gangrene appears in some cases to give rise to but little constitutional disturbance, and the child presents the same general aspect as formerly. In other cases, the child, already weakened by previous disease, is cross, feverish, and restless, with a quick pulse and hot skin, suffering much pain from the mouth, until the gangrene is completely esta- blished. Then the fever seems to subside; for, although the pulse remains very quick, the skin is cooler, the restlessness diminished, and the aspect more calm. The face is of a dull pale color, and has, if I may so speak, a dead look about it. The eyelids are not unfre- quently swollen, the nares encrusted, and the ala? nasi dilated in respiration. The lips are swollen, and frequently exhibit their share in the mischief going on. Altogether, the face has a singularly de- pressed and sorrowful, though tranquil, expression. The saliva is secreted abundantly, and escapes from the mouth, owing to the pain and difficulty of closing the mouth. At first, it is the ordinary secretion in excess, and perhaps tinged with blood, but afterwards, it becomes brown or black, mixed with gangrenous de- tritus. The breath is extremely offensive from the beginning; but, when gangrene is established, both the saliva and breath exhibit the charac- teristic fetid odor. The tongue is moist, sometimes yellowish or loaded, and occasion- ally exhibiting the color of the gangrenous spots. The thirst is in- tense, vomiting rarely occurs, and the appetite is not so completely destroyed as we might expect; in fact, when it does fail, it seems rather owing to the complications than to the disease of the mouth. The bowels are almost always deranged; diarrhoea is generally pre- 1 Observations on Midwifery, &c, p. 126. GANGRENE OF THE MOUTH. 401 sent; sometimes griping, with watery stools of a greenish or yellowish color. In a considerable number of cases, the intestinal disorder seems to have preceded the gangrene, and to have constituted the primary affection. The strength of the child is greatly reduced ; it is emaciated, weak, and helpless. 643. It has already been stated that gangrene may attack the ulcers on the first day; more generally, however, we find it set in from the third to the sixth day, and from that time the disease spreads, until, after more or less destruction of the tissues, it proves fatal at a period varying from five to eighteen days. During this time nothing can be conceived more distressing than the condition of the poor child, or more heart-rending than its appearance. As may be supposed, the great majority of cases terminate fatally, but some few cases do recover; mainly, those in whom the disease is primary, the constitution good, and which remain free from complica- tions. The improvement may take place before the gangrene has spread deeply, and then the mortified portion is cast off, leaving a grayish but more healthy ulcer ; the swelling of the surrounding parts dimin- ishes, and the constitutional symptoms improve. At a later period, should a favorable change occur, the entire gangrenous portion, both the mucous membrane and the cutaneous eschar, will be thrown off, leaving a granulating surface with healthy suppuration; the dead bone will exfoliate, and the wround gradually fill up and contract. Some writers have stated that the form of cancrum oris, which commences externally on the cheek, is more under the control of remedies than the other forms ; and Dr. Condie considers that the disease is less frequent in America than in Europe, and more manage- able. 644. The disease may be primary or secondary, as I have said; but it is not always easy to decide whether the complications have preceded the disease or followed it, so little attention* has been paid to them comparatively. We know that intestinal disorder is a frequent concomitant; it will certainly arise in the course of the disease; but it appears probable that in some cases the gangrene itself is rather a complication sympto- matic of the state of the gastro-intestinal mucous membrane. Another very frequent and very important complication is pneu- monia ; it occurred in eighteen out of twenty of Rilliet and Barthez's cases, and will require our most careful attention if we hope for success in our treatment. Whether primary or secondary is com- paratively of little consequence; it is in itself so serious that it must necessarily exercise a predominant influence both upon the course of the disease and of the treatment; for if the gangrene were cured, the patient would incur nearly equal risk from the pneumonia, in his exhausted condition. 645. Pathology.—MM. Rilliet and Barthez have given a minute analysis of the pathological changes in the different structures, effected 26 402 GANGRENE OF THE MOUTH. by the gangrene, drawn from the post-mortem examinations of twrenty- one cases they witnessed. I shall venture to give a short abstract of their record.1 After death, the portions of the skin surrounding the gangrene ra- pidly putrefy, and the cheek or the lip is swollen, purplish or greenish, tense and shining, hard to the touch, and exhibiting a profound cir- cumscribed tumefaction. At the most prominent point we find an eschar, either well-defined, round, or oval, and of a moderate size; or it may be large and irregular, extending in different directions towards the nose, eyes, and ears, even in some cases occupying nearly the entire face. In the latter case, the tumefaction is less, and not circumscribed. The depth of the eschar varies. The mucous membrane was always affected, sometimes in a limited and regular manner, and sometimes irregularly, and more exten- sively. The surface was reduced to a semi-fluid "putrilage," of a gray, brown, or black color, removable with the scalpel, and beneath which loose shreds of the mucous membranes were perceived. The gums shared in the destruction. When the gums were thus destroy- ed, the bones were exposed and became black, sometimes affected by necrosis, and exfoliated. This destruction was commensurate with the extent of the gangrene of the mucous membrane. The teeth, denuded and deprived of their support, became loose, and were easily detached, often falling out of themselves. The intermediate tissues were congested, and participated more or less in the gangrenous affection. In the milder cases, the adipose tissue was infiltrated with serosity, as were also the muscles; and such of these parts as were not actually touched by the gangrene, were distinctly recognizable. But as the disease advances, or in more severe cases, mortification attacks these tissues, especially those nearest the mucous membrane; so that the brown putrefied layer is of considerable thickness (five to eight millimetres), beneath which we find the adipose tissue, and the muscles, infiltrated with serous fluid, losingtheir distinctive organization, andbecominghomogeneous; whilst nearer the skin there is a layer of cellular tissue, hardened and infil- trated, but not mortified. It was rare to find the entire thickness of the cheek affected by gangrene. 646. The condition of the vessels and nerves has always appeared doubtful. In one case, examined by M. Billard, he found " nothing remarkable." M. Taupin states that he often sought for them, but always found them confounded with the other tissues, and impossible to distinguish from the soft gangrenous mass.2 MM. Rilliet and Barthez give the following results of their investi- gation : " In six cases, we made a long and minute dissection; and we found that when the vessels passed into a portion of tissue, infiltrated, but not affected with gangrene, they were perfectly healthy, permeable, and their coats scarcely thickened; that when they touched upon a 1 Mai. des Enfans, vol. ii. p. 129, et seq. 3 Journal des Connois. Med.-Chirurg., April, 1830, p. 140. GANGRENE OF THE MOUTH. 403 gangrenous part, they were still permeable, but their parietes were thickened, and had somewhat the aspect of the gangrenous portion. Lastly, when they traversed a gangrenous portion, it was still pos- sible to trace them through it, but that the entire extent of the vessel, as it traversed the mortified part, was closed from one side to the other, either by a small clot at either extremity, or by a larger one filling it throughout." Thus the artery was completely obliterated in three cases, and in as many the vein was filled with "liquid putril- age." The coats of both were thicker and softer than natural. Once only the nerves were examined: externally, they appeared like the surrounding tissue; their neurilemma was gangrenous, but the pulp was sound in color and consistence, and appeared to have resist- ed the gangrene. The following details show the comparative frequency of the seat of the disease in twenty-nine cases. The left cheek (externally or internally) w*as affected in 11 cases. The right cheek......10 " The lower lip ...... 4 " The lower lip and right cheek .... 1 case. The upperjip and right cheek .... 1 " The left cheek, the angle of reflection of the mucous membrane, and right cheek .... 1 " The lower lip, extending to both cheeks and upper lip, on both sides . . ... . 1 " 647. So much for the condition of the parts involved in the gan- grene ; but the post-mortem examination revealed other lesions con- nected with this disease, either as primary or secondary complica- tions, and which are of vital importance. The principal coincident disease was pneumonia, and the following summary exhibits the cha- racter and seat of this disease, and of the gangrene, in the same cases. ' Of these, gangrene of the right cheek in......1 Double gangrene, but especially l of the left cheek, in ... 1 Gangrene of the lower lip in . 1 Gangrene of the lower lip and right cheek in .... 1 •Double lobular pneumonia, es- "] pecially on the right side I Gangrene of left cheek in . 3 (with carnification in two j Gangrene of lower lip in . . 2 cases) in......5 J Double lobular pneumonia, es- J Gangrene of right cheek in . 3 pecially on the left side, in 6 t Gangrene of left cheek in . . 3 Lobar pneumonia of right lung ( Gangrene of upper and lower in........1\ lip in.......1 Lobar pneumonia of left lung } Ga ene of left cheek in . . i in........1 ) Carnification of left lung in . 1 Gangrene of right cheek in . 1 Out of HO cases there was found double lobular pneumonia in 4 404 GANGRENE OF THE MOUTH. f . 9 a 3) . iim . 4 it • . . 1 case. . . 1 a , . 1 a . 1 a . 1 a . 2 cases. oid, . 1 case. . . *2 cases. No pneumonia in . . . . 2 j Gangrene of right cheek in . 1 r ( trangrene of left cheek1 in . . 1 Thus, pneumonia (lobular or lobar) existed in eighteen out of twenty cases, and occasionally, though rarely, of the same side as the gan- grene. This accords with the experience of MM. Baudelocque and Taupin. In eight of these eighteen cases, the pneumonia was secondary, having supervened in the course of the gangrene. Other lesions, howrever, were discovered ; as, for example :— Entero-colitis, or softening of the intestine, in . 14 cases. Tubercles, Gangrene of the lung, Gangrene of the pharynx, Pleurisy, Pneumothorax, Peritonitis, Pharyngitis, . Nephritis, Infiltration of the pia mater, Hemorrhage into the arachnoid, Rachitism, At first sight, it might be supposed that the gangrene resulted from the obliteration of the artery ; but this is not borne out by the fact that, so long as the mucous membrane is alone affected, the vessel is quite pervious ; its obliteration must therefore be the effect, not the cause, of the gangrene. Dr. Condie states that, in the examinations he made, "the principal organs in which morbid appearances were present, were the stomach, intestines, and liver. In all the cases, the two former presented the indications of inflammation of a more or less chronic character; the latter appeared to be affected with hyperemia, rather than any struc- tural change. In the majority of cases, the mesenteric glands were greatly enlarged." " In the examination made at the Children's Asylum, between June 1, 1827, and January 1, 1830, the morbid appearances exhib- ited, were: enlargement and hardening of the mesenteric glands; a scrofulous condition of the glands of the neck; and, in some in- stances, tubercles of the lungs. In general, the whole substance of the lung was thickly studded with tubercles in various stages of in- flammation and suppuration. The condition of the gastro-intestinal mucous membrane is not recorded."2 In all the cases examined by Dr. Duncan, he found, "either decided ulceration of the intestinal mucous membrane, or enlargement and increased development of the follicular glands. In one case, the whole colon was an immense sheet of minute, circular, and deep ulcers ; while the portion of mucous membrane wdiich intervened was of a bright crimson hue."3 1 Mai. des Enfans, vol. ii. p. 135. 3Dublin Journal, vol. xxviii. p. 18. 2 Diseases of Children, p. 145. GANGRENE OF THE MOUTH. 405 648. Causes.—Cancrum oris is almost confined to infancy and early childhood. Of twenty-nine cases recorded by Rilliet and Bar- thez, nineteen were from two to five years old, and the remainder from six to fifteen. Of Dr. West's six cases, two were between two and three years old; one, three ; one between four and five ; one at six and a quarter; and one at eight years old. It does not appear, however, as was thought by Dr. M. Hall, to affect female more than male children. " The worst species of the complaint that I have happened to see," observes Dr. Underwood, "has been during the second period of den- tition, when the child has been shedding a number of teeth together, leaving the rotten stumps behind, which have been neglected to be drawn out. The whole gums will then sometimes be spongy, or dis- solve into foul-spreading ulcers."1 As might be expected, we meet the disease most frequently among the poor, and for obvious reasons. Their children are badly nou- rished, living in foul air, and crowded rooms, surrounded by, and participating in all kinds of uncleanness. Add to these exciting causes, a delicate constitution and lymphatic temperament, and we seem to have all the elements for the production of the complaint. Probably, for the same reasons, it appears endemic in crowded hospitals for children ; as, for instance, in the Children's Hospital at Philadelphia, where, out of 240 children, seventy were at one time affected with the disease; and in other hospitals also. Certain localities, likewise, seem peculiarly favorable to it. It is said to prevail on the coast of Holland, Sweden, and Denmark. According to the testimony of Thomassen and Thyssen, it prevailed epidemically in the Netherlands, as a consequence of gastric fever; and also, in 1838, in the Philadelphia Almshouse. I believe that few, if any authors maintain that gangrene of the mouth is contagious, although they prudently advise the separation of the healthy from those who are so affected. 649. We have already noticed certain complications of the disease, which may be primary or secondary; we must, however, inquire a little further as to those diseases in the course of which cancrum oris has been found to occur most frequently. This point is one of great importance, because, in the majority of cases, it is a secondary disease; in some, solely dependent upon another preceding it, or upon the state of the constitution induced by the latter. M. Barron observes that " it is never a primary affection, but ap- pears in children enfeebled by previous disease."2 Mr. Dease remarks that, in all the cases he had seen, the children " had a pale, bloated, sickly look, large belly," &c. Dr. Huxham, in his report for 1745, mentions, " I have more than once during this month witnessed a mortification of the mouth and fauces, and besides, a caries of the cheek and os vomeris, which occa- sioned a very painful kind of death, and that too, after measles." 1 Diseases of Children, p. 487. 3 Bull, de la Faculte de Med., 1816, vol. v. p. 158. 406 GANGRENE OF THE MOUTH. Dr. Willan refers to a gangrenous eschar of the cheek, occurring in a case of scarlatina. Dr. Marshall Hall states that, "in all the cases which have come to his knowledge, this affection had been preceded by fever, acute disorder of the digestive organs, inflammation of the lungs, variola, rubeola, or scarlatina. This affection would, therefore, appear to be in some measure the consequence of the exhaustion, debility, or irritation induced by previous disease."1 Dr. Cuming advances a similar opinion: "In every instance of this affection that I have met with, the constitution had been much de- bilitated by the existence of previous and long-subsisting disease. In two cases that fell under ray observation, the disease occurred as a sequela of measles; in another, in the advanced stage of dysentery; in a fourth, upon the termination of infantile remittent fever ; but it is more generally observed at the close of the exanthemata, than at that of any other of the acute affections to which children are liable."2 In M. Poupail's seventy-two cases, the affection followed an attack of intermittent or remittent fever; in nine of Dr. Jackson's cases, it accompanied or followed an attack of bilious or remittent fever. MM. Rilliet and Barthez agree completely with the opinion of M. Baron, already quoted : " The disease, in the course of which we have most frequently known gangrene of the mouth to occur, is measles. We have occasionally observed it in scarlatina, small-pox, and pneu- monia. We have also known it follow intestinal affections, hooping- cough, scrofula, &c." And they give the following summary of the primary diseases on which gangrene supervened:— On measles in Small-pox and measles, Scarlatina, Scarlatina and small-pox, (Supposed) cholera, . Pneumonia, primary and secondary, . Pertussis, with or without complication, Enteritis (chronic) and complications, Peritonitis and softening of the intestines, - Scrofula, ...... Intermittent fever, .... Enteritis (acute), .... Gibbosity, &c, ..... General tuberculization In Dr. Duncan's cases, the primary disease appears to have been generally an affection of the intestinal canal, although several of the cases occurred after measles. "Of the six cases which I have observed," says Dr. West, "and three of which I examined after death, two succeeded to typhus fever, two to measles, one came on in a child whose health had been com- pletely broken down by ague, and one supervened in a tuberculous 1 Edin. Med. and Surg. Journal, vol. xv. p. 548. 3 Dublin Hospital Reports, vol. iv. p. 232. ' . 12 cases. . 1 case. . 1 a . 1 a . 1 a . 2 cases. . 3 a . 1 case. . 1 a . 1 a . 1 a . 1 a . 1 (< . 1 u GANGRENE OF THE MOUTH. 407 child, who had been affected for many weeks with ulcerative stoma- titis in a severe form."1 We have already seen that, in ten cases out of eighteen, the pneu- monia preceded the gangrene ; so that the latter disease may sometimes be primary, and sometimes secondary, to the pulmonary affection. Nor can we, I think, doubt that there may be an intimate relation between scrofulous tubercle of the lungs and cancrum oris. Thus we find that the diseases which are most frequently attended by gangrene of the mouth are eruptive fevers; as measles, scarlatina, small-pox, &c.; intermittent and remittent fever; pneumonia, dis- orders of the intestinal canal, tubercles, and scrofula ; while, on the other hand, pneumonia and entero-colitis are those which most fre- quently supervene in the course of cancrum oris. By several writers, we find the resemblance between gangrene of the mouth and mercurial ulceration pointed out; and it has been sug- gested by Bretonneau, Hueter, and others, that true gangrene may follow the excessive use of mercury when the mouth is inflamed. 650. Diagnosis.—The only disease with which cancrum oris is likely to be confounded is the one last described, viz., ulcerated sore mouth. Both commence by ulceration, and in both we find salivation and a fetid odor; but in gangrene, the ulcer is covered by a putrid i layer, which soon becomes dark-colored; the ulceration extends more rapidly and further; there is more swelling, often an eschar on the lips or cheek, denudation of the teeth and jaw, and ultimately per- foration and destruction of the cheek. In ulcerated sore mouth, none of these latter characteristics occur. 651. Prognosis.—The prognosis is exceedingly unfavorable; very few cases, indeed, recover; and even when the gangrene appears checked, the child has to contend against very serious complications. Twenty out of twTenty-one of Rilliet and Barthez's cases died, and five out of six of Dr. West's. Still, as some have recovered, it is always our duty to use every remedy against the local disease, with- out overlooking any primary or secondary affection which may exist. 652. Treatment.—There are four indications to be fulfilled in our treatment of the disease: 1. To limit the gangrene, change the cha- racter of the surface, and remove the fetor of the discharges; 2. To invigorate the constitution of the patient; 3. To favor the separation of the eschar; and, 4. To remedy the complications either primary or secondary. 653. The first indication is most likely to be attained by the appli- cation of powerful caustics; weak ones are of no use. Moreover, merely to touch the gangrenous surface will have no effect; to suc- ceed, the caustic must reach the healthy tissue. Therefore, the layer of gangrenous matter must first be removed, or, if the situation per- mit, the gangrenous surface may be cut away, and then the caustic applied carefully and liberally once or twice a day. Various caustics have been tried, and some with success. Klatoch ■ Diseases of Infancy and Childhood, p. 356. 408 GANGRENE OF THE MOUTH. cured one case with pyroligneous acid; Hueter with acetic acid; Con- stant, by the acid nitrate of mercury; Baron, by the actual cautery; and Rilliet and Barthez by nitrate of silver and chloride of lime. M. Baron advises that muriatic acid be applied to the gangrenous spots in the mucous membrane at the commencement, and that, when the external eschar falls, we should apply the actual cautery; or, what is still better, that the eschar should be incised crucially, and then the cautery applied. Successful cases, thus treated, have recently been published by an American writer, Mr. Obree. Sulphuric acid has been successful in the hands of Bruineman and Courcelles. Mr. Dease speaks highly of the spirit of sea salt (muri- atic acid), which was used with benefit by Van Swieten previously. "I began," he says, "at first, to give it in decoction of bark, or infu- sion of chamomile flow7ers, but I could not get children to take it for a continuance, or in such manner as to give it a fair trial. I there- fore gave it in an infusion of red roses, which was strongly acidulated with it; this they took without reluctance. At the same time, I had the gangrene frequently washed with a decoction of chamomile acidu- lated with the spirit of sea salt; and when the gangrene was con- siderable, and the discharge large, dashing the parts with the decoc- tion, by means of a syringe, will more effectually wash away the sanies. After this was done, I ordered it to be dressed with the honey of roses and spirit of sea salt; and, over all, the carrot poultice to be applied. The child, at the same time, should be well supplied with broth, jelly, &c, and allowed wine liberally; good claret will answer best."1 Mr. Cooper prefers the strong nitric acid, with the internal exhi- bition of sulphate of quinine and dilute sulphuric acid. Mr. Pearson extracted the diseased teeth, and some pieces of bone, and directed a milk and vegetable diet, with bark, sarsaparilla, and elm bark. Locally, he preferred the dilute mineral acids, burned alum, decoction of bark with sulphate of zinc, tincture of myrrh, &c. In addition to the stronger caustics, or in the intervals of using them, M. Baron recommends external and internal applications of camphor and quinine. M. Billard advises frictions, either dry or aromatic, when the oedema appears; and as soon as the kernel is felt, the use of ammoniacal lini- ment, or a lotion of the hydrochlorate of ammonia. Richter and Rey derived benefit from the use of the chloride of the oxide of sodium. Dr..Condie found a strong solution of copper or zinc, applied twice a day, very beneficial; and in the Children's Hos- pital, Philadelphia, nitrate of silver v.Tas the only local remedy em- ployed, and the majority recovered. Creasote was very useful in the Philadelphia Almshouse, applied after incisions had first been made through the gangrenous sloughs. After each application of the caustic, for the purpose of separating the sloughs, the chloride of lime may be applied, in order to destroy the odor, and it also acts as a stimulant. 1 Observations on Midwifery, &c, p. 128. GANGRENE OF THE MOUTH. 409 The mouth should be syringed freely and frequently, and the parts kept dry and clean. When an eschar appears, a conical incision should be made, and the caustic applied and repeated every day until after the eschar separates. Rilliet and Barthez advise that the incision should also be filled with quinine. I need not say that, if there be carious teeth or loose portions of bone, they should be removed, as they wdll keep up an unfavorable irritation. 654. For the purpose of invigorating the constitution, it will be necessary to administer tonics as liberally as the condition of the digestive system will admit. Bark may be given in form of infusion, decoction, or syrup, or we may prefer the sulphate of quinine from its smaller bulk; beginning with half a grain, we may increase it to twToor three grains three times a day. Dr. Cuming says: "In a few instances in which the disease had made considerable progress, I have known recovery to take place under the administration of the sulphate of quinine and carbonate of ammonia; but in none of these cases had the ulceration extended so far as to involve the outside of the lips and cheeks. I have seen that Mr. Dease advises the internal exhibition of muriatic acid; and whether we give mineral or vegetable tonics, they must be assisted by the liberal use of wine. We cannot, of course, state the exact amount; but there need be no hesitation in giving as much as the constitution of the child will bear, according to its age, and with reference to the complications." Dr. Duncan found great benefit from the hyd. c. creta, with Dover's powder, and, although not at the same time, from acidulated decoc- tion of bark, or infusion of calumba with nitric acid. In addition, he derived the greatest good from counter-irritation to the abdominal sur- face. His principal efforts were naturally directed to the causes of the intestinal disease. The diet should be very nutritious—broths, jellies, minced meat, &c.—just as much and of the kind the child can best take. It will be necessary, however, to keep a constant check upon the tendency to diarrhoea, by chalk mixture with opium, or opium com- bined with the quinine or ammonia; or a drop of laudanum may be given once, twice, or thrice a day in milk. The child should be kept in a large, well warmed, and well venti- lated apartment; but, in our anxiety for pure air, we must beware of draughts of cold, remembering the liability to pneumonia in this disease. The most scrupulous cleanliness, both local and general, should be observed. I must repeat that the most anxious care and watchfulness of the physician should be directed to the complications. Knowing that in- flammation of the lungs so frequently occurs (whether primary or se- condary) in connection with cancrum oris, we ought daily to ascertain the condition of these organs, that, by detecting the earliest incursion of 410 TONSILLITIS. the disease, we may the more effectually apply the remedy1 The same may be said of entero-colitis, which also complicates this disease. For the suitable method of treating these diseases, I must refer the reader to the chapters relating to them. CHAPTER VIII. TONSILLITIS.--CYNANCHE TONSILLARIS.--QUINSY.--PHARYNGITE ERYTHEMATEUSE. 655. This disease, which consists of inflammation of those masses of mucous follicles called the tonsils or amygdala?, and of the neighbor- ing mucous membrane, is sufficiently common in children of all ages and constitutions; and, because it is painful and subject to ocular in- vestigation, has been noticed by almost all writers from Hippocrates to the present time. It is seldom so severe and acute in children as in adults, but is much more liable to take on a subacute form, enlarging these organs, con- tinuing for a considerable period, altering more or less the tone of voice, and impeding deglutition, hearing, and occasionally the breathing. 656. Symptoms.—Generally speaking, the complaint commences with the symptoms of a cold; the child is chilly, creeping to the fire, or it has regular rigors followed by fever; it is uneasy, distressed, and cross, with a huskiness of voice and a sense of roughness in the throat, which is shortly changed for soreness and pain, especially in attempt- ing to swallow. ■ Sometimes, however, as Dewees has observed, it appears to be a purely local affection, without fever or any constitutional disturbance.1 In the other cases, the fever continues to increase for a time; the skin is hot and florid; the face flushed and puffed ; the pulse rapid and full; the tongue loaded and white, with red papilla? appearing through the white coating. The thirst is great, but there are great pain and difficulty in swallowing fluids especially. Upon examining the throat, to which we are led at once by the complaints of the child, we find one or both tonsils enlarged, of a bright or deep red color.; the uvula, velum, palate, and pharynx red, swollen, and oedematous, but generally more painful on one side than the other, and on the surface we find more or less of thick, viscid, mu- cous secretion. In some cases, patches of coagulable lymph may be observed on the tonsils, giving the appearance of small sloughs. The extent of the swelling varies according to the intensity of the attack. In severe cases, the tonsils are so much enlarged that they almost close the pharynx, and protrude the swollen uvula forwards; ' Diseases of Children, p. 448. TONSILLITIS. 411 and not only so, but the deeper tissues appear involved, so that the neck appears enlarged, and, from the interruption to the circulation, gives to the face and neck a flushed or congested look. Beneath the angle of the jaw, the tonsils may be felt enlarged, hard, and painful, and the carotids are seen beating strongly. The child complains of soreness of the throat, and is continually' attempting to detach and expectorate the viscid mucus. Swallowing is very painful, but with soft solids less than with fluids; more so with the saliva than anything else, because of the increased muscular effort required, and the consequent pressure upon the inflamed parts. There are darting pains from the fauces to the ears, frequently some degree of nausea; and, in a few cases, we find respiration impeded; but this, I am convinced, is rare ; the rapid and hurried breathing being ordinarily owing to the fever. The fever may run very high, and delirium be an attendant upon the disease. This description, however, is rather of a very severe case than of the form ordinarily observed, which is marked by fever, soreness of throat, dysphagia, and inflammation of the tonsils, neither extremely distress- ing nor very persistent under ordinary management. 657. After a duration varying from a day to ten days or a fort- night, the attack may terminate in either of three ways :— i. In the great majority of cases, it terminates in resolution, by the gradual subsidence of the fever, the diminution of the inflammation, and the reduction of the swelling; after which, there remains a re- markable degree of weakness and lassitude. n. In those cases where the inflammation is subacute, or in those where the inflammation, at first acute, subsides only to a certain point, we have less fever and less suffering; but the disease does not subside so frankly as in the others. The fever and distress may disappear, but the swelling of the tonsils does not; they remain enlarged, as it were hypertrophied, for a long time, or permanently, in lymphatic or scrofulous children : they feel soft, but of tw7o or three times their natural size. There is no pain, but some difficulty in swallowing; and in all cases an alteration in the voice, similar to what is popu- larly called " speaking through the nose." Children, in whom the tonsils are thus left, are very liable to a re- turn of the inflammation on catching the slightest cold. in. Tonsillitis very commonly terminates in suppuration, though not quite so frequently as in adults. After reaching the maximum of intensity, the inflammation seems to subside, but not the swelling; there is less pain, but the mechanical obstacle to deglutition remains; the patient is wearied, exhausted, and almost worn out by suffering and want of food. At length, the tissues having been thinned, the abscess points and breaks, and the patient obtains complete relief. Generally, the abscess bursts internally; but cases are on record of its opening, or being opened externally below the angle of the jaw. The quantity of matter is never considerable; and, in some cases, 412 TONSILLITIS. we may fail in detecting any, from its being swallowed, and can only satisfy ourselves of its escape by the sudden relief of the distress. 658. Causes.—The ordinary cause of tonsillitis is cold, and we find the disease most prevalent in low, damp, and cold situations; and at those times and seasons when the weather is most changeable. A second attack of the disease is more easily incurred, and excited by slighter causes than the first. In some children, with enlarged and tender tonsils, I have observed them affected by atmospheric changes, without apparently having taken cold. 659. Diagnosis.—When very severe, the disease has some resem- blance to mumps ; but, in the latter, the pain and swelling are chiefly in the parotid gland, and extend from the angle of the jaw to the ear, and there is no inflammation of the tonsils, or redness of the neigh- boring parts. 660. Treatment.—If we see the child immediately after the com- mencement of the attack, it is possible occasionally to cut it short by a stimulating gargle, or by strong counter-irritants externally. If these fail, or if we are not called sufficiently early, yet, if the attack be mild, it will be easily subdued by gentle antiphlogistic mea- sures. A brisk purgative, followed by sudorifics, fomentations, or poul- tices ; warm pediluvia, with low diet for a few days, will generally afford relief. When the inflammation is considerable, and the fever high, we must have recourse to more decided measures. Topical bleeding, either by leeches to the neck, or scarifying the tonsils, will be neces- sary. The former, I think, are generally preferable, although Kopp speaks of the latter as the most prompt and efficacious remedy we possess. Occasionally, but rarely, it may be advisable to take blood from the arm in older children. After the leeches fall off, or when the bleeding has stopped, the most comfortable application is a light, warm poultice, frequently renewed. Great relief may also be obtained by inhaling the vapor of warm water; but this should be always done from the mouth of a jug, and never from the spout of a tea-pot, with children, on account of the danger of closing the lips, and drawing up the water. Internally, after freeing the bowrels well, we may give minute doses of tartar emetic, not so as to excite vomiting, unless the viscid mucus be very troublesome; but just so much as to lower the fever, and excite the action of the skin. Loeffler, and other continental physicians, speak very highly of the hydrochlorate of ammonia in tonsillitis. Dr. Condie states that he has derived very great advantage from it. He combines it with ipecacu- anha and calomel, so as to give three or four grains of it every three hours. 661. There are two other remedies generally used, but often with- out sufficient discrimination, and about which opinions have varied ; I mean gargles and blisters. At the commencement of the attack, stimulating gargles may be useful; but afterwards, I quite agree with Dewees that either stimu- TONSILLITIS. 413 lating or astringent gargles are rather injurious until the decline of the disease. During its height, warm water is the best gargle, or, if the viscid mucus be very troublesome, we may adopt Eberle's plan of using warm water slightly acidulated with vinegar. When the inflammation and fever are subsiding, we may use either acid or astringent gargles with benefit, or we may try the vapor of vinegar and water, as recommended by Hippocrates, or other medicated vapors. The same rule holds good with regard to blisters. During the in- crease and height of the disease, soothing applications externally are advisable; liniments, blisters, &c. seem to do harm; but, after the acute stage has somewhat passed, much benefit will be derived from stimulating liniments, mustard and meal poultices, or turpentine. I do not like blistering the throat of young children, if it can be avoided, as the surface is very apt to remain very sore, or perhaps to ulcerate. 662. When suppuration seems determined upon, we ought to encou- rage it by poultices, inhalation of aqueous vapor, gargles of warm water, &c. If there be much delay before the abscess opens, and if the patient be much exhausted, or if the swelling should be so great as to inter- fere with the breathing, it will be better to make an opening with a bistoury, taking great care that no movements of the child give rise to mischief. Dr. Mason Good mentions that, in some cases, tracheotomy has been found necessary; but such cases must be very rare indeed. The diet should be low until the disease subsides, and then the child must be nourished by broths, jellies, or meat, according to its age, and power of swallowing. 663. Dr. Dewees observes: "As regards the erysipelatous species of the disease, the treatment is somewhat different. We rely more on topical bleeding and the vesicatory applications; and, when aphtha? or sloughs appear, on stimulating gargles; and, in the event of extreme debility supervening, the system is to be supported by bark, wine, the carbonate of ammonia, and whatever else enters into the treatment of putrid sore throat."1 When the tonsils remain permanently enlarged, we must make some efforts to reduce them, not only on account of the liability to repeated attacks of inflammation, but because they involve a disagreeable change of voice, and discomfort in swallowing. Dr. Condie advises the repeated application of nitrate of silver; others, repeated small blisters externally; others, their removal by operation. Professor Hess, of Copenhagen, states that he has employed compression, by means of the index finger applied to the indurated tonsil, with success. This to be repeated three or four times a day; and, when the gland becomes softer, and absorption commences, gargles may be used.2 Each of these plans may succeed, and we may try any or all of them; but I would also suggest that the internal application of the caustic 1 Diseases of Children, p. 451. 2 Ranking's Abstract, vol. ii. p. 192. 414 PAROTITIS. tincture of iodine, as well as the external use of the ointment, should have a fair trial previous to any operation. I have seen it very suc- cessful in several cases. As to the prophylactic treatment, it is desirable, of course, that children liable to this affection should avoid all occasions of cold, and on the first sensation of sore throat, should be treated with external stimulating applications to the throat, such as mustard poultices, tur- pentine, compound camphor liniment, &c, and purgatives. CHAPTER IX. PAROTITIS.--CYNANCHE PAROTIDEA.--MUMPS. 664. This is a very common disease, although it rarely attacks very young children, seldom those under five or six years of age, and, according to Dr. West, more frequently boys than girls; but this does not accord with my experience. It consists of inflammation of the parotid gland of one or both sides, occurring together or separately; and during certain seasons it pre- vails epidemically, as in Dublin and other parts of Ireland this last winter. Dr. Stewart seems to regard it as one of those diseases which a child must generally have once in its life, but which rarely occurs a second time. 665. Symptoms.—In the majority of cases, the child seems suffering under a feverish cold for a few days before the local symptoms display themselves; it is chilly, uncomfortable, cross, and complains of aching of the limbs, followed by feverish heat of skin, quick pulse, thirst, &c, and then pain is felt about the angle of one or both jaws, and difficulty of opening the mouth to speak or masticate. In other cases, we have no preliminary feverishness, but the disease commences at once by pain or swelling at the angle of the jaw. The pain is soon followed by tumefaction behind the angle of the jaw, extending upward to the ear, forward a little on the cheek, and downwards to the maxillary gland, involving the parotid gland and the surrounding cellular tissue. It feels firm, hard, and hot, is pain- ful on pressure; but, generally speaking, the color of the skin is un- changed ; in severe cases, it becomes slightly red or pink. There are great pain and difficulty in opening the mouth and in moving the jaw, either to masticate or to swallow, although the dys- phagia is evidently not from sore throat. One or both sides of the face may be thus affected; or, after the sub- sidence of the one, the opposite may succeed to the swelling; and it is from the extraordinary expression of sullenness thus given to the countenance that the name " mumps" has been given to the disease. PAROTITIS. 415 666. If the attack be mild, the fever, swelling, and pain will be moderate, and after a few days will subside without the child having suffered much distress; but, in some of the .severe cases, the suffering is very great; the tumor is very large, hard, and exquisitely tender; the skin covering it of a reddish tinge; the difficulty of opening the mouth so great that the child can scarcely take food, and, even when in its mouth, it is almost impossible to swallow it. The fever runs very high, the pulse is full and rapid, and the brain is more or less involved, with delirium, &c, which have occasionally proved fatal, according to Dr. Cullen. Moreover, in such cases the swelling extends far beyond the paro- tid glands, and involves not merely the surrounding cellular tissue, but the submaxillary glands; and the suffering and distress are very great. Such cases are, fortunately, rather uncommon. 667. A remarkable peculiarity of mumps is the disposition to me- tastasis. The pain and swelling of the parotid gland will sometimes suddenly subside, and the mamma? in girls, or the testes in boys, become instantly affected with severe pain, swelling, and tenderness. "In the male," says Dr. Dewees, "we once saw the testes prodi- giously enlarged; much suffering wTas endured, and great hazard was incurred by the change. Violent fever and delirium accompanied this change of seat of the disease, and it required a perseverance in very active remedies to subdue them."1 It has been stated, by Dr. Hamilton and others, that this metastasis to the testes has been followed by the absorption of the gland, so that the tunica vaginalis became an empty sac. The breasts in female children become very painful, hard, and swollen, but it does not appear that they are liable to the same wasting away afterwards, nor do they run on to suppuration. Again, a similar metastasis may take place, and the brain or its membranes become the seat of the secondary attack; and this is more frequent, Dr. Stewart thinks, in those cases where no metastasis to the testes or mamma? takes place. This cerebral metastasis is highly dangerous. The child is attacked by coma or delirium, and may die in a few hours if prompt measures be not taken for its relief. 668. The duration of the disease varies much. In some cases, the swelling, pain, and fever reach their maximum in forty-eight hours, and then begin to subside; in others, not till the fourth or fifth day; and some are prolonged to ten or twrelve days. The disease is lengthened, also, in those cases in which the two glands are success- ively attacked. In by far the majority of cases, the attack terminates in resolution, after the height is reached; the fever and pain subside, the swelling diminishes, and the tenderness gradually disappears. But in some rare cases suppuration takes place, and matter makes its way to the surface. 669. Causes.—Cold from damp clothing, damp beds, &c, seems 1 Diseases of Children, p. 143. 416 PAROTITIS. to be the principal cause, where the disease is not epidemic. And in damp, marshy situations, those attacks seem to be endemic, and owing to the same cause. But it prevails, also, epidemically and very extensively during damp weather, especially in winter and spring. During the present spring of 1849, it has been very generally epidemic in Dublin and other parts of Ireland. I heard of one school in which there were twelve, another in wdiich there were sixteen children af- fected at one time; and there are probably few practitioners of this city who have not had abundant opportunities of witnessing differ- ent children of the same family attacked together or successively. Whether it really be contagious at the time when it is epidemic, as Dr. Stew7art supposes, is a question not so easy of solution as might be supposed, because, although children of the same family are un- doubtedly exposed to the influence of contact, they are also exposed to exactly the same epidemic causes. 670. Treatment.—The treatment required by simple cases of paroti- tis is very slight. We may administer an emetic, as Marlay advises, or a brisk purgative, followed by calomel and antimonials in small doses, with fomentations or poultices to the tumefied jaw, and these may be sufficient. But, when the swelling is considerable, the pain great, and the fever high, it will be necessary to apply leeches to the part affected, and to continue the poultices constantly, fomenting the jaw with hot water or decoction of poppy heads, whenever the poultice is renewed. The purgative may be repeated occasionally, and the James's powder, with or without the calomel, continued until the inflammation begins to subside. Pediluvia at bedtime, or an occasional warm bath, will be found very useful. When the testicles or mamma? are attacked, it will be necessary to apply leeches, fomentations, or poultices, according to the amount of inflammation. When this metastasis takes place, it has been thought advisable by some writers to apply blisters, or irritants of some kind, over the original seat of the mischief, for the purpose of bringing back the inflammation to the parotid gland. Dewees remarks: "We have always blistered the parts immediately over the parotids, and, we think, with decided advantage." Dr. Condie, however, does not believe that any good can result from this practice ; and I am induced to agree with him; at least, I have never found it necessary. When the brain is attacked, it will be necessary to meet the in- creased danger very promptly and actively by the usual means of leeching, cold lotions, blisters, calomel, and James's powder, with occasional purgatives, &c. 671. During the prevalence of mumps this last winter, I have seen a disease which might easily have been mistaken for it, but which is, in truth, inflammation of the cellular tissue in the neighborhood of the parotid, and which often ends in abscess. It has been noticed by Dr. Good as phlegmone parotidcea, and by Mr. James as angina ex- terna. In the beginning, it is very like parotitis; there are pain, sore- ness, and swelling near the angle of the jaw, but of one side only; PAROTITIS. 417 great difficulty in opening the mouth; pain in mastication; and febrile excitement; but the tumor is generally below the parotid, more super- ficial, and the skin is more discolored. In some cases, the inflamma- tion is deeper seated and more extensive, the tumor occupying, as Dr. Condie observes, the front of the throat from ear to ear, with oedema of the face occasionally. Suppuration generally takes place; the swelling becomes more prominent at one part, and paler generally ; softening occurs; fluctuation is felt; and ultimately the abscess bursts, or is opened, and the tumor gradually disappears. "Instead of a circumscribed inflammation and suppuration, the inflammation is occasionally deep-seated and diffused, and the pus, when it forms, is then liable to extend under the angle of the jaw to the pharynx, or downwards into the upper part of the thorax, pro- ducing extensive destruction of the cellular membrane about the neck, and great distress to the patient." "When suppuration takes place, the swelling acquires a doughy feel, and an indistinct fluctuation may be perceived at one or more points. The matter is slow in arriving at the surface, and in discharging itself externally. In some instances, distinct, deep-seated collections of. matter form, and the pus, mixing with the dead cellular membrane, becomes putrid, and the evolution of gas thus produced causes a kind of emphysematous condition of the parts. The febrile symptoms now assume a low, typhoid charac- ter, the strength of the patient is rapidly exhausted, and death very generally ensues; or, if recovery takes place in these extreme cases, an extensive and unsightly cicatrix deforms the patient for life."1 672. In casesof the simple phlegmonous inflammation, a few leeches should be applied to the tumor, followed by poultices, fomentations, and a brisk purgative. Dr. Condie recommends a cold lotion after the leech-bites have ceased bleeding. The patient must be kept on low diet. Whenever suppuration has taken place, and fluctuation can be detected, the abscess should be freely opened, and poultices continued after the free evacuation of the pus. With a little care, we may generally arrange the opening so that no mark shall be visible afterwards. When the inflammation is diffused, the early stage will demand a similar treatment; but, as soon as the swelling acquires a doughy feel, especially if there be difficulty of swallowing, impeded respira- tion, or cough, it will be advisable to make free incisions into the tumor, and then to apply poultices. If the child be much reduced, we must allow better diet, and perhaps, in some cases, wine and bark. 1 Condie on Diseases of Children, p. 172. 27 418 PSEUDO-MEMBRANOUS PHARYNGITIS. CHAPTER X. PSEUDO-MEMBRANOUS PHARYNGITIS.—DIPHTHERITE.--ANGINA PSEUDO- MEMBRANOSA. 673. In a former chapter, I described simple or erythematous pharyngitis, under the name of cynanche tonsillaris, or at least the description of the one may stand for the other, for any difference between them is almost imaginary. Now we have to do with a more serious affection, having much more complicated relations; essentially an inflammation of the mucous membrane of the pharynx, but which is accompanied by a secretion of coagulable lymph or false membrane, with or without a breach of the mucous surface. The disease appears to have prevailed from very early times. Are- ta?us mentions it as a complication of croup; P. Forest observed an epidemic at Alkmar, in Holland ; it appeared in Spain in the seven- teenth century; at Naples in 1618 ; and about 1636, at Kingston, in America. A similar epidemic prevailed in Paris from 1743 to 1748, and has been described by MM. Malouin and Chomel; in England about the same time, and at Cremona. I cannot agree, however, with Rilliet and Barthez, that the " putrid sore throat" of Dr. Fother- gill was diphtherite ; but rather gangrenous pharyngitis. We are mainly indebted for our knowledge of the disease to the labors of Dr. S. Bard, of New York,1 M. Bretonneau, of Tours, M. Deslandes, and Rilliet and Barthez. But it is not merely as an idiopathic or primary disease that this diphtheritic affection is to be considered ; it forms a very important complication of several diseases, particularly the eruptive fevers. We must, therefore, examine into its characteristics, both when primary and when secondary. 674. Symptoms.—Primary pseudo-membranous pharyngitis may commence very mildly, not unlike common sore throat, with a slight febrile excitement, or without any, the appetite and strength being but little deranged. Or, in some cases, the fever may be more in- tense, with general uneasiness, aching of the limbs, thirst, &c.; and shortly afterwards the child will complain of soreness of the throat, increased by swallowing, especially if the bulk be small. In the majority of M. Bretonneau's and Rilliet and Barthez's cases, there was but little fever; but in a few cases (four altogether) the fever was intense. The epidemic character may also modify this peculiarity ; thus, in the one described by Dr. Bard and M. Ferrand,2 1 Trans, of American Philosophical Society, vol. i. 2 Thesis, 1827, p. 8. PSEUDO-MEMBRANOUS PHARYNGITIS. 419 there was no fever; but, in the observations of M. L'Espine,1 it was intense. Pain in the pharynx is rarely severe; it is felt at the beginning chiefly, but it does not go on increasing; sometimes it is absent alto- gether, and I may say the same of the distress in swallowing. I have seen it very considerable, with a sense of heat and local soreness, and I have also seen it entirely wanting. This is the experience of M. Bretonneau.2 " The voice is commonly obscure and nasal, but not hoarse or whispering, unless the disease extends into the larynx, in which case the symptoms will be those of croup, already described. Cough some- times exists, but it usually resembles in sound that produced by the action of hawking rather than a common cough, and is altogether different from the tone of the cough of laryngitis."3 For a short time after the commencement of the disease, if we ex- amine the throat, we shall discover some redness and swelling of the tonsils, but we shall shortly perceive patches of coagulable lymph, here and there on these organs, of a white or yellowish-white color, more rarely gray, with thin edges, and w7hich, coalescing, cover the tonsils, palatine vault, and pharynx, with this lardaceous false membrane. Not only does it spread gradually over the neighboring parts, but it also increases in thickness, until the parts affected seem as if covered with curd, not evenly, and as if by a continuous membrane, but by patches, some large and some small, giving to the surface a lichenoid appearance, as M. Bretonneau justly describes it. Occasionally, they present the aspect of a deep ulcer or fissure. More or less, they will be found to cover the uvula, the tonsils, and the pharynx. Sometimes in the latter situation the layer is semi-transparent, or it may be covered with mucus, either of which circumstances may at first deceive us as to the existence of the falSe membrane. After the lapse of a few days, the false membrane begins to detach itself, not regularly, but here and there, leaving the mucous surface smooth and bright red; or it may become gradually thinner, until it entirely disappears, and then, in many cases, it is renewed more or less completely, and is again thrown off, until the disease is cured. Rilliet and Barthez state that, in twenty-one cases, the false mem- brane occupied the tonsils only in six; the tonsils and some part of the velum palati, in four; the tonsils, the vault of the palate, and the pharynx, in six; the tonsils and the pharynx, in five. 675. The false membranes, and the parts covered by them, some- times present a much more alarming aspect than the one just de- scribed. They appear as gray, reddish, or blackish shreds, attached to the tonsils or palatine vault; the soft parts of the fauces appear sphacelated; the vault of the palate, the tonsils, and the mucous mem- brane of the pharynx seem detached in part, and there are gray patches, with violet-colored edges, resembling gangrenous eschars. 1 Archives Gen. de Med., 1830, vol. xxiii. p. 521. 2 De la Diphtherite, p. 113, &c. 3 Meigs on Diseases of Children, p. 208. 420 PSEUDO-MEMBRANOUS PHARYNGITIS. The breath becomes very fetid, and there is profuse salivation.1 This form is rare, and resembles the putrid sore throat of Fothergill and others, in many points. 676. Four or five days after the appearance of the false membranes, we find the submaxillary glands become painful, swollen, and tender, especially on that side on which the inflammation is most intense. The cellular tissue of the neck may also become affected, and the neck increase in volume considerably; but this seems to be more ownng to infiltration of serum than to inflammation. When the pro- gress of the disease is favorable, the false membranes are thrown off, and not reproduced; the swelling of the submaxillary gland sub- sides, the redness of the mucous membrane disappears, and in eight or ten days the disease is cured. Cases may, however, terminate unfavorably by the extension of the false membranes to the air-passages, giving rise to croup, &c, or the disease may assume a typhoid type, but whether from the poisoning caused by the absorption of the putrid secretions, as supposed by M. Bourgeois,2 or not, may be doubtful. "In the commencement of the disease, the tongue is pointed, red at the edges, and covered on its surface with a thin layer of w7hite mucus, through which the enlarged and florid papilla? protrude. There is an increased secretion of saliva, which soon becomes dark-colored, from an admixture of blood discharged from the mucous membrane as por- tions of the pseudo-membranous deposit are detached, and of an offensive odor, from the vitiated state of the secretions of the throat and mouth."3 When the attack is severe, there is considerable fever, with heat of skin, quick pulse, difficulty and pain in swallowing; if the disease extend upward into the posterior nares, the child cannot breathe through the nostrils; 'and if into the Eustachian tube, the hearing will be imperfect, or perhaps complete deafness may be produced. So far, then, we find primary diphtheritis to be characterized by a few and unimportant general symptoms in the majority of cases ; by a certain amount of fever, loss of appetite, soreness of throat, and pain in swallowing, in others; and in all, by inflammation of the mucous membrane of the pharynx and neighboring parts, with a deposition of coagulable lymph, or curdy false membrane. 677. Secondary diphtheritis exhibits the following modification of these symptoms, according to Rilliet and Barthez : " 1. It commences by vivid and general redness and swelling of the palato-pharyngeal mucous membrane. 2. After an uncertain time, there appear upon the tonsils small, whitish or yellow patches, in general thin, super- ficial, and easily detached ; most frequently, limited to the tonsils, occasionally involving the uvula and palate, and more rarely the pharynx. According to authors, we find that the false membranes of secondary pharyngitis, and particularly in scarlatina, may assume a 1 Rilliet and Barthez, Mai. des Enfans, vol. j. p. 291. 1 Journal Gen. de Med., vol. cix. p. 441. 1 Condie on Diseases of Children, p. 160. PSEUDO-MEMBRANOUS PHARYNGITIS. 421 gangrenous appearance, having a strong resemblance to some already noticed. 3. The swelling of the submaxillary gland is the same. 4. The pain, often more intense than in the primary form, exhibits the same characteristics. 5. The fever, always more intense, most generally is dependent upon the original disease."1 678. Morbid Anatomy.—According to Bretonneau, the false mem- branes may sometimes be found on the first day of the disease, gene- rally somewhat later. They first appear as whitish or yellowish patches on the tonsils, circumscribed, and resembling flakes of curd ; increasing in number and extent, they coalesce more or less com- pletely. They adhere sufficiently firmly to the mucous membrane, vary in thickness, and increase by additional layers. Occasionally, they are mixed with blood, and acquire a gray or brown color, which has led to the supposition of their being gangrenous. They are in direct contact with the mucous membrane, and are not covered by epithelium, according to Bretonneau, Rilliet and Barthez. The mucous membrane beneath the deposition is more or less injected and red, and often presents spots of ecchymosis. Rilliet and Barthez and Guersent conceive that, in some cases, there is loss of substance from ulceration ; such cases, how7ever, are very rare. The submaxil- lary glands are enlarged, but rarely suppurate ; their tissue is tender, homogeneous, and of a whitish-red color at an early period, and re- sembling the structure of the kidney at a more advanced stage. 679. In secondary diphtheritis, we find the mucous membrane of a bright red, rough and unequal, much thickened and softened ; the tonsils enlarged, soft, and irregular; not unfrequently, also, we find a breach of surface : ulcerations of various forms extend in different directions, deep or superficial, with level or raised edges, and healthy or unhealthy surfaces. False membranes may be generally observed at different points; seldom over the entire fauces. They are generally thin, soft, and fragile, of *a whitish, grayish, or yellowish color, and mixed with purulent matter. Sometimes, the false membranes occupy the supe- rior or inferior part of the pharynx, the intermediate portion being intensely inflamed, and covered with purulent matter. The submaxillary glands are enlarged, red, and soft. Considerable difference of opinion prevails as to the pathological character of the disease. Bretonneau, Guersent, and others maintain that it is a specific inflammation ; Broussais and Emmangard, that it is a gastro-enteritis; Joly, that it is a hemorrhagic inflammation, in which colorless fibrine is exuded upon the inflamed surface ; Nau- rnann attributes it to a change in the condition of the blood, in con- sequence of which the albuminous portion is separated and exuded; and Andral regards the disease as hypera?mia of the fauces, with exudation of coagulable lymph. The latter is, no doubt, a true expression of the fact; but neither that nor any of these opinions deserve the character of an explanation of the nature of the disease. ' Mai. des Enfans, vol. i. p. 295. 4*22 PSEUDO-MEMBRANOUS PHARYNGITIS. For fuller details, I must refer the reader to M. Bretonneau's ela- borate work.1 680. Complications.—These are of two kinds: those which con- sist of an extension of the same disease, and those which result from the general condition of the patient. i. The secretion of false membranes may not be limited to the pharynx, but may extend itself to the nasal apertures, or into the larynx, trachea, and bronchi. This coincidence and succession are very remarkable in some epidemics. M. Bretonneau states that the angina or coryza appears first, then the laryngitis, then bronchitis. It is very rare that this order is reversed, and still more rarely does the disease appear in different parts simultaneously. It is especially in an epi- demic that these complications occur. I am not prepared to speak positively as to the extension of the diphtherite to the stomach and intestinal canal; but I confess I think it extremely probable, for we find shreds of what looks like the false membrane voided by stool in cases of this disease, and most, I sup- pose, have seen the diphtheritic deposit around the anus. ii. The disease may also attack remote parts of the body, particu- larly parts covered by raucous membrane, or from which the cuticle has been removed by a blister, according to M. Trousseau. Thus, the pseudo-membranous secretion may be observed upon the lips, ala? nasi, the concha, the external meatus behind the ear, in the groin, on the nipples, &c. in. Another class of complications, dependent upon some peculiar state of the constitution, consists of hemorrhages, which, however, are absent in some epidemics, though very common in others. For instance, Bretonneau makes no mention of it, whilst Bourgeois and Lespine. found it a common occurrence, either from the nose, from the mucous membrane, or from the skin, and to such an extent as to occasion death. iv. M. Bretonneau relates a case of the present disorder complicated by gangrene of the pharynx. v. M. Guersent has remarked that from the third to the seventh day the patient may be attacked by broncho-pneumonia or catarrhal pneumonia, which, at its commencement, is very insidious, and apt to be masked by the symptoms of the angina. These are the chief complications. Other diseases, as enteritis, erysipelas, or the eruptive fevers, may occur; but they can only be regarded as coincidences. 681. Causes.—That the same causes which give rise, to simple pharyngitis may be influential in causing the present disease, one can hardly doubt; but it seems in general that something additional is requisite for its production. The crowding together of children in a close habitation may give rise to it, as was observed at St. Denis by M. Bourgeois. Most frequently, however, the disease prevails as an epidemic, and 1 Des Inflam. speciales du Tissu Muqueux et en particulier de la Diphtherite, &c, pp. 240 et seq. PSEUDO-MEMBRANOUS PHARYNGITIS. 423 those cases which would otherwise be simple pharyngitis take on this character, and exhibit the curdy deposition. Besides the epidemics which I have mentioned at the beginning of this chapter, M. Bretonneau mentions their prevalence at Tours, in 1818 and subsequent years; M. Girouard, at Sancheville, in 1824; M. Ferrand, in 1825, at La Chapelle-Veronge; M. Guimier, at Vou- vray, in 1826 ; M. Bourgeois, at the establishment of the Legion of Honor at St. Denis, in 1827-8; M. Trousseau, at Sologne, in 1828; by M. Blaud, in the Canton de Vaud ; and by M. L'Espine, in the Royal Military School of La Fleche, in the same year. Some difference of opinion prevails as to whether the disease is contagious. From the facts collected by M. Guersent, from his own experience and that of others, he has come to the conclusion that it is, and in this opinion Rilliet and Barthez concur. In its secondary form, the disease may occur in the course of scar- latina, typhus fever, measles, remittent fever, &c, adding much to the distress of the patient, and sometimes to the danger of the primary affection. 682. Diagnosis.—i. The presence of the false membrane will dis- tinguish diphtherite from simple or erythematous pharyngitis, although, on the first day of the attack, the aspect of the parts may be precisely the same. ii. The peculiar characters of gangrene of the pharynx are equally well marked, and so different from diphtherite that there is little danger of our confounding them; the gangrenous eschar and odor, the loss of substance, and the absence of false membrane on the neigh- boring parts, are very characteristic, not to mention the difference in the symptoms and history of the two cases. Moreover, gangrene generally attacks children previously debilitated by disease, whereas primary diphtherite may occur in children who, up to that time, have been perfectly healthy. No doubt, the two diseases may attack the same child; but it is certainly a coincidence only. 683. Prognosis.—The prognosis of the disease will depend very much upon the extent of the disease, its complications, the state of the child's constitution, and the character of the epidemic. If the attack be limited to the pharynx, and occur sporadically, it is generally easily cured, according to MM. Bretonneau, Guimier, and others; although, in one such case related by Bretonneau, and another by Rilliet and Barthez, death took place. WThen the false membranes extend into the larynx and trachea, we shall have croup with all its danger; and when the skin takes on an inflammatory action, with or without false membrane, as in the epi- demic described by M. Trousseau, death may occur from exhaustion. A like result may follow in those cases in which the disease appears at the opposite extremity of the mucous membrane, the vulva, or anus. In secondary diphtherite, the danger will probably depend more upon the primary disease, although, doubtless, the secondary affec- tion will increase it. 684. Treatment.—The indications of cure are not quite so simple 424 PSEUDO-MEMBRANOUS PHARYNGITIS. as in the previous affections. Much will depend upon the extent of the disease, its disposition to penetrate into the larynx and trachea, the constitution of the child, and upon the character of the epidemic when the disease prevails extensively. Most writers, also, dwell upon the greater importance of topical applications. The principal caustic applications which have been employed are muriatic acid, nitrate of silver, powdered alum, and the chloride of lime; and they are said to act both by preventing an extension of the false membrane, and also by changing the character of the inflam- mation. M. Bretonneau used the first of these applications; and he recommends two thorough cauterizations, at an interval of twenty-four hours, and afterwards milder applications. M. Guersent substituted the nitrate of silver for the muriatic acid; but, in using this we must take care that the stick is not broken and swallowed. The chloride of lime, calomel, or alum can easily be applied to the diseased surface either by the finger or by a small roll of lint. Some one of these remedies should be applied as soon as the dis- tinctive characters of the disease appear, or as soon as the patient is placed under our care, and repeated as often as we may find necessary, judging from the change produced by it. 685. If the case be a slight one, occurring sporadically, and the child in good health otherwise, an emetic may be at once adminis- tered, the bowels properly freed, and the throat painted with a solu- tion of nitrate of silver every day, or every second day; which will probably be sufficient to cure the disease. But if the case be more severe, the inflammation and swelling greater, and the child of a robust constitution, it will be well to com- mence with the application of a few leeches to the throat, followed by poultices. Broussais, Emmangard, and others have ordered the ap- plication of leeches to the epigastrium ; but, unless there were decided tenderness in that region, I do not think it would be necessary ; and in no case should blood be abstracted when there are symptoms of depression or exhaustion. After the application of leeches, the case must be treated by caustics, purgatives, and perhaps by an emetic. In the intervals of cauterization, the vapor of hot water may be in- haled three or four times a day, or a slightly acidulated gargle used equally often. Internally, small doses of calomel will be found useful, either alone or in combination with ipecacuanha. Emollient drinks, iced water, lemonade, or acidulated water should be allowed, and an occasional warm bath or pediluvium will greatly add to the comfort of the patient. There is much difference of opinion as to the propriety of blistering the throat, and I confess that I agree with those who object to it as a rule. I do not deny that there are some cases which appear benefited by it, but in general I should much prefer simple poultices; or, if we •wish to excite irritation, poultices of mustard and linseed meal, or a liniment sufficiently strong to redden the skin. 686. If the disease be epidemic, but not exhibiting a typhoid cha- PUTRID SORE THROAT. 425 racter, the treatment will be nearly the same; a little more caution in applying leeches, the prompt use of caustics, and their repetition each day until the surface exhibits an altered appearance, the exhibition of calomel, mild purgatives, emollient or acidulated drinks, &c, will be equally necessary. But if the epidemic show a typhoid character, we must make a considerable change from the above plan. The parts must be cau- terized, and the bowels kept free; but we must carefully abstain from bleeding, and from everything calculated to lower the system. For this form of the disease, a very useful gargle may be made with decoction of bark and nitric acid, from twenty to fifty drops of the latter to half a pint of the former. And, in addition to this, we must administer bark, or ammonia, or both, internally, with a liberal use of wine, according to the circumstances of the child. Wendt advises enemata of decoction of bark, and Rilliet and Bar- thez concur with him. The diet must be regulated according to the character of the attack: if there be much fever and acute inflammation, it should be mild and spare; but when typhoid symptoms are present, the strength must be supported by beef tea, broths, &c. CHAPTER XI. PUTRID SORE THROAT.—GANGRENOUS ULCERATION OF THE PHARYNX. 687. There exists considerable confusion among writers as tp this disease; some having described under this name an aggravated form of diphtheritic sore throat, attended by dark-colored crusts, bad smell, &c; and others, on the opposite side, having nearly denied the exist- ence of such a disease. M. Bretonneau, I think, has proved that the angina maligna of many writers, was a modification of diphtherite; but the observations of M. Becquerel, MM. Rilliet and Barthez, and others, leave no doubt of the occasional occurrence of gangrenous ulceration; and, notwithstanding the opinion of the last-named writers, to which great respect is due, I cannot but believe that the "putrid sore throat" described by Dr. Fothergill, of London, was really this disease.1 He states that the disease was first noticed in London, and that it reappeared in 1742. Again, in the winter of 1746, "so many children died at Bromley, near Bow, in Middlesex, of a disease that seemed to yield to no remedies or applications, that several of the in- habitants w7ere greatly alarmed by it, some losing the greater part of their children after a few days' indisposition. Some others of the neighboring places were affected at the same time with the like dis- 1 First published in 1748,. and now included among his collected works, p. 167. 426 PUTRID SORE THROAT. ease, which, from all the accounts I have met with from those who attended the sick, was that here treated of. I am informed likewise that it raged at Greenwich at the same time." Gangrenous ulceration may attack the throat as a primary disease in children hitherto healthy, as in a case lately under my care; but it much more commonly supervenes in the course of other diseases; or ulceration of the mouth, previously existing, whether simple or aph- thous, may assume a gangrenous character and appearance. 688. Symptoms.—The disease may commence like a common sore throat, with some degree of fever, rigors, heat of skin, quick pulse, weariness, &c, but without exciting any alarm; and the patient may then complain of soreness of the throat, pain and difficulty of swallow- ing, &c. On examination, we find at first the pharynx and tonsils swollen, and of a dusky red, with perhaps a.spot of commencing ulceration, which enlarges daily, and shortly presents its peculiar characters. Or, as in Dr. Fothergill's cases, it may come on "with such a gid- diness of the head as commonly precedes fainting, and a chilliness or shivering like that of an ague fit; and these interchangeably succeed each other during some hours, till at length the heat becomes constant and intense. The patient then complains of an acute pain in the head, of heat and soreness rather than pain in the throat, stiffness of the neck, commonly of great sickness, with vomiting or purging, or both. The face soon after looks red and swelled, the eyes inflamed and watery, as in the measles, with restlessness, anxiety, and faint- ness. The disease frequently seizes the patient in the forepart of the day. As night approaches, the heat and restlessness increase, and continue till towards morning, when, after a short, disturbed slumber (the only repose they often have during several nights), a sweat breaks out, which mitigates the heat and restlessness, and gives the disease sometimes the appearance of an intermittent. If the mouth and throat be examined soon after the first attack, the uvula and tonsils appear swelled, and these parts, together with the velum pendulum palati, the cheeks on each side, near the entrance into the fauces, and as much of them and the pharynx behind as can be seen, appear of a florid red color. This color is commonly most observable on the pos- terior edge of the palate, in the angles above the tonsils, and upon the tonsils themselves. Instead of this redness, a broad spot or patch, of an irregular figure, and of a pale white color, is sometimes to be seen, surrounded with a florid red, which whiteness commonly appears like that of the gums immediately after having been pressed with the finger, or, as if matter ready to be discharged, were contained underneath." "The appearance in the fauces continues to be the same, except that the white places become more ash-colored; and it is now discernible, that what at first might have been taken for the superficial covering of a suppurated tumor, is really a slough concealing an ulcer of the same dimensions."1 * Works, pp. 202-205. PUTRID SORE THROAT. 427 Dr. Fothergill mentions other symptoms worthy of" notice. The first is an erythematous eruption on the face, neck, hands, and breast, with some tumefaction, and occurring generally on the second day. Another phenomenon is a swollen, hard, and painful condition of the parotid glands on each side; and if the disease be violent, the neck and throat are surrounded with a large cedematous tumor, sometimes extending itself to the breast, and, by straitening the fauces, increas- ing the danger. Delirium wras a frequent symptom in those cases; occurring the first night, bearing a direct relation to the feverish exacerbations, and equally relieved by the perspiration which broke out towards morning. The pulse was very quick for some days, but, although the uvula and tonsils were much inflamed, the difficulty of swallowing was less than might have been expected. The offensive putrid smell was not only evident to those around, but even to the patient himself. In severe cases, the disease extended to the inside of the nostrils, which were of a deep red or liver color, and a putrid sanies was discharged, so corrosive as to excoriate the parts over which it flowred. The lips also, and the margin of the anus, occasionally exhibited the same appearance. Dr. Fothergill thinks it probable, that the diarrhoea may be owing to this discharge being swallowed. Hemorrhages from the nose, mouth, and ears sometimes occurred ; in general to a,moderate amount, but in some cases proving suddenly fatal. They seemed to result from the injury of some arterial branch by the ulceration. The duration of this disease was variable. Some seemed to mend after the second day; others continued three, four, or six days, even when favorable, and the decline of the disease was marked by the disappearance of the eruption, the subsidence of the pulse and fever, and the throwing off of the sloughs, and the more healthy appearance of the ulcers. In unfavorable cases the diarrhoea persists; "they generally spit very little; the fauces appear dry, glossy, and livid; the external tumor grows large; they void their excrements without perceiving it, and fall into profuse sweats; respiration becomes difficult and labori- ous; the pulse sinks; the extreme parts grow cold ; and death in a few hours closes the scene."1 689. If, as appears to me, this disease were really gangrene, it was the primary form, and differed very widely in the acute character of its symptoms from the secondary form described by Becquerel, Guer- sent, Rilliet and Barthez, &c. In the latter, the chief general symp- toms resulted from the primary malady, whatever that might be; but the occurrence of the gangrene was chiefly marked by a profound alteration of the countenance, great depression, and the small, quick, pulse. Loss of appetite, thirst, and diarrhoea also existed, but they may have been the result of the original disease as well as of the gangrene. 1 Works, p. 220. 428 PUTRID SORE THROAT. The local symptoms we're often obscure, and sometimes uncertain. The fetid odor of the mouth was invariable, and of great value in those cases where the ulcer could not be seen, either from its situation, or the difficulty of opening the mouth. In none of Rilliet and Barthez's cases did the patient suffer any pain, and deglutition was easily effected, and not marked by the re- gurgitation of liquids through the nose. In one case, where the gan- grene was considerable, the patient drank and ate solid food until the day of her death. M. Guibourt mentions that one of his patients suffered severe pain and difficulty of swallowing; and in a case of M. Constant's, the patient incessantly put his finger into his mouth, as if to remove some- thing that annoyed him. The swelling of the submaxillary glands, and of the cellular tissue, was not remarked except in one case, nor the abundant, fetid, sanious salivation."1 As we might expect, the course of so serious a disease supervening upon another complaint, and in constitutions so enfeebled, is very rapid ; sometimes, two, three, or four days terminate life, and the case rarely passes the sixth. 690. Complications.—Of course, in secondary gangrene, some of the concomitant diseases which have been noticed, were merely coin- cidences; nevertheless, certain of the complications appear to be either an extension of the disease, or closely connected with it. i. The gangrene may extend gradually to the neighboring parts ; the nares, the mouth, the oesophagus, or the larynx. ii. Even distant organs may exhibit a similar morbid action; thus the uvula externally, or the lungs internally, have been attacked by gangrene during the course of gangrene of the pharynx. in. M. Guibert mentions a case in which oedema of the glottis occurred. iv. Pneumonia may occur, but it is less frequent than in gangrene of the mouth. v. In nine out of tw7elve cases there were tubercles in the lungs, but this we must regard merely as a coincidence. vi. I have already alluded to the occurrence of fatal hemorrhage in Dr. FothergiU's cases. I have seen the child seriously weakened by it, though not destroyed; but Dr. Mills has related two cases in which death occurred suddenly from this cause.2 691. Morbid Anatomy.—At the commencement of primary gan- grene, we find the mucous membrane of a florid or deep red color, with a white or ash-colored spot, according to Dr. Fothergill, or with an unhealthy looking ulcer at a somewhat later period. This ulcer may occupy one or both tonsils, the back of the pharynx, the poste- rior nares, or the commencement of the oesophagus ; and, as the dis- ease advances, we shall probably find it extending on either side; I have seen the uvula, velum, and soft palate, entirely destroyed by it. The surface, at first grayish or ash-colored, gradually becomes dark 1 Rilliet and Barthez, Mai. des Enfans, vol. ii. pp. 174-175. ' Edin. Med. and Surg. Journal, Jan. 1844. PUTRID SORE THROAT. 429 brown. Dr. Fothergill observes: " When the disease is of the mildest kind, a superficial ulceration only is observable, which may casually escape the notice of a person unacquainted with it. A thin, pale, white slough seems to accompany the next degree; a thick, opaque, or ash-colored one is a further advance; and, if the parts have a livid or black aspect, the case is still worse. These sloughs are not formed of any foreign matter spread upon the parts affected, as a crust or coat, but are real mortifications of the substance; since, whenever they come off, or are separated from the parts they cover, they leave an ulcer of greater or less depth, as the sloughs were superficial or penetrating."1 A dark reddish-brown hue may be given to the slough by the oozing of blood, but the brown color may exist independently. The odor is fetid, overpowering, perceived even by the patient, and rendering the room intolerable. Portions of the slough may be cast off, but it is rapidly reformed ; the surface underneath has generally an unhealthy appearance. 692. The secondary gangrene, described by the French writers I have named, may be either circumscribed or diffused. i. Circumscribed gangrene generally occupies the lower portion of this canal, near its junction with the oesophagus, either on its posterior or anterior surface, and consequently, it is not within view during life ; and we are mainly left to infer it from the putrid smell, and the accession of the symptoms I have mentioned. The gangrenous spots are sometimes oval, sometimes round, varying in size from a pea to a shilling; and it is very probable that the larger are formed by the coalescing of several smaller ones. The surface of these patches is depressed, gray, blackish, or quite black; the edges clear cut and yellow, and with the characteristic gangrenous smell. Beneath the slough, the mucous membrane and subjacent tissue are destroyed ; and so deeply, in some cases, that the muscles are clearly exposed. The surrounding mucous membrane appears unchanged, neither red, nor thickened, nor softened. When the slough is thrown off, we find an ulcer with more or less loss of substance, and which is occasionally covered afterwards by a layer of false membrane. However limited and superficial the gangrene may be at first, it may ultimately penetrate into the larynx or extend to the epiglottis ; or it may be confined to one or other tonsil. ii. Diffused Gangrene.—This form differs widely from the former; the eschars are quite irregular, and may occupy the entire vault of the palate, the velum, tonsils, and pharynx. The limit between the diseased and healthy tissues is not clearly defined, although the edges are sometimes formed by the detached epithelium. Sometimes the gangrene is superficial; and, though extensive, scarcely penetrates below7 the mucous membrane. The surface is unequal, of a gray- ish black, easily removed by the scalpel, and of unequal thickness. The submucous tissue is of a violet color; but when the deeper tis- i Works, p. 237. 430 PUTRID SORE THROAT. sues are affected, they become of a black color, and present the appearance of a mass of detritus. This form is generally of considerable extent, and spreads to all the neighboring parts; so that the palate, the cheeks, the gums, or,on the other hand, the epiglottis and larynx, may be attacked. Diffused gangrene is rather more common than the circumscribed form. Of thirteen cases, eight had diffused gangrene ; and in seven, it occupied the velum palati, the tonsils, and a great part of the pharynx.1 693. Causes.—Dr. Fothergill found the disease most frequent from September to December; but the peculiar condition of the weather seems to have little or no influence. It more frequently attacks chil- dren than adults ; and children under six years rather than over, ac- cording to Rilliet and Barthez. Dr. Fothergill states that more girls than boys suffer from it; but out of Rilliet and Barthez's thirteen cases, seven were boys, and six girls. All are agreed that children of feeble constitutions, or whose health has been destroyed.by previous disease, are very much more exposed to it; and there are certain diseases whose course it compli- cates as a secondary affection. These are the eruptive fevers, measles, scarlatina, or small-pox ; and likewise pneumonia, peritonitis, diph- theritis, and typhus fever. I have already mentioned that the milder forms of ulceration of the mouth and throat do occasionally assume a gangrenous character, probably owing to the peculiar state of constitution induced by pre- vious disease. It is said to prevail epidemically ; but wTe have no very well- authenticated information upon the subject. M. Becquerel, indeed, has observed a kind of epidemic in the Hopital des Enfans, and has recorded his observations.2 Some writers seem to consider it con- tagious. Dr. Fothergill remarks that, when one child of a family has it, all the rest take it, if they are not kept apart; but I should be very much inclined to doubt its being directly communicated from one person to another. 694. Diagnosis.—In cases where the gangrene is primary, there is not much difficulty in recognizing it; the ash-colored, brown, or black slough, the gangrenous smell, and loss of substance, would alone be sufficiently characteristic ; but in Dr. FothergiU's cases, there was oedema of the neck, and rapid sinking in the more serious cases, which were very different from other affections of the throat. In secondary gangrene, when circumscribed, and situated low down in the pharynx, the diagnosis may be very difficult; and I need not say that the age of the patient, and the difficulty of minutely investi- gating the throat, will increase the chances of our overlooking or con- founding the disease. In such cases, the fetid odor will be very important; but, as that may arise from gangrene of the mouth or lungs, we can only fix upon the larynx as its seat, by finding those 1 Rilliet and Barthez, Mai. des Enfans, vol. ii. p. 1C9, el seq. 3 Gazette Me licale, 1843. ABSCESS BETWEEN THE PHARYNX AND THE SPINE. 431 other parts free from disease. It is true, as Rilliet and Barthez ob- serve, that it will not signify if we do mistake as to this point; but it is very important that we should not mistake diphtherite for gangrene, to which, in some cases, it bears a strong resemblance, the odor being occasionally fetid, and the sloughs dark-colored. If we have watched the case from its commencement, we shall not be likely to make this mistake ; but if not, or if we should still be doubtful, the application of caustic, by changing the vitality of the parts, and effecting the separation of the apparent sloughs, will show, in cases of diphtherite, that the mucous membrane has not really been destroyed. 695. Prognosis.—The disease is very serious; nay, very fatal. A great proportion of cases of primary gangrene die, and a still larger number of secondary cases. The profound destruction of parts, the disposition to spread; the unhealthy condition of the patient, added to the injury inflicted by the primary disease, render recovery very hopeless. 696. Treatment.—The result of Dr. FothergiU's experience was,. that however acute the symptoms might be, the patient wTas never re- lieved by bleeding. He gave a mild emetic, occasionally following by warm, aromatic, and stimulating medicines, wine, broths, &c. Lo- cally, he recommends gently stimulating gargles; in mild cases a stronger one, with the mel Egyptiacum in more severe ones. Means are also to be taken to arrest the diarrhoea and hemorrhage, if present. Rilliet and Barthez recommend an attempt to limit the extent of the gangrene by muriatic acid, or the application of the chloride of lime to the parts affected. An occasional emetic may favor the separation of the eschar, and may prevent the injurious effects of the putrid de- tritus which may have been swallowed. Gargles of decoction of bark, with nitric acid, are useful; but, if the child be too young to gargle, they may be injected with a syringe. Internally, the constitution must be invigorated by a liberal allow- ance of bark (syrup of quinine is a pleasant form for children), am- monia, wine, broths, &c. CHAPTER XII. ABSCESS BETWTEEN THE PHARYNX AND THE SPINE. 697. Before passing to the consideration of the diseases of the stomach, I feel it right to notice the disease so well described by my friend, Dr. Fleming, in his interesting paper,1 both on account of the alarming symptoms to which it gives rise, its simple method of cure, and because I am not aware that it has been noticed by any author, before Dr. Fleming, as occurring during infantile life. 1 Dublin Medical Journal, vol. xvii. p. 41. 432 ABSCESS BETWEEN THE PHARYNX AND THE SPINE. The disease in question is an abscess formed behind the pharynx, and between it and the spine; and, when acute, it appears to consist in inflammation and suppuration of the loose cellular tissue in this situation, and occasionally of a lymphatic gland, not unfrequently to be found here; when chronic, it partakes of the nature of scrofulous abscesses. It may occur at all periods of life, from infancy to manhood. Dr. O'Ferrall has recorded a case of this affection at the age of four months, which Dr. Fleming witnessed in consultation with him.1 698. Symptoms.—The symptoms are very characteristic, although at first one might attribute it to some affection of the nervous system. They may be divided into the premonitory and the essential. "The premonitory indication of local uneasiness, but yet common to all affections of the throat, complained of, or otherwise, according to the age of the child, and on examination not accompanied with propor- tionate visible lesion. The essential, often very suddenly supervening, and indicated by derangement of the cerebral, circulating, and respi- ratory symptoms, alternating with the comparatively healthy condition of those systems, according to the alteration in the position of the in- dividual; fixed and retracted state of the head, with rigidity of the muscles at the back of the neck, and more or less locked state of the jaws; painful deglutition, impossibility of swallowing, solids and fluids convulsively darted forwrard through the mouth and nose; repeated acts of deglutition, without the presence of any fluid in the mouth, and on examination of the fauces, a firm projecting tumor felt beyond the base of the tongue, and, if seen, presenting a smooth, rounded, highly vascular appearance behind the soft palate, usually occupying the median line, but occasionally inclining to either side. These essential symptoms, accompanied with the ordinary characteristics of suppura- tive fever." "Fever, more or less sthenic in its character, according to the peculiarity of constitution of the child, is always present, and, I think, precedes the development of the local symptoms." 699. As regards the chronic abscesses, the " symptoms attendant upon them are in a much milder degree of the same character with the acute; and, perhaps, the more prominent are the remarkable effects produced on the respiration by change to the recumbent posture. There is absence of fever, and throughout the day the child is free from any obvious illness; able to play, and join in the amusements of other children. I have known them not to complain of any uneasiness in the throat, and attention to be directed to it from the raucous breath- ing during sleep. In fact, the symptoms much resemble those of common scrofulous induration of the tonsil. They are hence cases of comparatively minor importance; there is time to investigate them. Indeed, with them may be complicated chronic enlargement of the tonsils. I have met with them after scarlatina, after variola, and after measles. In fact, they are some of the sequela? of those cuta- neous diseases, and, like them, may be accompanied with suppura- 1 Dublin Hospital Gazette, 1845, March 1, p. 20. ABSCESS BETWEEN THE PHARYNX AND THE SPINE. 433 tion of the internal or external ear, and so come under the description of similar cases already alluded to, as described by Petit." 700. Diagnosis.—When the tumor is large, and the cerebral symp- toms intense, the case may not unlikely be set down as one of disease of the brain; or, at an earlier period, it may be mistaken for disease of the cervical portion of the spine. In all such cases, a careful examination of the throat should be made, as the presence of the tumor will remove such doubts at once. Moreover, the difficult deglutition, the regurgitation of fluids through the nose, &c, point decidedly to some mechanical obstruction, and an examination will at once prove that it is not from enlarged tonsils, but from a firm projecting tumor beyond the base of the tongue, and generally in the centre of the pharynx. 701. Treatment.—Dr. Fleming's experience has proved that sur- gical interference is as effectual as it appears to be essential, from the symptoms; and, " not alone from the fact of certain fatal results from mechanical pressure on, and interference with, vital organs, but also from the situation of the abscess being particularly favorable to ex- tensive diffusion." In one case only has Dr. Fleming seen a spon- taneous opening occur; the abscess was situated high up, and the matter passed through the nose. For increasing the facility of the operation, Dr. Fleming has con- trived an instrument consisting of a " trochar about four inches long, one extremity of the canula being slightly curved, the other with a ring on its upper surface to receive the forefinger; into this canula was passed a jointed stiletto, with, at its opposite extremity, a ring for the thumb, and a movable serew, to graduate the projection of its point." The greatest caution must be observed; an assistant must hold the head firmly, and be ready to throw it forward when the puncture is made. The operator should pass his left forefinger to the back of the pharynx, and, fixing the point of it upon the tumor, use it as a guide to the trochar, so as to place it on the most prominent part of the tumor, when pressure on the stiletto will effect the object in a mo- ment. Dr. O'Ferrall recommends that the operator should stand behind the patient, and pass the " forefinger of his left hand between the palate and the tongue, carefully avoiding the latter, until it reach the abscess; the trochar is thus readily guided to the point intended to be punctured, and thus all danger to the surrounding parts is avoided." " Dr. O'Ferrall, in similar cases, would, in future, prefer a straight bistoury, having the cutting part short, as the density of the carving of such abscesses renders the plunge of a trochar unsafe." For fuller details, illustrated by very interesting cases, I must refer my readers to Dr. Fleming's excellent paper. 28 434 DISEASES OF THE STOMACH. CHAPTER XIII. DISEASES OF THE STOMACH. 702. Before proceeding to describe the different affections of the stomach and intestinal canal, I shall avail myself of the researches of Billard, and Rilliet and Barthez, to lay before my readers the condition of the mucous membrane of this canal in health, as it is quite possible for an uninstructed person to mistake some of these appearances for the result of disease. Billard remarks: "Now, from the examination of the stomach in several embryos and foetuses, it appears that the internal surface of this organ is of a light red color, more or less marked; that the in- ternal membrane soon show's the existence of villi; that they are more evident than in adults ; and that this internal membrane, towards the fourth or fifth month, less adherent than the other membrane, may be separated from them with great ease. Meckel observes that it is very thick towards the fourth or fifth month of pregnancy. At first sight it might be thought to be the case, but it should be remembered that the muscular coat is almost always raised with it; and the subjacent cellular membrane, which, not being quite so distinct, is added to the mucous membrane, adheres to it, and is raised at the same time. At birth, the stomach of an infant is but little dilated. It encloses a quantity of ropy mucus, with w7hich there is sometimes mixed some small grumous particles, apparently composed of concrete mucus. In still-born children there is found a layer of mucus, more or less thick, adhering to the surface of this organ. Upon raising it with the nail or the back of the scalpel, the internal membrane is seen beneath this layer perfectly healthy. This mucus disappears after a few days; and this is, doubtless, what several authors, and Capuron in particular, mean by the name of saburra, the removal of which it was necessary to effect immediately after birth. We shall see that the same thing exists in the intestinal tube, when we shall be able to appreciate more fully the nature of the advice given for the expulsion of this substance."1 703. The same author, after describing the gradual formation of the intestinal tube, and its condition at different periods of foetal life, proceeds to examine the state of this organ at birth, the matters which it contains, and the phenomena of the first alvine evacuations. "The duodenum has a rosy appearance, which is continued to the jejunum, but is less remarkable in the ilium. The jejunum has some traces of the valvula? conniventes; the villi are equally developed, and very often in the jejunum are found some separate mucous follicles, 1 Mai. des Enfans, Stewart's Trans., p. 238. DISEASES OF THE STOMACH. 435 about the size of the head of a pin, and almost always white; some follicular plexuses, slightly projecting, also white, and often with a little black point on the top, as observed in adults, are met with in the ilium. The ilio-ca?cal valve is a little projecting, and the open- ing which it surrounds extremely small; in most children it would be difficult to pass even a crow-quill. At this age, it prevents the regur- gitation of substances and even gas from the great intestines to the small, but allows a free passage for the contents of the small intestines to the large. This can easily be proved by passing a current of water through one or the other of the extremities of the digestive tube; in the one direction the water passes freely, while in the other it will meet with an insurmountable obstacle. Neither do the ca?cum or colon as yet present their depressions and prominences in as distinct a manner as afterwards, or as they appear in adults. After birth, the internal membrane of the digestive passages gradually loses its habitual color, and becomes of a milky white, and continues for some time flocculent. During the whole of the first year it is remarkable for this appearance, and for the abundant secretion of mucosity. The matters contained in the intestinal canal of a young infant vary with reference to the color and consistence. Generally, there is found in the duodenum and jejunum thick mucous substances, of a white color, adhering to the walls of the intestines; sometimes collected together in certain parts, and sometimes spread over them. They are often colored yellow, owing, probably, to the bile; and there are also found balls or small masses of a green color, which are observed in the intestines a long time after the expulsion of the meconium. I have found them in a child eight or ten days old; it would appear that they do not possess any irritating property, for their contact never produces inflammation of the mucous membrane. It is very common, also, to find about the ilio-ca?cal region an accumulation of yellow and frothing liquid; the large intestines are always filled with meconium, of the consistence of pitch, and of a deep green color, a circumstance noted by all authors." "When all the liquid parts of the intestinal tube are removed, there still remains a layer of thick mucus adhering to the internal surface of the canal, forming on it a kind of plastering. This layer may be raised with the nail, under the form of a pellicle, resembling, to a superficial observer, portions of the mucous membrane itself. It is probably this layer of mucus that certain practitioners regard as vitiated matters, or saburra, for the expulsion of which they have recommended purgatives from the time of birth. " But whether this mucus be for no other object than protection of the mucous membrane when exposed to the contact of unaccustomed ali- ments, or whether it be a simple deposit of a fluid contained for a long time in the alimentary canal, attaching itself, without any use, to its surface, it never remains there but for a short time, and detaches itself, without the assistance of any purgative, by a kind of natural exfoliation. This exfoliation occurs in very thin lamella?, which, being rolled together, form the small white flocculi so frequently met 436 DISEASES OF THE STOMACH. with in the stools of young children ; and where the surface of the duodenum or jejunum is colored with bile, it is this layer of mucus that is colored; so that, in removing it, the color also disappears from the intestine." " As soon as the child has commenced a new kind of alimentation, the contents of the intestines change their appearance, the phenomena of digestion becoming, with respect, to the manner in which it is performed, analogous to what it will be during the re- mainder of life. A great deal of importance is usually attached to the first discharge from the bowels; and nurses are eager to administer to a child just born some mild purgative, under the fear of retaining, for too long a time, a substance which absurd prejudices have induced them to regard as irritating, and as capable of exercising a serious effect on the system. I am far from entertaining any such ideas, for I can see in the meconium no irritating or chemical property; but I conceive that a prolonged retention of this matter may produce, if it be not evacuated, effects analogous to those which obstinate costive- ness produces."1 704. MM. Rilliet and Barthez have drawn their observations from children somewhat older. According to their statement, the gastro- intestinal mucous membrane is of a grayish white, or clear rose gray, the color varied by venous ramifications. Its thickness, which is not considerable, varies in different regions, as does its tenacity. The submucous tissue is of a dull white color, rather thin in general, re- sisting, and intersected by venous arborizations, more voluminous, but less numerous than those of the mucous membrane. The muscular coat underneath is recognizable by the direction of its pale or rose- colored fibres. The mucous membrane varies in different situations; it is thinner and paler in the great cul-de-sac of the stomach, less consistent, and less firmly adherent to the subjacent tissue; and this change of character is often so sudden and so complete, as to give the appear- ance of a line marking the limits of the cul-de-sac; in other cases, the transition is gradual. The capacity of the stomach varies ; it is often considerable; but, unless disease be present, this is a matter of no moment; in other cases, the organ is much contracted. Of course, the smoothness of the internal surface will be modified by these conditions. The mucous membrane of the small intestines, often colored by its contents in its superior portion, is of a grayer color than that of the stomach ; it is tolerably thick in the duodenum, but gradually dimin- ishes towards the inferior termination. Its adherence to the subja- cent tissue is but slight, and slips may easily be raised even close to the valvula? conniventes. The isolated follicles are contained in the thickness of the mucous membrane, and are not visible except under the influence of disease. The patches of follicles are, on the contrary, alw7ays visible along the free border of the intestine, and increasing in number towards its inferior portion, as in the adult. Numerous small 1 Mai. des Enfans, Stewart's Trans., p. 273. DISEASES OF THE STOMACH. 437 black points are also observed, sometimes scattered irregularly, in other cases, collected in different parts, and giving a grayish black or black color to that part of the surface. In the large intestine, the mucous membrane, is thin at first, and goes on increasing to the rectum, and the authors remark that it is always thinner at the lower side of the natural obstructions of the canal, e. g., at the cardia, pylorus, caput ca?cum coli; and from each of these points it gradually increases in thickness until we arrive at the next obstacle. The mucous membrane of the ca?cum permits a number of venous ramifications, which disappear lower down, or only reappear in the rectum ; and we find a considerable number of fol- licles, each marked by a gray spot, with a small opening of a darker color, which leads to its cavity.1 705. Let me now point out a few of the changes which take place after death, and which require to be carefully distinguished from those which are the result of disease. i. Obeying the physical laws, the fluids after death gravitate to the inferior parts of the body ; and, in the intestines, we therefore find the vessels of the most depending portions filled with blood, and forming more or less extensive arborizations; which, however, are not always present, nor are other parts exempt from the same ap- pearance. ii. These arborizations, however, are not always cadaveric; that is, they may be produced immediately before death, or in the act of dying, when the termination is accompanied by general congestion, as in asphyxia. When this is the case, the vessels have a deep violet color, and are rather situated in the submucous than the mucous tissue. m. At a later period, the blood escapes from the vessels and colors the mucous membrane, which it penetrates as if by imbibition, form- ing large spots of a dull-red color, in which no vessel can be dis- covered. In other cases, the blood distils through the membrane, and colors the mucus of the intestinal canal; or it maybe effused beneath the mucous membrane, following the sinuous track of the vessels from w7hich it escapes. iv. At a still later period, the mucous membrane acquires a green tinge, similar to what may have been previously observed on the ab- dominal parietes; this is an evidence that putrefaction is considerably advanced. v. There is another change about which there is considerable dif- ference of opinion; I allude to softening of the mucous membrane, which by some has been regarded as the product of disease, and by others as a cadaveric change, and I can scarcely doubt that both are right. As far as my knowledge extends, I am quite prepared to agree with Rilliet and Barthez; who observe, "In conclusion, we believe that simple ramollissement of the stomach, and especially of its greater cul-de-sac, may exist both as a disease and as a cadaveric phenome- ' Rilliet and Barthez, Mai. des Enfans, vol. i. p. 433. 438 DISEASES OF THE STOMACH. non; but that, considering the circumstances of temperature and putrefaction in which we ordinarily find it, we regard it, when disco- vered by dissection made twenty-four or forty-eight hours after death, as more frequently cadaveric than morbid. The intestinal mucous membrane, on the other hand, undergoes this change more frequently from disease than as a cadaveric change."1 706. In conclusion, I will just enumerate the principal pathological changes which may be observed in the mucous membrane. i. Redness in the form of arborizations, bands, or vascular lines, or uniform. ii. Softening, in which the mucous membrane is reduced to a kind of pulp, so that in extreme cases it may be scraped off, but cannot be raised in strips at all. This degree generally coincides with the uniform red color. m. Thickening.—This change may occur with or without softening; it gives prominence to the parts so affected, whether only a few points or a more extensive surface. The increased thickness is demonstrated by carefully cutting through the mucous membrane only, in different parts. These three changes are the result of simple inflammation, and may be observed in any part of the intestinal canal. iv. False Membranes, which may be more common than is sup- posed, but which are removed as secreted by the passage of matters through the intestinal canal. They may be deposited in small white patches here and there, or they may form a more extensive thin layer, white, gray, or yellow, slightly adhering to the mucous membrane, and often mixed with the fa?cal matter. v. Ulcerations.—These are sufficiently common in typhoid fever, and tubercular disease, and may be seated either in the mucous mem- brane or in its follicles. vi. Pustules.—It is very rare to meet with pustules in the stomach or intestinal canal, although such are recorded by Rilliet and Barthez. vn. Softening non-inflammatory.—Three forms have been noticed by the authors just quoted: 1. Simple or pultaceous; 2. Gelatiniform; and, 3. White or opaline ramollissement. Although the usual signs of inflammation may be absent in these cases, it is by no means certain that the morbid change is not a more distant result of inflammation. The evidence we possess, carefully examined, would, I think, lead us to the conclusion that the colorless softening, without vascularity, is, probably, the termination of a series of morbid actions, of which inflammation was the beginning. * Mai. des Enfans, vol. i. p. 441. INDIGESTION. 439 CHAPTER XIV. INDIGESTION.--VOMITING.—W'EANING BRASH. 707. The affection which has been described under the term vomiting, and more recently termed indigestion, differs very consider- ably from the adult disorder so designated, although it appears equally independent of organic disease in many cases. Vomiting is, no doubt, the prominent symptom; but we must dis- tinguish between that which results from an unhealthy or irritable condition of the stomach, and that which is merely the expulsion of an excess of food. It is a natural effort of the stomach of infants, and a great advantage, that, when too much food has been swallowed, the excess is returned, whilst the proper quantity is retained, and the child is saved from the consequences of over-feeding. This is a species of organic intelligence, which supplies the place of that knowledge which is afterwards acquired. "The milk is generally thrown off in an unchanged condition, and the infant is so little an- noyed by the vomiting, that it will often preserve its usual placid and cheerful countenance while the milk is regurgitating from its stomach. This variety of vomiting may, therefore, be regarded rather as a salu- tary than a morbid occurrence ; for the superabundant nourishment, with which the digestive organs are habitually overloaded, would, doubtless, soon give rise to indigestion, and its various disagreeable consequences, if the stomach did not regularly relieve itself by throw- ing off a portion of its oppressive load."1 Common sense will teach the mother in such cases to diminish the quantity of milk the child is allowed to take at each nursing, until it is reduced to the capacity of the digestive powers, and no other treatment will be necessary. 708. But the vomiting which occurs in the disease I am describing, does not necessarily result from the stomach being overfilled, but from its incapacity to digest what it has received, and an irritability which occasions it to reject it. It may be originally caused by over- feeding, but the effect continues after the cause has ceased. This indigestion may occur at any age. I shall notice it as we see it during suckling, after weaning, and at a later period. 709. Symptoms.—During the first year of life, while the infant is still at the breast, the earliest symptoms of the disorder we shall be able to observe will be a pallid look, languor, and considerable dis- comfort. The infant is evidently unwell; it cries and whines, and appears never easy except when at the breast. It sucks greedily, without appearing satisfied, and shortly afterwards vomits the milk, either fluid, as it received it, or curdled (and not a small portion—the 1 Eberle on Diseases of Children, p. 205. 440 INDIGESTION. surplus—but the whole, or nearly so), with evident distress, paleness of face, &c. A good deal of stress has been laid upon the fact of the milk being curdled or not, as an evidence of the presence of a morbid amount of acid in the stomach. Undoubtedly, it is not a natural state when the milk is rejected as a solid, firm curd, but it is certainly a mistake to suppose that no change takes place in the fluidity of the milk in healthy digestion. Underwood remarks: "Not that the milk ought not to curdle in the stomach, which it always must, in order to a due separation of its component parts, and which is the chief, if not the only digestion it undergoes in the stomach;"1 and experience confirms his observation, that it is only when the curdling is in ex- cess that it is to be regarded as an evidence of disease. Upon this excessive coagulation, M. Billard has the following ob- servations : "Van Swieten and Rosen have remarked that it is very common to meet with milk coagulated in the stomach without being digested. The authors first mentioned attribute it to the superabund- ance of acid in the stomach. A very evident acid smell is often detected in the mouth of a child : like that, for instance, which is observed after an attack of indigestion. I found in fifteen infants that died with other affections than those of the digestive organs, the stomach filled with coagulated milk; there were but three exhibiting a slight injection of the stomach; in the remaining twelve the walls of this organ were white and perfectly healthy. I am inclined to think that this coagulation of milk proceeded from some other cause than inflammation. Does this result from the milk taken by the child abounding in caseine, or is it the presence of acid in the stomach that so quickly coagulates this fluid? Does this acid exist, in the first place, in the stomach? Is it the result of the decomposition of the milk? Does this indigestion depend upon the w7ant of vital activity and nervous action which is displayed in the stomach during the operation of the digestive functions ? These are questions I am unable to solve; but, whatever be the cause of this phenomenon, I point it out as the effect of a true gastric indigestion, without inflam- mation of the organ, and without apparent lesion of its walls; and I wish particularly to direct the attention of physicians to this fact, that they may not be led to conclude that a child is affected with gastritis whenever it is unable to digest the milk that it has taken, or when the milk is vomited some time after in a coagulated form."2 So that a minor degree of coagulation being a part of the healthy process of digestion, an excessive degree may be owing either to ex- cessive acid, deficient nervous power or vital inaction ; and, on the other hand, milk vomited unchanged, after it has remained some time in the stomach, is an equal evidence of an incapacity of digestion. Dr. Dewees says: "If there be a deficiency of acid in the stomach, and a vomiting be produced, the milk will come up unchanged. Nausea almost always attends this variety; the child may be observed 1 On Diseases of Children, p. 223. 2 Mai. des Enfans, Stewart's Trans., p. 243. INDIGESTION. 441 to become pale, and evidently to struggle against the efforts of its revolting stomach. The milk is rejected with great force in a large column;^ and not unfrequently a portion passes through the nostrils." 710. To return. The child is attacked by frequent vomiting, after which it looks pale and exhausted; but it is as eager as ever to suck again. Occasionally, much alarm has been felt in consequence of blood being mixed with the ejected milk ; but this is owing to the nipples having cracked, and the child having drawn blood when sucking. The bowels are not necessarily affected ; they are sometimes in a natural state, sometimes, constipated, and occasionally too free. Nor does the child suffer, generally, from pain or tympanitis, although the stomach may be troubled with flatulence. This alternation of sucking and vomiting is gradually followed by emaciation and exhaustion, and a sinking of the vital powers; but there is no evidence at all of inflammation of the stomach. The child derives no nourishment from its food, and, in the end, if relief be not afforded, dies of exhaustion from starvation. In such cases, however, it is not uncommon to have a new train of secondary symptoms occur, such as heaviness, stupor, convulsions, &c. ; in fact, in all cases of prolonged disorder of the stomach or bowels, the most watchful attention should be directed to the condi- tion of the nervous system, and the most prompt efforts made to relieve the earliest symptoms of disease of these organs. If relief be not afforded to this species of indigestion, the infant may linger on for five or six weeks, gradually become weaker, thinner, and more unable to digest its food, until, at length, it sinks from ex- haustion, or from some secondary attack. 711. At the time of weaning, or soon after, the child is very apt to suffer from indigestion, in consequence of the change of food. This disorder, however, is not confined to the stomach, but involves, appa- rently the entire intestinal canal. It may come on a few days after weaning, or not for some weeks. Dr. Cheyne has given an admira- ble history of this disease, under the term "Atrophia Ablactatorum." " The first symptom," he says, "is a purging, with a griping pain, in which the dejections are usually of a green color. When this purging is neglected, and, after continuing for some time, there is added a retching, with or without vomiting: when accompanied by vomiting, the matter brought up is frequently colored with bile. These increased and painful actions of the alimentary canal produce a loathing of every kind of food, and, naturally, are attended with emaciation and softness of the flesh, with restlessness, thirst, and fever. After some weeks, I have often observed a hectic blush on the cheek ; but the most characteristic symptom of this disease, is a con- stant feverishness, the effect of increasing griping pain, expressed by the whine of the child, but especially by the settled discontent of his features; and this expression of discontent is strengthened towards 1 Diseases of Children, p. 374. 442 INDIGESTION. the conclusion of the disease, when the countenance has shared in the emaciation of the body. " In the progress of the disease, the evacuations from the belly show very different actions of the intestines, and great changes in the biliary secretion ; for they are sometimes of a natural color, at other times, slimy and ash-colored, and sometimes lienteric. Towards the end of the disease the extremities swell, and the child becomes ex- ceedingly drowsy ; but these I rather conceive to arise from debility, than to be pathognomonic symptoms. It is remarkable, in the ad- vanced stages of the disease, that the purging sometimes ceases for a day or tw7o, but without any amelioration of the bad symptoms ; nay, I think that children decay even faster than when the purging is most violent. The disease seldom proves fatal before the sixth or seventh week, and, in this short time, I have seen the finest children miser- ably wasted. I have seen, though rarely, a child recover, after the disease had continued three or four months ; and again, I have seen the disease cut short by death, in the second, third, or fourth week, before it had reached the acme; the sudden termination having been occasioned by an incessant vomiting and purging, or by convulsions from the immense irritation in the bow'els."1 To this graphic de- scription I have little to add ; except that, in many instances, the symptoms of gastric disturbance precede those which indicate intes- tinal derangement, and which is the reason why I have introduced the disease here, rather than under the head of diarrhoea. The dis- ease, as Dr. Cheyne observes, is by no means rare, and, if neglected, is very fatal; but, if taken in time, is sufficiently manageable. It is more common with children who have been wreaned abruptly, and at an unusually early period. 712. At a later period, the child's stomach may become disor- dered, and an effort may be made for relief by vomiting and purging, or both ; after which, the child may resume its usual health. Or the derangement may continue, the appetite may be impaired, and the food taken appear to disagree with the stomach ; the child is pale, fretful, and uneasy, especially after a meal; complains of pain in the stomach and bowels, resembling colic or spasm ; is troubled with flatulence; and, occasionally, the belly is swollen and tympanitic. The breath is sour, and there are acrid eructations, with repeated vomiting of undigested or half-digested matters ; after which, the child seems somewhat relieved. If this state of things continue, the intestinal canal becomes irri- tated, and purging sets in, and the evacuations are generally of a green color, accompanied by colic. The little patient is soon reduced in flesh and strength; his countenance is pale and depressed ; his pulse weak, and sometimes quick; the appetite diminished, and the animal spirits sunk. Occasionally, the food passes through the bowels almost unchanged, constituting the disease called lientery. In some cases, the purging alternates with constipation. 1 Essay 2. On Bowel Complaints, p. 16. INDIGESTION. 443 In process of time, other organs become involved; the liver gives evidence of functional disturbance; but by far the most serious com- plication, and one by no means uncommon, is the head, as manifested by stupor, coma, or convulsions. This secondary affection, so com- mon towards the end of gastric or intestinal diseases, places the patient in the greatest danger, from its occurring at a time when active treatment is nearly impossible, owing to the weak state of the child. No case requires greater watchfulness, none more judicious and skilful treatment, than these cases; and, do what we may, a large propor- tion die. If no complication occur, the indigestion may often be cured, after an uncertain duration of from a week to a month; but it may also prove fatal from exhaustion. 713. Morbid Anatomy.—As a general rule, post-mortem examina- tion reveals no trace of disease; now and then, as Billard has observed, we may find vascular ramifications in the coats of the stomach; but this may be either the normal condition of the stomach with food in it, or a cadaveric change. Ordinarily, the stomach and intestines are more bloodless than usual, semi-transparent, and unequally distended with air. The mucous membrane is pale throughout, and occasionally softened. " The want of color," Dr. Stewart remarks, " is almost al- ways the first degree of a species of softening, which should not be confounded with a species of inflammation. The disease described by M. Cruveilhier, under the name of gelatiniform disorganization of the mucous membrane of infants, would appear, from the detail of symptoms, to be a violent species of the disease now under considera-* tion. M. Duges, in his Manual d'Accouchemens, in speaking of a similar affection, remarks that he has found the interior coat of the intestines covered with a white mucus, of a pulpy consistence, and bearing a resemblance to imperfect chyle, and which inattentive ob- servers might mistake for the softened mucous membrane. The mucous follicles, he observes, could be still seen on the intestinal surface."1 The post-mortem appearances in "weaning brash" are thus de- scribed by Dr. Cheyne: " I observed in every instance that the intestinal canal, from the stomach downward, abounded with singular contractions, and had in its course one or more intussusceptions; that the liver was exceedingly firm, larger than natural, and of a bright red color; and that the enlarged gall-bladder contained a dark green bile. In some dissections, the mesenteric glands were swelled and inflamed ; in others, however, they were scarcely enlarged, and had no appearance of inflammation. These contractions and intus- susceptions wrere entirely of a spasmodic nature; as, in the latter, the contained part of the gut was easily disengaged from that which formed its sac, and in no part of the entanglement was there adhesion or even the mark of inflammation; and the contracted portions of the intestines were again permanently dilated by pushing the finger into 1 Diseases of Children, p. 184. 444 INDIGESTION. them. These appearances lead me to imagine that weaning brash, in its confirmed state, is imputable to an increased secretion of acrid bile, or rather to the morbid state of the liver which occasions this; of which, however, I am afraid to attempt the explanation."1 714. Causes.—Before weaning, indigestion may be caused by ex- cess in the quantity of milk, or by giving the child the breast too often, or too soon after vomiting, in order to quiet it. Deficiency or excess of the nutritive qualities of the milk, or its possessing bad or irritating qualities, may also give rise to it; and the latter condition may be caused by errors of diet on the part of the nurse; by her in- dolence, luxurious habits, giving way to passion; by the presence of the catamenia, by the too great age of the milk, and by too prolonged nursing, as I have heretofore observed.2 The process of digestion may be disturbed, and the gastric powers deranged, by tossing or moving the child about, too soon after suckling. After weaning, the most common of all causes is some error in diet; the child is fed too much or too frequently, or upon improper food; and when the stomach, with the admirable organic intelligence which it possesses in childhood, rejects what is not proper for it, instead of taking a hint, and giving it a change of food, or at least a rest, more food is given, and probably of the same kind, so that the sto- mach becomes permanently deranged, and that w7hich was a healthy process becomes a symptom of a morbid condition. Another cause, and doubtless a frequent one, is dentition. The stomach and bow*els are very apt to be more or less disturbed during this process; and, though distressing, it is the least injurious of all the reflex irritations to which dentition gives rise. It ceases, also, when the irritation is removed by scarification. Underw7ood and others have attributed this vomiting to the sup- pression of accustomed discharges, or the sudden cure of cutaneous eruptions. Dewees doubts this; but Eberle mentions a case in which the child was attacked by vomiting whenever a discharge from behind the ears was dried up, and which was relieved by reproducing it. 715. Diagnosis.—The absence of permanent pain, tenderness, and fever; the weak, quiet pulse, and clean tongue, will generally suffice to distinguish this complaint from gastritis. The success or failure of the treatment will also throw some light upon the matter. But there are two other diseases with which it might be con- founded, at a certain period, and from which it is of the highest im- portance to distinguish it. Vomiting is often among the earliest symptoms of meningitis; at a period, indeed, when it sometimes requires a practised eye to detect more. But we may always find some nervous disorder, disturbed sleep, starting, staring, heaviness, flushed face, suffused eyes, headache, &c, none of which are remark- able in the present disease, and upon the presence or absence of which our decision must be made. Again, vomiting occurs in strangulated hernia, but a careful exami- 1 Essay ii. p. 23. 2 Vide chap. iii. INDIGESTION. 445 nation, which, in such cases, should never be omitted, will enable us to pronounce upon the presence or absence of the hernia. 716. Treatment.—The first object is to regulate and correct the food of the infant as to quantity and quality. If the disorder can be fairly traced to an excess of milk, of course'it is easy to remedy that, and it should be done forthwith. But if, as is more frequently the case, we have reason to believe that the milk disagrees with the infant, the nurse should be changed, and a new one obtained, whose milk is of a suitable age. Nay, even if there be a doubt about it, it will be better to make the change. When satisfied about the nurse, I would advise that the infant should only be allowed to take half the usual amount of suck at a time, and have it oftener, if necessary, until the stomach recovers its tone. If the bowels be confined, they should immediately be freed by an enema, as their action tends to quiet the stomach. I have found nothing so effectual in tranquilizing the gastro-intesti- nal disturbance, as the following mixture:— R. Mist, amygdal; Aquae carui, aa. ^ss; Spts. amnion, arom. gutt. v; Tincturae opii gutt. ii vel. iii. M. A teaspoonful may be given, two, three, or four times a day, and at the same time some counter-irritant should be applied over the stomach: either a poultice of mustard and linseed-meal, a liniment containing a small quantity of laudanum, or a small blister. Dr. Eberle recommends small doses of calomel and ipecacuanha. "I have repeatedly succeeded in arresting vomiting," he says, "from inordinate gastric irritability in infants, by exhibiting the eighth of a grain of calomel, with one-sixth of a grain of ipecacuanha, every hour or two, in conjunction with the application of a stimulating poultice or plaster over the epigastrium."1 In obstinate cases, he advises "a grain or two of morphia to be sprinkled on the surface of a small plaster of common cerate, and laid over the pit of the stomach." Dr. Stewart speaks highly of rhubarb and ipecacuanha. Dr. Underwood says: "A drop or two of the aqua kali, or a little Castile or almond soap, are excellent remedies; not only as they will correct acidity, but promote the secretion of bile, as well as a generous warmth in the great passages, and assist the digestion. For which purpose, also, myrrh is an excellent remedy, when infants are a few months old."2 The gums should be carefully examined, and a free incision made, if there be the least evidence of irritation from the teeth. 717. Dr. Cheyne recommends that, in the beginning of "weaning brash," when the attack is slight, we should give a dose or two of rhubarb, at intervals of two days, and a half or third of a grain of ipecacuanha, with six or eight of prepared chalk, and some aromatic powder, every four or five hours. If there be much griping, an ano- ■ Diseases of Children, p. 210. 3 Ibid., p. 225. 446 INDIGESTION. dyne enema may be given. The diet must also be regulated care- fully, and animal substances are better than vegetable. Eggs, fine ship biscuit, arrowroot custard, the juice of lean meat, plain animal jellies, and milk, are the chief articles of nourishment. A wet-nurse would undoubtedly be the best, if the child were young and would take the breast; and the best substitute I have found for this is ass's milk. In the severe cases, Dr. Cheyne found more benefit from half a grain of calomel twice a day for some time, with anodyne enemata for the relief of the pain, than from anything else. 718. WThen the child is still older, if his stomach have been over- loaded, or if he have taken indigestible food, it will be well to com- mence with an emetic, after which we may have recourse to small doses of laudanum, with or without ammonia, and external irritation. The bowels must also be kept free; but if diarrhoea be present, with much pain, an anodyne enema may be administered. If there be any evidence of biliary derangement, small doses of calomel, or hyd. c. creta, will be very useful, followed occasionally by a purgative, or combined with an astringent, according to the state of the bowels. Carbonate of soda, magnesia, or lime-water and milk, may be given if there be an excess of acid in the stomach; and the dilute muriatic acid, or lemonade, if there be a deficiency. Dr. Condie speaks very highly of a combination of magnesia, extract of hyoscyamus, calomel, and ipecacuanha; and also of a few drops of spirits of turpentine, or the ethereal solution of camphor. External irritation, by mustard liniment or blister, is of great use; and if there be colic, laudanum may be applied externally, as w7ell as internally. Sometimes great relief is afforded by fomentations, or by a large linseed poultice to the belly. When the disease has been arrested, tonics maybe necessary. I have found great benefit from two or three grains of carbonate of soda, and as much powdered columba, three times a day. "In that form of infantile indigestion in which softening of the stomach is most likely to occur, a trial may be made of hydro-chloride of iron, which appears to have frequently succeeded in restoring the healthy functions of the stomach in the hands of Pommer, Herjt, Camerer, Droste, and others."1 The diet must be carefully regulated, and it is far better to retro- grade a little, and substitute a simpler diet than the one to which the child has been used. Milk, eggs, arrowroot, panada, &c, will answer better than animal food. 719. When the head is becoming involved, no time must be lost in making the best use we can of derivatives and counter-irritants. Mustard cataplasms or blisters to the legs, blisters to the head or neck, cold lotions to the head, &c, must be tried in succession. In few cases can we venture to take blood or apply leeches, and yet the dis- ease must be checked quickly, if the child is to live. Meantime, the treatment for the primary complaint must go on, except, perhaps, a more sparing use of laudanum. 1 Condie on Diseases of Children, p. 183. GASTRITIS. 447 If the child be greatly reduced, more nourishment must be given; jellies, broths, or beef tea will be necessary, and sometimes wine whey; nor have I found the head symptoms increased by it, but fre- quently lessened as the extreme exhaustion was relieved. CHAPTER XV. GASTRITIS.--INFLAMMATION AND SOFTENING OF THE STOMACH. 720. Inflammation of the stomach and its consequences have not received very much attention from authors, until comparatively re- cent times, although it is probable that some of the cases described under the term "vomiting" were really of this nature. Saillant,1 Fleisch,2 Lesser, Maunsell and Evanson,3 and others, have noticed the disease; but we are more indebted to Dunglison,4 Billard, Stewart, Condie, Rilliet and Barthez, &c. Jaeger,5 Camerer, Morgagni, San- difort, and Hunter, described a softening occurring at the larger ex- tremity of the stomach; and since their time Ramisch,6 Vogel, Hufe- land, Cruveilhier,7 Billard, Bouchut, Barrier, Rilliet and Barthez, &c, have thrown much light upon the subject, although there are still questions left undecided. Inflammation of the stomach is by no means a frequent disease, nor is it always so well marked as to enable us to distinguish easily between it and functional disorder, such as I described in the last chapter; and, moreover, it is frequently combined with irritation or inflammation of the intestines. It may be either primary or secondary, but, according to Rilliet and Barthez, far more frequently the latter than the former. 721. Symptoms.—The symptoms are not always very character- istic, and, in some cases, are very obscure. In certain cases, Rilliet and Barthez remark that the disease is completely latent, revealing itself by no symptom, or by some trifling phenomenon which escapes notice ; as, for example, one or two vomitings after medicine contain- ing tartar emetic or ipecacuanha ; or vomiting, apparently sympathetic at the commencement of the primary malady. Among these cases we find erythematous, pseudo-membranous, or ulcerated gastritis, and, above all, softening of the stomach."8 Ordinarily, however, as M. Saillant observes, the child complains of more or less pain, often very severe, occurring in paroxysms at short intervals, with violent contortions of the body. Vomiting is a com- 1 Mem. de la Soc. de Med., 1786, p. 327. a Die Entzundung, &c, p. 230. 3 Diseases of Children, p. 277. 4 On Diseases of the Stomach and Bowels in Children, 1824, p. 180. 6 Hufeland's Journal, May, 1811, and Jan. 1813. 6 AUg Lit. Zeitung, No. 56, May, 1826, p. 447. ' Anat Path., Livraisons, 4-7, &c. 8 Mai. des Enfans, vol. i. p. 405. 448 GASTRITIS. mon occurrence, both at the beginning and during the course of the disease, though there may be considerable intervals. The matters ejected are, first the ingesta, then a greenish or yellowish fluid, and, in some rare cases, according to Denis,1 blood. We must, however, be careful, if the infant be at the breast, not to mistake the source of the blood, which may have been drawn from the mother's nipple. In some of the worst cases, the vomiting is excessive as to quantity, and incessant. Rilliet and Barthez have remarked that the vomiting is more troublesome when softening occurs than in simple gastritis, although there is often a sudden and complete cessation for some time before death. The bowels may or may not be disturbed. In some cases there is rather obstinate constipation ; in others, and more frequently, there is diarrhoea. The abdomen is generally swollen and tympanitic ; the epigastrium hot, tense, and tender on pressure; the thirst great; the appetite lost; the tongue sometimes loaded and white, sometimes dry and red at the point and edges. The urine is generally scanty; the pulse is quick and small, but not weak; the skin hot and dry. Thus, then, the principal symptoms are the heat, tension, pain, and tenderness of the epigastrium, with vomiting, and a quick pulse and fever. 722. But the attack " may become chronic and continue for a length of time, with occasional vomiting, some degree of tension and tender- ness of the epigastrium, irregular appetite, occasional diarrhoea alter- nating with costiveness, a dry and harsh condition of the surface, febrile symptoms of a remittent character, and progressive emaciation. White softening of the stomach, with perforation, may occur in these cases; or, the irritation being transmitted to the brain, effusion into that organ may take place; or, tubercles becoming developed in the lungs, the patient may die with all the symptoms of tubercular phthisis."2 723. Inflammation of the stomach may result in softening, ulcera- tion, or gangrene. I do not know that there are any symptoms by which we may detect the two latter occurrences during life. Under the title " gelatinous softening," M. Cruveilhier has described a well- marked disease; and more than once Billard has seen an accurate diag- nosis made by M. Baron. M. Billard thus enumerates the symptoms: " The disease usually commences with symptoms of violent gastritis, such as tension and pain in the epigastric region ; the substances discharged by vomiting are not only the milk and drinks, but yellow and green fluids, occurring either immediately or long after eating or drinking. There sometimes exists a diarrhoea, varying in different subjects. It will return after having ceased for one or two days. The stools are often green, like the matters discharged by vomiting. The skin is cold at the extremities; the pulse, generally irregular, is, how- ever, very inconstant; the face continually expresses pain, and is wrinkled, as if the child were crying; the cry is painful, and the respi- ration jerking; and the general restlessness, induces a belief of the 1 Mai. des Enfans, Nouveaux-nes, p. 46. 2 Condie on Diseases of Children, p. 184. GASTRITIS. 449 existence of a cerebral affection. To these symptoms succeed a general state of prostration and insensibility, occasionally disturbed by a return of the pain, producing from time to time the same restlessness, which appeared at the commencement of the disease; and lastly, at the end of six, eight, or fifteen days, and sometimes later, the patient sinks, wasted by wakefulness, continual vomiting, and pain. In very young infants scarcely any fever is manifested in the midst of this disorder. When the disease is chronic, the progress of the symptoms is slower."1 724. Morbid Anatomy.—On post-mortem examination the stomach exhibits the different modifications of inflammatory action I have re- cently noticed. 1. There may be found a diffused redness in some parts, or, it may extend in bands or lines along the longitudinal folds, or in vascular ramifications; such is the erythematous gastritis. 2. Or we may discover, in some portion of the stomach, a pseudo-membranous secretion, analogous to that in muguet. 3. The follicular glands may be chiefly affected ; enlarged, prominent, and ulcerated. 4, The in- flammation may have terminated in gangrene, with general disorgani- zation of the tissues, or a limited disorganization, resembling an eschar.2 5. The mucous membrane, or all the tissues of the stomach, may be softened. 725. But a little more detail is necessary touching this " ramol- lissement gelatiniforme," which is thus described by M. Cruveilhier: " This softening always proceeds from the interior towards the exte- rior. There is, at the beginning, simple separation of the fibres by a gelatinous mucus, and, in consequence, the parietes are thickened and semi-transparent. Shortly after, the fibres themselves are involved, and disappear, so that the softened stomach or intestine resembles trans- parent gelatine, in the form of a tube, or a portion of a tube. If the transformation be complete, the disorganized portions are removed, layer after layer, those which remain becoming gradually thinner. The peritoneum alone resists for some time, but at length it is attacked, worn, and gives way, and perforation of the stomach results. The parts thus transformed are colorless, transparent, apparently inor- ganic, completely deprived of vessels, and exhaling an odor resem- bling that of milk. The softened portions are decomposed much less quickly than the unaltered portions. Boiling, which converts the stomach and intestines into a jelly, gives a perfect idea of this morbid alteration."3 M. Billard has described two forms; the first, answering pretty accurately to the above description of M. Cruveilhier, he regards as pathological, but not the second species, in which the gastric tissues are simply deprived of color and softened. The great pathological questions connected with this morbid change are:* 1. Is it a pathological or cadaveric change? 2. If pathological, is it the result of inflammation or a disease sui generis? 1 Mai. des. Enfans, Stewart's Trans., p. 267. » Rilliet and Barthez, Mai. des Enfans, vol. i. p. 459. Denis, Mai. des Nouveaux- nes, p. 56. 3 Anat. Path., livr. 4-7, &c. 29 450 GASTRITIS. M. Valleix says: " It seems to me impossible, in the present state of science, to distinguish during life, the cases of simple pale softening with thinning, from those in which the softening is associated with evident traces of inflammation;'" and further on he gives his opinion that it is the result, either pathological or cadaveric, of chronic gas- tritis. M. Billard observes: "What inference shall be drawn from the preceding facts and considerations? That the gelatinous softening of the stomach consists in a disorganization of the mucous membrane of this organ, caused by intense inflammation, acute or chronic; that this disorganization is characterized by an accumulation of serosity in the walls of the organ, a swelling and gelatinous consistence of the mucous membrane at a part usually circumscribed, situated generally in the larger curvature of the organ, and round which there are more or less evident traces of acute or chronic inflammation; that this dis- organization entails others, may give rise to spontaneous perforation causing speedy death; and that it may be developed not only at the period of the first dentition, as in most of M. Cruveilhier's cases, but even in very young infants, of which I have reported examples."2 Rilliet and Barthez regard this as a secondary lesion, and as most likely the result of inflammatory action. M. Bouchut denies that it is an isolated disease, but a consequence of the acidity of the fluids contained in the digestive canal.3 Jaeger, Camerer, and Zeller refer it to a paralysis of the nerves of the stomach, with increased acidity of the gastric juice. Cruveilhier and Rokitansky admit two kinds of softening; one pa- thological, the other cadaveric. Rokitansky conceives that the softening of the stomach in children is pathological, and dependent upon a disease which he regards as almost peculiar to early life. M. Barrier differs from those who regard it as a specific disease; he thinks it most frequently cadaveric and chemical; but, if patholo- gical, that it is the result of an anterior morbid condition.4 Dr. Dunglison considers that there is little difficulty in pronouncing it the result of previous inflammation.5 Dr. Carswell agrees that it may be either cadaveric or pathological; and that when it is the latter, the symptoms are those of gastritis or enteritis; and he adds, that "there are no symptoms referable to the state of softening which we have described, considered in itself, and as a termination of inflammation of the mucous membrane.6 Dr. Stewart regards this softening, as well as the other morbid changes, to be the result of inflammation.7 Dr. Condie remarks: "Without denying that the stomach may be dissolved after death, in consequence of the generation in its cavity 1 Guide de Med. Prat., vol. v. p. 118. 2 Mai. des Enfans Nouveaux-nes, &c, p. 232. 3 Ibid., p. 231. •» Mai. de l'Enfance, vol. ii. p. 118. s Diseases of Stomach and Bowels, p. 183. 6 Cyclop, of Pract. Med., vol. iv. pp. 13-15. • Diseases of Children, p. 249. GASTRITIS. 451 of an excess of acid; and being well aware that a softening of the tissues of the stomach and of other parts of the alimentary canal may be produced by causes affecting the nutrition, and impairing the co- hesion of the various tissues, altogether independent of inflammation, we are still convinced, from the result of our own observations, that the gelatinous softening, so frequently observed in children who have died of acute gastritis, is invariably the effect of intense inflammation of the mucous and other tissues of the stomach."1 Dr. West " has not been able to discover any peculiarity in the character of such symptoms (of disordered functions), nor even any constancy in their occurrence; nor have I observed that,the disease of which the infant died has exercised any appreciable influence in predisposing to softening of the stomach, or in preventing its occurrence."2 Dr. West also mentions a recent theory of Dr. Elsasser.3 " He refers the alteration of the tissues, not to the gastric juice itself, but to the acids generated during the decomposition of the food Contained within the stomach and intestines at the time of death; and endeavors to account for the frequency of the occurrence in the case of infants, from the facility with which a free acid is generated in the milk which forms the chief part of their sustenance. According to his researches, which appear to have been carefully conducted, the change never ought to take place when the stomach is empty; but his assertion that it never does, is opposed to universal experience."4 Further, the same excellent writer mentions that, in Herrich and Popps' work,5 there is " a table of 104 cases in which softening of the stomach was found after death from different causes and at various ages. In no instance were symptoms observed, that would have enabled any one to pronounce beforehand, that: softening of the stomach would be dis- covered after death. In by far the greater number of cases the stomach was empty, showing that the cause was very often independent of digestion; while the period of childhood, the rapid course of the fatal disease, and death from cerebral affections, were the only cir- cumstances that appeared to have any clearly appreciable influence in favoring its production." It appears, then, that redness with thickening or softening, or both, are undoubted proofs of inflammation; that false membrane, ulcera- tion, and gangrene, are equally conclusive evidence of previous or accompanying gastritis; but that pale, gelatiniform softening may be either the result of disease or a change which takes place after death. The balance of evidence is in favor of one at least of the forms of this curious alteration of structure' being the result of inflammation, but the cause of the other is uncertain. 726. Causes.—Gastritis may arise from the continued use of im- proper food converting the indigestion described in the last chapter 1 Diseases of Children, p. 186. a Diseases of Infancy and Childhood, p. 371. 3 Die Magenerweichung der Saiiglinge, Stutgard, 1846. 4 Diseases of Infancy and Childhood, p. 371. s Der plotzlichen Tod aus inneren Ursachen, p. 330. 452 GASTRITIS. into actual inflammation, or from eating acrid substances or swallowing poisonous matters. Nay more, it would appear from the observations of Rilliet and Barthez that the continued use of powerful remedies, such as tartar emetic, croton oil, in secondary affections, gave rise to gastritis, and even though the dose were moderate. Although these medicines, are valuable, and in some cases necessary, still this should be a warning to use great care and watchfulness in their administra- tion. As a general rule, I have not found one sex more liable to the dis- ease than the other; but of thirty-one cases of gastritis, observed by Rilliet and Barthez, twenty-three were boys and eight girls; and of twenty-seve*h cases of softening, fourteen were boys and thirteen girls. The latter was much more frequent before the age of six than after- wards ; the former nearly equal at all ages. Children of weak con- stitutions, or who have been exhausted by disease, seem more liable to the complaint. The usual exciting causes—cold, damp, exposure, bad food, crowd- ing, &c, may influence the production of this disease as well as others; but we find that it is frequent as a secondary affection; and the prin- cipal diseases in the course or towards the termination of which it occurs are—meningitis, meningeal apoplexy, pneumonia, and the eruptive fevers. "In many cases, particularly in young infants, the inflammation of the stomach is preceded by an attack of stomatitis; in others, the stomatitis occurs subsequently to the gastritis."1 727. Diagnosis.—The most characteristic symptoms of gastritis are pain, heat, tenderness and tension of the epigastrium, with vomiting; and when these are present we can have no doubt of the nature of the attack, nor any difficulty in distinguishing it from the indigestion I described in the last chapter; but in many cases these symptoms are less marked, and in some they are absent; and then, undoubtedly, it will be difficult, if not impossible, to arrive at any certainty. We have already seen, on the highest authority, that there are no symptoms which indicate the occurrence of softening. 728. Treatment.—The first indication is, of course, to remove every possible cause". If the child be young, it will be well to change the nurse; or, if older, to substitute some bland, easily digested food for that it has been habitually using. If it be teething, the gums must be lanced freely; and if the bow7els are confined, a purgative enema should be given at once. If the symptoms of gastritis should occur during the treatment of another disease, we must, of course, give up the use of all powerful and irritating medicines, and seek to accomplish our object in some other way. Should the patient be tolerably strong, and the gastritis primary, or if secondary, and the child not much reduced, it will be advisable to apply a few leeches to the epigastrium, limiting the amount of the bleeding; and, after that has stopped, applying a light, warm, linseed- meal poultice. 1 Condie, Diseases of Children, p. 185. GASTRITIS. 453 If, however, the child cannot bear this, or if partial relief only be obtained by it, some irritating application will be advisable—a pretty strong liniment, mustard poultice, or a blister. I am inclined to think that the latter is, on the whole, Jess painful, as well as more effectual. Great advantage is sometimes derived from dressing the blistered surface with ointment in which there is a small quantity of opium or morphia. M. Billard advises the tartar emetic ointment; but I should hesitate to use this, on account of the gastric irritation it sometimes occasions, even when applied externally. The more distressing symptoms, vomiting, heat at the epigastrium, &c, may often be soothed by very cold drinks, or by a small fragment of ice swallowed now and then. There is no great choice of internal medicines: a minute dose of calomel, or the hyd. c. creta, two or three times a day, with a little chalk and opium, or Dover's powder, will be useful. Or we may order a mixture with mucilage, syrup, and spearmint water; and one, two, or three drops of laudanum to the ounce, of which a teaspoonful may be taken three or four times a day. Dr. Condie gives from one-sixth to one-half of a grain of calomel every one or two hours. " This we have known," he says, " in a large number of cases, to suspend very promptly the irritability of the sto- mach, and to produce a favorable change in the symptoms generally. In cases attended w'ith frequent, thin, acid evacuations from the bowels, the calomel we have found very generally to arrest the diarrhoea and render the stools of a more consistent and natural appearance. We ordinarily combine with each dose of the calomel a grain or two of cal- cined magnesia, and give it mixed in a little mucilage; but when there exists very great irritability of the stomach, we direct the calomel, combined with a few grains of powdered gum acacia, to be placed dry upon the tongue, the child being shortly afterwards given to drink a spoonful of thin mucilage."1 The diet must be carefully arranged—simple, bland, and unirritating it ought to be. Milk in any form, milk and lime-water, mucilage, blanc-mange, arrowroot, tapioca, sago, &c, may be used according to the age of the child. After weaning, I have found ass's milk a very nice substitute for cow's milk. But the quantity is as important as the quality; it will be quite necessary to diminish the usual amount, nay, in some cases, to give only what is necessary to support life. 729. There is no special treatment for softening of the stomach; the remedies employed for the gastritis, if they are successful, will super- sede the necessity of others for the ramollissement, and if they fail we have none other more effectual. Rilliet and Barthez recommend chiefly the gummy extract of opium; or, if this cannot be given internally, muriate of morphia is to be sprinkled over a small blistered surface at the epigastrium. Dr. Lion, of Breslau, depends principally upon external means and ' Diseases of Children, p. 187. 454 DIARRHOEA. a suitable diet, very small quantities of food at a time, a warm bath, mild enemata, exercise in the open air, an aromatic plaster to the stomach, and internally the decoction of acorns, carbonate of iron, or the tinct. ferri muriatis.1 Chronic gastritis may be treated by nearly the same means; leeches will not be necessary, but small and repeated blistering will be most advantageous, with a warm bath occasionally, and mild unirritating diet. Dr. Condie speaks highly of a combination of calomel, ipeca- cuanha, and hyoscyamus. The state of the bowels must be carefully regulated. CHAPTER XVI. DIARRHOEA.—CHOLERA INFANTUM.—ENTERITIS. 730. There is no complaint so common in infancy and childhood as disordered bowels ; and this we can easily understand, on account of the delicacy of the mucous membrane, and the novelty, so to speak, of the functions it is called upon to fulfil, in the first instance; and the variety and irregularity, both of quantity and quality, of the food submitted to it in after years of childhood, to say nothing of the reflex disturbances arising from irritation of other organs, and of which this is the most frequent seat. .This disorder of the bowels varies in extent, intensity, and results, in every possible way. In some, there is merely an increased loose- ness, temporary, and without any ill effects; in others, the purging continues long, with some inroads upon the constitution, but without any deviation from the normal condition of the discharges. Again, the quantity of the discharges may not only be increased, but the quality may be very much changed, indicating, in some cases, a more extensive, in others a more serious morbid action; and, lastly, this disordered function may be accompanied with symptoms which indi- cate the presence of inflammation, whose actual existence may be proved after death. And yet, it is often very difficult to draw the line between functional disturbance and organic disease. The symptoms may be identical, or nearly so, and the results may be analogous. I have, therefore, thought it better to include all in the one chapter ; noting, so far as I am able, the gradations and the symptoms signi- ficant of each. Let me remark, also, that although, for the convenience of descrip- tion, gastritis, enteritis, and colitis are treated separately; yet, we more frequently find them conjoined in practice, as gastro-enteritis or entero-colitis, than isolated, as the reader will find them in books. This is an inconvenience which cannot be altogether avoided. 1 Ranking's Abstract, vol. i. p. 177, from Caspar's Wochenschriit, No. 34. DIARRHOEA. 455 Diarrhoea, then, whether functional or the result of inflammation,1 may be either acute or chronic, either primary or secondary. 731. Symptoms.—Dewees, Eberle, and others, have classified diar- rhoea, according to the character of the discharges, in the following manner:— i. Feculent Diarrhoea, in which the discharges are increased in quantity and frequency, but preserve their natural character; the evacuations being preceded by slight nausea, and accompanied with some pain. n. Bilious Diarrhoea.—"In this species the fa?ces are loose, copious, and of a bright yellow or green, and the bowels are stimulated to in- ordinate action by an overcharge of bile, either vitiated or not. This complaint is very frequent among our children during the heat of our summer, or as the fall approaches. The influence of a hot sun upon the action of the liver, is well known to everybody. It is familiar to common observation that, after a spell of very warm weather, even the healthy evacuations of the adult give evidence of its rapid formation, and sometimes of its abundant absorption. Thus, the fa?ces are ob- served to be loaded with bile, and the urine to be deeply tinged with it; and when the complaint of which we are treating seizes upon children, it is called the 'liver complaint.' "This action of the bowels, as in the species just considered, some- times relieves them of their stimulating contents, and will thus effect its own cure; hence this species, like the others, may be ephemeral, and not be more formidable than the feculent species, unless the form- ation of bile goes on almost indefinitely, or fever be provoked."2 in. Mucous Diarrhoea.—The evacuations in this variety contain a considerable amount of mucus, or may perhaps consist almost entirely of it. The discharge may not be very frequent nor very large; there are generally some little tenesmus, and occasionally a little blood. Ordinarily, their color is greenish, or light green, and very offensive. Sometimes they resemble chopped spinach; at other times yellowish or greenish clay, with a very bad odor.3 I have observed that, in many cases, these green stools are originally yellow, but become quite green in an hour or two. How far Dr. Golding Bird's opinion, that the green matter is blood in some way changed, is true, I do not know. The mucus is at first thin and transparent; afterwards it becomes thicker, opaque, and almost puriform. This form appears to arise from sudden transitions of the weather, or from a sudden chill. ' M. Billard divides the disease into erythematous gastritis, with or without alteration of secretion, follicular enteritis, and enteritis properly so called. M. Valleix describes simple enteritis, and enteritis combined with muguet. Rilliet and Barthez treat all va- rieties under the title of gastro-intestinal inflammation. M. Barrier speaks of acescent, follicular, serous, flatulent, and verminous diacrisis. M. Bouchut and Dr. West make a division into, 1,catarrhal diarrhoea; 2,inflammatory diarrhoea. M. Trousseau divides the diarrhoea of infants into four species: 1, bilious; 2, mucous; 3, lienteric; and 4, chole- riform diarrhoea, or cholera infantilis. M. Legendre regards the majority of cases as alterations of secretion, and the morbid lesions rather as their consequence than their cause. J Dewees, Diseases of Children, pp. Jol--. 3 Hamilton, Management of Infants, p. 69. 456 DIARRHEA. iv. Chylous Diarrhoea.—In this form, the discharges are whitish or milky. There appears to be rather a deficient secretion of bile, than any obstruction to its escape, as it is never attended by jaundice. This milky fluid is supposed by some to be chyle, and Dr. Dewees asks why the lacteals do not absorb it? and he debates whether this arises from their incapacity or from the badly concocted nature of the chyle. Might it not be well to precede these by another question,— whether this fluid be chyle at all, and not rather a morbid secretion from the intestines?—which I am inclined to believe. A child thus attacked becomes rapidly weak and emaciated; and, if not soon relieved, sinks from exhaustion. 5. Lienteric Diarrhosa.—This is characterized by the transit of the food nearly unchanged through the alimentary canal. It sometimes follows some of the other species, but more frequently dysentery. The child is uneasy after eating, and soon has a desire to go to stool, when it passes the food taken shortly before. "It generally," says Dewees, "commences during the chronic state of diarrhoea, by showing, per- haps, that some one article of diet only has passed the bowels un- changed, as potato, apple, or other vegetable substance, or fruit, which has been incautiously given to the child. This is pretty soon followed by other articles, as meat, &c, and finally, everything almost that enters the stomach is speedily conveyed through the intestines, with little or no appearance of having been acted upon by the powers of the stomach. The appetite is sometimes voracious in this disease, and the thirst is always considerable."1 Dr. Mason Good, thinks that there is a deficiency of biliary secre- tion, as in the last variety; but with this opinion, Dr. Dewees's opinion does not agree: he considers that the "complaint is seated altogether in the stomach itself, and owes its existence to the too great irritability of this organ; for no sooner is food lodged in it, than it makes efforts by an increased peristaltic action to discharge it, and the intestines transmit it with equal speed to their extremity, there to be discharged."2 732. So much for the varieties of the evacuations of diarrhoea. The other symptoms will vary in different cases, but not altogether accord- ing to the peculiar discharge. There is generally a certain amount of uneasiness and pain; sometimes this is very considerable, accom- panied by rumbling in the bowels, and an escape of flatulence. There is often considerable tenesmus and forcing, so that the child is very unwilling to cease its efforts, and these are sufficient in many cases to cause a troublesome prolapse of the anus. This seems to be the result of relaxation of the sphincter ani, from the frequent dis- charges, and the violent forcing efforts made by the child. When once it occurs, it is generally reproduced with each evacuation, and may degenerate into a habit that will persist after the diarrhoea is relieved. If the discharge be considerable, the child is rapidly reduced in flesh, and in young infants the muscular substance becomes quite 1 Diseases of Children, p. 391. 3 Ibid., p. 392. CHOLERA INFANTUM. 457 soft and flabby. It is also much weakened, so as not to be able to run about, or walk without great fatigue. There is an expression of weariness, depression, and sinking about the face, in some cases re- sembling collapse, until reaction takes place. The eyes are sunk, surrounded by dark circles, the features are sharpened, and in pro- longed cases the child acquires an appearance of age. The tongue may be either white and coate'd, or red, and occasionally there is a curdy matter something like the commencement of muguet. The thirst is greatly increased, sometimes quite intense, with great dry- ness of the mouth. At first, the pulse is but little altered, but if the disease continue long and severe, it becomes very quick and small, with hot skin and other evidences of fever. The abdomen is rarely tender on pressure, but it is sometimes distended by flatus; more frequently, I think, at least in the earlier stages, it appears shrunk, concave, and empty. In some cases we find a sudden collapse, resembling that of cholera, after which the child rapidly sinks, unless reaction can quickly be produced. CHOLERA INFANTUM. 733. There is, how*ever, another variety of diarrhoea which I must notice, and which seems to be far more frequent in America than in these countries. It is not, however, limited to America, but is com- mon in other warm climates. The reader will find most valuable in- formation upon this disease in the essays of Dr. Rush (1789), Dr. Miller (1800), Dr. James Mann (1805), Dr. Jackson and Dr. Horner (1829), and in the excellent treatises of Dewees, Eberle, Stewart, and Condie. It appears more common in the southern and western States, during the months of July, August, and September, and chiefly in the cities. In Philadelphia, it is more frequent than in New York or Boston: "In the latter city, it has been doubted whether the disease exists in its genuine form." "In Philadelphia, during a period often years, from 1835 to 1844, inclusive, 2583 infants perished from this complaint, being nearly 11 per cent, of the whole number of infants under five years of age who died during that period, and 5.3 per cent, of the entire mortality of the city." Dr. Condie further remarks that, "the disease occurs as an endemic in all the large cities throughout the middle and southern, and most of the western States, during the season of the greatest heats; making its appearance, and ceasing earlier or later, according as the summer varies in the period of its commence- ment and close. Thus in Pennsylvania, Maryland and Virginia, Ken- tucky and Ohio, it commences sometimes early in the month of June, and continues until October, prevailing to the greatest extent in July and August; whilst in the more southern States it appears as early as April or May, and frequently cases of it occur until late in November. Its only subjects are infants, chiefly those between four and twenty months of age, seldom attacking them younger or older, being com- 458 CHOLERA INFANTUM. monly confined to the period of the first dentition. So generally is this the case, that an infant's second summer is considered by mothers as one of unusual peril; and should it escape at that age an attack of cholera, or pass safely through the disease, it is considered to have a fair chance of surviving the period of infancy."1 734. The disease is often preceded by diarrhoea ; but in the majo- rity of cases, according to Eberle, the vomiting and purging commence together, with no other premonitory symptoms than languor, fret- fulness, loss of appetite, or a morbid craving for food. In whatever way it commences, however, the characteristic vomiting and purging soon appear ; with great prostration, emaciation, and sinking. From the beginning the pulse is quick, small, and somewhat tense. The tongue is covered with a slight white fur at first; but as the dis- ease advances this may disappear, and the tongue assume a bright, dry, and polished appearance. "At first, the discharges from the bowels usually consist of a turbid, frothy fluid, mixed with small portions of green bile, or of a nearly colorless water, containing small flocculi of mucus. After the disease is fully developed, the evacuations very rarely exhibit any traces of bilious matter, the biliary secretion being evidently entirely suspended. In some instances, the disease commences and proceeds with such vio- lence as to exhaust the vital powers, and terminate in death in the course of a single day. More commonly, however, the vomiting and purging are not so rapid as to prostrate the system immediately, and the disease continues for five or six days before convalescence begins, or fatal exhaustion ensues. In many instances, the vomiting, in the course of four or five hours, becomes less and less frequent, and finally ceases altogether, or recurs only two or three times daily, while the diarrhoea goes on, until at last it assumes a strictly chronic character. In the early stages of the disease, the little patient is evidently harassed with painful and distressing sensations in the stomach and bowels; and when the discharges are violent and very frequent, the muscles of the abdomen, and even those of the extremities, are apt to become affected with spasmodic contractions. If the disease do not terminate fatally during the first few days, rapid emaciation ensues, the hands and feet become cold and pale, while the head and body are always preternaturally warm; the skin is usually dry and harsh, and acquires a peculiar welted appearance, particularly on the inner part of the thighs and over the abdomen. The countenance becomes pale and contracted, the eyes inanimate and sunk, the nose sharp, and the lips thin, dry, and wrinkled. " The thirst is always very great, more especially after the disease 1 Diseases of Children, p. 212. During the present epidemic of Asiatic cholera (1849), my- friends Drs. Asken and O'Reilly inform me that the proportion of children under five years of age admitted into two of the hospitals, is in the proportion of 1 child to 25^ adults, as follows: Brunswick-street Hospital,—Total number of cases, 407. Children: males 4, females 8. Died: males 1, females 4. Cured: males 3, females 4. Green-street Hospital,—Total number of cases, 797. Children: males 15, females 16. Died: males 7, females 12. Cured: 12. CHOLERA INFANTUM. 459 has continued for some days, and no drink is palatable but cold water, which is generally thrown up soon after it is swallowed. Food of every kind is usually loathed and refused. If the disease be not subdued or moderated by proper remedial means, the little patient by degrees becomes somnolent; he sleeps with the eyes half open, rolls his head about when awake, and at last sinks into a state of insensibility and coma, and dies in a paroxysm of convulsions, or under symptoms resembling those of acute hydrocephalus. When the disease is of protracted duration, or assumes a chronic form, the alvine discharges generally acquire a dark, very offensive, and acrid character. The digestive powers become so enfeebled that almost everything taken into the stomach passes through the bowels in an imperfectly digested state. Aphtha? finally appear on the tongue and inside of the cheeks; the face acquires a bloated or cedematous appearance; the abdomen becomes tumid and tympanitic; the parts about the anus are exco- riated by the acrid discharges, and towards the fatal conclusion, spots of effused blood under the cuticle sometimes appear on various parts of the body, more especially on those upon which the patient lies. The little patient at last lies in a comatose and insensible state, with the eyelids half open, and the eye turned up so as completely to hide the cornea."1 This admirable description of Dr. Eberle, at once points out the similarity and also the dissimilarity between the symptoms and course of cholera in infants and in adults; but there are one or two other symptoms, pointed out by Dewees, which are worthy of notice. One of them is a "crystalline eruption upon the chest, of an immensity of watery vesicles, of a very minute size. The best idea we can convey of the appearance of this eruption, is to imagine a vast collection of vesicles apparently produced by flirting an equal number of very minute drops or particles of boiling water, and each particle producing its vesicle."2 Dr. Physick, Dr. Rush, and Dr. Condie, have wit- nessed examples of this eruption, but it appears to have escaped Dr. Eberle. Dewees considers it an invariably fatal symptom; but Dr. Condie says that he has "in many instances known the patient to recover, even when this eruption has been the most extensive and distinct." It may, however, "readily escape observation, if not looked for; it requires that the surface in which it has spread itself should be placed between the eye and the light, and viewed nearly horizontally." " There is another symptom," Dr. Dewees adds, " which attends the last stage of this complaint, which is much more common but not less fatal; which is, the thrusting of the fingers, nay almost the hand, into the back part of the mouth, as if desirous of removing something from ' Eberle on Diseases of Children, p. 283. I may just observe upon this last symp- tom, which, with the half-open eyelid, gives such a distressing look to the child; that any one who lias watched a baby go to sleep, or even carefully traced their own physical sensations during the initiatory part of this process, must have observed that the turning up of the eyeball is almost invariable; that, in lact, it is one of the natural and healthy phenomena of sleep. s Diseases of Children, p. 417. 460 ENTERITIS. the throat. The popular opinion is, that there is a worm irritating the back part of the fauces. And we may mention another, which we do not remember to have seen noticed, which is, the escape of a live worm or worms in the .chronic stage of this affection. If the worm come away dead there is nothing in the circumstance, but if alive it is a fatal sign."1 735. The duration of this disease varies very much, sometimes terminating fatally in five or six hours, in other cases running on for many weeks. Children sometimes recover from the most hopeless condition, and in all such cases bilious matter reappears in the stools ; and always when this occurs, together with warm moisture of the skin, and a better pulse, we may hope for a favorable issue. But when the pulse is weak and thready, and the evacuations watery and colorless, or reddish and mixed with flocculi of mucus, writh un- easiness and restlessness, or stupor and insensibility, we may fear the worst. ENTERITIS. 736. At the commencement of a bowel complaint, it is by no means easy to decide whether it be an ordinary case of diarrhoea, or whether there may not be inflammation of the mucous membrane of the intestine, as the symptoms are much alike. Even at a later period, the distinction is not very marked ; nor is the difficulty less- ened by the fact that, when the diarrhoea has continued for some time as a functional disturbance, it is very liable to degenerate into enteritis or entero-colitis. Enteritis may commence, then, with moderate diarrhoea, which does not interfere with the child's comfort or its amusement for six or seven days, at which time there supervenes pain in the belly, fever, thirst, loss of appetite, and increase of the diarrhoea. Or the attack may be more sudden ; with headache, vomiting, diar- rhoea, pain in the bowels, fever, thirst, and loss of appetite. The characteristic symptoms are vomiting, diarrhoea, heat, and ten- sion of the abdomen from flatulence, and tenderness on pressure. The amount often varies ; it is seldom very intense with young children. The tongue is found generally moist, red at the end, and along the edges ; there is a disagreeable taste in the mouth, and the breath is offensive. The thirst is great, and the appetite lost. The vomiting continues for some days, and then subsides. The diarrhoea generally continues throughout the complaint, but in some cases it ceases as the disease advances. The abdomen is distended, and is painful when pressed; rarely at the epigastrium, according to Rilliet and Barthez, but rather in the umbilical region or iliac fossa?. The temperature of the abdomen is increased in proportion to the intensity of the inflam- mation, and is greatest when the disease is at its height. The color, consistence, and odor of the discharges vary much, nor ' Diseases of Children, p. 417. ENTERITIS. 461 do I believe that any very important inferences are deducible there- from. They are sometimes green, sometimes yellow7 or reddish, brown, or clay-colored. Rilliet and Barthez give the following as the constituents of the stools, the varying proportions of which will influence the consistence and color: 1. The residue of the food, in- completely digested. 2. A secretion of serosity, which is not always present. 3. Mucus, which is almost always present, enveloping the more solid portions: it is variously colored by the bile, is soft and gelatinous. 4. Bile, which colors the stools, and, alone or mixed with mucus, forms the clear or green flocculi. 5. Pus, the presence of which it is difficult to ascertain, unless the fa?cal matter be some- what solid, upon which it then appears as streaks or lines. 6. False membranes, or their debris, are occasionally detected. 7. Blood, not fluid, nor occurring as hemorrhage, but mixed with faecal matter, in stria?, brownish or bright red, or sanious, from mixture with mucus or pus.1 M. Billard mentions that, in four cases, he found an exhalation of blood from the mucous membrane in erythematous enteritis.2 The evacuations are almost always voluntary, and passed con- sciously, except towards the termination of the disease ; but in some cases, the urgency is so sudden and so great that the child has not time to call for assistance, and has, therefore, erroneously been sup- posed to have involuntary motions. As the disease advances, the skin becomes dry, pale, yellowish ; the face wrinkled, old-looking, and expressive of depression and dis- tress ; the debility and the emaciation are very great. M. Jadelot lays great stress upon the lineaments of the face. " One of the most certain marks of abdominal affection is the first general lineament, which extends from the commissure of the lips to the lower part of the face, wThere it loses itself; the second, the nasal lineament, ex- tends from the inside of the ala? of the nose, and surrounds the whole of the orbicularis oris muscle. These are not to be always seen in very young infants, yet some trace of them may be observed ; as a fold, on the commissure of the lips, or outside of the orbicular muscle, corresponding with the nasal lineament. When the child suffers vio- lent pain, there is a corrugation of the skin of the forehead ; and indeed the sudden appearance of wrinkles in any part of the face al- most always indicates the presence of abdominal pain, and demands the attention of the physician, for they are invariably marks of dis- tress not to be overlooked. A pinched expression of face, without the presence of any particular lineament, in very young infants, is always a sign of gastro-intestinal inflammation."3 737. Chronic Diarrhoea.—Functional disturbance of the bowels, if not fatal, may subside into a chronic form of diarrhoea; acute en- teritis may also be succeeded by the chronic phase of the disease, and the similarity between these chronic disorders is even greater than 1 Mai. des Enfans, vol. i. p. 494. 2 Mai des Enfans Nouveauxnes, &c, p. 202. 3 M. de Salle's translation of Underwood. Stewart on Diseases of Children, p. 253. 462 DIARRIICEA. between the acute forms. The bowels continue relaxed, with a con- siderable variation in the character, quantity, color, and consistence of the discharges; occasional griping pain, tympanitic inflammation of the abdomen, great general emaciation, loss of appetite, thirst, foul tongue, &c. The fever assumes a kind of remittent type ; but is never very intense; the pulse is rather quicker than natural, but weak. The surface is dry, and becomes of a dirty color. Dr. Dewees has included " weaning brash" in his description of chronic diarrhoea ; and, in some instances, it may fairly be so deno- minated, but it is generally more acute, and the irritation involves the stomach as well as the intestinal canal. 738. Let us now briefly notice the complications of this intestinal disorder, or those secondary affections which are most apt to occur in its course. i. We found, when treating of muguet, aphtha?, ulceration of the gums, cancrum oris, pseudo-membranous pharyngitis, &c, that, in a great proportion of cases, they were secondary to an inflammatory affection of the intestinal canal; and every day's experience shows us that, at least, the milder forms may occur in the course of acute or chronic diarrhoea, where no decided evidences of actual inflammation are present. n. Children suffering from any of the varieties of diarrhoea, from cholera infantum, or from enteritis, are very liable to affections of the nervous system ; and this, either at the commencement, or after the primary disorder has continued some time. In the first, we find the diarrhoea set in furiously, with high fever, heat of skin, quick pulse, &c, and then a convulsion, partial or general. In the latter case, and by far the more frequent, the convulsion is generally preceded by sleepiness, starting, wildness of eye, stupor, or coma; the cerebral irritation advances more slowly, but is even more to be feared. A post-mortem examination does not necessarily afford evidences of meningitis, but yet the complication requires a modification of similar treatment; and will prove equally fatal, if the remedies be not early and skilfully applied. in. Dr. Stewart states that there are many marks of irritation in the pulmonary system; but my experience would rather confirm the observations of Rilliet and Barthez, that this is a comparatively rare complication. No doubt, a child suffering from diarrhoea will occa- sionally have a short cough; but I do not think that we often see bronchitis well marked in such cases. 739. Morbid Anatomy.—i. So long as the diarrhoea is not inflam- matory, a post-mortem examination will reveal but few changes be- yond the presence of the peculiar secretion in the intestines. Out of twenty-eight cases, M. Legendre observed four in which there was not the slightest change in the mucous membrane, although the disease had lasted from three weeks to four months. He considers that the morbid conditions which are found, are the consequence of the prolonged secretion.1 1 Recherches, &c, sur quelques Mai. de l'Enfance, p. 367. CHOLERA INFANTUM. 463 M. Billard has discovered enlarged muciparous follicles, but not inflamed, in children dying from excessive serous discharges; and this, I believe, is nearly all the positive alteration observed, unless the disease run on into inflammation. Most of the morbid appear- ances recorded as having been noticed in cases of diarrhoea, were the result of inflammation, and prove the cases not to have been mere irritation, or to have transcended those limits. We shall presently enumerate them. Dr. WTest has quoted, in a note, the experience of Messrs. Friedle- ben and Fleisch, from the Zeitschrift fur Rationelle Medicin, vol. v. 1846. "Their observations are founded on fifteen infants, all of whom were under one year old, who were brought up either exclu- sively, or in a great measure, on artificial food; and who died, after long-continued illness, in a state of atrophy; or else sank rapidly under profuse watery diarrhoea. In cases of the former class—a state regarded by the writers as the result of chronic inflammation of Peyer's glands—were the chief morbid appearances; while in those instances where death took place rapidly, a swollen and congested con- dition of the same bodies, betokening, as they believe, their recent inflammation, was almost always present. They found, too, that in all these cases the disease of the colon was comparatively slight, and was evidently secondary to the more serious changes in the small intestine."1 M. Legendre alone, I believe, has noticed the fatty degeneration of the liver in prolonged diarrhoea. The organ is not increased in size, nor is its specific gravity diminished, but its color is mottled with yellow patches.2 ii. In cases of cholera infantum, the liver' is almost always en- gorged, and generally greatly enlarged. Dr. Dewees speaks of its occupying two-fifths,3 Dr. Lindley4 one-half, and Dr. Horner5 two- thirds of the abdominal cavity. It is firmer and more solid than natural, but without perceptible change of structure. There are abundant evidences of inflammation in the stomach and small intes- tines ; red, inflamed patches, inclining to purple, may be observed, especially in the duodenum; nor are they limited to the small intes- tines, as Drs. Jackson and Dewees thought, Dr. Horner and others having found them in the large intestines. Dr. Horner has added another pathological characteristic to those observed before; he has shown that very extensive inflammation of the mucous follicles of all the intestines is present, in this agreeing with the observations of MM. Billard, Roederer, and Wagler. in. The morbid changes discovered in the mucous membrane of the small intestines in enteritis, are very similar to those we noticed in the stomach. Redness, partial or general, occasionally limited to a « Diseases of Infancy and Childhood p. 395, note. 2 Recherches sur quelques Mai. de l'Enfance, p. 376. 3 Diseases of Children, p. 400. « American Journal of Medical Science, vol. xxiv. p. 305. 5 Ibid., for February, 1829. 464 ENTERITIS. small portion of the intestine, with or without ramollissement. This erythematous inflammation is the most common; pseudo-membranous enteritis is more rare, and is seated at the lower portion of the intes- tine. Simple ulceration is comparatively rare; most commonly the ulceration is follicular. But here again we meet with inflammation of the follicles and of the groups of glands. The isolated follicles are prominent, rounded, and giving to the finger the sensation of a grain, somewhat soft, about the size of a pin's head ordinarily, and occasion- ally somewhat larger. They are more voluminous in the upper than the low7er portion. Paler and more transparent than the rest of the mucous membrane, they are sometimes surrounded by a red circle. When punctured, there escapes a drop of serous fluid. The glands of Peyer are frequently inflamed, and become swollen and thickened, and are easily removed by scraping with the scalpel. Their surface may have a mamellonated appearance, or be equally developed and prominent; red, or of a rose color; smooth, with a number of depressed points, the orifices of the mucous follicles.1 Dr. West thus sums up the alterations he has observed in the small intestines: "They consist in a more or less\intense redness of the mucous membrane, which appears thickened, and presents something of a velvety appearance, shaded over with numerous dark spots, the orifices of the solitary glands. In other instances, the surface of the reddened mucous membrane appears slightly roughened, as if sprin- kled over with fine sand; while near to the ca?cum the roughening is often greater, the membrane appearing elevated into rough, orange- colored prominences, separated by narrow lines, of a dead white color, which mark the situations where, by the destruction of the mucous membrane, the subjacent tissue is exposed." "Besides this affection of the mucous membrane of the ilium, Peyer's glands are not unfrequently very well marked in the lower part of the small in- testine; and their surface presents a punctated appearance, due to the unusual distinctness of the orifices of the sacculi which compose each gland. Occasionally, a few7 of them are congested and sw'ollen, and once or twice I have observed one or two spots of ulceration on that cluster of Peyer's glands which is situated close to the ileo-ca?cal valve; but in every instance, the affection of the small intestine has appeared to be secondary and quite subsidiary to the disease in the colon."2 The mesenteric glands are most frequently unaffected; sometimes they have been observed to be increased in size and congested, but in general they retain their normal appearance and size. Softening of the mucous membrane is extremely common in in- fants, either limited in extent or extending throughout the intestine. 740. In some rare cases, traces of cerebral congestion, or of disease of the membranes of the brain, are discoverable; but in general, even when head symptoms have occurred, but little information is obtained by a post-mortem examination. 1 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 478. 3 Diseases of Infancy and Childhood, p. 394. ;• ENTERITIS. 465 The lungs are almost invariably healthy, and the mucous membrane iree trorn inflammation, quite justifying the remark I made as to the 741 iUch comPlic*tion with diarrhoea. ' t ♦* i Ses-~A]l the varieties of irritation and inflammation of the intestinal canal are as common with infants as with older children. i do not think we can say more common, although the delicate unused condition of the mucous membrane might well predispose them to it.1 Ine chief causes of diarrhoea are, cold, damp, improper food, or excess of proper food, dentition, and variations of atmospheric tem- perature. r On a comparison of the results of five years' observation at the Children's Infirmary, Dr. West found that "In the three months, Nov. Dec. and Jan. diarrhoea formed 7.2 per cent, of all cases of disease Feb., March, and April, ... 8.3 " « May, June, and July, .... 13.0 " " August, Sept., and Oct., . . . 24.4 " " Dr. Condie very truly remarks that food, which is ordinarily suit- able, will sometimes disagree with the same children, and give rise to diarrhoea; and, during infancy, of course, the babe will be affected by any change in the nurse's milk, whether the result of bodily or mental conditions. The loose discharges about the period of dentition appear connected with the enlargement and inflammation of the mucous follicles, as Billard has observed; and M. Bouchut found that only twenty-six out of 110 actually escaped at this age, whilst forty-six suffered very severely.2 Mucous diarrhoea occasionally follows the suppression of cutaneous eruptions, or the drying up of sore ears. 742. Cholera infantum seems limited by age, few cases occurring beyond the second, and never beyond the fifth year. " During twenty years, the deaths from cholera infantum, in Philadelphia, amounted to 3,576; namely, in infants under one year of age, 2,122; between one and two years, 1,186; between two and five years of age, 268." " The influence of a high atmospheric temperature in the production of cholera infantum is shown by the fact that its prevalence is always in proportion to the heat of the summer, increasing and becoming more fatal w7ith the rise of the thermometer, and declining with the first appearance of cool weather in the autumn. A few hot days in succession in the month of May are sufficient to produce it; while, in the height of its prevalence, a short period of cool weather will dimin- ish, if not entirely suppress it."3 But heat alone is not sufficient; it requires, in addition, confined and impure air, for we find that the disease is nearly confined to large cities—that little or none is seen in the country, although the heat is quite as intense. Infants who have been prematurely weaned, and children whose diet is bad or in excess, are extremely obnoxious to • West, Diseases of Infancy and Childhood, p. 388. 3 Mai. des Nouveaux nes, p. 196. 3 Condie on Diseases of Children, p. 215. 30 466 ENTERITIS. an attack, and probably the irritation of dentition may be among the predisposing causes. The causes of enteritis are almost identical with those of diarrhoea. Unwholesome food, irritating matters, excess, dentition, cold, impure air, &c, are as likely to give rise to the severer as to the milder affec- tion. 743. But we must not forget that diarrhoea, whether functional or organic, may, in any or all of its varieties, be a secondary affection, and that this may either be the result of the primary disease, or of the remedies employed in its cure. Thus, we find that, in the course of the eruptive fevers, meningitis, bronchitis, pneumonia, &c, diarrhoea is very apt to set in, and espe- cially when these have been treated by calomel, tartar emetic, or purgatives. The symptoms do not differ materially from those already enume- rated, although they are more or less masked by the predominance of the primary disorder. We find diarrhoea, pain, and perhaps some de- gree of tenderness, tympanitic swelling, and tension of the abdomen; which may subside, all but the diarrhoea; the tongue is moist, red at the point and edges, the face becomes pale and wrinkled, with the naso-labial trait "well-marked, the eyes are hollow, &,c.; and this con- dition may continue until either the primary disease is cured or proves fatal. Or the attack may come on more suddenly and more severely in the course of an acute disease, with excessive vomiting, copious diarrhoea, tension and enlargement of the abdomen, with a dispropor- tionate degree of tenderness (so as almost to lead us to suspect perito- nitis), great exhaustion, &c. 744. Diagnosis.—i. The distinction between diarrhoea from exces- sive secretion, and that which is the result of enteritis, is by no means easy, not only from the similarity of symptoms and course, but also because the former is very apt to run on into the latter. The most characteristic difference is the amount of fever, the pain, and the ten- derness on pressure, which are much more marked in the latter. n. On the other hand, there is less acute tenderness, less pain and fever, in enteritis than in peritonitis; the expression of countenance is different also. in. The previous history will almost always show7 that the head symptoms are secondary, and that, therefore, we are not called upon to treat simple meningitis. The previous, and, in most cases, the prolonged diarrhoea, and the gradual development of nervous symp- toms, are very unlike the course of the disease when primary. 745. Prognosis.—i. In simple diarrhoea, if we see the ca^e early, our prognosis will, upon the whole, be favorable; but, if the disease be of longer standing, and have resisted the ordinary means of relief, we cannot conceal from ourselves that considerable danger attends the complaint. A cessation of vomiting, a decrease of the purging, subsidence of the abdomen, and the return of appetite, constitute the favorable symptoms, while an increase of these symptoms with higher ENTERITIS. 467 fever, or sinking, or the accession of any complication, especially of the head, will leave but little hope. It is scarcely possible to have a more fatal complication than a cerebral attack towards the termina- tion of an exhausting diarrhoea. ii. The same observations.will apply to moderate cases of enteritis: in severe cases, the prognosis is more unfavorable, and the chances of some fatal complication greater. in. Cholera infantum is a most fatal disease; a very large propor- tion of children are carried off by it. 746. Treatment.—The first duty is to remove every possible cause of the disease; if we have any reason to suppose that the nurse's milk does not agree with the child, it will be necessary to change the nurse ; and it will be well to choose one whose child is rather older than our patient, as, the younger the milk, the more likely it is to purge the infant. If the child be weaned, we must correct any errors of diet, either as to quantity or quality, and, as a general rule, substitute a bland, milky, or farinaceous diet for any kind of animal food. Ass's milk for young children, arrowroot, tapioca, panada, &c, are all very wholesome in irritations of the intestinal canal. If the teeth be at all at or near the surface, or everi when at some distance if the child suffer from irritation of the gums, they ought to be freely divided dow7n to the teeth, and rather beyond the limits of those coming to the surface. Very often, the irritation which a child would bear in health, without any inconvenience, will be quite suffi- cient to neutralize the effect of our remedies when diarrhoea is pre- sent. 747. These points being attended to, we have next to consider what medicines we shall employ ; and, on the supposition that irritat- ing matters require to be removed, many physicians commence with a purgative of rhubarb, magnesia, or castor oil. Undoubtedly, if such matters were in the intestinal canal, this would be right; but disordered evacuations are no proof of it; and I very much prefer calming the irritation first, and then, if necessary, clearing out the bowels. For this purpose, nothing is better than the chalk mixture with some aromatic and a drop or twro of laudanum to the ounce. I find that small divided doses answer just as well as larger ones, and I prefer laudanum to syrup of poppies, because, if fermentation takes place with the latter, the acetate of morphia is formed, and the child may get an overdose. Mucilage, syrup, sal volatile, aniseed water, with the same amount of laudanum, will answ7er equally well, with the advantage of being slightly stimulant. Or, the hyd. c. creta may be combined with the pulv. creta? c. opio, or with Dover's powder, in proportions according to the age of the child. A starch enema containing a few drops of laudanum will often re- lieve the irritation quicker than anything else, and, given at bedtime, will secure a good night's rest. It may be repeated as often as necessary. 468 ENTERITIS. If the discharges be acid, we may combine an alkali with the fore- going. I have found great advantages, in obstinate cases, from the use of external irritation, either by mustard and meal poultices, or the com- pound camphor liniment with laudanum. A plain poultice applied twice a day affords great comfort, or the abdomen may be fomented. If the discharges continue, and are still excessive, a more decided astringent may be given; the infusion of catechu, or decoction of log- wood, or the tincture of kino; or catechu may be added to the chalk mixture. Dr. West speaks most highly of the extract of logwood and tinc- ture of catechu, five grains of the former and ten minims of the latter to be given three times a day, in some sweetened aromatic water, to an infant a year old. "Pure argil has been, of late, much used in diarrhoea accompanied with acidity, as it forms with the acids an astringent salt. The sub- stance is prepared from the sulphate of ammonia and alumina, by ex- posing it to a strong red heat in a crucible. Argil in the form of a white powder possesses great astringent powers. Riecke recommends the formula? which are subjoined."1 R. Emuls. sem. papav. ^ihss; R. Argill. purse Jjss; Argillas purse, Qii; Gum Arabic ^i; Syr. althaeae ^ss. M. Sacch. alb. JJii; A teaspoonful for a child two years old. Aqua? foeniculi ^iii. M. A teaspoonful for a child a year old. 748. The foregoing treatment seems so far suitable to any of the varieties of diarrhoea, but some modifications have^been suggested in the different species. In mucous diarrhoea, we are advised to endeavor to restore the action of the skin as well as to restrain the discharge, and for this purpose ipecacuanha has been recommended by Good, Dewees, Stewart, Condie, &c. Dr. Good gives it alone, or united with opium ; Dr. Stewart alone, or with cretaceous preparations; and Dr. Condie combines it with calomel, acetate of lead, and hyoscyamus. As an astringent, Dr. Stewart speaks highly of an infusion of the root of the geranium maculatum, half an ounce to a pint, and also an infusion of the bark of the rubus villosus, or common blackberry. To an infant of six months a teaspoonful may be given five or six times a day, and a tablespoonful to a child of two or three years. Dr. Eberle recommends a few drops of the balsam copaiba in emulsion when mucous diarrhoea is somewhat chronic, and Dr. Condie has found it very useful. In bilious diarrhoea, we are advised first to clean out the bowels, and then to give small doses of calomel with laudanum, or the hyd. c. creta with Dover's powder. Dewees recommends the tartrate of antimony in small doses ; but I confess I should be very unwilling to give it, lest it should increase the gastric irritation, or perhaps give rise to gastritis. 1 Stewart on Diseases of Children, p. 198. ENTERITIS. 469 M. Trousseau recommends the neutral salts, ipecacuanha, and, if there be much mucous disturbance, opium.1 The child should be removed to a cool atmosphere, have a tepid or warm bath daily, and drink plentifully of gum water, rice water, &c, and be supported by a bland farinaceous diet. In chylous diarrhoea, Dr. Dewees advises low diet, rennet whey, or gum water, anodyne injections at night, and minute doses of calomel during the day—"say a quarter grain every four hours, with the twentieth of a grain of opium." " We have thought we derived ad- vantage from the application of a blister to the back of the neck, and keeping the body unusually warm."2 ^ Very much the same kind of treatment is recommended for lienteric diarrhoea; abstinence from much food, and that given to be milky or farinaceous; frictions to the abdomen, chalybeate water, with a minute dose of laudanum; fresh, pure air, &c. Dr. Dewees ordered friction with tartar emetic ointment; but, for reasons before stated, I very much prefer compound camphor liniment, or a mustard and meal poultice, or a blister. M. Trousseau states that the stools are acid, and, to correct this, he gives either magnesia, from one to five grains daily; lime-water, one scruple to one drachm; or the bicarbonate of soda, from two to eight grains. In addition, he advises mineral baths, containing from two to six ounces of sulphate of iron; sulphurous or aromatic baths, with decoctions of sage, lavender, or rosemary; a pint of red wine, and common salt; fresh air, and sunshine. 749. In cholera infantum, the great desideratum is to tranquilize the stomach; until that is done, not only is the disease unchecked, but the suitable remedies cannot be exhibited. For this purpose, Dew7ees recommends wrarm water to "encourage the puking," and enemata of warm water to clear the bowels. This appears to me to be acting upon the supposition that there is some irritating matter still in the stomach and bowels; and, with all respect to Dr. Dewees and others who have advocated the same plan, I believe it to be an error, or at all events an assumption of which we have no proofs. That discharges are foul and acrid, does not prove that they cause the evacuations; it only proves that such discharges have their origin in disordered action or secretion, and it is to that our attention should be directed. Calomel in small doses rubbed up with sugar; or the hyd. c. creta with Dover's powder; or small quantities of laudanum in a mixture, may be given with very good effects. Anodyne injections, warm baths, warm and stimulating frictions to the extremities, with stimu- lants internally, if there be much threatening of collapse, must all be tried. A blister over the stomach will often arrest the vomiting. "When the vomiting persists, we have found a few drops of spirits of turpentine, or of a solution of camphor in sulphuric ether, repeated at short intervals, seldom to fail in removing it. When the vomiting is ' Ranking's Abstract, vol. iv. p. 202. 1 Diseases of Children, p. 391. 470 CHOLERA INFANTUM. violent and frequent, the application of a few leeches to the epigas- trium will be found decidedly advantageous. When everything else fails, we have very seldom been disappointed in removing irritability of the stomach, by the administration of the acetate of lead in solu- tion."1 Dr. Eberle recommends the plan first adopted by Dr. Parrish, of blistering behind the ears in cholera, and the administration of small doses of calomel and ipecacuanha, and a stimulating poultice over the abdomen. If w7e suspect the existence of acid in the stomach and bowels, we may combine chalk with the calomel, or we may adopt Dr. Kuhn's plan of giving magnesia with ammonia. Dr. Condie gives Kuhn's formula as follows:— R. Magn.calcin. ^iv; Pulv. g. Arab. *^i; Sacch. alb. gii; Aq. menth. pip. 33s; Aquae font. §iiss; Aquas ammon. pur. gtt. xlviii to gtt. clxiv, according to the age of the child. The dose is a teaspoonful every two hours.2 When the stomach is quieted, we may have recourse to any of the remedies already mentioned, to restrain the action of the bowels; of these, probably, the acetate of lead and opium, in small doses, pro- portionate to the age of the child, will be found the best; and, when these watery discharges are diminished or changed for those contain- ing feculent or bilious matters, the treatment will then be the same as for diarrhoea. When cholera infantum becomes more chronic, we may have re- course to warm baths, frictions or blisters to the abdomen, anodyne injections, astringents, and a slight improvement in the diet. Some of the preparations of iron maybe tried. Eberle speaks highly of the tartrate, others of the persesquinitrate of iron. Sulphate of quinine is also very useful occasionally. Dr. Condie recommends powdered charcoal in conjunction with rhubarb, ipecacuanha, and hyoscyamus, when the discharges are acrid, offensive, and dark-colored. In addition, as the disease appears to be produced by hot, impure air, and deficient ventilation, the child ought to be removed to a cooler and purer atmosphere; and, as soon as the stomach will bear it, the diet must be improved in quality, and stimulants given in due propor- tion to the age and circumstances of the child. 750. The treatment of enteritis differs but little from that of gastri- tis detailed in the last chapter, except that, when it has been preceded by exhausting diarrhoea, we must be cautious not to push antiphlogis- tic remedies too far. If the pulse be pretty good, and the prostration not too great, wre may apply leeches to the epigastrium, in number according to the age and strength of the infant, intensity of the disease, &c.; and the 1 Condie on Diseases of Children, p. 218. 3 Diseases of Children, p. 290. ENTERITIS. 471 bleeding should be stopped immediately, unless we superintend the operation ourselves, as Maunsell and Evanson suggest. It is easy to repeat the leeching, if necessary, but far from easy to remedy excessive loss of blood. Warm baths, when the child is not too weak, and fomentations to the abdomen, are most valuable; or, what is less troublesome, a suc- cession of nice, warm, soft poultices. I do not think the profession in these countries are fully aware of the great value of poultices in internal and deep-seated inflammations. Nothing can be more marked than the relief afforded, and their soothing effect upon children. Some degree of counter-irritation may also be necessary, either by means of mustard poultices, liniments, or blisters. Sinapisms or even blisters may be applied to the extremities with benefit. Internally, calomel or gray powder will be very useful, if it can be given without increasing the irritation ; and if not, we may either use mercurial inunction, or dress the blister with mercurial ointment. Opium alone, or in combination with the above, or in the form of laudanum, pulv. creta? cum opio, or Dover's powder, will afford relief from the pain and gastric irritability, and will render tolerable other remedies. The diarrhoea may generally be arrested by some of the astringent remedies mentioned already—chalk, lead, kino, catechu, &c.; and the diet must be carefully regulated. It is not a prime object to ac- cumulate nourishment; if this be given too soon, the disease will rather be increased. Mucilaginous drinks, or milk, with-very light, thin, farinaceous food, appear to be the most suitable; and when the disease is on the decline, we may gradually give more nourishment, and wine if necessary. Of course, every possible exciting cause must be re- moved, and the gums lanced, if required. 751. Chronic diarrhoea requires a slight modification of the treat- .# ment already laid down. In addition to the. calomel, chalk, ipeca- cuanha and hyoscyamus, recommended by Dr. Condie, the acetate of lead, with or without laudanum, the vegetable astringents, &c, we are advised to try spirits of turpentine, balsam copaiba, the perses- quinitrate of iron, in doses of two or three drops of the liquor every two or three hours, in sugar and water, &c. One of the occasional symptoms I have already noticed, the pro- lapsus ani, demands a word as to its treatment. So far as it depends upon relaxation resulting from frequent discharges, the relief of the diarrhoea will cure it at the same time; but it does often remain, because of the habit of sitting long at stool and forcing, which the child acquires during the course of the disease. Now7, in order to remedy this effectually, all we have to do is to place a board, with a small perforation, across the chair or vessel the child uses, and to place the latter so that the child cannot touch the ground with its feet. So circumstanced, no excessive forcing can be used, and I have re- peatedly found the plan successful. I am indebted for the suggestion to my friend Dr. Corrigan of this city. It will rarely, if ever, be necessary to have recourse to any surgical 472 ENTERITIS. operation for its cure. If it persist, a little gall ointment, or a small astringent injection occasionally, will almost always be sufficient. I need hardly say that the gut is to be returned immediately each time it prolapses, by applying gentle pressure with one or two fingers, previously oiled. Another very troublesome occurrence, as Dr. West has remarked, is the intertrigo occasioned by the contact of acrid fa?ces. Generally, this results from want of due cleanliness; but I have seen it in chil- dren with an irritable skin ifi spite of the utmost care and watchful- ness. The best remedy is careful sponging after each evacuation, and anointing the parts, when dried, with zinc ointment, zinc cream, or ointment of the acetate of lead. Dusting the neighboring parts with lapis calaminaris is also of great use in protecting them. 752. As regards the complications, I need not say much, having already treated very fully of them ; and I must refer the reader to the chapter on Diseases of the Mouth and Pharynx. But I wish to im- press most forcibly upon all the importance of carefully watching for the first inroads of cerebral complications, and of promptly applying the very few7 suitable remedies at our command. It is not often that we can venture to apply leeches under these circumstances; if the case will admit of it, of course it should be done; but if not, we must have recourse to counter-irritation to the scalp or to the extremities, and to calomel, if the stomach and bowels will bear it, or to mercurial in- unction or dressings. Notwithstanding the head symptoms, we are not to abstain from opiates, if the state of the bowels requires it, because the continuance of that irritation will be far more injurious to the brain than the small quantities of laudanum I have recommended. Again, the head symptoms show themselves very often at the time when the constitution of the child has been so much weakened as to require wine or other stimulants; and although these are somewhat counter-indicated by the attack of the nervous system, I have found the child suffer more by their omission than by their continuance. I recommend, therefore, that they should be continued, but with caution and -watchfulness. 753. Secondary diarrhoea, with or without enteritis, requires no other modification of the treatment here specified, than what results from the coincident treatment of the primary malady, and the state of constitution induced by it. The diet I have mentioned should, in every variety, be bland, milky, and farinaceous; very moderate also in quantity, and repeated at dis- tant intervals, so as not to give the stomach too much to do at once. Fresh, pure air, and a change from town to the country, are of great value. Warm baths, to cleanse the skin, and promote its functions, absolute cleanliness, and suitable warm clothing, are quite necessary. I have seen most beneficial effects in chronic diarrhoea from a swathe of new flannel being worn round the abdomen next to the skin. DYSENTERY. 473 CHAPTER XVII. DYSENTERY.--COLITIS. 754. In the last chapter, I mentioned that inflammation of the small intestines was frequently accompanied by inflammation of the large intestines, constituting the entero-colitis of the French authors; nay more, that this compound affection was of more frequent occur- rence than either element separately; and some evidence of the mor- bid lesions was brought forw7ard under the head of Morbid Anatomy. Rilliet and Barthez have given a table of these diseases, and of their conjunction numerically; and I shall quote it, in the hope of impress- ing upon my junior readers the difference between a written descrip- tion of disease and clinical experience; how, what is very clear and definite in the one, is obscured by combinations and modifications in the other, which yet cannot be described on paper; and how necessary it is in practice to bear in mind the relations of one disease to another, as well as the characters of each disease. The authors I have named, met with forty-five cases of enteritis, and 113 cases, of colitis; either erythematous, pseudo-membranous, ulcerous, or pustulous; ninety cases of follicular enteritis; sixty-four cases of follicular colitis; twenty-eight cases of softening of the small intestines; and thirty-five cases of softening of the large intestines; and these, occurring in 185 cases, were thus associated :- Enteritis alone, in Colitis alone, .... Entero-colitis alone, Follicular enteritis alone, Follicular colitis alone, Follicular entero-colitis alone, Enteritis and follicular enteritis, . Colitis and follicular colitis, . Enteritis and follicular entero-colitis, Colitis and follicular enteritis, Colitis and follicular entero-colitis, Entero-colitis and follicular enteritis, Entero-colitis and follicular colitis, Entero-colitis and follicular entero-colitis, Softening of the large intestines, . . Softening of the small and large intestines, Enteritis and softening of the large intestines, Colitis and softening of the small intestines, Colitis and softening of the large intestines, Enteritis, colitis, and softening of the large intestines, 2 32 11 12 3 10 8 12 2 17 11 7 4 7 8 10 1 2 1 2 cases. case. cases. case. cases. 474 DYSENTERY. Softening of the small intestines and follicular enteritis, in 1 case. Softening of the large intestines and follicular colitis, . 1 " Softening of the small intestines and follicular colitis, . 1 " Softening of the small intestines and follicular entero- colitis, . . . . . . . . . 1 " Softening of the large intestines and follicular enteritis, . 3 cases. Softening of the large intestines and follicular entero- colitis, ......... 1 case. Softening of the small and large intestines, and follicular enteritis, ......... 2 cases. Softening of the small and large intestines and follicular colitis,.........2 " Softening of the small and large intestines, and follicular entero-colitis, . . . . . . . . 3 " Colitis, softening of the small intestines, and follicular en- teritis, ......... 1 case. Colitis, softening of the small intestines, and follicular colitis, ......... 3 cases. Colitis, softening of the small intestines, and follicular en- tero-colitis, . . . . . . . . 3 " Entero-colitis, softening of the large intestines, and folli- cular enteritis,1 ........ 1 case. From this minute tabular view, it is evident that no arrangement or division of these affections can be based upon morbid anatomy ; for we find, in a great number of cases, that lesions of the large and small intestines, are more frequently conjoined than separate; and that, therefore, in making a distinction, we must rather be guided by the history and symptoms of the disease, than by the result of post-mortem examination. So far, however, this distinction is borne out—that we do, in fact, find, in a certain number of cases, that the disease of the small and large intestines existed separately, and that the latter cases were much more frequent than the former. 755. Without any w7ish, therefore, to make a clearer distinction than we find at the bedside, I have still thought it well to treat the irritation and inflammation of the small intestines separately in the last chapter; and to complete the history of this complicated affection of the digestive tube, by treating of colitis, or, as it is usually termed, dysentery, in the present chapter; first, repeating that, as in the former disorder, when disease of the small intestines predominated, we found that the large intestines participated, to a certain extent; so, in the present disease of the large intestines, we shall find that the small intestines are by no means in a state of integrity. Dysentery, then, consists in an inflammation of the large intestines chiefly, and may occur in children of any age; although it appears to be less frequent in infants than older children. It may present itself in either an acute or chronic form, and may be either primary or secondary. 1 Mai. des Enfans, vol. i. p. 488. DYSENTERY. 475 756. I shall first notice Acute Primary Colitis. This may be de- veloped in the course of ordinary entero-colitis, by the diminution of the enteritis, and the consequent predominance of the inflammation of the large intestine, and the early symptoms will be those of which I spoke in the last chapter. Or, it may commence by uneasiness, broken sleep, irritability, some increase of the regurgitation of milk, and diarrhoea of feculent matter. So far, the attack appears one of simple diarrhoea, without fever, and with the mouth cool and moist. After a few days, however, the disease changes its character a good deal, the evacuations become more frequent, smaller, and with less feculent matter, until they consist of little more than small quantities of mucus mixed with blood, or even of blood chiefly. They are pre- ceded by pain and followed by tenesmus; indeed, it is difficult to induce the child to leave the chair, or to forbear extreme forcing. Occasionally, masses of feculent matter are expelled. The abdomen swells, becomes hot, tympanitic, tense, and tender, and there is a corresponding degree of fever, with hot skin, quick pulse, and evening exacerbations. The child rapidly emaciates, his flesh feels flabby and soft, his face is dis- tressed and anxious, wrinkled, and with a look of age; the eyes are dull, sunk, and with a dark circle around them. 757. If the disease be not arrested, these symptoms increase. The abdomen becomes more distended, and very tender on pressure ; the child complains of severe pain, especially when the bowels are moved; the discharges may preserve their ordinary character, or they may become dark-colored, acrid, and highly offensive. From the irritating nature of the evacuations, the anus and sur- rounding parts become red, hot, painful, and excoriated. M. Bouchut observes, that " erythema of the thighs and buttocks exist in five- sixths of the cases of entero-colitis. It commences with the disease, and appears ordinarily some days previously. At first, there is simple redness, with reddish papula?, more or less confluent, on the thighs, scrotum, or vulva, and on the inside of the limbs down to the ankles. The epidermis on these papula? becomes eroded, and superficial ulce- rations, whose red and bleeding surface is on a level with the surround- ing skin, are the result. These ulcerations spread and unite until they sometimes form an ulcer of considerable extent, and constitute in them- selves a serious disease."1 These ulcers are gradually covered with a false membrane, which becomes organized and covered with epidermis, as the process of healing makes progress. The erythematous redness which attacks the ankles and heels may also run on into ulceration. These accidents are by no means common in private practice, as M. Trousseau has shown that they are dependent upon a want of clean- liness, more likely to occur in a hospital. Redness and excoriation we do constantly see, however, and with all care it is difficult, if not impossible, to prevent it. At an advanced stage of the disease we also not unfrequently find aphthous patches around the anus. Prolapse of the gut, also, is by no means uncommon. 1 Mai. des Nouveaux-nes, p. 221. 476 DYSENTERY. The fever continues; the pulse is quick; the heat of surface un- equal; the extremities often cold; the thirst considerable; the mouth hot and dry, often attacked by aphtha?, especially at the angles; there is great depression of strength, with extreme emaciation. Colitis may terminate fatally, at an early period, from the intensity of the disease; but more frequently it is protracted for several weeks, and the child sinks from exhaustion; or coma and other cerebral symptoms supervene, and carry off the patient. The principal complications of dysentery are affections of the mouth, such as muguet, aphtha?, cancrum oris, &c, and cerebral irritation or effusion, just as we found to be the case with diarrhoea and enteritis; and the observations I there made apply equally well to the present disease. 758. Chronic Dysentery presents nearly the same array of symp- toms, but in a minor degree. Frequent discharges of mucus mixed with blood, occasionally of fa?cal matter; uneasiness and pain in the bowels, tenesmus, more or less tension and tenderness of the abdomen; a dry mouth, thirst, no appetite, aphtha? at the angles of the mouth and about the anus; great prostration, extreme emaciation, &c. We find cases occur as the partially successful result of treatment, or as an effort of the constitution to throw off the disease; but, after remaining in a chronic state for some time, they very frequently prove • fatal from exhaustion. 759. Secondary Dysentery is more frequent in the course of the eruptive fevers, and the characteristic symptoms show themselves from the sixth to the tenth day. There may probably be a diarrhoea for some days before, and then the discharges become sanguinolent, either black or red, and mixed with mucus. The evacuations are frequent, and accompanied with tenesmus. The abdomen is tense, tender, and generally hot, and the constitutional symptoms very marked—fever, dry, hot skin, anxious, distressed countenance, sunken eyes, &c.; but these may, of course, be partly owing to the primary affection. The following is the description of the disease, by M. Constant, in an epi- demic which occurred at the Hopital des Enfans: " The disease ordi- narily commenced by abdominal pains, accompanied by borborygmi and frequent desire to evacuate the bowels. The discharges wrere scanty, passed with great efforts, and consisting, at first, of greenish or yellowish viscid mucus, soon replaced by whitish mucus mixed with blood, and lastly consisting of arterial blood, either pure or mixed with small quantities of stercoral matter, or the remains of membrani- form concretions. At the same time, there were griping pain, tenes- mus, and pain in the rectum and anus; but this latter symptom was wanting in some cases. It was only a short time before death that we witnessed coldness of the extremities, failure of the pulse, and cadaveric expression of the face. In no case were there headache, singing in the ears, stupor, epistaxis, lenticular eruption (macula?), sudamina, or the sibilant rale in the chest, which so constantly occur in the course of severe fevers. The intellect remained intact until DYSENTERY. 477 the approach of death. In two cases only the tongue was dry and loaded."1 More than half of the cases referred to by M. Constant died, and all Rilliet and Barthez's cases, after an interval of from four to fifteen days from the commencement of the diarrhoea, and from three to ten after the appearance of the dysenteric symptoms.2 760. Morbid Anatomy.—In all cases there is evidence of inflam- mation, often very intense, in the large intestines, and often also in the smaller. The mucous membrane is red, swollen, thickened, and of slight consistence, often very much softened, with small ecchymoses here and there. In the great majority of cases the mucous follicles are enlarged, and their orifices widened and ulcerated. M. Bouchut gives the following result of his observations on young infants: "The large intestine was affected throughout in all cases, but the disease was chiefly confined to the mucous membrane. The intestine was ordinarily contracted, as it had been left by the spasm of the muscular coat, and the mucous membrane was of course thrown into a number of-folds, the edges of which presented marks of inflam- mation. The color of the membrane varied from a pale rose to a bright scarlet, interrupted by the enlarged, whitish, prominent mucous crypts, depressed in the centre, and filled by a grayish fluid. At the edges of the folds erosion and ulceration occurred, of an irregular form, superficial and narrow, with red but not raised edges, and a surface of the same color as the surrounding tissue. Ulcerations were also found in the intervals of these folds, small, superficial, and round, hardly to be distinguished except by their inflamed borders, and prob- ably occupying the mucous follicles. In those infants who died quickly, the mucous membrane was of a marked thickness; but in cases which were prolonged, with great emaciation, it was very thin, and, in some cases, scarcely discernible. It was generally softened, especially in those cases where the membrane was very red." The mucous follicles were always developed, with their orifices generally dilated or ulcerated. The cellular membrane was somewhat thickened, and slightly harder than usual. The muscular tissue was unchanged. The mesenteric glands were occasionally enlarged, but unaltered in color or texture.3 M. Constant has stated, that in all his cases there was false mem- brane on the surface of the large intestine. In all, the mucous mem- brane was of a deep red color, thickened, rough, and unequal in its surface, and presenting different degrees of softening. Dr. Mayne states that he found an undue degree of vascularity of the peritoneum, congestion of the absorbent glands, thickening and induration of the coats of the intestine, the mucous membrane varying in color from a bright red to green or purple, in some cases covered with a bran-like exudation, in others ulcerated. The ulcers were « Gazette Medicale, 1836, p. 101. g Mai. des Enfans, vol. i. p. 530. 3 Mai. des Nouveauxnes, p. 210. 478 DYSENTERY. sometimes small and isolated, in others, superficial and extensive, and, in a third variety, large, irregular, ragged, and penetrating. The small intestines were generally healthy; the liver was sometimes ex- tremely congested.1 761. Causes.—I do not know7 that either age or sex has much in- fluence in the production of the disease ; it occurs in both sexes indif- ferently, and at all ages, especially about the period of dentition. Atmospheric influence, however, is clearly traceable; heat, moisture, and impure air seem to be the three principal elements. Thus we find it more frequent in the latter part of the summer and beginning of winter. The usual exciting causes of diarrhoea will give rise to it; improper food, or an excessive quantity; cold, damp, deficient clothing, denti- tion, &c. Moreover, in certain localities it is endemic; foundling hospitals, fever houses, the densely populated and badly ventilated parts of towns, &c. Epidemics of dysentery are by no means unfrequent. I have alluded to the one described by Constant in the Hopital des"Enfans, in 1835. Dr. Cogswell described one which prevailed in the State of New York.2 My friend, Dr. Mayne, has described an epidemic which prevailed in the South Dublin Union Poorhouse, between April, 1846, and August, 1848, during which 127 male children under ten years wrere attacked, and seventy-four died. The disease prevailed equally among the female children under Dr. Shannon. In a great many of the cases the disease occurred as a sequela of measles, proving rapidly fatal. Dysentery may supervene as a secondary affection upon diseases of the mouth, chronic diseases of the lungs and skin, and especially in the course of measles, scarlatina, and small-pox. 762. Diagnosis.—The only positive distinction between dysentery and diarrhoea, is the presence in the former of small muco-sanguineous evacuations with severe tenesmus. In general, dysentery is much the more severe, with more suffering and decidedly more fever. 763. Prognosis.—Even as a primary disease the prognosis must often be unfavorable, and still more when it supervenes upon a dis- ease which has already exhausted the strength and constitution of the patient; in fact, very few of the latter cases recover. In general, it is very obstinate, not amenable to treatment; and, unless seen early and treated promptly, it is very apt to wear out the patient, even when not of sufficient intensity to destroy life quickly. The most favorable symptom is the recurrence of fa?cal matter in the stools, the return of appetite, and the disappearance of fever. 764. Treatment.—Bearing in mind that there are in all cases evi- dences of inflammation of the large intestines, and that often very severe, we need not hesitate in primary dysentery to apply leeches along the track of the colon, in numbers proportioned to the child's 1 Dublin Journal, May, 1844, p. 298. 3 New York Med. Repository, vol. ii. p. 127. DYSENTERY. 479 strength and the severity of the attack. Some writers have recom- mended these applications to the verge of the anus, but Dr. Condie objects to this, on account of the difficulty of stopping the leech-bites occasionally, and I quite agree with him. In secondary colitis, the condition of the child generally precludes the possibility of applying leeches; but for this, they would be equally suitable. In chronic dysentery, they are rarely necessary. Bleeding from the arm has been advised when the child is strong, the attack severe, and the fever high; the necessity of the case must of course determine its propriety. After the leeching nothing will be so comforting as a linseed-meal poultice applied hot, and renewed every hour. Fomentations and warm baths are also very beneficial. There is considerable difference of opinion as to the use of purga- tives, and the time for their administration. No doubt there is gene- rally an accumulation of fa?cal matter above the diseased portion of the intestines, which must be evacuated; it is true, also, that the discharge of fa?cal matter is a first symptom of improvement; but I confess I prefer, as in diarrhoea, quieting the excessive irritation in some degree first, and then administering moderate purgatives at intervals. We may begin then by a starch and opium enema, or a mucilagi- nous or chalk mixture with laudanum, or acetate of lead and opium, or calomel, ipecacuanha, and hyoscyamus, or Dover's powder, in doses proportioned to the age of the child. One-third of a grain of calomel, as much ipecacuanha, and one-twelfth of a grain of opium, may be given every three or four hours, to a child of a year old; but if the stomach be irritable the ipecacuanha must be omitted. In the epidemic described by Dr. Mayne no medicine was so useful as mercury, given early, in small doses rather than large ones, and continued until the evacuations exhibited a beneficial change, or until salivation occurred. Next to mercury, alkaline medicines were most useful; the liquor potassa?, or lime water, with a small quantity of opium were found very soothing. Opium, in full doses, aggravated the disease; purgatives were rarely useful; the bitartrate of potass in large doses failed; turpentine was of little use, except in cases of relapse; and ipecacuanha was perfectly ineffectual.1 Medicated enemata, as a means of acting locally upon the intes- tines, are strongly advised by M. Trousseau and others. These.may be composed of the acetate of lead, with or without laudanum, sulphate of zinc or copper, the aramonide of copper, &c.; but the one M. Trousseau prefers is the nitrate of silver, in the proportion of one or two grains to eight or ten ounces of water, once a day in mild cases, or twice a day when the attack is severe. It will be necessary first to clear out the bowels w7ith a lavement of warm water, and then throw up the solution with the long tube and syringe. Dr. West has used gallic acid in an enema; and in protracted cases, i Dublin Journal, May, 1840, p. 302 et seq. 480 DYSENTERY. when the tenesmus was very distressing, one of black wash containing laudanum, or one containing two grains of sulphate of zinc. When the irritation is somewhat lessened we must proceed to eva- cuate the bow7els, and I do not know a better means than castor oil diffused in mucilage, with a fewr drops of laudanum, as suggested by Dr. Stewart and Dr. West. Dr. West's formula for an infant a year old is as follows :— R. 01. ricini gl; Pulv. acacise J")i; Syr. symp. gi; Tinct. opii gutt. iv; Aquae flor. aurant. gvi. M. A teaspoonful every four hours. Or we may give a few grains of rhubarb and magnesia. After the acute stage has somewhat passed, a succession of small blisters to the abdomen will be found of great service should the attack be prolonged ; and we may also give some of the vegetable astringents recommended in diarrhoea, as being useful as tonics as well as in restraining the discharges. " In an epidemic of dysentery that occurred among children in Washington county, New York, an infusion of w-hite-oak bark, black- berry root, and yarrow, in milk, with the addition of sugar, was found, according to Dr. Cogswell, to be productive of the best effects."1 The following is the formula employed:— R-. Cort. querci alb., Rad. rub. villos, aa §ssj Fol. achill. milleflor. giii; Coque in lactis gi. A dessertspoonful to be given frequently. In the epidemic of 1835, at Paris, the treatment consisted of local blood-letting, opiates by the mouth or rectum, and astringents. When these failed, or the disease became chronic, a large blister was applied to the abdomen.2 The treatment of chronic dysentery is but a modification of what I have now laid down: counter-irritation, enemata of lead and opium, of nitrate of silver, &c.; calomel and ipecacuanha, with hyoscyamus or Dover's powder, warm baths, &c. Williams and others speak very highly of the persesquinitrate of iron, &c. Dr. Graves, in his excellent work, mentions that he has found the pernitrate of considerable use in chronic dysentery in adults; I do not see why it should not be tried with children, though I am not aware of its having been given as yet.3 765. The child should be warmly clothed with flannel next the skin, and should have plenty of fresh, pure air. The diet at first must be bland and simple ; mucilaginous fluids and milk and water may be given for drink; and for food, some farinaceous substances in very limited quantities. 1 Condie, Diseases of Children, p. 244. 3 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 533. " Clinical Medicine, vol. ii. p. 226. DYSENTERY. 481 After a while, indeed, the diet must be improved, as it will be essential to keep up the strength ; and it may be necessary to give wine or brandy. Dr. West observes : " As to the time when stimu- lants are to be given, or the quantity in which they are to be em- ployed, no definite rule can be laid down. Each case must be treated for itself; and, to be treated successfully, it must be watched most closely. The necessity for stimulants may arise suddenly, or the need of their administration may be but temporary; while the infant's state in the morning affords, in cases of severe diarrhoea, no sure cri- terion to judge what its state will be at night. In general, it is not until the active symptoms have begun to decline that stimulants are needed, nor even then are they required in the larger number of in- stances." "About half a drachm of brandy, given every two or three hours to a child qf a year old, in a quantity of a few drops at a time, mixed with the cold milk and water, or the thin arrowroot with which it is fed, will often have the effect of arresting the sickness as well as of rallying the sunken energies of the system. No stimulant has ap- peared to answer the required ends better than brandy, and, when sufficiently diluted, children take it very readily. Sometimes, how- ever, when it has been necessary to continue it for some time, it has seemed to occasion pain in the stomach, and even to nauseate the child ; and in this case the compound tincture of bark, or the aromatic spirits of ammonia, or the two together, may be substituted for it; and there is seldom much difficulty in administering them, if they be mixed with milk, and sufficiently sw7eetened." Again, "the support of the child's strength is a matter of no less importance in chronic dysentery than the suppression of the diarrhoea. The great weakness of the patient, and the manifest distaste for nou- rishment of all kinds, often render it necessary to continue the use of brandy for several days, or even for several weeks. For an infant not weaned, there can be no better food than that which is furnished by the breast of a healthy nurse. In the majority of cases, however, the child has been either in a great measure or altogether weaned before the affection came on, and consequently it is a less easy matter to supply it with suitable food. Farinaceous articles, such as arrow- root, sago, &c, are less easily assimilated in early life than in adult age ; and in cases of this kind they not unfrequently pass through the alimentary canal unchanged. Milk, too, does not always agree, and is sometimes ejected almost at once, unless it be given in a state of extreme dilution. Under these circumstances, we must not hesitate to give strong beef or veal tea in small quantities, but at short intervals, to the patient; for though it be true that the bowels are often ex- cited to increased action, in cases of chronic diarrhoea or dysentery, by animal broths, yet this is a smaller hazard than that of the child dying for want of sufficient nourishment."1 1 Diseases of Infancy and Childhood, pp. 406, 40S. 31 482 HELMINTHIASIS. CHAPTER XVIII. HELMINTHIASIS.--INTESTINAL WORMS. 766. There is scarcely an attack to which children are liable, nay, scarcely a symptom, which has not been attributed to worms, or in some way or other connected wTith them ; and that, not only by the people, but by medical authorities, with whom, indeed, popular prejudices generally originate. Even at the present time, any dis- ease whose nature is not very clear, any symptom of disorder of the digestive system, or of general nutrition, which is obscure, is solved by the magical abracadabra of " worms ;" so that we are in some danger of being driven into the opposite extreme, and of supposing them not merely innoxious, but, with Roederer and Wagler, and Dr. Butter, rather advantageous. It may be as well, therefore, to commence this chapter by stating that, while I neither deny the existence of worms, nor certain symp- toms which are coincident with their presence, I very much doubt whether any such symptoms are caused by them. These symptoms may be a coincidence, merely, or they may be the result of an irrita- tion which gives rise to worms. Again, I do not believe in the ex- istence of any symptoms pathognomonic of worms. Many such have been enumerated, but we may meet them all, repeatedly, without a trace of worms. I quite agree with my friend Dr. West, that the only proof of worms being present is seeing them. Having premised thus much, I shall first notice the varieties of worms which have been observed in the intestinal canal, referring my readers, for more lengthened details, to the elaborate researches of Bremser, Rudolphi, Bellingham, &c. 767. a. The ascaris lumbricoides occupies the small intestines principally, and is found sometimes in great numbers, occasionally accumulated in the form of a ball. It is usually from three to twelve inches long, and from one to two or three lines in diameter. Its natural color is white, but it presents the color of the substances it swallows. It occasionally finds its way into the stomach, and may be discharged through the mouth or nostrils. b. The bothriocephalus latus, tcenia lata, or broad tape-worm, is thinner and wider than the common tape-worm, and very long, being often twenty feet long. Cases are on record of much greater length ; it is said to have been sixty, seventy, or even a hundred feet. Its color is a dirty white, though it becomes gray when put in spirits. It has a large head, with two lateral grooves, which Rudolphi con- ceives to be organs for the absorption of nourishment. It is an in- WORMS. 483 habitant of the small intestines, and is said to be very common in Poland, Russia, Switzerland, and some parts of France. The tcenia solium, or common tape-worm, is white and flat; its anterior extremity long and slender, with a narrow neck and a minute head, armed with four suckers, between which the mouth is situated, surrounded by a circle of five hooks. The posterior extremity is round, and the joints that separate from it are called cucurbitani. It is found in the small intestines, where it may attain a great length. There may be several together, and occasionally other worms are found along with it, according to Rosen. It is not common in very young children, although now and then it has been found in the intestines of the foetus. Fortassin states that it occurs most frequently in persons engaged in preparing materials from fresh animal substances. The tricocephalus dispar, or long thread-worm, is probably the most common, and is found in the upper portions of the large intestines. It is generally from an inch and a half to two inches in length; the anterior portion of its body is slender like a hair, and the rest much thicker. It is white, or colored by what it has swallowed. Its mouth is at the capillary extremity, which is always adherent to the intestine. The sexes are indifferent individuals. The number is almost always small; very often only a single one is found. The oxyuris vermicularis, or ascaris, or thread-worm, is much smaller, being from one to four or five lines long; white, slender, and elastic, blunt at its anterior end, and with a rounded mouth. It is very common in the large intestines of children, and especially in the rectum. It is generally found in considerable numbers, imbedded in mucus, and often in rounded masses. These are the chief intestinal worms: however, Dr. Dewees has named several others, as the distoma hepaticum, fluke, or fasciola, the scarabceus, or beetle-grub, and the oestrus, or bots; and he alludes to -worms or larva? introduced by accident, and producing spasmodic colic, with griping, and occasionally vomiting or dejection of blood. 768. Symptoms.—Let us now examine the symptoms which are said to precede, accompany, and follow7 the appearance of worms. Indications of gastro-intestinal disturbance generally precede the attack, such as disgust for food, loss of appetite, or voracious appetite, or perhaps each alternately; hiccough, dribbling, fetid breath, nausea, acrid eructations, sero-mucous vomitings, very acid; borborygmi, umbilical colic, sometimes constipation; at others, glairy or mucous stools, meteorism, &C1 These symptoms continue; and to them are added pallor and puffi- ness of the face, softness of the flesh, emaciation and weakness, a slight, tickling cough, headache, agitation, sleeplessness, dilatation of the pupils, itching of the nose, grinding of the teeth, creeping of the skin, and some degree of fever. The stomach and bowels are evidently disordered, the child complains of a good deal of pain, and of a troublesome itching about the anus. The urine may be turbid, 1 Barrier, Mai. de l'Enfance, vol. ii. p. 207. 484 WORMS. yellowish, or whitish, like milk and water. Finally, worms may be detected in the alvine discharges. Dr. Horner first noticed an cedematous swelling of the upper lip and lower part of the nose, which he regarded as very characteristic; and Dr. Heberden thus sums up the symptoms from which worms may be suspected: " Headaches, torpor, vertigo, disturbed dreams, sleep broken off by fright and screaming, convulsions, feverishness, thirst, pallid hue, bad taste in the mouth, offensive breath, cough, difficult breathing, itching of the nostrils, pain in the stomach, nausea, squeamishness, voracity, tenesmus, itching of the anus towards night, and dejection of films and mucus." Now, that we have evidence here of considerable disease of the mucous membrane, no one would question; but upon which symptom could we safely rest our diagnosis of the existence of worms, except their presence? Brera and others consider the face as characteristic; sometimes pale, sometimes flushed, and sometimes of a leaden color, with a dark circle under the eyes, which are dull and inexpressive, with tumefied nares and upper lip, itching of the nose, and epistaxis.1 According to M. Roman, the tongue has a pathognomonic charac- ter, consisting of small, prominent, isolated, rough, tubercular points, particularly at the edges. The breath is acid, or has a sickly odor, and the saliva is abundant.2 M. Guersent mentions the glairy evacuations mixed with blood, and of a greenish yellow color, with the abdomen sometimes tumefied, sometimes flat.3 Others lay great stress upon the umbilical colic, or upon a feeling of constriction in the pharynx. Others, again, upon the acceleration and irregularity of the pulse, or upon the nervous symptoms. Now7 I do not mean to deny that such symptoms, and many others, may occur during an attack of worms; but I do say, that we meet them all when no worms are present, and that upon them as evidence we can place little reliance, and as proofs they are worth nothing. I perfectly agree with Rilliet and Barthez, who, after ample personal experience and extensive research, remark: "The examination of our own facts, compared with those published by authors, has led us to the conclusion that there is no other pathognomonic sign of the pre- sence of worms but their expulsion."4 When any are expelled, it is presumable that there are more, although this is only probability, not proof.5 769. Suppose we find the symptoms I have enumerated, or a suf- ficient number of them, including the decisive one of worms in the evacuations; are we quite sure that the symptoms are caused by the presence of worms? That similar symptoms may arise from gastro- intestinal irritation w7e know ; and may not the worms, when present, be an accidental and harmless complication, or may they not even be an effect of the previous condition of the mucous membrane. It is a * Page 162. a Ann. de la Soc. Med. Prat, de Montpellier, vol. xxii. p. 110. a Diet, de Med., vol ii. p. 243. * Mai. des Enfans, vol. iii. p. 609. 6 Barrier, Mai. de l'Enfance, vol. ii. p. 206. worms. 485 difficult question, and one upon which it would be presumptuous to speak positively ; but I am very much inclined to think that ordinarily worms give rise to very few symptoms at all, and that they may pro- bably be the consequence of the preceding disorder of the intestinal canal. It is right, however, that I should notice some other very important effects of worms, or what have been supposed to be such. MM. Mondiere1 and Charcelay2 have advocated the opinion that worms may perforate the intestine during life ; and-, from having found them in the cavity of the peritoneum, Rilliet and Barthez seem to take the same view. It is opposed, however, by Rudolphi, Bremser, Scou- tetten, Jules Cloquet, and Cruveilhier, who remarks that " the worms found in the cavity of the peritoneum, or in stercoral abscesses, did not arrive there by perforating the intestine, but because it had been perforated previously."3 Worms have escaped from, or been discovered in abscesses of the abdominal parietes; and it has been supposed that the abscess was the result of the perforation and transit of the worms. M. Chailly gives an example of a case in a child of two years of age ; and M. Mondiere, who has collected and analyzed the facts on record, con- cludes that the abscess may occur in any part of the abdomen, but is more common near the umbilicus, or the inguinal canal; and that the symptom which marks the passage of the wopm, is a painful sensa- tion of puncture in one particular spot, follow,ed by a colorless swell- ing, which gradually suppurates. M. Charcelay has published a case of fatal hemorrhage from the intestine, in consequence of the division of a small artery by a worm as it perforated the intestine. Wedekind published an essay on the strangulated hernia, occa- sioned by the accumulation of worms ; and Rilliet and Barthez regard this supposition as " not irrational," although their researches have not furnished them with an incontestable instance. Inflammation of the intestine is stated to have been the result of the accumulation of worms. Dr. Dewees mentions a case, in which ninety-six worms, the short- est six inches, the longest ten, were discharged at once, forty-five of them in one mass. The child previously appeared " in great and constant agony." Again, intestinal worms have been discovered in other organs. MM. Guersent and Tonnelle relate cases of their discovery in the liver : Haller, Arronsohn, Bland, and Tonnelle, of their presence in the air-passages, the results of which were sometimes serious or even fatal. They have, also, been found in the nasal canal, the frontal sinus, and the ears. Lastly, a series of nervous attacks have been attributed to them; convulsions, chorea, pseudo-meningitis, meningitis, &c. 1 L'Experience, June 25, 1838. 2 Recueil de la Soc. Med. dTndre et Loire, 1839. 3 Diet, de Med. et Chir. Prat., vol. vii. p. 338. 486 worms. As I have said, I cannot take upon myself to deny the explanation of these occurrences ; but I am at liberty to confess that I am not satisfied to attribute these effects to worms ; there is too much of the "post hoc ergo propter hoc." 770. Causes.—It would be a useless waste of time and space to enter fully upon the qucestio vexata of the origin of worms; I must refer such of my readers as are desirous of fully informing themselves upon the subject, to the works I have already mentioned. It is suffi- cient for ray purpose to say, that one party believe that they or their germs are derived from without, but that they undergo certain modi- fications within the intestinal canal; the other party, at once the most numerous and most distinguished, that they are entirely formed within the body, whether by hereditary derivation or spontaneous generation. But wThat are the causes which favor their production ? Bremser thinks that their formation depends upon there being more digested than absorbed matter in the intestines ; and that from this animalized matter, vermin are formed. Cruveilhier admits that a superabund- ance of nutrient materials may have something to do with their pro- duction. It would appear that an hereditary predisposition to worms is transmissible. The age, at which they are most frequent, is from three to ten years, although we meet them much younger. Between these two periods, M. Guersent observed them in one-twentieth of the children. They are also said to be more frequent with girls than boys, and in children of'a lymphatic temperament. Worms are more prevalent in some countries, and in some districts, than in others ; for example, in Savoy and Chambray, in France, throughout Holland and Switzerland, in certain parts of Germany and Russia. Mr. Marshall, Deputy Inspector of Hospitals, observes that Euro- peans and Africans are very much subject to worms in India. Mr. Annesley states that scarcely one in ten Hindoos is free from worms. Moreover, the different species of«worms prevail in different locali- ties, according to Bremser, Rudolphi, and others ; the bothriocephalus latus being more common in Switzerland, Poland, Russia, and some parts of France ; and in Egypt, Holland, Germany, and the greater part of France, the ta?nia solium ; the oxyuris and lumbricoides are more frequent in Great Britain, America, West Indies, and India. According to Bremser, worms prevail more in cities than in the country ; but Dr. Condie has not found this to be the case. It would seem that cold, damp, low, unhealthy situations favor their production, and that they are more frequent during the spring and autumn than the other seasons. On this account we should ex- pect that the children of the poor and wretched would be most afflicted by them, and this we find to be the case. Do worms occur as an epidemic ? It would appear so, from the various accounts we have received. Worm fever is described by various authors ; but it may, I think, be resolved into a gastro-enteric fever of the ordinary kind, compli- WORMS. 487 cated by a discharge of worms, whether essential or accidental, it would be hard to say. Roederer and WTagler found worms in the intestines of most of those who died of the epidemic mucous fever of Gottingen; and in a similar fever which prevailed at Naples, in 1836, Thibault detected worms very frequently. 771. Treatment.—Recollecting what I have said of the little value to be placed upon symptoms as indicative of worms, the reader will see the importance of ascertaining, as far as possible, by the only sure means, whether there be worms, before adopting any specific line of treatment. It would be worse than foolish to administer the more powerful remedies against worms, in a case in which we have no proof of their existence. But, further, as we are not certain that the disor- der, which is undoubtedly present, results from the presence of worms, I confess I much prefer trying to relieve the distress first, and then, if necessary, having recourse to means for destroying and expelling the worms. I am happy to have the support of Dr. Condie in this mode of practice. He states that "in any supposed verminous case, there- fore, we would advise that all heating and irritating vermifuges be abstained from, and that our treatment be directed chiefly to restore the regular, healthy action of the digestive organs, and the strength and vigor of the body generally. We have been in the habit of pur- suing this plan for a number of years, and have seldom been disap- pointed in promptly and effectually curing our patients, and have had but little necessity for resorting to either of the articles wThich strictly appertain to the class of anthelmintics."1 W7ith this view, the diet of the child should be carefully regulated; not only must it be limited to plain food, but even that must be given in smaller quantities than usual, and at regular times. In many cases, we must be as rigorous in diet as was recommended in the chapter on diarrhoea. But if the irritation be not so great, in addition to bread and milk, rice, and arrowroot, w7e may allow a portion of animal food, chicken broth, beef tea*, chicken, or mutton chop. Vegetables, if used at all, must be so very moderately; fruit and confectionery should be interdicted. Air, exercise, and warm bathing, come next in importance to t\\e regulation of the diet, and within reasonable limits should be carefully and fully employed. But little medicine may be required. A few grains of hyd. c. magnesia, if the bowels are confined; or hyd. c. creta, if free, may be taken two or three times a day. If there be diarrhoea, with much intestinal irritation, the remedies already re- commended must be employed,—counter-irritation, poultices, opi- ates, &c. If the bowels are steady, and the tongue pretty clean, I have seen good effects from the combination of a bitter tonic and an alkali; for example, two grains of powdered coluraba root, with as much bicar- bonate of soda, two or three times a day, for a child of two years old. * Diseases of Children, p. 232. 488 WORMS. 772. But supposing that there are no symptoms of gastro-enteric irritation or inflammation, or that these have been subdued, and we are required to attempt the removal of the worms, "to what medicines should we have recourse?" Anthelmintics have been divided into those which succeed by de- stroying the vitality of w7orms, and those which merely remove them. Dewees and others divide them into: 1, those which act medicinally upon worms; 2, those which act mechanically; 3, those which pre- vent the development of their ova, or injure the young of the vivi- parous, or act beneficially upon the stomach and bowels.1 Among the former, we may include turpentine, which maybe given to very young infants, if mixed with mucilage, milk, almond-milk, &c, and sweetened. From five to thirty drops may be given three times a day, according to the age of the child. It is by no means a pleasant medicine, nor will children continue to take it willingly for any time, although they may consent to do so for a few days. It may also be given in the form of enema, combined with gruel or barley- water, and with great benefit, in the case of ascarides in the rectum. The dolichos pruriens or cowhage, is highly recommended. It should be very carefully combined with honey or syrup, and a teaspoonful given for two or three mornings, before breakfast; the last dose being followed by a purgative. Its operation seems com- pletely mechanical, the minute hairs wounding and irritating the worms: it is said to be chiefly useful against the ascarides and lum- brici.2 The fucus helminthocorton is a favorite remedy with French phy- sicians, and their opinion is confirmed by Dr. James Johnson, of Lon- don, who recommends a strong decoction to be given as an enema. Dr. Eberle advises that an ounce of the helminthocorton, with a drachm of valerian, should be boiled in a pint of water until reduced to a gill, and a teaspoonful given three times a day. He considers it to be not merely an excellent vermifuge, but as very useful in that state of the alimentary canal which gives rise to wTorms, particularly when there is want of appetite with mucous diarrhoea.3 "The oleum chenopodii is a remedy in considerable repute with American practitioners. We have employed it in some cases with considerable advantage, as follows:— "R. Olei chenopodii ^i, Sacch. alb. pur., gum. acaciee, aa. giss. M. dein adde aq. menth. sativ. ^iiss. M. " A teaspoonful every three hours, for two days in succession, to be followed then by a dose of castor oil.'"4 Dr. Dewees considers the Spigelia Marilandica (Carolina pink) as the most efficacious remedy against luinbrici. He gave the infusion w7ith sugar and milk, and in large doses for three or four days ; the last dose followed by a brisk cathartic. Bremser and Eberle speak highly of the following formula:— 1 Diseases of Children, p. 493. a Neligan, Medicines and their Uses, p. 20. 8 On Diseases of Children, p. 266. •» Condie, Diseases of Children, p. 234. WORMS. 489 R.—Sem. santon., fol. tanaceti vulg. contus., aa ^ss; Rad. valer. pulv. Jjii; Rad. jalap, pulv. s;iss ; Sulph. potass, ^ii; Oxymel scillse, q. s. ut fiat Electuarium. A teaspoonful to be taken two or three times a day, for six or seven days. It is more effectual, however, when so given as to produce consistent evacuations rather than w7atery stools. The empyreumatic oil of Chabert is regarded by Bremser, Brera, and Rodolphi, as one of our best anthelmintics. From fifteen to twenty drops may be taken daily by children from two to seven years old. Dr. Vauvert states that flowers of sulphur, taken in the morning before eating, is a most efficacious remedy. The Stannumgranulatum is recommended by Alston, Patten, Brera, &c. Its modus operandi we cannot explain, but it occasions the worms to be evacuated. It may be given in doses of from half a drachm to two drachms twice a day, in treacle or syrup, with an occa- sional cathartic.1 " Common salt," Dr. Condie observes, " is, perhaps, one of the best anthelmintics we possess; it has often succeeded in the destruction of worms when other remedies have failed. It was a favorite remedy with Dr. Rush; and whenever we have been able to induce children to take it in a sufficient dose, we have never been disappointed in its effects: an ordinary sized teaspoonful, dissolved in a wineglassful of water, is the proper dose for a child of two or three years old." M. Peschier, of Geneva, has strongly recommended the tincture of the buds of the male fern (polipodium filix mas); and it is asserted by his brother that he cured 150 cases of lumbricoides, tricocephali, and ta?nia, in nine months. Dr. Fosbrooke obtained great success also with this remedy: the dose is from one to ten drops, in pills, or on sugar. Dr. West speaks favorably of the decoction of the bark of the pomegranate root, in cases of ta?nia, w7ith an occasional purgative. Many other vermifuge remedies have been highly lauded, such as tannin, garlic, tin filings, geoffroya inermis, any of which may be tried if those I have enumerated should fail. Each of these remedies, and many others, have been vaunted, as of sovereign efficacy in worms; and yet each will fail, owing probably, as Dewees shows, to the one kind of worm being affected by one anthel- mintic, but not by others: certainly " that which shall detach and expel from the bowels lumbrici shall not stir the ta?nia sodium." We must, therefore, endeavor to suit our medicine to the peculiar kind of worm.2 773. The second class of anthelmintics includes all brisk cathartics. Calomel, alone or in combination with jalap, scammony, or rhubarb. Castor oil, gamboge, and aloes, in the case of ascarides. A full dose may be given, and repeated after a day or two, and we shall seldom fail to discover a quantity of these little animals in the evacuations. 1 Dunglison, Diseases of Stomach and Bowels in Children, p. 60. 3 Eberle, Diseases of Children, p. 264, et seq. 490 JAUNDICE. In cases of ascarides, the greatest relief is often afforded by injec- tions, so as to wash out the rectum completely. The decoction of the fucus helminthocorton, turpentine in gruel or water, black wash ; solu- tion of common salt, aloes, or sulphate of iron; lime-water and milk, assafetida and milk, olive oil, sulphuret of potash, &c. A bougie smeared with mercurial ointment, and passed into the rectum, is said to destroy these vermin very effectually. 774. After the worms, or a great portion of them, have been evacu- ated, the child will derive great benefit from the exhibition of some tonic. Marley recommends the infusion of columba or gentian, with infusion of rhubarb, and a little of the compound spirit of ammonia; Dr. Stokes, the tincture of aloes, wTith the sesquichloride of iron ; Dr. Rush, the carbonate of iron; Dr. Dewees, equal parts of the carbonate of iron and common salt; M. Cruveilhier, the " wine of quinine" to lymphatic children. CHAPTER XIX. I. JAUNDICE.--II. ENLARGEMENT OF THE LIVER, SPLEEN, ETC. 775. I have included these subjects in one chapter, not because of any necessary or inseparable connection between them, but rather because it seemed useless to make several chapters about diseases concerning which we know so little. I shall, therefore, first treat of jaundice in infants and children. I do not think it is by any means so rare as some authors have stated. If any one will take the trouble to watch an infant for a few days after birth, they will find the skin very red for a day or two; then it assumes a yellowish tinge, and finally becomes fair. The yellowish tinge varies in intensity up to a decided yellow, jaundice color. And in many cases I have seen infants remain suffering from this kind of jaundice for some days, and then, after suitable treatment, acquire their proper color. "In some instances, the skin of the infant will be marked by dull, yellow, irregular blotches (maculce hepaticce), more or less extensive, and sometimes occupying the greater part of the surface. The color of these blotches varies very much in intensity; and in cases where there exists considerable derangement of the alimentary canal, they occasionally assume a very dark hue (melasma); in some instances, they are accompanied with a prickly or tingling sensation. The dis- ease appears to be most generally connected with derangement of the digestive organs; the color of the skin being dependent upon a mor- bid secretion from the cutaneous vessels; it has little or no affinity with jaundice."1 1 Condie, Diseases of Children, p. 632. JAUNDICE. 491 In other cases, the infant is born jaundiced, the skin and conjunc- tiva? quite yellow; these are not very common instances. Or, after acquiring a proper color, the child is attacked by jaundice from some of the causes to be noticed presently. 776. Symptoms.—The symptoms are so characteristic that we cannot easily mistake the disease. The skin is yellow, or greenish yellow; the conjunctiva? the same color; the urine and perspiration contain a large quantity of bile, and stain the napkins and shirt of the child yellow. The face looks thin, wrinkled, and old; the appe- tite is diminished; if very young, the infant sucks feebly, and does not seek after the breast. The discharges from the bowels may be dark-colored, if the meconium have not been entirely discharged; afterwards they are generally whitish or grayish: in some few cases their color is natural. At the commencement of the disease the bowels are generally constipated; but I have seen an attack ushered in by diarrhoea, which ordinarily occurs after a few days. The tongue has a yellowish-white fur, especially towards the base, and the palate occasionally exhibits whitish patches, which resemble the false membrane of muguet. Vomiting occurs sometimes, even after a moderate meal, but it is by no means an invariable accompaniment. There is frequently some griping, which the child shows by sudden cries and retraction of the limbs. Such are the ordinary symptoms of jaundice; in the greater num- ber of cases there is neither swelling nor tenderness of the abdomen or region of the liver; but, in some cases, M. Baumes mentions having found the hepatic region swollen and tense.1 When the disease assumes a chronic character, it is attended by progressive emaciation, tumefaction of the abdomen, sometimes with oedema of the lower extremities, or effusion into the peritoneum. The tongue becomes dry, and of a dark brown color; and at an ad- vanced stage there are occasionally spots of purpura, or bleeding from the mucous membranes. Induration of the cellular tissue also some- times, but rarely, complicates this affection. The disease may last from a few days to a fortnight, and then the skin acquires its proper color, the bowels become regular, and the appetite returns. But although, in general, it is a mild disorder, un- attended by danger, we find that now and then it proves fatal. 777. Pathology.—It is not easy to explain the occurrence of jaun- dice in many cases. It may doubtless arise from some malformation or obstruction in the gall-duct, and I am inclined to think that this is the most common cause with young,infants. This obstruction may be caused by inspissated matter in the duct, or by inflammation of the mucous membrane, extending from the duodenum, as may be the case when jaundice supervenes upon diarrhoea. Again, congestion and inflammation of the liver may give rise to jaundice, although hepatitis is not a frequent disease of childhood. 1 Traite de l'lcterus ou Jaunisse des Enfans de Naissanco. 492 JAUNDICE. The symptoms do not differ much from those already enumerated, except that in addition there is a degree of fullness and tenderness of the hepatic region. We must not forget how important a part the liver has played during foetal life, and its undue size at birth; this disproportionate activity previously, and the change to comparative quiescence after birth, may have something to do w7ith the liability to the complaint. Lastly, jaundice may be caused by organic deterioration of the liver, though it is not always present, nor indeed are these diseases very frequent in childhood. 778. Causes.—Various exciting causes have been enumerated. M. Anthorn knew jaundice to occur after immersion in cold water. M. Levret conceives that the blood remaining in the umbTfical vein, after it is tied, may become corrupted, and give rise to engorgement of the liver and jaundice. M. Andrieu attributes it 1o pressure of the hands of the nurse upon the head of the infant: but these causes are not very probable, to say the least of them. The irritation caused by the first attempts at digestion, improper food, excess of food, cold, damp, &c, may doubtless give rise to it. Constipation, by causing an accumulation of bile in the intestines, and its absorption, may favor its production, according to M. Baumes. Dr. West remarks, that "the children in whom jaundice is most frequent and most intense, are the immature and the feeble; while in none is it so often met with, or in such an intense degree, as in in- fants affected with induration of the cellular tissue, in wdiom the yellow color is often so deep as to be manifest in the serum infiltrated into their cellular tissue, or poured out into the cavities of the chest or abdomen. Interruption of the function of the skin, and great im- pairment of that of the lungs are, as you know7, the grand character- istics of that affection ; while, in many instances of it, the foetal pas- sages are still pervious, and the blood circulates in part through channels which ought to have been closed from the time of birth. These facts seem to substantiate the opinion entertained by many writers of high authority, that the jaundice of children is not due to any cause seated primarily in the liver, but rather to the defective respiration and the impaired performance of the function of the skin, of which the hepatic disorder and consequent jaundice are but the effects."1 779. Prognosis.—In those cases which proceed from mechanical obstruction, from irritation extending from the duodenum, or from temporary congestion of the liver, the prognosis upon the whole is favorable ; after a little time, the disorder gradually subsides, and the infant is restored to health. Other cases, however, are not so fortunate, and these I apprehend to be chiefly those in which the liver is organically affected. The child becomes emaciated and exhausted, "The appetite is lost, the bowels are permanently deranged, and the child is gradually worn out; it may be carried off finally by an attack of convulsions. 1 Diseases of Infancy and Childhood, p. 376. JAUNDICE. 493 Dr. A. B. Campbell has related three fatal cases. In one case the gall-duct was obstructed by inspissated bile, and the other two by congenital absence of the hepatic and cystic ducts.1 The latter kind of cases are generally characterized by the occurrence of hemorrhage, generally from the umbilical cord, which can only be at most tempo- rarily arrested. 780. Treatment.—For the cases which arise from retention of the meconium and accumulation of bile in the intestines, nature has pro- vided a mode of cure in the purgative qualities of the early milk; the bowels being cleared, the cause is removed, and the child will re- cover. Or, if necessary, we may aid this by a dose of purgative medicine ; rhubarb, castor oil, or, what I have found even better, a single grain of calomel, repeated every day or every second day. If we have reason to suppose that there is irritation or inflamma- tion of the duodenum, we must first endeavor to relieve that by fomen- tations, poultices, counter-irritation, and internally by mucilaginous or chalk mixtures, with opium, the hyd. c. creta with Dover's powder, &c. WThen the diarrhoea or vomiting is relieved, then we may either continue the mercury with chalk, or have recourse to calomel, as the child may be able to bear it. Should there be enlargement and tenderness in the region of the liver, indicative of irritation or inflammation, it may be necessary to have recourse to a leech or two, followed by poultices, and afterwards to blisters, accompanied by the internal administration of calomel or the hyd. c. creta, as the bowels may be able to bear it. After the bowels have been regulated, M. Baumes recommends the black oxide of iron, the tartrate of iron and potass, or some vege- table tonic. In the chronic form of the disease, Dr. Condie speaks favorably of turpentine, for the relief of the flatulent pains, in doses of from five to ten drops every three hours ; at the same time, he gives hyoscyamus, ipecacuanha, and carbonate of soda, and applies a camphorated mer- curial plaster over the right hypochondrium. He has also found benefit occasionally from the alkalies, in combination with a weak infusion of hops or taraxacum. Considerable care should be taken of the diet, especially if there be much disturbance of the bowels. The nurse must be changed, if there be any suspicion that her milk disagrees with the child ; and at a more advanced age, nothing but bland, unirritating food should be allowed. Milk, arrowroot, panada, &c, will be found most suitable until the disease subsides, and then we may have recourse to a more invigorating diet. 781. Enlargement of the Liver, fyc.—Comparatively little notice has been taken of enlargements of the liver in children; they are not generally noticed in the systematic works; and I am chiefly indebted to a valuable monograph of my friend, Dr. Battersby, for the follow- ing details.2 ' Northern Journal of Medicine, August, 1844. 3 Dublin Journal, May, 1849, p. 308. 494 JAUNDICE. Dr. Graves describes hypertrophy of the liver, as "that state in which there is an increase of size in the organ, with induration and imperfect secretion, but without any remarkable tenderness. This condition in children is accompanied with irritability of the digestive organs, fretfulness, emaciation, loss of sleep, and impaired nutrition. It is only a form of general cachexy, connected with the scrofulous diathesis, affecting secretion and nutrition in general, and the diges- tive and biliary systems in particular."1 Dr. West has seen cases of what " he believes to be hypertrophy of the liver. For the most part, they were associated with very obvious indications of a scrofulous habit; but on one occasion only was there any serious disturbance of the general health; the child, in that in- stance, suffering from very severe diarrhoea, which had succeeded to a state of somewhat obstinate constipation."2 Rilliet and Barthez mention enlargement of the liver when speaking of hepatitis, which they consider very rare, having only seen six cases of it: "It commences by a slight febrile movement, accompanied by increased thirst and loss of appetite. At the same time, or shortly afterwards, an icteric tint is perceived, limited at first to the conjunc- tiva?, and slight, but soon becoming very marked. The liver then augments in volume, passes the ribs, extends to the epigastrium, and, ascending in the hypochondrium, increases the dullness of that region. The tumor'is ordinarily indolent, easily circumscribed when the abdo- men is soft and flexible, but is defined with difficulty when it is dis- tended. At the same time that the jaundice and tumefaction of the liver are manifest, the urine becomes changed and of the color of beer. The stools were few, liquid, and discolored. At the end of a variable time, the febrile movement diminishes and disappears; thirst is no longer felt; the appetite is recovered. The tumor of the liver, which has progressively diminished, still continues; it, how7ever, soon disappears. The icteric coloration is in part effaced; the urine re- covers its normal color, and at the end of twenty or thirty days all the morbid symptoms have disappeared."3 Of Rilliet and Barthez's six cases, five recovered. 782. Dr. Battersby's cases, in some respects, resemble the fore- going description, although the history and results differ considerably. He met with sixteen cases; and out of eleven, six died, two of them of scarlatina ; four recovered," and one remained under treatment. As to the ages, one was under one year; four, from one to two years; six, from two to three years; one, from three to four years; one, from four to five years; and three, from six to seven years. As to the symptoms, Dr. Battersby observes: " In thirteen there was, in general, a slight febrile action, with tenderness on pressure over the liver; in some, the stools were uncolored, and the urine was deeply tinged. In ten, jaundice existed for some time; in five, ascites or anasarca; in one, phthisis; in one, pompholix; and one was af- fected with laryngismus stridulus. The children were generally lan- ' Clinical Medicine, p. 566. * Diseases of Infancy and Childhood, p. 442. 3 Mai. des Enfans, vol. i. p. 578. JAUNDICE. 495 guid, wasted, and had a dirty, jaundiced hue of countenance. The abdomen was much enlarged, its veins were distended, and the liver could be most distinctly felt extending, at various degrees of distance, from the jibs to the pelvis. In one case only, I received intelligence of pain being felt in the right shoulder. Instead of the enlargement of the liver disappearing in twenty or thirty days, I have seen it after the continuance of a year, one year and six months, two years, and even three years and a half." In one case, clots of black blood were passed by stool and vomiting a week before death. But the most remarkable symptom, and one which, so far as I know, has not been noticed in children as a concomitant of disease of the liver, was a depraved appetite, or pica, as it is called. It was ob- served in seven of these cases of enlargement of the liver; but whether the direct result of the disease, or the consequence of some condition of the stomach induced by the disease, it is not easy to say. " As a general rule," Dr. Battersby remarks, "this is one evidence of undue lactation; for, of fourteen cases in which I noted it, the average dura- tion of suckling was twenty months; six of these cases were suckled two years and upwards; and one of them, weaned at one year, was continued at the breast for seven months during the utero-gestation of a succeeding child. I have remarked, that these little children eat greedily of coals, cinders, ashes, lime off the walls, dirt, shoes, paper, and even their own ordure. Children affected with pica are very delicate and wasted, their complexion is sallow, ana?mic, and waxy, the abdomen enlarged. The bow7els are generally too free ; the stools are of all colors—green, yellow, black, or white." I have seen a case, however, in which this depraved appetite was apparently hereditary, and unconnected either with nursing or dis- order of the stomach or liver. In twro cases, the hypertrophy of the liver originated in disease of the heart; and, in another,it was complicated with pleuritis and peri- carditis. In the only post-mortem examination given by Dr. Battersby, the liver was greatly enlarged, red, and filled with blood, but unaltered in structure. 783. Treatment.—If we see the case early, and have reason to sup- pose the existence of active inflammation, or if, at a later period, there be much tenderness, the child will derive relief from the appli- cation of leeches in numbers proportioned to its strength. If it be too weak for leeches, or if the symptoms do not demand them, counter-irritation by blisters or liniments may be tried. A very good plan is to paint the abdomen with tincture of iodine, over the region of the liver, every morning. Internally, mercury is the best remedy. It must be given in such a form and dose as shall be tolerable to the bowels, and it will scarcely be advisable to push its use too far. The ioduret of iron acts very beneficially at a more advanced stage of the disease. It may be given in syrup, in doses of one-eighth of a grain, three times a day, to a child of two years old. 496 ENLARGEMENT OF THE SPLEEN. If the child be a year old, it must be weaned immediately, and a good nourishing diet allowed; if under a year it will probably be advisable to change the nurse. 784. Enlargement of the Spleen.—This disease has hitherto been supposed to be peculiar to adults, but Dr. Battersby has observed seven cases of it, apparently the consequence of undue lactation. Of six of these cases, three died ; it is, therefore, a serious disease. Their appearance agrees with the description given by Piorry: "When the spleen has been long affected, the skin gets a dull aspect; a grayish coloration presenting sufficiently well a light-colored Creole shade, but with color less warm and more ashy. It is the integuments of the face, especially, where this coloration is most remarkable. It is not the yellow-ochrey color of icterus, nor yet the discoloration of chlorosis; it is a shade quite special, which has been very ridiculously called bluish icterus."1 "The conjunctiva is bloodless, and the patients manifest a perfect indifference to everything around them. They have a sickly, pallid look, and the wasting of the body is not in proportion to the paleness; they are truly chlorotic; they have invariably pica; the bowels are generally irregular; the abdomen is full. The patient's bulk will remain pretty good for a longtime, although he will become blanched in a state of anaemia. The blood is not proper in quality, it is deficient in fibrine, and likewise in red particles. The peritoneum sometimes becomes affected, and produces ascites, which renders the detection of the spleen difficult. The diagnosis is generally very easy, long before the spleen has attained a large size. The heart is unaffected in these cases. It has been said that the spleen is often hypertrophied in scro- fula and rickets; this, however, is by no means an established fact; and when there is tumefaction of this organ there is no peculiarity about it, and the other viscera, especially the liver, are simultaneously engaged."2 Dr. West connects enlargement of the spleen with intermittent fever and malaria: "The only instance of it," he says, "which I have had an opportunity of observing, was presented by a little girl six and a half years old, who had lived at Fernando Po from the age of two and a half years, having had dysentery at three years, and fre- quent attacks of fever subsequently. The enlargement of her spleen had first become apparent at five years of age ; and when I first saw her, a few weeks after her return from Africa, it had attained so con- siderable a size that her abdomen measured tw7enty-one and a half inches in circumference. The spleen in this case reached from under the ribs, quite down into the pelvis, and forward as far as the mesial line of the abdomen. Independently of the patient's history, which, in a case of this kind, would be of itself sufficient to prevent an erro- neous diagnosis, the relations of the swelling were characteristic ; for, although situated at the side of the abdomen, it did not extend back- wards into the lumbar region, so as to fill it up completely, as an en- 1 Traite de Diagnostique et de Semeiologie, p. 287. ' Dr. Battersby, Dublin Journal, May, 1844, p. 318. PERITONITIS. 497 larged kidney would do, but a considerable interval existed between the posterior margin of the tumor and the vertebral column."1 The diagnosis of the enlargement of,the liver and spleen is almost always easy by an abdominal manipulation, the tumefaction on the right or left side being very characteristic, and the dull sound on per- cussion marking as clearly the limits of the tumor. I have seen such cases occasionally myself among the ill-fed, ill- clothed, and neglected children of the poor; in the better ranks, I do not think either disease frequent; nor can I agree with Dr. West, that the enlargement of the spleen is necessarily connected with intermit- tent fever, which is rare in Dublin. 785. Treatment.—The only treatment which Dr. Battersby has found of any use, is wreaning the child when oversuckled, and giving nourishing food ; sending it out freely into the open fresh air; and ad- ministering internally the ioduret of iron, and externally painting the abdomen with the tincture of iodine, or friction with the ointment of hydriodate of potass. CHAPTER XX. PERITONITIS. 786. Inflammation of the peritoneum is a rare, and, when acute, a very fatal disease among children, much less frequent than either pleurisy or pericarditis, and, if I might judge by my own experience, I should add than arachnitis; but Rilliet and Barthez found it more so than the latter. In examining the bodies of children who have died from other diseases, it is by no means uncommon to find evidences of pleuritis or pericarditis which have been cured, but we scarcely ever find such traces in the peritoneum ; from which I infer either that the disease is very rare, or that it carries off its victim. Rilliet and Bar- thez met with a dozen cases of acute peritonitis. M. Thore found that acute peritonitis existed in about six per cent. of all the infants who died at the Hospice des Enfans trouves. This affection has been but little noticed by writers upon diseases of children. Dr. Romberg, of Berlin, in 1833, published a valuable paper upon the subject.2 Meissner3 has entered pretty fully into the subject. Heyfelder,4 and Malespini,5 and Thore,6 have published some interesting papers. It is noticed by Drs. Stewart and Condie. Peritonitis may be either acute or chronic, the latter occasionally 1 Diseases of Infancy and Childhood, p. 446. 3 Wochenschrift fur die gesammt. Heilkunde, 1833, Nos. 17, 18. 3 Ibid., vol. ii. p. 66. * Studien in Gebiete der Heilwissenschaft, 2, B. D. S. 190. s Archives Gen. de Med., 1840. 6 Ibid., Aug., Sept., 1846. 32 498 PERITONITIS. being of a scrofulous character, and accompanied with the deposition of tubercular matter on the serous membrane. The disease may be either primary or secondary, but much more frequently the latter. It may occur before birth, as the researches of Duges, Billard, Simpson, &c, have proved, and at any age subsequently. Of M. Thore's cases, thirty-five out of fifty-nine were less than a fortnight old, and none above ten weeks. 787. i. Acute Peritonitis.—The attack is generally somewhat sud- den, coming on either in the midst of health, or in the course of some other disease, and marked by severe abdominal pain, commencing, perhaps, at some one part, but quickly spreading over the entire ab- domen, and greatly increased by any movement. In very young infants it is sometimes not very well marked at first, but, with very few exceptions, it is always present. The pain rapidly becomes very acute, greatly increased upon pressure; the abdomen becomes swollen, tense, and tender: sometimes dull, sometimes resonant on percussion. After effusion has taken place it is always dull. This dullness and tension is general when the entire peritoneum is affected, but partial and local, when the peritonitis is circumscribed; and at the part affected we may feel a kind of tumor. Vomiting, which is so com- mon a symptom in adults, is not general with children. Rilliet and Barthez met with it only in two cases. Constipation also is very rare; it is more common to find a diarrhoea, which is very distressing, as well on account of the pain* which accompanies it, as from the efforts necessary, and the disturbance of the child afterwards. The pulse is small and very quick; the face has an expression of acute distress and great suffering; the tongue is generally moist, but loaded; sometimes clean, sometimes dry and loaded: there is great thirst, with an entire loss of appetite. The skin is hot, and occasion- ally at the commencement there are rigors, but not always. The breathing is quick, high, and short, not from any thoracic affection, but from the pain caused by the pressure of the descending diaphragm in a fuller inspiration. After effusion has taken place, there may be a mechanical impediment to full and free respiration. 788. In unfavorable cases, these symptoms continue and increase ; the pulse becomes insensible, the pain intense, the abdomen very large, the countenance extremely drawn, the anxiety very great, and death soon closes the scene. In more favorable cases, when the peritonitis is circumscribed, the symptoms diminish in intensity, the tumefaction becomes less and less painful, and finally disappears; the pulse becomes slower, the thirst less, the fever subsides, and the digestive functions are restored: or the symptoms, subsiding to a certain extent, may take on a chronic character. Another mode of termination occasionally occurs. Dr. West ob- serves:1 "The active symptoms diminish in intensity; the abdominal parietes grow thin at some spot, where a passage at length is formed, 1 On Diseases of Infancy and Childhood, p. 416. PERITONITIS. 499 through which pus is discharged, and recovery sometimes slowly fol- lows; the result of a process precisely analogous to that which nature has recourse to in pleurisy, when she brings about the evacuation of the fluid through an opening spontaneously formed in the parietes of the thorax. An instance of this mode of cure of peritonitis in a child seven years old was related by Dr. Aldis, at a meeting of the Medico- Chirurgical Society, in November, 1846.x A few similar cases may be found in medical journals;2 and one has come under my own ob- servation in the person of a little girl, whose history I formerly re- lated,3 as affording an illustration of that rare affection, inflammation of the sinuses of the dura mater." The duration of the disease is very variable; some cases have proved fatal in twenty-four hours; others have continued for weeks. Rilliet and Barthez have given us the duration of nine cases : "In two, it terminated in one day ; in one, in three days; in one, in five days; in one, in tw7enty-six days; in two, in twenty-six and twenty-seven days; in tw7o, in thirty-six and thirty-seven days."4 There is no essential difference between the symptoms of primary and secondary peritonitis; the former is, perhaps, more frequently circumscribed; and the latter, supervening upon other serious affec- tions, hardly permits a hope of cure. 789. Morbid Anatomy.—The serous membrane is generally found vascular and red, either partially or generally, and principally that portion of it which covers the intestines or the appendages. The sub- serous cellular membrane or the muscular coat may be infiltrated and softened, so as to be easily torn. In almost every case we find either liquid secretion poured out into the cavity, or false membranes. Some- times the fluid is serous, clear, abundant, and of a lemon color; in other cases it is troubled, and mixed with albuminous flocculi; or it may be purulent matter; thick, yellow, or greenish-yellow. The quantity varies from a cupful to several pints. The purulent matter is generally found in the pelvis; and, according to the quantity, the fluid will distend the abdominal cavity more or less completely. False membranes generally co-exist with effusion, slight, thin, and elongated; or in the form of thin, soft, gelatinous layers, of a whitish or yellowish color, but seldom very firm or thick; they unite the con- volutions of the intestines, more or less filling up the interstices, and, if the disease be prolonged, forming adhesions between different parts, and undergoing gradually the same sort of transformation we noticed in pleurisy. In one-third of M. Thore's cases, evidences of pleurisy were also discovered. 790. Causes.—Any of the ordinary exciting causes of inflam- mation may give rise to peritonitis, exposure to cold or wet, falls, blows, &c. 1 Medical Gazette, November. 1846. 3 Bernhardi in Preuss. Med. Zeitung, No. 10, 1842; and Beyer. Caspar's Wochens- chrift, 1842, No. 5. 3 Lecture vii. p. 81. * Mai. des Enfans, vol. i p. 564. 500 PERITONITIS. Or, it may be the consequence of a surgical operation, and occa- sionally it follows the perforation of the gall-bladder, the stomach, or intestines. Thus, Rilliet and Barthez state that, in one case, it was the result of tapping; in another, of a fall; in a third, of the rupture of the gall-bladder; in a fourth, of ulceration perforating the intes- tines.1 Again, it may be a secondary attack, occurring in the course of other diseases, as ascites, typhoid fever, scarlatina,2 or tubercles. In seventeen out of M. Thore's sixty-three cases, the peritonitis followed on erysipelas, and in four, on phlebitis of the umbilical vein. 791. Diagnosis.—i. Acute peritonitis is more likely to be con- founded with enteritis or entero-colitis than with any other affection; in both, there are pain and tension of the abdomen, with vomiting and diarrhoea; but in peritonitis the pain is far more intense, the tender- ness far more acute: the aggravation of suffering by the least move- ment; the drawn, anxious face, the quick pulse, and the fluctuation in the abdomen, are unlike the characteristics of enteritis. ii. The localized peritonitis has some resemblance to the symptoms of abscess in the iliac fossa; but the latter may be distinguished by the slowness with which the tumor is formed, its defined and limited seat, its progress, the slight degree of fever, and by its final evacua- tion, internally or externally. 792. Prognosis.—Nothing can be more serious than the prognosis ; peritonitis following perforation is almost necessarily fatal. Secondary peritonitis is so grave an addition to any other disease, that we can hardly hope for the child to escape; and the same maybe said of general peritonitis; there is no more mortal disease. The only cases in which there is much chance of recovery, are those in which the inflammation is partial, limited to one spot, and moderate in degree. 793. Treatment.—The indications of cure are simple enough; the only difficulty is to fulfil them. We must first attempt to relieve the inflammation by antiphlogistic treatment; and for this purpose, unless the child be greatly exhausted by previous disease, a number of leeches, large in proportion to the age of the child, should be applied to the abdomen, or blood taken from the arm. Unless we can thus make an impression upon the disease at an early period, there will be little chance of success, and therefore we must act promptly and boldly. More moderation will be requisite when the disease is second- ary and the child reduced; but still we must venture to leech, if we would hope to save the child, and to repeat the leeching according as the disease requires it, and the patient will bear it. After the leeches fall off, a warm light poultice should be applied, and repeated every two hours, if the weight of it do not cause dis- tress, in which case we must substitute frequent fomentations. Next to bleeding, the most important remedy is mercury, given so as to affect the constitution, as indicated either by tenderness of the gums or mercurial diarrhoea. I have generally found frequent small ' Mai. des Enfans, vol. i. p. 568. *" Stewart, Diseases of Children, p. 263. PERITONITIS. 501 doses of calomel better than larger ones, and in conjunction with mercurial inunction more effective than alone. For example, to a child of two years old, half a grain of calomel, with a grain of the pulv. creta? c. opio, may be given every two or three hours, and at the same time the abdomen smeared thickly with ung. hyd. fort., over which the poultice may be applied, or the inside of the thighs rubbed with the ointment; or we may adopt Sir B. Brodie's method, and apply a flannel bandage, smeared with the ointment, around the thighs or legs. But if diarrhoea be present, we may have to modify this plan, and either diminish the dose of calomel or increase the opium, or substitute for it the hyd. c. creta, or perhaps content ourselves with the external use of mercury only. Next to calomel, perhaps the most useful remedy we possess is opium, in peritonitis, as Drs. Graves and Stokes have shown; and although more caution will be necessary with children than with adults, yet the effects upon the disease are equally satisfactory. It may be given in combination with calomel or gray powder, if they can be borne; but if not, it may be continued alone, with benefit to the diar- rhoea as well as the inflammation of the serous membrane. If there be obstinate constipation, of course purgatives must be given, but we must take care that we do not ourselves render the exhibition of calomel impossible, by exciting too much action of the bowels. In general, I much prefer trusting to the calomel acting suf- ficiently upon the bowels, as well as upon the constitution. More- over, if the peritonitis be the result of perforation of the intestine, it will be of great consequence to suspend the action of the bowels, and to cause constipation, so that, instead of purgatives, we must give opium and astringents. 794. But the remedies I have enumerated are not merely calcu- lated to fulfil the first indication ; they meet the second, which is, to remove the results of inflammation, at a more advanced period, by increasing absorption ; and the third, that of preventing the further escape of matters from the intestines into the cavity of the peri- toneum. I have said nothing as yet of blisters, because they are unsuitable at first; but after due leeching, when the first acuteness of the attack is over; and at a later period, when effusion has taken place, they are highly useful, and I have found more benefit from small ones repeated than from large ones. Warm baths are occasionally beneficial and always soothing, if the child be not too weak. The diet of the patient in primary peritonitis must be rigorously restricted ; a little milk and water or whey, and a little toast, will be sufficient. In secondary peritonitis, however, though it must be moderate, we must have some regard to the exhausted condition of the child, and must support the strength, in order that we may have a chance of curing the disease. In addition to milk in any form, therefore, we shall have to allow weak chicken broth or beef tea. 795. ii. Chronic Peritonitis.—Slight allusions to this form of dis- 502 PERITONITIS. ease may be found in some of the writers on diseases of children, and more details by Baron,1 Abercrombie,2 Gregory,3 Billard, Rilliet and Barthez, Sir H. Marsh, West, &c. M. Billard gives a short notice of chronic peritonitis, and relates the following case:— " Josephine Perrine, a?t. ten months, of a good size, but thin and spare, had already cut the two incisor teeth of the lower jaw, when she was suddenly seized with dyspnoea. The child, usually lively, had become morose and fretful. She entered the infirmary on the 22d of January, 1826. The abdomen was tympanitic, the respiration a little difficult, and was indistinctly heard at the upper part of the right side of the chest; the tongue was dry, pulse small, skin burning; she was affected with diarrhoea, consisting of green and mucous fa?ces. On the 23d, the diarrhoea became more light colored. On the 24th, the same general symptoms, but wilhout fever; tension of the abdo- men, facies hippocratica, forehead wrinkled. On the 26th, deglutition difficult, retching, whenever drinks were given, very feeble. The isthmus of the fauces appeared of a bright red. Death took place on the morning of the 27th. "Post-mortem Examination.—Body considerably emaciated ; gene- ral paleness of the integuments ; nearly two ounces of yellow serosity were found in the abdomen. Numerous and firm adhesions existed between the transverse portion of the colon and the great curvature of the stomach. Some of the convolutions of the small intestines were likewise adherent, but in a less solid manner. The mucous membrane of the stomach was of a pale rose color; that of the small intestines was covered with red stria?, and a number of slate-colored spots existed in the whole length of the colon, &c."4 Sir Henry Marsh published some interesting cases of this disease in 1843, to which I had the honor to add some supplementary remarks, the substance of which is here reproduced.5 I shall now shortly detail the first case which occurred to myself, and for the diagnosis and successful treatment of which I am under obligation to Sir H. Marsh. Mary----, a?t. 6, a healthy child, of delicate, fair complexion, fair hair, &c, about December, 1840, was observed to be somewhat unwrell; she suffered from occasional attacks of diarrhoea, w'hich, after a time, either subsided, or were relieved by the usual remedies. Oc- casionally, she complained of shooting pains through the abdomen, coming on irregularly, and lasting but a short time, but not accom- panied with tenderness or swelling. Her appetite became delicate and fastidious, with some thirst. The pulse was scarcely quickened; her countenance became pale, and she became thin. Matters con- tinued in much the same state for about a month,—occasionally attacks of pain and diarrhoea, with loss of appetite, &c.; but after 1 On Tubercles, &c, p. 131. 2 Diseases of the Abdominal Viscera, p. 191. 3 Med.-Chir. Trans., vol. ii. p. 259. « Mai. des Enfans, and Trans., by Dr. Stewart, p. 354. 6 Dublin Journal, March, 1843, p. 1. PERITONITIS. 503 this time I observed that the abdomen became gradually swollen, with a distinct sense of fluctuation, uneasiness on motion, but no pain on pressure. The pulse rose to 130, and there was a certain amount of fever, especially in the evening, with an occasional rigor. The emaciation had increased, and the other symptoms continued much the same. By Sir H. Marsh's advice, hyd. c. creta, gr. ii, P. Jacob, gr. i, was given every four hours. The abdomen was well rubbed with ung. hyd. fort., and she took a warm bath at bedtime. This treatment was continued a fortnight without any manifest improvement, and without the constitution being affected by the mercury. The transient pain, the swelling with fluctuation, the quick pulse, the fever with exacerbations in the afternoon, and drowsiness, all continued. The appetite was rather improved. She had become by this time both thin and weak, wras very unwilling to exert herself, and complained of abdominal uneasiness upon moving about. A blister was then applied to the upper part of the abdomen, and dressed with ung. hyd.; frictions with a scruple of the same oint- ment were used twice a day, and the internal medicines omitted. Under this treatment she shortly began to amend. The pain re- turned less frequently, and at length ceased; the abdomen gradually though slowly diminished in size, until fluctuation was no longer per- ceptible; the bowels became regular, the pulse tranquil, the fever disappeared; in about six weeks from the commencement of the treatment she was convalescent. I have since seen several cases of the same kind which were bene- fited by similar treatment. 796. Chronic scrofulous peritonitis, with effusion, may follow acute inflammation, or it may occur without our being able to recognize any preceding acute stage, coming on so gradually, in fact, that we may not be aware of the nature of the disease until it is fully developed. As M. Duges observes, "there may be occasional pains, colics, irre- gular attacks of diarrhoea, emaciation, paleness, for weeks or even months before the disease is fully established."1 From the earlier and more prominent symptoms being referable to the mucous membrane of the intestinal canal, the real affection may be overlooked, and the fatal results attributed to the diarrhoea. It may also be either, primary or secondary, more frequently the latter. 797. Symptoms.—From what has already been said, it will be gathered that the mode of invasion varies widely. In one class of cases the patient labors under diarrhoea for a considerable time, with or without pain; the appetite is pretty good, the temperature natural, and the pulse quiet; but at length—it may be weeks or months—w7e hear complaints of a sensation of pricking, or of paroxysms of pain, and a feeling of tightness in the abdomen, which, upon examination, is found to be more or less swollen. 1 Diet, de Med. et de Chir. Prat., vol. xii. p. 295. 504 PERITONITIS. In other cases, there is a certain amount of pain from the beginning, occurring in paroxysms, with perfect intervals; and though at first limited to one part of the abdomen, yet by degrees spreading over and occupying the whole. Again, as Dr. Abercrombie remarks, " in a very important modifi- cation of the disease there is no complaint of pain ; the patient merely speaks of a feeling of distension, with variable appetite and irregular bowels, and with these complaints becomes progressively emaciated. In many cases, indeed, the early symptoms are so slight that no atten- tion is paid to them until the emaciated appearance of the patient excites alarm. The abdomen, on examination, is probably found tumid, and in some degree tender in various parts; and, upon ques- tioning the patient, it is found that there has been some degree of pain for weeks and months. In other cases there has been no actual pain, but a feeling of tenderness, which gives rise to uneasiness on pressure, or when any part of the dress is tight over the abdomen; but in many cases the disease steals on to an advanced period without any com- plaint of tenderness or pain."1 The observations of M. Andral2 are confirmatory of Dr. Aber- crombie's remarks; Dr. Gregory, however, states that tenderness on pressure is present from the commencement.3 So much for the mode of invasion. Sooner or later, in the majority of cases, the patient complains of pain, occurring most frequently in paroxysms of varying intensity and duration, with intervals of com- plete relief; beginning in some one part of the abdomen, and gradu- ally spreading over the entire. In the words of Dr. Gregory, " the attacks of acute pain occur in paroxysms at first, not oftener, perhaps, than once or twice in a day; but, as the disease advances, they increase in frequency, and, at the same time, in violence. I have seen them happen as often as once in ten or fifteen minutes ; they do not last long, and, immediately after an attack, the child appears lively, as if nothing ailed it."4 There is frequently, perhaps generally, a certain amount of tender- ness on pressure, especially at the part to which the pain is at first limited, though it is not very remarkable in many cases. The patient almost always complains of uneasiness on attempting to walk or stand, and in some cases finds it impossible to stand erect. After an uncertain interval, the patient complains of a feeling of distension, and requires the dress to be left loose ; and then, if an ex- amination be made, the abdomen will be found more or less swollen. Percussion generally yields a dull sound, but not always, for when the bowels are much disordered, they sometimes become tympanitic. Fluctuation is, I think, perceptible in all cases, if the examination be carefully made; but it requires especial care with young children to guard against the action of the abdominal muscles, and the natural elasticity of the integuments. The best mode is to lay the child on its 1 Diseases of the Abdominal Viscera, p. 192. 3 Mai. de 1'Abdomen, in Clin. Med., vol. iii. p. 587. 3 Med.-Chir. Trans., vol. ii. p. 263. * Ibid., vol. ii. p. 2C4. PERITONITIS. 505 back, and accustom it for a short time to the presence of the hand upon the abdomen ; then, placing one hand, with the fingers separated, on one side, and percussing very gently with the other, the muscles will not be excited into action; and, if fluctuation be perceptible with the second or third finger, we may be certain of the presence of fluid; for the pressure of the forefinger upon the skin effectually arrests the vi- bration which results from its elasticity. I have dwelt rather minutely upon the mode of examining the abdomen, because, in many cases, from the paucity and obscurity of the symptoms, our diagnosis must chiefly depend upon the presence or absence of fluctuation. The enlargement of the abdomen is not always equable; in some cases, especially in the commencement, the umbilical region protrudes. As the effusion increases, the entire abdomen enlarges, loses its soft- ness, and becomes tense and hard, though occasionally unequally so. The skin of the abdomen is hot and dry, and has the appearance of being stretched and diminished in thickness. In very chronic cases, large blue veins are visible traversing the abdomen. When the mesenteric glands are diseased, it is possible, in some cases, to detect their enlarged condition, by making careful examina- tion, at an early period, before the abdomen is much distended. In some rare cases the intestinal canal preserves its integrity for a long time; the tongue is pretty clean, the appetite much as usual, the bowels regular, or perhaps rather constipated; but, in the large ma- jority of cases, we find the tongue white, loaded, and flabby; more or less thirst; the appetite irregular and fastidious, sometimes increased, more frequently impaired or lost altogether; the bowels relaxed or constipated, perhaps alternately; the stools fetid and of a whity-brown or bluish color. "At first," says Dr. Gregory, "the stools are green, slimy, or fetid; but, when the disease has existed about six weeks or two months, they will be found to consist of a whitish or whitish- brown matter, of the consistence of thin pudding; nor do the eva- cuations differ more in quality than they do in quantity from those in health. The quantity passed by the child in twenty-four hours, and that without the aid of medicine, is often enormous; and I have seen it taken notice of by the parents as greatly exceeding what the child could have taken in by the mouth." "This state of the bowels fre- quently continues for six weeks or two months, the body of course wasting the whole time, until diarrhoea at length comes on, attended with petechia?, which, in the course of three or four days, puts a period to the child's life."1 When the effusion is considerable, the breathing maybe rendered rapid and laborious, owing to the pressure upon the diaphragm. There may be another cause for the dyspncea, however; for, as in one of Sir H. Marsh's cases, it sometimes happens that the serous membrane of the chest is affected, with effusion into its cavity. At first, the pulse is scarcely altered; but, as the disease advances, it increases in frequency, varying from 100 to 140, but is diminished in strength and fullness. The heat of skin is increased. * Med.-Chir. Trans., vol. ii. p. 265. 506 PERITONITIS. In almost all cases, when the disease is fully established and the fever marked, there are distinct evening exacerbations of a hectic cha- racter, during which the pulse rises, the temperature augments, the face is flushed; there is much thirst, and the urine is high colored, &c. After this state has continued an hour or two, it gradually subsides. Generally speaking, throughout the course of the disease, the secre- tion of urine is diminished in quantity. It is hardly necessary to add, that so formidable and long-continued a disease is attended with great emaciation and exhaustion. As the disease progresses, the local symptoms are aggravated; the quick pulse and fever, with exacerbations, more remarkable; the weakness and incapability of exertion more extreme; the patient, in short, is utterly worn out.1 798. Terminations.—The course of the disease is generally very long; it may be prolonged for several months, and then may termi- nate variously. i. In resolution. Under proper treatment the inflammation may be subdued, and the effusion absorbed, and this termination is the more practicable the less the mesenteric glands are affected. In such cases, we find the unhealthy condition of the intestinal canal gradually cor- rected, the appetite return, and the fa?cal evacuations become natural; the pulse diminishes in frequency, the fever and exacerbations cease. The last symptom remaining is the abdominal distension; but this, too, gradually subsides until fluctuation can no longer be detected. These successful cases, however, are not the most common. n. In a circumscribed collection of the effused fluid, and its final evacuation, with more or less subsidence of the original affection. Under such circumstances, patients have been known to recover. Dr. Burns mentions a case of this kind ;2 and Dr. Abercrombie states that the matter may make its way through the abdominal parietes or the inguinal ring.3 An interesting case of this termination was related to the Surgical Society, by my friend, Dr. O'Reilly. Such cases, how- ever, are very rare. in. In death. The majority of cases terminate thus at different intervals from the commencement of the attack. Instead of diminish- ing, the symptoms progressively increase in intensity. The abdomen is very tense and tender, the fever high, the pulse very quick and feeble, the thirst considerable, the diarrhoea persistent, the exacerba- tions severe, the emaciation and exhaustion extreme. The coun- tenance becomes sunken, the extremities cold, the surface covered with a clammy sweat, and occasionally dotted with petechia?, and at length, after a prolonged period of suffering, death closes the scene. In some cases, the disease is brought to an earlier termination by ulceration and perforation of the intestines, which converts the chronic peritonitis into acute. 799. Morbid Anatomy.—Occasionally, the vessels of the peritoneum • Burns's Midwifery, p. 811. ' Midwifery, p. 811. * Diseases of the Abdominal Viscera, p. 195. PERITONITIS. 507 are injected, though sparingly; there is more or less serum effused into the abdominal cavity, with shreds of lymph floating therein.1 The intestines are more or less agglutinated together, and often thus assume the appearance of sacs of matter. Where there has been per- foration of the intestines, we find fa?cal matter mixed up with the serum, and can generally detect the communication with the intestine through which it has passed. The peritoneum itself is often thick- ened, and coated with a layer of lymph ; sometimes it is studded with miliary tubercles, or has tubercular matter deposited upon it. In some cases, the mucous membrane is intact; in others, ulceration has advanced to different stages. The mesenteric glands may be free from disease, or they may be enlarged, and contain tubercular matter. Dr. Abercrombie states, as the result of his experience, that "on dissection, the bowels are generally found more or less extensively glued to each other, and to the parietes of the abdomen, and the omentum is often involved in the disease. There is sometimes ulcer- ation of the mucous membrane, and not unfrequently the peritoneum is in many places much thickened, and studded with small tubercles ; in some cases, again, there is great thickening of all the coats of the intestines at particular parts. In many cases, there are left amid the adhering portions of the intestines, cavities full of purulent matter, which is generally of an unhealthy or scrofulous character. There is frequently disease of the mesenteric glands of the liver or lungs."2 Dr. Gregory observes that, "on cutting through the parietes of the abdomen, all traces of abdominal cavity will be wanting. The mesen- tery, bowels, and peritoneum lining the parietes, will be found united together into one mass. The peritoneum, in all its duplicatures, ap- pears thickened, and on cutting through the diseased mass, very large quantities of scrofulous matter will be found. The raucous membrane of the bowels, particularly of the small intestines, appears ulcerated in various places, and at these points of ulceration the convolutions of the intestines communicate, so that instead of forming one line of canal, as they will continue to do even in advanced stages of chronic peritonitis, they constitute a mass of tubes communicating freely with each other, and with the thickened and ulcerated peritoneal mem- branes by innumerable openings. The matter which will be found both within and.without the mucous membrane, will be observed to correspond exactly with that which was passed during life by stool."3 800. Causes.—Various exciting causes have been mentioned as giving rise to the disease; such as bad diet, cold, privations, excesses, dentition, constipation, &c, and doubtless with truth; but nevertheless, in the majority of cases, it will be extremely difficult to say, exactly, what is the exciting cause. In the cases which have fallen under my own observation, it appeared to be the result of an extension of irri- tation from the intestinal mucous membrane. It also occurs as one of the sequela? of febrile diseases, such as scar- 1 Burns's Midwifery, p. 811. Denis, Mai. des Enfans Nouveaux-nes, p. 119. 3 Diseases of the Abdominal Viscera, p. 193. 3 Med.-Chir. Trans., vol. ii. p. 26G. 508 PERITONITIS. latina, measles, &c. It may be worth remarking that none of the children, in whom it occurred at an early age, were born of mothers who had suffered from puerperal fever. 801. Diagnosis.—When pain and swelling of the abdomen, with fluctuation, are present, the diagnosis will be easy; but in those cases in which there is no pain, and but slight tenderness, with little dis- order of the digestive organs, there may be great difficulty. Our principal guide is the enlargement of the abdomen, which ultimately always occurs, and the fluctuation, which, by a little care, may gene- rally be perceived. When there is much dyspnoea, or w7hen the diar- rhoea is severe, we must be on our guard against supposing the disease limited to the chest or mucous membrane of the intestines. WTe know- that both may be seriously involved, concurrently with the peritoneal membrane. The same may be said of the mesenteric glands; they may also be diseased; but when they are affected alone, we shall find neither the abdominal swelling (at least to the same extent) nor the fluctuation. 802. Prognosis.—The prognosis, in the majority of cases, is un- favorable. Where the peritoneum alone is affected, the patient has certainly a chance of recovery; but if the mesenteric glands, or the mucous membrane of the intestines, or the pleura, be involved, the case w7ill probably terminate unfavorably. 803. Treatment.—The treatment usually recommended is com- prised in a few lines,—short in proportion to its hopelessness. Leeches to the abdomen, fomentations, purgatives, of which calomel forms one of the ingredients, alteratives sometimes, tonics, chalybeates, absorb- ents, &c. Such is the catalogue usually given. The question, how- ever, deserves a little more detail, inasmuch as a certain number of the cases are curable, if wre are called in reasonably early. General bleeding, I believe I may say, is never required; but when the pain is distressing, especially if there be parts of the abdomen tender on pressure, we may afford relief by the application of a few leeches; to be repeated, if necessary. The abdomen should be fomented with a decoction of poppy heads, twice a day, or oftener, if the paroxysms of pain be frequent; or a piece of lint wet with laudanum may be laid over the abdomen; and every night, or every other night, the patient should take a warm bath. If the bow7els be confined, a dose of castor oil, or Gregory's pow- der, must be given occasionally; but if diarrhoea be present, it may generally be checked by the pulv. creta? cum opio, or any other astringent combined with an anodyne. Dr. Gregory advises lau- danum for this purpose. But our principal reliance is upon mercury, given so as to affect the gums, if possible. I believe that the credit of thus administering mercury in this disease, is due to Sir Henry Marsh, as I have found no allusion to it in any authority. It may be exhibited internally, or by inunction; in many cases the latter is preferable; as, when diar- rhoea occurs, the bowels are too irritable. A scruple of the strong ung. hyd. should be gently rubbed in over the abdomen, night and PERITONITIS. 509 morning, and continued until the gums are touched, or the disease shows signs of yielding to the treatment. Blisters to the abdomen are very useful; they should be small, and applied successively to different parts, and dressed with the blue oint- ment. Should the disease give way, the moment the febrile action ceases will be the proper time to commence the use of tonics ; and the diet, which up to this time should be bland and unstimulating, though nutritious, may consist of broths, meat, and a moderate quantity of wine or porter. During convalescence, the patient must be confined to the house at first, and only by degrees allowed to take air and exercise. The clothing should be warm, with flannel next the skin. At a more advanced period of convalescence, a removal to the country w*ill be of essential benefit. SECTION V. DISEASES OF THE SKIN. 804. My object in the present section is simply to give a brief sketch of those eruptions which occur most frequently in children; neither superseding the necessity of consulting more elaborate works upon the subject, nor attempting to solve the various physiological and pathological questions connected with this class of diseases. Although I agree with those who object to many points of the classi- fication of Dr. Bateman, yet, in order to avoid confusion, I think it better to make use of his terminology, and, to a great extent, of his arrangement, specifying any points of difference as they arise. That the varieties of cutaneous eruptions are caused by the difference of the tissues involved, and the varying amount of inflammation, I fully believe, with perhaps one exception,—and with regard to that the question can hardly be considered as settled. Commencing, therefore, w7ith the slightest of these diseases, we shall consider successively the papular, squamous, vesicular, and pustular diseases in order. For fuller details, I must refer my readers to the works quoted below.1 CHAPTER I. STROPHULUS.—PRURIGO.--PITYRIASIS.--ROSEOLA. I. STROPHULUS, OR RED GUM. 805. This is ordinarily the earliest eruption to which infants are liable ; it is very commonly seen a day or two after birth and from time to time during the first year of infantile life. It appears to arise from the irritability of the skin, and its sensibility to reflex irritations : 1 Willan on Diseases of the Skin. Bateman on Cutaneous Diseases. Biett, Abreee pratique sur les Maladies de la Peau, by Cazenave and Schredel. Lecons sur les Mai de la Peau, par P. L. A. Cazenave. Eruptions of the Face, Head, and Hands, by Dr. Burgess. Portraits of the Diseases of the Scalp, by W. C. Dendy. On Eruptive Diseases of the Scalp, by Dr. Neligan; and in the Dublin Journal, Aug. 1848. PRURIGO- 511 thus, at an early period, it seems to be owing to the assumption of its proper functions by the stomach and intestinal canal; at a later period, to some disorder of these organs, or to dentition, &c. WTillan and Bateman have described five varieties : the strophulus intertinctus " is characterized by papula? of a vivid red color, situated most commonly on the cheeks, forearms, and back of the hands, but sometimes universally diffused. They are usually distinct from each other, but are intermixed with red dots or stigmata, and often with larger red patches, which have no elevation. Occasionally, a few small vesicles appear on the hands and feet, but these soon desiccate without breaking."1 The other varieties are mere modifications of this one; sometimes we find minute, hard, whitish, elevated specks mixed with it (stro- phulus albidus); or the eruption is more extensive and general, of a more vivid red, and sometimes in large, irregular patches (s. confer- tus); or it occurs in small circular patches or clusters of papula?, arising and exfoliating on different parts of the body (s. volaticus); or it may consist of large papula?, with a smooth shining surface, without inflammation, around the bases (s. candidus). 806. Very little treatment is necessary, and no local applications, beyond daily and careful ablution, or an occasional warm bath. In young infants, as the digestive system becomes used to the exercise of its functions, less and less cutaneous irritation of the skin is excited, and the disease subsides of itself. When it proceeds from morbid irritation of the bowels, however, it will be relieved by a few grains of gray powder, with rhubarb ; or, if the bowels are too free, a little chalk mixture, with a drop or two of laudanum to the ounce. If the teeth are troublesome, and the gums swollen or inflamed, it will be necessary to lance them freely, so as to remove the distress. II. PRURIGO. 807. The disease is characterized by an eruption of papula? of the same color with the surrounding cuticle, accompanied with severe itching. There is but one variety, the Prurigo mitis, which fre- quently affects young persons. It is "accompanied by soft, smooth papula?, somewhat larger and less accuminated than those of lichen, and seldom appearing red and inflamed, except from violent friction ; hence an inattentive observer may overlook the papula? altogether, more especially as a number of small, thin, black scabs are here and there conspicuous, and arrest his attention. These originate from the concretion of a little watery humor, mixed with blood, which oozes out when the tops of the papula? are removed by the violent rubbing or scratching which the severe itching demands. This constant fric- tion also sometimes produces inflamed pustules, which are merely ' Bateman on Cutaneous Diseases, p. 2. 512 PITYRIASIS. accidental, how7ever, when they occur at an early period of the com- plaint. The itching is much aggravated both by sudden exposure to the air and by heat; whence it is particularly distressing when the patient undresses himself, and often prevents sleep for several hours after he gets into bed."1 It appears to be most frequent in spring or the beginning of sum- mer, and certainly with children occasions great distress. It is quite distinct from scabs or itch, and yet, if neglected, it is quite possible that it may degenerate into that complaint. 808. Treatment.—The tepid bath, or frequent ablution with warm water appears to be almost the only local remedy necessary, though at first the disease seems rather aggravated than relieved. I have found the addition of sulphuret of potash to the warm water afford great relief to the itching. Internally, Dr. Bateman recommends the use of sulphur, alone or combined with soda or nitre, and that this should be followed by the mineral acids. We must take care to regulate the bow7els; if they are not too free, the hyd. c. creta, with rhubarb and a little carbonate of soda, will act kindly and beneficially. III. PITYRIASIS. This eruption is characterized by irregular patches of thin scales, which exfoliate and reform, but which neither form crusts nor are accompanied with excoriation. The first variety of Bateman (p. ca- pitis) is that with which we have chiefly to do. It is observed on the head of many, if not most infants, in the form of dandriff, as it is called, and appears rather as an excess of cutaneous secretion than as a disease. It is most common on the top of the head, but it often extends to the forehead, where we may see a band of small whitish scales, easily removed by friction ; but on the top of the head and at the occiput the scales are larger, and, if neglected, rather resemble a large, dirty patch. Among the poor this state of the scalp is almost universal, and, I do not doubt, forms an appropriate preparation for more troublesome eruptions in that region. Even with infants who are carefully tended, it requires patience and constant watching to prevent the formation of a layer of scaly secretion. Dr. Neligan remarks: "If we examine the condition of the scalp in pityriasis capitis, the surface is found to be closely covered with the imbricated scales, with small intervals here and there; the skin of the unaffected parts presenting a smoother or more polished appearance than natural. On removing one of the scales we find that the spot on which it is seated is soft, and that another fine scale may be removed from it; and it is not until after the removal of several scales each finer than the preceding, that we arrive at the reddened and inflamed surface of the scalp, which is somewhat depressed."2 1 Bateman on Cutaneous Diseases, p. 15, 3 Dublin Journal, August, 1848, p. 41. ROSEOLA. 513 The principal annoyance which it occasions is the itching; and the efforts of the infant of course tend to increase the inflammation and irritation. 809. Treatment.—Daily and careful ablution of the head is neces- sary with all infants, and especially when this disposition to excessive secretion is manifest; but I have certainly seen this disease aggravated by the frequency and profuse use of soap, which acts as an irritant to the tender skin of the infant. Very little, if any, soap should be used; if warm or cold water be not sufficient, oatmeal and water, or a little of the yolk of egg, may be employed; and, after the head is dry, a small quantity of very thin oil may be applied ; or, if the skin appear red, a lotion of almond milk (3iv) and acetate of lead (gr. xii). At a more advanced age, soap may be used more freely, followed by the same oily or soothing applications, or an alkaline or spirituous lotion, according to circumstances. It will be generally advisable to remove the hair, or to keep it very short, and especially if its growth appear to have been injured. IV. ROSEOLA. 810. This eruption is a rose-colored efflorescence, not contagious, and without either wheals or papulae. Bateman describes seven varie- ties; but we are principally concerned with tw7o of them, the roseola autumnalis, which " occurs in children in the autumn, in distinct cir- cular or oval patches, which gradually increase to about the size of a shilling, and are of a dark, damask-rose hue. They appear chiefly on the arms, and continue about a week, sometimes terminating by de- squamation. There is little itching, tingling, or constitutional affection connected with this efflorescence, and its decline seems to be expedited by the use of sulphuric acid internally:" and the roseola infantilis, which is a closer rash, with fewer interstices, sometimes disappearing after a few hours, or recurring and disappearing for days together, occupying sometimes a limited space, in other cases being very gene- ral, and accompanied with smart, though temporary, febrile action. It appears to be the result of intestinal irritation, or of dentition, and it is not uncommon in the course of fevers. Previous to the eruption of small-pox, there is an eruption of roseola, and a similar one after vaccination; but these are of trifling importance, and indeed I should hardly have mentioned roseola at all but for its resemblance to measles or scarlatina in some cases, but particularly to measles. I have no doubt but that some of the cases in which it is supposed that measles or scarlatina has occurred twice in the same child, were in one instance cases of roseola. There is sometimes considerable febrile action before the eruption, and the eruption may present a striking resemblance to either of these diseases; but in general the fever is infinitely less, and the eruption dies away much sooner. Moreover, there is less lachrymation and 33 514 HERPES. suffusion of the eyes; rarely any bronchitic affection or sore throat; and, finally, it does not run through the family. 811. Treatment.—The removal of the irritation, caused by denti- tion, or disordered stomach and bow7els, is in general quite sufficient to cure the affection, which, in itself, is of no moment. CHAPTER II. HERPES.--ECZEMA.--RUPIA. I. HERPES. 812. We now pass on to a different class of diseases, in which the cuticle is not merely prominent, but in w7hich it is separated from the cutis, and raised above the level of the surrounding parts by the effu- sion of serum. The characters of a vesicle, as distinguished from a pustule, are thus stated by Bateman: "It is a small orbicular eleva- tion of the cuticle, containing lymph, which is sometimes clear and colorless, but often opaque and whitish, or pearl-colored. It is suc- ceeded either by scurf or by a laminated scab." Of that form of disease which I shall first notice, herpes, Dr. Bate- man makes five varieties: H. phlyctenodes; H. zoster; H. areuatus; H. labialis; and, H. preputialis. But, as the majority of these affect children only incidentally, I shall enter into details concerning one species only, the herpes arcuatus, or ring-worm, which Dr. Neligan considers to be the true ring-worm of the scalp. As we generally see it, it appears in small circular patches, with the vesicles best marked at the circumference; but this I believe to be because the disease, which commences by a single small vesicle, spreads concentrically, the centre healing whilst the circumference spreads and enlarges by successive crops of vesicles, producing in a short time the appear- ance of a ring. The vesicles are very minute, and in the course of a week form scabs, which fall off, leaving the cuticle underneath red for some time. Fresh vesicles may form, dry up, and the scabs fall- or the original circles may remain red, and the cuticle throw off scales merely. Other circles meanwhile may form, and thus spread on the upper part of the body, the arms, chest, back, face, and scalp. There is no febrile disturbance attendant upon this eruption nor any inconvenience beyond a disagreeable itching and tingling in the patches. 813. Dr. Bateman has noticed another form of herpes, "in which the whole area of the circles is covered with close-set vesicles and the whole is surrounded by a circular inflamed border. The vesicles are of a considerable size, and filled with transparent lymph. The ECZEMA. 515 pain, heat, and irritation in the part are very distressing, and there is often a considerable constitutional disturbance accompanying the eruption. One cluster forms after another, in rapid succession, on the face, arms, and neck; and sometimes, on the day following, on the trunk and lower limbs. The pain, feverishness, and inquietude do not abate till the sixth day of the eruption, when the vesicles flat- ten, and the eruption subsides. On the ninth and tenth days, a scabby crust begins to form on some, while others dry and exfoliate; the whole disease terminating about the fifteenth day." Dr. Bateman seems to doubt whether herpetic ring-worm is conta- gious, because the other herpetic eruptions are not. M. Biett lays great stress upon its not being contagious; upon its vesicular character; and upon its not injuring the hair, as distinguish- ing it from porrigo scutulata.1 Dr. Neligan has no doubt of its contagiousness; he regards it as completely proved as that of small-pox. It certainly attacks more than one member of a family or school consecutively, and in some cases I have thought was undoubtedly communicated from one child to another. 814. Treatment.—The hair must be cut short, and, if there be much irritation, soothing applications are to be applied; if not, we may at once apply our special remedies. Strong astringent applications seem to be the best: the solution of the salts of iron, copper, zinc, or of borax, alum, &c, are very successful. The tincture of the muriate of iron I have found very useful: the tincture of iodine or nitrate of silver will cure it equally w7ell. Common ink (which contains sulphate of iron, and galls) is a very favorite popular remedy. M. Biett speaks highly of lotions of carbonate of soda or potash; and his experience is confirmed by Dr. Neligan, who recommends the use of both ointment and lotion of these alkalies; and, if a more stimu- lant treatment be necessary, a dilute citrine ointment. The stomach and bowels should be carefully regulated, and the skin kept in a state of great cleanliness. II. eczema. 815. The varieties of eczema described by Dr. Bateman are not at all peculiar to children, and are not mentioned as attacking the scalp. But my friend, Dr. Neligan, has described a disease under the name eczema capitis, which is by no means uncommon. It is essentially a vesicular eruption, but in the different stages it presents varied ap- pearances, because probably of the increase of the inflammation from rubbing, scratching, &c, so that it often resembles the eczema impe- tiginodes of Willan and Bateman, an intermediate stage between a vesicular and pustular disease. 1 Mai. de la Peau, by Cazenave and Schedel, p. 110. 516 ECZEMA. The appearance of the eruption is preceded by itching, tingling, and heat; then the minute vesicles are seen crowded together in irre- gular patches, or scattered over a large surface. They usually appear first behind the ear, close to the edge of the scalp, from whence they spread over the ear itself and the scalp. "The interspaces between the vesicles and the whole of the scalp, on which they are seated, is red and inflamed; in most cases, the vesicles are so minute as to be scarcely recognizable, or at least are not seen by the physician, until they have burst, and given exit to a copious exudation of a serous fluid, by which the roots of the hair are ceraented together. In the acute form of the disease, this serous exudation continues for a long time, and is a most troublesome symptom; but, in the chronic forms—and some cases assume a chronic character almost from the first—it rapidly dries into furfuraceous scales, which are pushed forwrard by the hairs as they grow. With the progress of the affection, the ap- pearance of the diseased surface varies much; sometimes it is scarcely, if at all, elevated above the healthy parts, and is only to be recognized by the watery exudation which keeps the hairs in a con- stantly moist state. In other cases, the scalp is raw or excoriated, and secretes a thin whitish pus, which dries into grayish-brown scabs, presenting cracks or fissures through which the inflamed surface is seen. In a third form of the disease, the serous exudation dries rapidly into extremely thin membranous scales, which are readily removable by the slightest friction, but cause much itching; and a fourth variety is characterized by a repeated eruption of minute patches of vesicles, the patches rarely exceeding the size of a small bean, all on the scalp, which pass through the stages of eczema, as witnessed on other parts of the cuticular surface, and disappear in seven or eight days, but to be rapidly succeeded by a fresh outbreak of the disease."1 So long as the surface of the cutis remains unbroken, the hair is uninjured; but, when the inflammation involves the roots of the hair, or ulceration of the cutis destroys them, the hair is either weakened in its growth, or altogether obliterated. Eczema does not appear to be a contagious disease, nor can we name any special cause for it; it may be connected with dentition or intestinal irritation, like other eruptions. 816. Treatment.—I quite agree with Dr. Neligan that more harm than good is done by shaving the scalp, at least in the acute stage of any eruptive disorder. The hair should be cut very close with a pair of fine scissors, and kept very short; this occasions no irritation, and affords sufficient facility for applying remedies, and for keeping the head clean. In no severe or acute case, however, should the head be washed with soap ; water alone, or oatmeal and water, will be suffi- cient. The local treatment will, in the first instance, depend upon the amount of inflammation; if this be great, the first object is to soothe and lessen it by emollient applications, such as poultices ' Dublin Journal, August, 1S48, p. 37. RUPIA. 517 fomentations, or the warm water dressing. When the surface is less red and angry looking, we may try the alkaline applications recom- mended by Biett and Neligan—the carbonates of soda or potash, either in the form of ointment or lotion. I would wish to impress upon my junior readers the fact that, with some children, greasy applications altogether disagree, and seem to aggravate the eruption, whilst, with the same children, the same remedies in the form of lotion will suc- ceed perfectly; and, as this can be known only on trial, we should change the vehicle if we do not find it answer, before deciding against the remedy. Dr. Neligan forms the ointment of either carbonate by adding from tw'enty to thirty grains to an ounce of lead, and the lotion by dissolving half a drachm in a pint of rose-water or distilled water. The ointment is to be applied three times a day, and should be washed off every morning with the lotion: if the lotion only be used, it should be applied five or six times a day. The carbonate of soda is preferable when there is much inflammation, as being less irritating than the carbonate of potash. In all cases, Dr. Neligan keeps the child on milk diet during the entire period of treatment. In chronic cases, where some stimulant is required, a very dilute citrine ointment may be used.1 I have found singular benefit in all the moist eruptions, where the inflammation is not too great, from the use of black wash; it dries the surface, and forms scabs, which must be carefully removed, in order that the lotion may get at the diseased surface. In some cases, a lotion of acetate of lead in almond-milk, or decoction of poppy-heads, is very soothing. The bow7els must be regulated, and, in some obstinate cases, a few alterative doses of mercury may be advantageously given. M. Biett recommends acid drinks. III. RUPIA. 817. Dr. Bateman states that " rupia is characterized by an ap- pearance of broad and flattish vesicles in different parts of the body, which do not become confluent; they are slightly inflamed at the base, slow in their progress, and succeeded by an ill-conditioned discharge, which concretes into thin and superficial scabs, that are easily rubbed off and presently regenerated."2 We are only concerned w7ith one of his three varieties, however, the rupia escharotica, which appears to be identical with the disease de- scribed by Dr. Whitley Stokes and others under the name of pem- phigus gangrenosum. Dr. Bateman says that " it affects only infants and young children when in a cachectic state, whether induced by previous diseases, especially the small-pox, or by imperfect feeding and clothing, &c.; whence, among the poor, where it is commonly seen, it often terminates fatally. The vesicles generally occur on the ' Dublin Journal, August, 1849, p. 45. a On Cutaneous Diseases, p. 243. 518 IMPETIGO. loins, thighs, and lower extremities, and appear to contain a corrosive sanies; many of them terminate with gangrenous eschars, which leave deep pits."1 MM. Cazenave and Schedel describe it as commencing with livid spots, slightly prominent, upon which the epidermis is soon elevated by the effusion of serum until they form large bulla?, flat, and of ir- regular form, surrounded by a livid circle. These vesicles break, and expose irregular ulcerations, varying in depth and extent, with red border and unhealthy surface. There is severe pain, with much fever, and sleeplessness; and, when the disease is extensive, death may occur in a week or two. In one or two cases which came under my care, I was informed that the disease commenced by a vesicle filled with clear serum, which enlarged speedily, and the serum became opaque. The bor- ders were slightly red. When I saw the case, the bulla? had burst, and exposed an irregular ulceration with defined edges slightly in- flamed, and with a tolerably healthy surface. The disease occurs in this country among its poor, neglected, and unhealthy children, and is popularly called "burnt holes." 818. Treatment.—It will be necessary to attempt to improve the general condition of the child, if we hope to cure the local disease. Cleanliness, comfortable clothing, pure air, and good diet must be afforded. If there be much fever, of course the diet must be moderate but nourishing, and by degrees broth, beef tea, or solid animal food may be given. The local applications will consist, in the first instance, of caustics —the nitrate of silver, the acid nitrate of mercury, dilute nitric or muriatic acid, &c.—so as to change the surface and arrest the ulcer- ation, after which poultices may be applied. M. Biett has succeeded with the proto-ioduret and deuto-ioduret of mercury in the form of ointment; a scruple of the former, and from twelve to fifteen grains of the latter, to an ounce of lard. CHAPTER III. IMPETIGO.--PORRIGO. I. IMPETIGO. 819. We now come to the consideration of pustular eruptions and the one I shall first notice is one which occasionally assumes a vesicu- lar appearance, although really pustular. Impetigo, moist or running tetter, is marked by small psydracious pustules, neither accompanied 1 On Cutaneous Diseases, p. 244. IMPETIGO. 519 by fever, nor contagious, nor communicable by inoculation. Dr. Bateman says that it chiefly occurs on the extremities, but it may also attack the head. In children, it is very apt to appear in parts where there is much movement, such as the flexures of large joints, and is accompanied with intense itching. It may be excited by dentition, disorder of the stomach and bowels, &c, and is frequent in children of deteriorated constitutions. When it attacks the scalp, it is preceded for a few days by feverish symptoms, and sometimes by vomiting; the scalp is hot and tender, and with a slight redness where the eruption is about to appear. The pustules are psydracious, occurring singly or in groups, with inflamed bases. Each pustule contains thick, yellow, purulent matter, which is soon matured, and forms a greenish-yellow scab. This form Dr. Neligan considers to assume a chronic form but rarely; fresh pustules appearing in different parts of the scalp as the old ones heal. 820. " The second form of the disease is characterized by the eruption occurring in groups of pustules; but the individual pustules are also different in character, being of the variety which has been termed achores. Their appearance is attended with more decided symptoms of inflammation, both general and local; and the heat and itching are in many cases so severe, that children tear the scalp, and prevent the disease from presenting the truly pustular character of the first stage. The eruption usually commences on the forehead, in- volving at the same time some of the hairy scalp. The inflamed patches vary in size and form in different cases; in some, extending in their longest measurement not more than from half an inch to one or two inches, while in others the greater part of the scalp is involved from the very commencement. In nearly every instance, the skin bordering on the scalp is more or less engaged in the disease, and it often appears at the same time in the ears or on some part of the face. The pustules are not so large as when they occur singly; their coats are apparently thinner, and the pus which they contain is not so con- sistent, and is of a richer yellow color. They usually become con- fluent before they burst, and the resulting greenish-yellow (when chronic, greenish-brown) scab is consequently much more extensive. Wlien the eruption has continued for any length of time, large quan- tities of bright yellow pus are secreted beneath the greenish crusts, which separate in cracks, to give exit to the matter, exhibiting beneath the highly inflamed, raw surface of the scalp, from which the pus is secreted."1 The disease does not appear to be contagious; it chiefly occurs in infancy and childhood, and may last for years, if neglected. It con- stitutes the crusta lactea of authors. I cannot agree with Dr. Neligan that the hair is unaltered; it is not so rapidly or so completely destroyed as by porrigo; but, if the dis- ease be of long standing, the roots of the hair are injured, and its growth checked; it becomes thin and poor-looking. 1 Dublin Journal, August, 1848, p. 39. 520 PORRIGO. In this, as in other severe eruptions of the scalp, the glands at the sides and back of the neck, below the hair, are apt to be enlarged and tender, but they rarely suppurate. Small abscesses sometimes form at the nape of the neck, close to the roots of the hair. 821. Treatment.—From the amount of inflammation present, our first applications must be of a soothing character. After cutting the hair as short as possible with a pair of scissors, a poultice of bread and milk, or linseed meal, may be applied over the inflamed parts, or they may be frequently fomented with the decoction of poppy-heads. At the same time, if the child can well bear it, a brisk purgative should be given, and the child put upon low diet, or confined to milk, as Dr. Neligan recommends. With children who are in bad health, or whose constitution has been impaired, we must use caution as to purgatives, and it may be desirable to allow a more generous diet. When the redness is diminished, and the irritation is calmed, we may use a lotion of the sugar of lead, black wash, or the alkaline lotion recently described, with the alkaline ointment. This treatment, with cleanliness and pure air, will soon effect a change in the aspect of the disease, unless the child be teething, and then, although dentition did not cause the disease, it may be kept up for some time, until the teeth are cut. Even lancing the gums, which should always be done, will not always immediately relieve the irri- tation. II. PORRIGO, OR SCALD HEAD, Has been generally regarded as an inflammatory disease, and is so still by Mr. Erasmus Wilson. According to the researches of Schon- lein, Gruby, Hughes, Bennett, Corrigan, Muller, Lebert, Robin, &c, it is a vegetable growth, and their views are regarded as accurate by Dr. Neligan. It attacks children of all ages, especially from three to twelve years. Dr. Neligan saw one instance of it in an infant of eight weeks old. Dr. Bateman describes six varieties : the porrigo larvalis, or crusta lactea, the porrigo purpuranS, the porrigo decalvans, the porrigo lupinosa, the porrigo scutulata, or ringworm of the scalp and the porrigo favosa. They differ in the size of the pustules, and the form of the crusts or scabs. 822. The porrigo larvalis " commonly appears first on the forehead and cheeks, in an eruption of numerous, minute, and whitish achores which are crowded together on a red surface. These pustules soon break, and discharge a viscid fluid, which concretes into thin yellowish or greenish scabs. As the pustular patches spread, the discharge is renewed, and continues also from beneath the scabs, increasing their thickness and extent, until the forehead, cheeks, and even the whole face become enveloped as by a mask (whence the epithet larvalis) the eyelids and nose alone remaining exempt from the incrustation. The eruption is liable, however, to considerable variation in its course the PORRIGO. 521 discharge being sometimes profuse, and the surface red and excoriated, and at other times scarcely perceptible, so that the surface remains covered with a dry and brown scab. When the scab ultimately falls off, and ceases to be renewed, a red, elevated, and tender cuticle, marked with deep lines, and exfoliating, is left behind." Other parts of the body may be attacked, and the irritation occasions loss of sleep, and much distress to young infants. The description I have quoted from Bateman resembles that of impetigo, already given, by Dr. Neligan, and it would often be difficult to decide whether the eruption was impetigo or porrigo larvalis, unless we confine the genus porrigo to the porrigo scutulata and favosa. The treatment recom- mended for impetigo is w7ell suited to the present species. THE PORRIGO SCUTULATA, OR RINGWORM OF THE SCALP, Has given rise to great difference of opinion as to whether it is a pustular or vesicular disease. Willan, Bateman, Biett, and the older writers, class it among the former; some of the French writers, espe- cially M. Cazenave, among the vesicular. Dr. Neligan considers herpes to be the true ringworm; and Dr. Burgess1 regards this form as the result of abnormal irritation of the bulbs of the hair. WThen such emi- nent dermatologists differ, I cannot expect to be able to decide. I can scarcely doubt, after the examination I have made, that there is a form of ringworm, the element of which is a vesicle ; but this does not prove that a pustular eruption may not assume this character. Dr. Burgess's description differs equally from that given by Bateman and that by Neligan. Dr. Bateman states that " it commences with clusters of small, light, yellow pustules, which soon break and form those scabs over each patch which, if neglected, become thick and hard by accumulation. If the scabs are removed, however, the surface of the patches is left red and shining, but studded with slight elevated points or papula?, on some of which minute globules of pus again ap- pear in a few days. By these repetitions of the eruptions of achores, the incrustations become thicker, and the areas of the patches extend, often becoming confluent, if the progress of the disease be unimpeded, so as to affect the whole head. As the patches extend, the hair cover- ing them becomes lighter in its color, and sometimes breaks off short; and, as the process of pustulation and scabbing is repeated, the roots of the hair are destroyed, and at length there remains uninjured only a narrow border of hair round the head."2 Dr. Burgess, one of the most recent writers on the subject, thus describes the disease: "We have seldom an opportunity of seeing ringworm in the early stage; for the patient, even, is not aware of its presence for some time after its development; and the first indication is a trifling degree of itching in the parts, which is relieved by the dislodgment of a thin scruff in the act of scratching. It is this cir- 1 Eruptions of the Face, Head, and Hands, p. 176. 3 On Cutaneous Diseases, p. 169. 522 PORRIGO. curastance which first directs attention to the disease. If examined now, there will be found neither heat, redness, nor moisture on the morbid surface, but a thin layer of furfuraceous matter, of an oval or circular form, surrounding the hair, either singly or in small groups. These circular patches are always few in number and limited in ex- tent; frequently there is only a single diseased spot to be found on the head, which, if observed early, will be found to extend from a small point or nucleus by its periphery, until the spot attains a certain size, of limited circumference, when it ceases to extend, and within these limits the disease passes through its various phases. The skin is dry, uneven, and covered with rough eminences, insensible to the eye and to the touch, which give it the appearance of the prickly condition of skin called "cutis anserina." These mammillary pro- jections are enlarged and diseased hair follicles, propelled by the hair in its growth from beneath the level of the skin; and, if we endeavor to pull the hair, it will not be detached from the root, but break on a level with, or a short distance from, the mouth of the follicle. The hair that grows on the morbid surface, after it has arrived at the con- dition described, does not attain any length, but breaks spontaneously at a short distance from the skin, leaving an exposed patch of the scalp, which always maintains a circular, disk-like form. The ends of the broken hairs are jagged, discolored, twisted, and not unlike the filaments of flax and tow. If the disease has not been arrested at this stage, the furfuraceous, scaly matter will become agglomerated, and form dry, thick, dirty, yellow-looking scabs or incrustations, thicker at their circumference than towards the centre. It is the irri- tation produced by these scabs, but more particularly by the action of the nails in scratching or trying to dislodge them, that produces the pustules, and subsequently the discharge of the contents around the original disease, which deceived Willan, and induced him to place ringworm amongst the pustular eruptions of the scalp. He mistook an incidental or superinduced lesion for the element of the disease, which is totally different."1 Whether Dr. Burgess is right in considering these pustules as acci- dental, produced by the cause he mentions, may be doubted I think • nor is this inconsistent with his view of the nature of the disease which he regards as " the result of a vitiated or abnormal nutrition in the organs which secrete the hair, analogous to scrofulous degenera- tions which occur in other structures of the body. The seat of the disease is not in the hair, but in the organs which secrete it • and the vegetable productions so minutely described by Gruby of the exist- ence of which there can be no doubt, are a secondary product and not the disease itself." 823. Let us now see what has been observed of this " vegetable parasite." M. Gruby remarks: "On examining attentively with the microscope this grayish-white powder, wdiich is seen on the morbid surface, you will be surprised to find that it is composed of a number 1 Eruptions of the Head, Face, and Hands, p. 177, PORRIGO. 523 of cryptogamia. On submitting the hairs which grow on this surface to the same method of examination, we shall observe a great quantity of these cryptogames embracing the cylinder of the hair on all sides, and forming round it a perfect vegetable sheath, which accompanies the hair for a short distance after its exit from the follicles. The structure of the hair becomes less transparent; the fibrous portion is interspersed with extremely minute granular molecules, which separate the fibres from each other in part or wholly, the size of which is es- timated at the five-thousandth part of an inch in diameter; and the shaft of the hair is distinctly enlarged or hypertrophied. The cryptogame surrounding the hairs at their basis, by contact with the adjoining hairs, involves them in the same morbid condition, altering the texture gradually, until they break off short, and thus expose a circular patch of partial baldness. These vegetable parasites are produced with sur- prising rapidity. On issuing from the follicle, the hairs become gray- ish for a certain distance, and, in eight days, break at the line where the cryptogame surrounds them. The hairs which are most enlarged resist for a longer period, and, according as they rise above the level of the skin, are attacked by the parasitic fungus. They are often surrounded at their base by a quantity of cryptogamia sufficient to form a small grayish elevation. It is these accumulations which have been mistaken for pustules, vesicles, and the secretion of the sebaceous follicles." In the midst of such varying opinions, all that seems agreed upon as to the disease is the presence of circular or oval spots of, at first, a furfuraceous secretion, upon which, ultimately, something like pus- tules, at least, appears; that the hair is at first injured, and then falls; that in all probability the disease involves the follicle; and that the secretion is of the nature of a vegetable parasite. The disease is also highly contagious, and, according to Gruby, it is transmitted by means of the furfuraceous powder, or crypto- game. Approximation of the head, or wearing the same cap, hat, or bonnet, will communicate the disease to another person hitherto free. I have seen spots of ringworm produced on different exposed parts of the body of a person employed in dressing the head of a child in whom this scurf was very profuse, which so far confirms M. Gruby's opinion. This affection is sufficiently common in children from three years old, and often proves very obstinate, lasting several years. Those of a feeble and flabby habit, the ill-fed, ill-clothed, and uncleanly, who live in unwholesome habitations, are the most exposed to it; but it may be communicated to those in health and of good constitutions. 824. Treatment.—So long as the spots exhibit much redness, our applications must be adapted to soothe; poultices, emollient fomenta- tions, &c. will be most suitable. The hair must be clipped as short as possible, which is much better than shaving, though more tedious, and requiring more frequent repetition. When the inflammation is subdued, or the disease has become chro- nic, we may proceed with more direct attempts to act upon the dis- 524 PORRIGO. eased portion. " In the more irritative states, the milder ointments, such as those prepared with the cocculus Indicus, with the submuriate of mercury, the oxide of zinc, the superacetate of lead, or with opium or tobacco, should be employed; or sedative lotions, such as decoctions or infusions of poppy-heads, or of tobacco, may be substituted. When there is an acrimonious discharge, the zinc and saturnine lotions, with the milder mercurial ones, such as the ung. hyd. pra?cip. albi, or the ointment of calomel, or a lotion of lime water with calomel, are advan- tageous. According to the different degrees of inertness which ensue, various well-known stimulants must be resorted to, and may be dilut- ed or strengthened, or combined, according to circumstances. The mercurial ointments, as the ung. hyd. pra?cip.; ung. hyd. nitrico- oxydi; and especially of the hyd. nitrat., are often effectual remedies; and those prepared with sulphur, tar, hellebore, and turpentine, the ung. elemi, &c, separately or in combination, occasionally succeed, as well as preparations of mustard, black pepper, capsicum, galls, rue, and other acrid vegetable substances. Lotions containing the sul- phates of zinc and copper, or the oxymuriate of mercury in solution, are likewise occasionally beneficial."1 M. Biett was in the habit of using the sulphuret of potash, the iodide ■ of sulphur, or solutions of the sulphate of copper, zinc, nitrate of silver, corrosive sublimate, &c, with success. M. Cazenave recommends an ointment of one part of pitch to two of citrine ointment, and another with a scruple of tannin to an ounce of lard, as the most effectual ointments in this disease. Dr. Burgess speaks highly of a " lotion of the bicyanuret of mer- cury, in the proportion of one or two grains to the ounce, according to the amount of stimulus required, which will be found more serviceable than these, or even the solution of the bichloride of mercury, so com- monly used in this eruption and in favus." If the latter be used, lint soaked in it should be applied to the parts, and covered with thin gutta percha or oil-skin; but the former is to be laid on with a camel's hair pencil. " The local remedy, however, which I have found most effec- tual in the treatment of this obstinate complaint is the vapor of iodine and sulphur, conveyed directly to the morbid patch through a caout- chouc tube, from any simple apparatus for igniting the compound, the patient lying in the horizontal position during the application of the vapor. It will stimulate the parts greatly if applied for twenty minutes, and the diseased surface, which was previously dry and pale, will appear slightly red and bedewed with moisture. The following formula will be strong enough to commence with, which may be after- wards increased according to circumstances: R. Sulphur, giii ; Iodini, gr. xii. to gr. xxiv. To be divided into six powders. One to be applied three times a day."'1 The local applications I have found most useful, after the redness had subsided, are the black wash, diluted citrine ointment, ointment of 1 Bateman on Cutaneous Diseases, p. 172. 3 Eruptions of the Head, Face, and Hands, p. 182. PORRIGO. 525 the acetate of lead or oxide of zinc, or hydriodate of potass, and when chronic and obstinate, nitrate of silver or tincture of iodine—the latter particularly. The patches should be painted with it every second or third day. 825. But local treatment will not be sufficient; we must carefully remove any irritation, such as that from dentition or disordered bowels, and regulate the state of the stomach and bowels; after which, in badly nourished, lymphatic, or scrofulous children, we must endeavor to raise the tone of the system by good diet and tonics, either mineral or vegetable, or the mineral acids. Dr. Burgess recommends the citrate of iron in infusion of quassia, or a bitter infusion with the hydriodate of potass. Much time is generally required, and great care, before this obstinate disease is cured, and if the treatment be suspended too soon, before the surface of the patches is smooth, pale, and free from scurf, a relapse is almost sure to take place. I think that, when the disease has been so far subdued th^t nothing marks its having existed but the bald spots and a slight excess of furfuraceous scales, I have derived much benefit from a wreak ointment of hydriodate of potass; and at this stage oint- ments seem more useful than lotions. The hair must be kept quite short until some time after the disease is cured, and when there is no longer danger of much irritation, it may be well to have the entire head shaved once or twice; it strengthens the growth of the hair on the bald spots, and secures an even length over the head. When it is allowed to grow, a little very thin oil of almonds may be used occasionally; the common hair-oils are far too thick, and only neutralize all efforts at cleanliness. The head should be washed occasionally; but nothing can be more injurious both to the tender scalp and hair than the liberal use of soap. By far the best substitute is a portion of the yolk of an egg; if it be well washed off with fresh water, it leaves the scalp perfectly clean and pale, and the hair soft and silky. PORRIGO FAVOSA. 826. This peculiar disease is regarded by Willan, Bateman, Ali- bert, Biett, and the older writers, as a pustular disease, as the result of inflammation; by Mahon as a morbid secretion of the sebaceous glands; by Dr. J. H. Bennett, M. Erichsen, and Dr. Burgess as a tubercular disease; and by Schdnlein, Gruby, Remak, Robin, Neli- gan, &c. as a vegetable production. In the first stage, it gives rise neither to heat of the scalp nor itch- ing ; it commences generally at the edge of the scalp, and from thence spreads rapidly over the head, very often occupying nearly the entire surface of the scalp. The eruption is occasionally, but more rarely, seen on different parts of the body. "The appearance of this eruption is so peculiar, and so distinct from all the other eruptive diseases of the scalp, that it cannot pos- 526 PORRIGO. sibly be mistaken for any of them. It first appears in the form of small, yellow7, dry spots, about the size of a pin's head, of a bright yellow 'color, seated on the surface of the skin, which is depressed slightly by them; each spot is distinct, hemispherical, slightly con- cave, or cup shaped, on its free surface, and convex beneath, where it is adherent to the skin. On removing the small diseased mass, that portion of the scalp on which it was seated is found to be some- what depressed, smooth, and shining. A single crust of the disease, or favus, as it has been termed from its honeycomb appearance, is often traversed by one hair, or sometimes by two hairs, which appear to grow, as it were, from its very centre, or most depressed portion. This has given rise to the notion that the disease is one of the bulbs of the hair; but the fact of its appearance on other parts of the body, which are quite free from hair, is a sufficient refutation of this opinion. The eruption spreads by additions to the outer edge or cir- cumference of each crust, which thus retains its hemispherical cha- racter, until it attains a diameter of two or three line,s, or sometimes more. In a case which I have had recently under my care in hospital, some of the favi which were seated on the back of the trunk were fully half an inch in diameter; on the head, however, they rarely exceed the size above mentioned. The adjacent favi, as they in- crease, unite with each other, and form large, irregularly shaped masses, in which the original circular form of the individual crust is lost; the centre also of each is changed in appearance, and, instead of the cup-shaped depression, the entire surface is covered with alter- nate elevations and depressions, or, so to speak, ridges and furrows, concentrically arranged. The eruption thus increasing, the whole of the scalp—often, too, the forehead, neck, and parts of the trunk__be- come encased in one large yellow crust, at the edges of which some favi, of the peculiar characteristic appearance, are invariably to be seen. The crusts of porrigo are of a pale, sulphur-yellow color; they are hard and dry, and break with short fracture, exhibiting within a mealy powder of a paler yellow than the external surface. They may generally be removed with facility from the scalp ; but they bring away with them a thin layer of epidermis, which is firmly adherent to their under surface, through which small projections may be seen with a moderate lens, sometimes with the naked eye. These projec- tions or processes pass into the dermis beneath; and, when the crusts are torn forcibly away, blood issues through the small orifices into which they were inserted. From the very commencement of the eruption of porrigo, the hair becomes altered: much of it falls out and the straggling hairs that remain are thin, broken, weak, whitish' and readily removable with the crusts of the disease in which thev are firmly imbedded. When this affection has continued for any length of time, bald patches are left after cure, on which the hair does not again grow; and, even when it has been cured at an earlier stage the hair never regains its proper character, being weak, thin and of a pale, whitish-yellow color. As the disease advances,' much irrita- tion of the scalp is produced; small pustules form here and there in PORRIGO. 527 spots as yet unaffected with the eruption; the tingling and heat are so unbearable as to compel the patient to tear the surface wTith his nails, even to such a degree as to cause ulceration; innumerable pediculi are engendered; the favous crusts emit an abominable odor, resembling that of urine; and a copious offensive discharge is secreted by the pustules and ulcerated spots: in short, an individual affected with this disease in its aggravated form becomes a loathsome and disgusting object."1 In some parts of the inflamed surface, ulceration occurs, spreading irregularly, and becoming very troublesome. The great irritation of the scalp is extended along the lymphatics, and the glands around the neck become enlarged and tender; they sometimes, but rarely, suppurate. M. Biett observes that it is rare that any internal organ becomes inflamed. 827. With regard to the character and appearance of this-vegetable favus, Dr. Neligan gives the following extract from M. Robin: "Re- duced to powder and placed under the microscope, it presents a mix- ture—1. Of tortuous, branching tubes, without partitions, empty, or containing a few molecular granules (mycelium). 2. Straight or crook- ed, but not tortuous tubes, sometimes, but rarely, branched, containing granules or small rounded cellules, or elongated cellules, placed end to end, so as to represent partitioned tubes, with or without jointed articulations (receptacles or sporangia in various states of develop- ment?); 3. Finally, sporules, free, or united into bead-like strings. The mycelium is very abundant near the inner surface of the external layer, to which it adheres. The spongy, friable mass of the centre of each favus is principally formed of the sporules and the different tubes containing mycelium, already described (sporangia or receptacles?). We often find mixed with them mycelium tubes, but in small quan- tity. All these elements pass insensibly into each other; empty tubes (mycelium); tubes containing small round corpuscles; tubes with corpuscles as large as the smaller sporules; sporules placed end to end so as to resemble a hollow, partitioned cylinder, with a tendency to separate at the joints; and free sporules. Bennett has given a good drawing of this arrangement."2 828. That porrigo favosa is a contagious disease, we have proof in the experience of ages; and that it can be propagated by inoculation has been shown by Remak and Bennett, although Gruby and others failed. They failed, as Neligan observes, because, in addition to the mycelia by which it is propagated, they wanted the proper soil, i. e. the state of constitution produced by filth, close air, bad feeding, and insufficient clothing. 829. Treatment.—Our first object is the removal of the crusts and the diminution of the inflammation, and this will be best attained by the application of poultices for twenty-four hours, which should be ' Neligan, Dublin Journal, August, 1848, p. 52. * Des Vegetaux qui croissent sur l'Homme et sur les Animaux vivans, 1847, p. 8. 528 PORRIGO. changed as often as they become dry. The hair should be cut as close as possible previously, but not shaved at this period. Dr. Bateman recommends the application of the ung. zinci, or the ung. hydr. pra?cip. albi, mixed with the former or with a saturnine ointment, or "the ointment of the nitrate of mercury, diluted with about equal parts of simple cerate, and of the ceratum plumbi super- acetatis," varying the proportions of the ung. cera? according to the degree of inflammation. M. Biett speaks most favorably of alkaline or sulphurous applica- tions, or acid lotions : The subcarbonate of soda or potash, in form of ointment at first, and aftenvards more diluted as a lotion; or the fol- lowing lotion, which is much used at St. Louis:— R. Potass, sulphuret. gii; Sapon. alb. gnss; . Alcohol, rect. Jji; Aquae calcis § vii. M. Muriatic or nitric acid much diluted, sulphurous douches—or, if more powerful applications are needed, solutions of sulphate of zinc or copper, nitrate of silver, or corrosive sublimate—may be tried. M. Biett has also found benefit from the use of the iodide of sulphur, applied by gentle friction in the form of an ointment, containing from a scruple to half a drachm to an ounce of lard.1 M. Mahon has a depilatory which removes the hairs very com- pletely. M. Chevalier believes it to be chiefly composed of lime and carbonate of potash. The carbonate of potash, the lotion recom- mended by Biett and Neligan, of which I have already spoken, will answer this purpose very well. Dr. Neligan's method is as follows: "As soon as the poultice is removed, the head is w7ell washed with the stronger carbonate of potash lotion, and slightly brushed with a soft hair-brush, or a roll of lint; the scalp is then covered with the carbonate of potash ointment, spread on lint, and over it a closely fitting oil-silk cap is placed; the ointment is renewed twice daily. By the use of these applications the crusts of the eruption are generally completely removed in from two to three days. The carbonate of potash ointment is, at the expiration of this time, replaced by one containing the iodide of lead, in the pro- portion of half a drachm of the iodide to an ounce of prepared lard • the head is to be still washed every morning with the carbonate of potash lotion. In some cases, it will be found that the iodide of lead ointment excites a certain degree of inflammation of the surface of the scalp after it has been used for some days; when such occurs it should not be applied for a day or two, and the lotion alone employed three or four times daily. After this first attack of inflammation dis- appears, I have not seen it again recur, although the use of the oint ment hac\ been persisted in for months. The strength of this ointment should be increased after a fortnight; if the disease again appears even to double that above indicated." ' ' Cazenave and Schedel, Mai. de la Peau, p. 244. PORRIGO. 529 After this treatment, or any other, has been continued for some time, it should be suspended for a time, to see if the disease will recur, or if it be really cured. If it re-appear, we must again have recourse to the external applications, as well as to the internal remedies. Professor Hebra, of Vienna, directs his attention first to the destruc- tion of the plant, and then to the prevention of its reproduction : "With this view, he orders the hair to be cut close; and, after the favous crusts are softened by a sufficient quantity of oil, the head should be enveloped in warm fomentations, composed of a melange of soap and bran, which are to be continued until the incrustations cover- ing the scalp begin to swell, and detach themselves from their bases. After removing these softened crusts with a spatula, the brush and comb should be used, and the scalp examined carefully (which will be found very red, bleeding easily, and the seat of several excoria- tions), so as to ascertain if there is still any favous matter remaining; for it is necessary to remove the seeds of the disease from the epider- mic cells and hair follicles, in order to prevent their reproduction. To attain both these objects, M. Hebra strongly recommends lotions of the deuto-chloruret of mercury, of the nitrate of silver, or of arsenic, and the ointment of the iodide of lead, as very efficacious remedies. He also sometimes employs ointments of the cocculus Indicus, of quick- lime, of the carbonate of potash, the citrine ointment, and the dilute mineral acids. He has then succeeded more rapidly in completing the cure by the following method than by any other: the favous matter being removed from the scalp, the dilute acetic acid should be rubbed over the morbid parts until they bleed slightly; when this occurs, the acid is to be omitted, and an alcoholic solution of iodine applied in its stead, and continued for several weeks, until the parasite ceases to be produced."1 Dr. Burgess speaks favorably of alkaline lotions and iodide of sul- phur, as recommended by M. Biett, but he prefers the vapor of iodine and sulphur to all other remedies. I have found the nitrate of silver and caustic tincture of iodine very useful, after the removal of the crusts and hairs. 830. But external applications alone, will not be sufficient. In almost all cases, the disease is a constitutional one, and must be met by constitutional remedies. After due care in the removal of all irri- tation from teething, or gastro-intestinal disturbance, and a careful regulation of the stomach and bowels, we must afford the child the relief of cleanliness, pure air, and a more invigorating diet, at the same time avoiding crude vegetables and fruits, and all stimulating substances. Milk puddings, broths, and plain animal food may be given, according to circumstances. Dr. Neligan confines the patient entirely to a milk diet. The medicines recommended by Bateman are alterative doses of mercurials, "especially when the biliary secretion is defective, the abdomen tumid, or the mesenteric glands enlarged ;" small doses of 1 Burgess on Eruptions of the Face, Head, and Hands, p. 195. 34 530 PORRIGO. calomel, either alone or with soda, and some testaceous powder, or, if the bowels are irritable, the hyd. c. creta. If the patient be of a squalid habit, or the glandular affections severe, bark and chaly- beates, or the muriate of barytes combined with the former, will be of service. Dr- Neligan speaks most highly of the iodide of arsenic, which he says may be safely given to the youngest child, " its effects being, of course, duly watched." "The dose of this preparation is, for an adult, from one-tenth to one-fourth of a grain, very gradually in- creased; for a child six years old, one-fifteenth of a grain; and for a younger child, from one-eighteenth to one-twentieth of a grain. It is best given to adults in the form of a pill, made with dry manna and a little mucilage; to a child it is best administered in the form of powTder, its minute division being perfected by means of a little white sugar or aromatic powder. When the system is saturated with this medicine, we usually find that some constitutional symptoms, such as acute headache, dryness of the throat, &c, are manifested; but, in some cases, I have given it in full doses for many weeks without any manifestation of its effects further than those produced on the disease for which it was administered. W7hen, however, it gives rise to the symptoms above mentioned, its use should be intermitted for some days, and an active purgative administered."1 1 Dublin Journal, August, 1848, p. 56. SECTION VI. ERUPTIVE FEVERS. CHAPTER I. MEASLES.--RUBEOLA.—MORBILLI.--ROUGEOLE. 831. Measles consists essentially in an exanthematous eruption of the skin and mucous membranes, of a circular or crescentic form on the skin, preceded and accompanied by fever, running a defined course, occurring epidemically, or propagated by infection, and gene- rally attacking a person but once during a lifetime. It is much more common among infants and children than among adults, and among the latter than with old people; and, without going so deep as some writers have done, the explanation seems to me natu- ral and easy. The disease is by no means uncommon; it is often epidemic, and always contagious or infectious; and, of course, a child takes it the first time it is exposed to its influence, which must happen before it is many years, or perhaps many months, old. The reason that fewer adults than children take it is, simply, that the majority of adults had it when children. Some dispute has arisen as to the antiquity of measles, some authors contending that they were known to the ancients; but Gruner1 and Sprengel have shown that they appeared about the same time as small-pox. The earliest account we possess is by Rhazes; Avicenna has also described this disease, and distinguished it from small-pox, with which it has been often confounded even in comparatively modern times. The distinction was first clearly made by Forestius (1597), Schenck (1600), Riverius (1655), and especially by Sydenham (1676), and Hoffmann (1718). It has been confounded with scarlatina so recently as in the writings of Morton and Watson; indeed, as Dr. George Burroweshas remarked, the distinction between the two diseases was not thoroughly esta- blished until Dr. Withering's Essay on Scarlet Fever, in 1793, and Dr. Willan's Treatise on Cutaneous Diseases, were published. 832. Some notion of the frequency and fatality of measles may be gathered from the fact stated by Dr. Gregory, that, on an average of five years, nearly 6 per cent, of the mortality of London is'due to 1 Var. Antiq. ab. Arab, solum repetend., sect. 7,14, 17. 532 MEASLES. measles and scarlatina. According to the Fifth Report of the Regis- trar-General, 81 per cent, of this mortality occurs in children under five years old, and 97 per cent, in children under ten years old. In his admirable Report upon the Table of Deaths, appended to the Census of Ireland taken in 1841, Mr. Wilde states that, in the ten years preceding, the deaths from measles amount to 30.739, in the proportion of 100 males to 96.12 females. " Compared with all dis- eases, the deaths from this cause amount to 1 in 38.62, and with all the epidemic affections to 1 in 12.4, being the sixth most fatal disease of this class. With the exception of the year 1840, when 4.491 deaths from this cause are returned, measles have presented the most remarkable uniformity throughout the entire period. The age at which the disease has proved most fatal was from birth to the end of the first year, when the sexes were 100 males to 86.74 females; from the first to the end of the fourth year, 100 to 100.04; from the fourth to the fifteenth, as 100 to 100.57; from the fifteenth to the thirtieth, 100 to 138.76; and after 30, as 100 to 161.81.'" Now7, as we know that a large proportion of those attacked by the disease recover, we may infer, from these tables of mortality, the very great frequency of measles. 833. Symptoms.—After exposure to the epidemic influence or to contagion, an interval elapses before the child exhibits any symptoms of the disease. This period of incubation, as it has been termed, may vary from a few days to two or three weeks. In the majority of the cases inoculated by Dr. Home, the fever showed itself in about the seventh day. M. Bouchut, in an epidemic in the Hopital Necker, found this period range from twelve to thirty days after, exposure.2 As a general rule, it will, I think, be found that the fever commences from the fifth to the eighth day. The course of the disease, after the fever has set in, may be divided into the period of invasion, of eruption, and of decline, and each of these may be successively described. 834. Period of Invasion.—The earliest symptom is a sense of weariness, and a chilliness increasing to a rigor, and followed by febrile heat of skin and quick pulse, increasing in intensity for some hours. Or the child may at once awake in the midst of high fever with dry skin, flushed face, a very quick pulse, thirst, &c, in which case there is, occasionally, some little remission at the appearance of the eruption. The face soon becomes flushed, the eyes injected suf- fused, sensitive to light, and with incessant lachrymation; the'eye- lids are swollen, and the child is constantly rubbing them and the nose, in consequence of the incessant itching and tingling. The nasal mucous membrane is red, congested, and so irritable that the contact of air occasions perpetual sneezing. Sometimes epistaxis occurs, and there is always more or less of a thin, acrid secretion at first, which afterwards becomes thicker, and finally muco-puriform The bronchial mucous membrane is equally affected; from the be- ' Report upon the Tables of Deaths, &c., p. 13, 2 Mai. des Enfans nouveaux-nes, p. 487. MEASLES. 533 ginning, there is a hoarse, rough cough, dry and laryngeal, and which comes on in kinks. It is certainly very characteristic; but I doubt whether we could decide upon the nature of the attack by this symp- tom alone. Heberden and Peter Frank met with cases in which the cough did not appear till after the eruption. These symptoms do not come on gradually, but commonly appear at the very outset of the disease all together. Other symptoms occur during this period, but without any regular order. M. Heim1 has noticed a peculiar smell, which he compares to recent goose-quills, and which lasts five or six days; Home compares it to that of small-pox; and Heyfelder thinks that it is stronger in the morning than in the evening, and when many patients are together. I have certainly noticed a peculiar heavy smell, which appeared to be owing to increased cutaneous secretion; but I have not noticed its increase in the morning. On the other hand, Guersent, Condie, Rilliet and Barthez have not perceived it. MM. Blache and Guersent mention that they have frequently ob- served a punctated rose color of the vault of the palate to precede the eruption of measles, quite distinct from the redness observed in scar- latina, as had been previously remarked by Heim and Marc d'Espine.2 Nausea and vomiting occasionally occur during this period; but, in general, the gastro-intestinal mucous membrane seems less affected than the pulmonary. The lymphatic glands of the neck, and along the margin of the eyelids, are not unfrequently enlarged. The urine is generally scanty, of a deep color, very acid, and of increased density. The urea, chlorides, and sulphates are frequently increased, with a small proportion of albumen.3 835. The symptoms I have enumerated are generally present, but they may be differently grouped; sometimes the nervous symptoms predominate, and we may have delirium, stupor or convulsions; in other cases, the pulmonary or gastro-intestinal may be more marked, as will be showTn by great dyspncea, and frequent cough; or by vomit- ing and purging. Moreover, if the attack of measles occur in the course of another disease, these precursory symptoms will generally "be much less marked. They occupy ordinarily from two to four days; seventy-two hours according to Dr. Gregory; but, in some cases, Blache and Guersent have known them prolonged for seven, eleven, or even fifteen days. Rilliet and Barthez have given the result of their observations in forty cases of normal measles: in one case, there were no precursory symptoms; in one, they lasted a few hours; in eight, one day; in eleven, two days; in seven, three days; in eight, four days; in two, five days; and in two, seven days.4 836. Period of Eruption.—About the third or fourth day, we may observe a few distinct, elevated, red papula? on the face or forehead, resembling flea-bites in size and color, very like those at the com- mencement of variola or in typhus fever, but speedily acquiring a very different appearance. These rapidly increase in number, more pro- ' Hufeland's Journal, 1812. 3 Diet, de Med., vol. xxviii. p. 338. 3 Ibid. * Mai. des Enfans, vol. ii. p. 681. 534 MEASLES. fusely on the face, but spreading to the chest, body, and extremities, very quickly. As the number increases, they coalesce, and, in so doing, present their characteristic appearance of irregular semicircles, of a florid red color, or crescents, with clear skin in the centre, or now and then a single spot. This appearance, which was first pointed out by Dr. Willan, is quite peculiar to measles, and at once distinguishes it from scarlatina. The surface of the eruption is perceptibly elevated above the sur- rounding skin, especially on the face, which is altogether swollen and puffy, and less so on the body and limbs. "In many persons," as Dr. Willan has remarked, "miliary vesicles appear, during the height of the efflorescence, on the neck, breast, and arms; and papula? often occur on the wrists, arms, and fingers."1 On the second or third day of the eruption (the sixth of the disease), the rash is at its height, after which it begins to subside; at first on the face, where it first appeared; then on the body and limbs; so that, on the ninth day, little more than slight discolorations of the skin can be detected, and even these disappear by the end of the tenth day from the invasion of the disease. Until the eruption begins to decline, it is accompanied by intense itching occasionally. I have known children kept awake all night by it, and so excited that I feared every moment an attack of convul- sions. In other cases, the itching is more troublesome during the period of desquamation. 837. Unlike some other eruptive fevers, the general symptoms do not appear to be relieved when the eruption makes its appearance: in some cases, the pulse may be a little quieter, but in general it is as quick as ever, and the fever as high or higher; the skin is intensely hot, but moist; the tongue loaded with w7hite or yellow fur, inter- spersed with the enlarged, red papilla?; the vault of the palate and the pharynx are red, and feel dry and rough; the thirst is great, and the appetite entirely lost, until the disease declines; and on the gums around the edges of the alveoli, a soft, white pellicle is often deposited, which can easily be raised with the finger-nail. The catarrh of the mucous membranes continues, the eyes are suf- fused and weeping, the mucus secreted by the conjunctiva? is more abundant and thicker, and, drying during the night, the eyelids are temporarily glued together; the secretion from the nasal mucous mem- brane is of a thicker consistence, but not less copious; the cough continues, but is a little softer; the voice is still rough and hoarse- there is no diminution in the dyspncea or the bronchitic rales heard in the chest. The face is as much swollen as ever, and remains of an intense red color until desquamation commences. The duration of this period varies from three to six or eight days or even longer. M. Reveille-Parise mentions a case in which the eruption w7as as vivid as ever on the tenth day.2 The disappearance 1 Bateman on Cutaneous Diseases, p. 60. 3 Gazette Medicale, 1835, vol. iii. p. 360. MEASLES. 535 is gradual, and follows the same order as their appearance ; they be- come fainter in color and flatter; the slight red areola around the papula? disappears, and the whole acquires a yellowish tinge. In those parts w7here the eruption was most intense, certain yellow- ish spots, stigmata or maculae, remain, and which have been noticed by MM. Guersent and Blache, Rayer, and Trousseau. They are not very apparent when the child is quiet, but when excited, they assume a deeper color; they seem to be seated in the cutis, and do not disap- pear under pressure; but, whether they are a kind of ecchymosis, M. Trousseau will not venture to say. They appear connected with a severe form of measles.1 The general symptoms, and the irritated condition of the mucous membranes, simultaneously and gradually diminish. 838. Period of Desquamation.—About the seventh or eighth day, the desquamation of the cutis commences. In some cases, this pro- cess is scarcely marked at all; in others, it is confined to the face and chest, where the eruption has been most severe. Unlike the de- squamation in scarlatina, in measles we find very small furfuraceous lamella?, which appear like fine whitish dust, or in some cases only a cracking of the cuticle. The process, when perceptible, lasts for three or four days, during which time an equal progress has been made towards health in the general symptoms. The pulse has be- come quiet, the skin cool, the tongue cleaner, the thirst less; some little wish is expressed for food; the voice recovers its natural tone; the cough is softer, and the expectoration free. It not unfrequently happens that at this time diarrhoea sets in, and presents all the aspect of a crisis, in which light it is regarded by many authorities. After this period, if nothing intervene, the progress of the patient to perfect health is rapid and complete. 839. Thus far, I have described only a simple, uncomplicated case of measles, which we have seen is marked by preliminary fever and coincident irritation of the mucous membranes; by a semicircular or crescentic eruption of red papula?, with a continuance of the fever and irritation; and by the final desquamation of the cuticle, with subsidence of the fever, local irritations, and general symptoms: the entire pro- cess occupying from ten days to a fortnight. Such cases are most favorable, and we may say always recover; but we have also seen that measles is a very fatal disease in children, and it is now our duty to inquire into the causes of this fatality, and it will, in almost all cases, be found to depend upon some modification of the dis- ease, or upon a defective constitution in the child, or upon some complication. 840. Let us then consider 1. The Modifications of Measles.—a. The eruption may vary as to extent; in some, it is abundant and universal; in others, it is limited, and consists of but few distinct papula? or rings. b. The color may differ much in different cases; ordinarily, it is 1 Bouchut, Mai. de l'Enfance, p. 294. 536 MEASLES. of a vivid or deep red; in other cases, pale and dirty-looking in sickly children; or it may assume a dark livid color, the rubeola nigra of Willan. c. The eruption may vary its seat; it may commence and continue most marked, as in a case I lately saw7, upon the hands, shoulders, or back, or upon the cicatrix of a blister. In the morbillous fever of Sydenham (1674), it was principally on the neck and shoulders; in an epidemic at the College de Vendome, in 1826, M. Gendrin ob- served it was confined to the face. In a case mentioned in Rust's journal, the eruption occupied one-half of the body only.1 d. The eruption is sometimes much more distinct and prominent, and this form has been called by the French "rougeole boutanneuse:" these papula? become flattened about the third or fourth day. e. In some rare cases, the spots resemble purpura, being really ecchymoses underneath the cuticle, just as blood may be at the same time effused into other organs. The spots are blood-red at first, but gradually become yellow as absorption goes on. In other instances, they are brown, or nearly black; according to Rayer, this hemor- rhagic measles differs from that variety called by Willan " rubeola nigra." None of these variations involve either inconvenience or danger in themselves; the latter may indicate a source of danger in some weak- ness or deteriorated condition of the constitution, and may serve to put us on our guard against the occurrence of hemorrhage in more important organs. /. Again, the course of the disease may be anomalous; the eruption may disappear too soon, and altogether, or it may return in a day or two, accompanied with an increase of fever, and the development of symptoms indicating internal disease. "Dr. Willan first noticed this circumstance. He records two cases of the kind in his Reports of the Diseases of London. Frank, of Vienna, has observed the same thing. Dr. Conolly recites a like case, where the renewed eruption was so copious and intense on the face as to make it impossible to recognize the features. Some years ago, a case in every respect similar occurred at Brompton to Dr. Seymour and Mr. Chinnock. Ten days elapsed in this instance before the renewal of the exanthe- matic action."2 The disappearance may be owing to some accidental cause, as cold, irregularities of diet, &c, or may result from internal organic disease. Whenever it occurs, we should never rest until, by repeated and careful examination, we have assured ourselves of* the integrity of every organ of the body, or have detected the seat and nature of anv internal disease. ^ Such deviations are not unfrequent, when measles occurs in the course of another disease, or in certain epidemics, or in hospitals for children. 841. Three other anomalies I must notice: i. The rubeola sine 1 Bull, de Ferrussac, 1829, vol. xxvi. p. 286. 3 Dr. Gregory on Eruptive Fevers, p. 104. MEASLES. 537 catarrho of Dr. Willan, which he observed " in a few rare instances, during an epidemic rubeola, which is only important as it leaves the susceptibility of receiving the febrile measles after its occurrence. The course and appearance of the eruption are the same as in rubeola vulgaris; but no catarrh, ophthalmia, or fever accompanies it. An interval of many months, even two years, has been observed between this variety and the subsequent febrile rubeola; but the latter more frequently takes place about three or four days after the non-febrile eruption."1 Dr. Gregory says " that it is a very rare variety, and only interest- ing in a pathological point of view." Dr. Hosack witnessed it in New York in 1813, and Dr. Dewees mentions that he has had several opportunities of seeing it. It is, I think, extremely doubtful whether such cases are measles at all; they appear to me to belong to the order roseola, of which I spoke in the last section; at all events, they possess no distinctive charac- teristics of measles, for the eruption of roseola may present the semi- circular or crescentic form. Dr. Gregory remarks that, if the prelimi- nary fever continue seventy-two hours, the disorder is measles, whether catarrh be present or not; but, if the eruption succeed a fever of twenty-four or forty-eight hours, it is not true measles. ii. During an epidemic of measles, it has sometimes happened that children have been attacked by fever and catarrhal symptoms so closely resembling those of measles, that the case has been assumed to be measles, although no eruption makes its appearance. Morton mentions such a case of "morbillous fever," as it has been termed. De Haen, Morton, Vogel, &c. assert that cases of this kind frequently occur during an epidemic. Dr. Eberle observes: "It certainly is not uncommon, during the prevalence of epidemic measles, to meet with fever attended with the usual catarrhal symptoms of the malady, but unmarked by its peculiar eruption. Richter observes that persons affected by these fevers are generally exempt from the disease during the subsequent progress of the epidemic."2 It would, of course, be difficult to pronounce such, to be cases of measles, nor have we any evidence to prove that the attack confers the usual immunity for the future, even though the patient may escape the disease during that epidemic. hi. Many writers mention the occurrence of measles more than once in the same individual; but we must reject all such histories as wrere written before the distinction between scarlatina and measles was distinctly laid down, and also all reports not authenticated by medical evidence; and then it seems probable that the cases will be much reduced in number. Rosenstein says that, in forty years' prac- tice, he never met with such a case; and Dr. Willan and others have made similar statements after twenty years' practice. Dr. Baillie has shown, however, that they may recur a second time in the same person, with febrile and catarrhal symptoms.3 Dr. Dewees 1 Bateman on Cutaneous Diseases, p. 63. -3 Diseases of Children, p. 429. 3 Trans, of a Society, &c, vol. iii. p. 253. 538 MEASLES. seems doubtful about it, except where the first attack may have been the rubeola sine catarrho. Dr. Hone mentions a case in which glan- dular enlargement followed measles, and after this had subsided, in the course of six months, the patient had measles again.1 Genovesi attended forty-six cases in Santa Cruz, who had the dis- ease before; and Duboscq. de la Roberdiere prescribed, during the epidemic at Vire, in 1777, for persons whom he had cured in 1773. Dr. Eberle witnessed but one unequivocal example. Rayer mentions three instances which occurred to himself. MM. Guersent and Blache remark: " We have seen infants with measles twice in the same year. With one little child, we observed in the space of six weeks two very irregular eruptions of measles, with varioloid occurring between. In another case, the first eruption was mild; but the second, which occurred twro months afterwards, was extremely severe; and, more recently, a young girl of thirteen years, who had been treated by one of us for measles, in her infancy, was attacked for the third time. This last eruption was extremely confluent; but she was free from bronchitis, and coryza appeared only on the decline of the disease."2 Dr. Condie mentions that several such cases have come under his notice. I have, in common with others, seen several cases of measles in persons who were said to have had the disease before, but I confess I never could quite satisfy myself about them. However, a short time ago, one of my children was seized with the fever and catarrhal symptoms of the usual duration, followed by the characteristic erup- tion, upon the hands first and most marked; then upon the face, body, and limbs, and which Dr. Stokes agreed with me was certainly measles. Yet I have a record, written at the time, of his having had the disease, well marked, seven years ago; and of other children having taken it from him. This time it has not been propagated. 842. Other and much more important variations of measles have been noticed, dependent upon the predominance of some general cha- racter, or upon some particular state of the constitution. These may be very numerous, if we take each complication as the characteristic • but I prefer leaving the complications for the present, and noticing merely the inflammatory, congestive, and typhoid type of measles. i. We may form a very good idea of measles with predominance of inflammatory character, or inflammatory measles, by supposing the description I have already given to be exaggerated raanyfold. The fever runs very high; the pulse is rapid, full, and bounding; the skin burning hot, and of a vivid color; the eyes and nose incessantly running; the catarrh severe; frequent cough, dyspnoea, pain, &c indicating some pulmonary complication; headache, confusion of'ideas' perhaps delirium or convulsions. Blood drawn exhibits the buffy coat' The eruption appears early and copiously, is more prominent and more intensely red than usual, and the face is unusually swollen. This variety seems excited chiefly in children of a full, plethoric 1 Med. Facts and Experiments. Mai. de la Peau, p. 148. 3 Loco citato, p. 677. MEASLES. 539 habit, who have been highly fed, and kept in close or warm rooms, or who suffer much from teething. The complications most common are convulsions, croup, pneumonia, and gastro-enteritis. ii. The congestive form is remarkable for a deficiency of vital energy. Reaction is tardy and imperfect; there is much depression; the face is pale, the features sunk and anxious; the pulse labored and weak; breathing oppressed, and the extremities cold. The eruption may not appear at all, or partially here and there. Children of a feeble constitution seem most liable to this form. In two cases of the kind related by Dr. Armstrong, they died comatose and convulsed, and, upon examination, great engorgement of the lungs was detected. in. The typhoid or malignant form of measles is characterized by the usual symptoms of typhus fever. The pulse is occasionally nearly natural, but more frequently wTeak and quick; the skin is dry and burning, and petechia? may be observed in different parts. Colliquative sweats, diarrhoea, and hemorrhages occur, and the entire system is prostrated. Dr. Gregory thus describes this variety: "The eruptive fever is severe, and attended with unusual symptoms. The fever is typhoid, not inflammatory. The eruption appears too early or too late. It perhaps recedes after having showTn itself, and partially reappears. The stomach is irritable; vomiting is both severe and protracted; there is delirium, with wildness of eye, or coma; the belly is tender ; there is purging of unhealthy stools ; the extremities are cold, the pulse small and wavering. On the surface appear petechia? or ecchy- mosed patches of eruption; the fauces assume a livid or dusky red color; blood passes by stool; there is much oppression at the praecor- dia, and abundant muco-serous discharge from the chest, indicating the congested condition of the lungs and their mucous membrane. In these almost hopeless circumstances, children may die in forty-eight or sixty hours, asphyxiated by the condition of the air passages; others die of coma or convulsions; some are worn out more slowly by diar- rhoea and bloody stools."1 This form prevailed epidemically at Plymouth in 1745, in London in 1763, and in Edinburgh in 1816. 843. Complications.—i. Convulsions.—I have already alluded to this complication as occasionally ushering the disease; it is not very common; but we may now and then observe it in the inflammatory form, in the first period of measles or in the second, as the result, apparently, of reflex irritation. In most cases, it appears a simple attack, but in others we can discover traces of cerebral or meningeal congestion after death. In almost all cases, the abstraction of blood by leeches, or counter-irritation of some kind, will be necessary, with free evacuation of the bowels; but for details, I must refer the reader to the chapter on convulsions. 844. n. Inflammation of the pharynx or larynx is a tolerably fre- 1 On Eruptive Fevers, p. 109. 540 MEASLES. quent complication of measles, as of scarlatina, but the larynx is more commonly the principal affection. The redness of the pharynx is slight, without swelling or ulceration; but the mucous membrane of the larynx is often red, ulcerated, softened, or covered with false mem- brane constituting true croup. In some few cases, the croup may be spasmodic. The attack generally occurs about the third or fourth day; some- times, both the larynx and pharynx are affected simultaneously; in other cases, successively. Nor does the complication prove so fatal as might have been expected, for, according to Guersent and Blache, a great proportion are cured when the measles are of a mild form; and, in many children who are carried off by some complication at a late period of the disease, very severe lesions of the larynx are ob- served to be in progress of cure. I have already indicated the treat- ment of secondary croup. m. Broncho-pneumonia.—The most frequent and most important of these complications is inflammation of the bronchial tubes and lungs; and although these two affections are distinct, yet are they so often combined, that Guersent and Blache consider them together, and with sufficient reason. Thus, they met with twenty-four cases of bronchitis, seven of pneumonia, and fifty-eight of lobular broncho- pneumonia. This affection may occur during the preliminary fever, the decline of the eruption, or after the measles is apparently cured. But it is far more frequent during the first period; and it is found to influence the course of the measles, just as its own course is influenced by the pri- mary malady. WThen it does not occur until the second period, it does not appear to modify the measles; each disease runs its course; but the pneumonia has the character of a secondary disease. When it occurs after the disappearance of the measles, it is a primary dis- ease, affected, doubtless, by the condition of the child, but generally lobar, unless other complications have intervened, in which case it is more frequently lobular. Dr. Gregory has given a very graphic picture of this complication : "It is a slow-creeping, insidious form of inflammation, which too often throws the practitioner off his guard. No positive complaint is made. The child droops, and appears exhausted. Imagining that the disorder has weakened his patient, the practitioner directs some mild tonic. Meanwhile, pneumonic engorgement (or pneumonia in its first stage) creeps on. The lungs become more and more congested and at length solidified. Convulsive fits now take place; alarm is taken, and leeches are applied; but the mischief is irreparable. Dys- pncea increases. The child becomes drowsy; the feet cold. The pulse sinks. Florid effusion now takes place from the bronchial membrane Another and another fit succeeds. Rattles are heard in th* th™** The child dies!"1 mroat.— In some cases, we find bronchitis alone, or mixed with some nodules 1 On Eruptive Fevere, p. 106. MEASLES. 541 of lobular pneumonia, and so severe as to cause death; in other cases, the pneumonia exists alone, but more frequently they are combined, and the morbid appearances, discoverable after death, are those I have already described. The symptoms are those of pulmonary disease: cough, dyspncea; moist bronchitic or pneumonic rales, more or less intermingled, bron- chial respiration, vocal resonance, dulness on percussion, &c, as heretofore laid down, but which may be overlooked in these cases, or confounded with the ordinary catarrhal symptoms by superficial ob- servers. In every case of measles, whether apparently complicated or not, the chest should be carefully examined at short intervals, and great care should be taken lest mild cases should be rendered severe or fatal by the complication, in consequence of the neglect of needful precautions. The attack seems influenced by age: thus, the younger the child, the more liable to pneumonia; at a more advanced age, bronchitis more commonly prevails. When the complication is developed dur- ing the first stage, it seems rather an extension of the irritation of the mucous membrane than owing to any special exciting cause. At a later period, it may arise from cold, sudden recession of the eruption, &c. Occasionally, pneumonia is the characteristic of an epidemic. Dr. Dewees says: "We remember to have seen it epidemic in the spring of 1785 or 1786, at which time almost every case was marked by pneumonic symptoms of greater or less violence. This disease was of difficult management; it ran its course with unusual rapidity; and not unfrequently terminated in death; and, in all instances almost, the cough was severe, obstinate, and of very long duration."1 iv. Pleuritis.—Guersent and Blache speak of this affection as of extreme rarity; but, if I may trust my own experience, I should be inclined to think it more common than has been supposed. I was consulted, the other day, about some children who had got over the measles pretty well, but who were not recovering satisfactorily. Their principal complaint, the mother told me, was a short cough and some pain in the side, but she mentioned the matter as rather trifling. Two of the children were brought to my house, and, on examining care- fully, I detected in each, pleurisy of the left side with great effusion, and displacement of the heart. The attack may occur during the first or second period, but I sus- pect that it is more frequent after the measles are over, as one of their sequela?. The symptoms may be very slight, as in the cases I have noticed, or they may be more severe, with high fever; but we shall be certain to find cough, pain in the side, occasional or constant, with dulness on percussion, bronchial respiration, vocal resonance, un- equal vibration, &c. I do not know that it is a very fatal complication, unless the child be much run down by the previous illness. It is certainly very tedious, and will require considerable attention and care. As I have 1 Diseases of Children, p. 508. 542 MEASLES. before mentioned, it is seldom possible to bleed; but counter-irritation, with mild mercurials, and some expectorant mixture, answers very well. Diuretics I have also found very useful. 845. v. Muguet, fyc—W7hen speaking of the various forms of sto- matitis, ulcerated sore mouth, cancrum oris, &c, I mentioned that they occasionally occurred as secondary affections in the course of measles; but, generally, also, as secondary to some disorder of the intestinal canal. It is not improbable that these diseases of the mouth are more frequently the result of the gastro-intestinal disorder than dependent upon the measles; and, in treating them, we must have respect to both complications. They are more frequent in cachectic infants, and in those who are ill fed, and live in badly-ventilated rooms. Gangrene of the pharynx is extremely rare; much more so than gangrene of the lung. vi. Gastro-enteritis.-^Colitis.—Disorder of the stomach and bowels is so common in measles that few writers have omitted to notice it; and it has formed one of the divisions of several authors. " It is chiefly marked," Dr. Copland observes, "by accumulations of sordes in the stomach and bowrels; by loaded tongue; pain and tenderness at the epigastrium,hypochondria, and bowels; by morbid, bilious, and offensive alvine evacuations; by the great severity of the cough; by depression of the energies of the frame; the slower and less abundant eruption on the skin; by weakness and frequency of the pulse; and by severe pains in the lower limbs and forehead. It sometimes cha- racterizes summer and autumnal epidemics, particularly during", or soon after, warm and moist seasons; and it occurs sporadically in weak children during the periods of the first and second dentition, in the imperfectly nourished, and in those who have had their bowels long neglected."1 Vomiting and diarrhoea may accompany the invasion of measles, and the stomach afterwards regain its tranquillity, whilst the irrita- tion of the bowels continues, or both may persist. Again, as we have seen, diarrhoea not unfrequently occurs towTards the termination of measles, as a critical evacuation. Or, lastly, the symptoms of functional disturbance may assume the character of inflammation, and the disease assume a much more serious aspect, with tenderness and tension of the bowels, and espe- cially of the epigastrium. Guersent and Blache found such cases rare; in the majority, there was no post-mortem evidences of inflammation. They remark that gastro-enteritis may complicate measles under any of its forms either as acute or chronic, simple, dysenteric, typhoid, or cachectic. Colitis or dysentery occasionally occurs, but more rarely, accom- panied with the usual symptoms of pain, tenderness, frequent and small evacuations of mucus mixed with blood. In thirty-seven cases, Rilliet and Barthez found secondary normal 1 Diet, of Practical Medicine, part ix. p. 815. MEASLES. 543 entero-colitis; in six, th§ chronic and cachectic; in two, the dysen- .teric; and in one, the typhoid form. In neither can we estimate the amount of febrile action due to the complication, because of the fever accompanying the measles. The pulse is always quick, the tongue coated, with thirst, heat of skin, &c. It is not easy to point out the causes of this complication; probably much is owing to improper food, and much to impure air. Certain epidemics are thus characterized: Dr. Copland states that " Dr. Abercrombie, of Cape Town, described to him an epidemic prevalence of measles in the colony, which presented much of this character; the complication with diarrhoea, or enteritis, or dysentery—or the super- vention of them during the decline of the measles, or even some time after recovery from that disease—being very frequent and uncom- monly fatal."1 846. vii. Ophthalmia.—We have seen that injection and suffusion of the conjunctiva, with increased secretion both of the mucous mem- brane and the lachrymal gland, characterized the first two periods of normal measles; but this irritation subsides spontaneously in favorable cases, leaving a slight excess of sensibility only, for a few7 days. But in some cases, from the sixth to the twelfth day, the child has an attack of simple, or it may be of purulent, ophthalmia, which may even terminate by the loss of sight. More frequently, we see the conjunctiva of the lids chiefly affected, with some degree of swelling, redness of the membrane, lachrymation, secretion of mucus, sensibility to light, and incessant itching. The attack has no effect upon the course of the eruption. It has been remarked as prevailing very ex- tensively in some epidemics, as the one mentioned by Heyfelder, where it proved both troublesome and serious. Little active treatment is necessary in the ordinary forms. Fomenta- tion with warm water, decoction of poppy-heads, or of chamomile flowers, in the first instance, with the addition of some astringent, as alum or zinc, or a weak solution of nitrate of silver when the disease becomes more chronic, and some counter-irritation, will generally be sufficient to cure the disease. When it depends upon the cachectic condition of the child, an improved diet, as convalescence advances, will act favorably upon the local affection. vin. Otitis.—Inflammation of the ear is not a very frequent com- plication, though it occurs sometimes. It may occupy the external meatus only, or it may involve the deeper structures, and occasion permanent injury. Pain, more or less acute, deafness, sensibility to sound, and pain on pressure, will generally be present, and serve to point out the nature of the attack. It seldom occurs in the first or second period of the disease, but generally when the measles are dis- appearing, and is caused probably by cold. Dr. Condie speaks of its occurring in children of a scrofulous habit, and of its becoming chronic. Leeches, fomentations, and blisters will probably be found sufficient 1 Dictionary of Practical Medicine, part ix. p. 816. 544 MEASLES. to relieve the disease; but, for further detailstof these last two com- plications, I must refer my readers to the special works upon these diseases. _ . ix. Hemorrhages.—I have already mentioned a modification of the eruption of measles which appears to be the result of ecchymosis, like purpura hemorrhagica; but this disposition may extend to other in- ternal organs, such as the intestines most frequently, the kidneys, bladder, gums, or nose. Such complications are more or less im- portant in themselves, but far more as indications of a broken-down constitution, or a change in the composition of the blood, which may ultimately prove fatal. x. Eruptions.—Measles is followed by a variety of eruptions—- herpes, eczema, porrigo, &c.; either because the cutaneous excite- ment has left a disposition to morbid action, or because the state of the constitution is peculiarly favorable to these affections. " Por- riginous eruptions on the head, and serous ulcerations behind the ears, also frequently occur, and, in some instances, induration of the mesenteric glands, and marasmus. Among the occasional conse- quences are herpes, boils on different parts of the body, discharges from the ears, and anasarcous swellings."1 Nor are these unfavorable. Dr. Armstrong remarks that, " when any cutaneous affections arise after measles, the internal organs re- main free from disease; and, even when some internal disorder has existed, I have not unfrequently seen it disappear on the occurrence of some spontaneous eruption of the skin."2 xi. Tubercles.—In scrofulous children, a rapid development of tubercular deposit not unfrequently dates from an attack of measles. It may show itself in glandular enlargement, mesenteric disease, or phthisis. The occurrence has no essential connection with measles but originates in the condition in which the eruptive disease leaves the constitution. xn. Anasarca.—This, which is so common a complication of scar- latina, occurs also with measles, but much less frequently and much less seriously. Guersent and Blache observed it from the twelfth to the twentieth day; and, in favorable cases, it disappeared after a few days. In some cases, it was more serious; accompanied by albumi- nuria, it terminated in death; and after death the kidneys exhibited the appearance of Bright's disease. 847. Morbid Anatomy.—U. Fabre has given the following sum- mary of the pathology of measles, independently of the eruption When measles terminates fatally without any complication, the organs are generally found in a state of congestion, more or less marked sometimes of a blackish-red color. Occasionally, the follicles of Pever and Brunner are enlarged, as in scarlatina and small-pox another analogy between these diseases and typhoid fever. The blood which is found in the vessels after death is black and fluid, and the cavities of the heart contain no coagula. The results of chemical analysis 1 Eberle on Diseases of Children, p. 435. 3 Practical Illustrations, &c, p. 175. MEASLES. 545 correspond to these characters; the fibrine preserves its mean propor- tion (3 parts in 1000). M. Andral found, in several adults attacked by measles, that the fibrine preserved the proportion of from 2J to 3| during the first stage, but that it diminished after the eruption. The proportion of red globules is augmented: from 129 in 1000, M. Andral found it as high as 137, 140, and 146.1 Vogel placed the seat of the eruption in the epidermis; more recent researches have showrn that it occupies the rete vasculosa of the skin. I have not thought it necessary to describe the morbid appearances of any of the complicated forms of measles. I have already given the morbid anatomy of the different secondary diseases, and I must refer my readers to them. 848. Causes.—That measles is infectious is admitted by all, but how soon the infectious effluvium is formed, and how far it may ex- tend, is not settled. Dr.^Williams thinks that the blood throw's off infective emanations during the eruptive fever, and prior to any erup- tion. Much will probably depend upon the virulence of the disease. It may also be carried from the sick, and communicated to third par- ties ; the party conveying it participating in the attack with the others, and at the same time. It is said, also, that it may be conveyed by a person who does not take the disease to third parties, and some cases I have heard would seem to justify this conclusion. But, in addition to its infectious nature, and to its facility of convey- ance by woolen or porous bodies, it may also be spread by contagion and by inoculation. Vogel, Wachsel, Brown, Munro, and Tissot pro- duced measles by inoculation with the blood of a person laboring under the disease, or with the serum of the vesicles which are occa- sionally mixed with the eruption. It was hoped that inoculation might be as successful with measles as with small-pox, in exciting a milder form; but this has not been found to be the case, and the practice has never prevailed. " By a recent notice in one of the Austrian medical journals, it ap- pears that Dr. Katona, of Borsoder, in Hungary, has tested, in a large number of cases, the efficacy of inoculation for measles. In a very fatal and wide-spread epidemic, which prevailed during the winter of 1841, Dr. Katona inoculated 1122 persons with a drop of fluid from a vesicle, or with a drop of the tears of a patient affected with the dis- ease, the fluid being inserted in the same manner as the virus in vac- cination. The operation succeeded in about 93 per cent, of the cases in which it was performed, producing a mild attack of measles. A red areola at first formed around the puncture by which the fluid was inserted, but soon disappeared. On the seventh day, the fever com- menced, with the usual prodromi of measles; on the ninth or tenth day, the eruption made its appearance ; on the fourteenth, desquama- tion commenced, with a decrease of the febrile symptoms; and by the seventeenth day the patients were very generally well. In no one of the inoculated cases did the disease terminate fatally." 1 Bibliotheq. du Medecin.-prat., part xvii. p. 448. 35 546 MEASLES. It occurs also as an epidemic, owning probably to some peculiar state of the atmosphere, and is certainly conveyed and propagated by it. The following are some of the principal ones:— An epidemic was observed in London in 1769,1770, 1773, 17/4, and described by Sydenham; in Upsal in 1752, described by Rozen; at Plymouth in 1741, by Huxham; in London in 1763 and 1768, by Watson ; at Vire in 1772 and 1773, by Poliniere and Le Pecq de la Cloture ; in Paris in the years 6 and 7 of the Republic ; by Consbruck in 1800, 1801 ; in Edinburgh in 1816 ; in Paris in 1828, and again in 1833; in Hungary in 1841; and in the Hopital Necker in 1843. Dr. J. Duncan has described an epidemic of measles which occurred in the North Union Poorhouse between March and June, 1842; 56 children were attacked, and 15 died; 11 were under one year, 10 between one and two years, 22 between two and five years, and 13 above five years. The complications were as follows: in 12 cases, there was pneumonia; in 13, convulsions; in 8, bronchitis; in 4, phthisis; in 5, croup; in 1, peritonitis; in 3, ulcerated tonsils; in 4, prolapsus ani succeeded; and in 5, ophthalmia succeeded.1 Such epidemics are frequently characterized by the predominance of one or other complication, and their mortality generally depends upon this, and the type of the disease. 849. The origin of the disease is quite unknown; it has been attributed to minute insects in the air, or to some unknown composi- tion of the atmosphere; but we can prove nothing. It is transported, either by atmospheric influence or by individuals, to distant countries, although it is not always possible to mark its transit; and some dis- tant lands seem to escape it altogether. Thus, it is stated by M. d'Angheira to have been imported into America in 1518; and Dr. Stewart says there are no records of its appearance in North America before 1713. It appeared for the first time in St. Helena in 1808, and the same year it returned to Madeira after an absence of five years. "A few years ago," says Dr. Copland, "measles was introduced into the Cape of Good Hope, where it had not appeared for about thirty years, by a vessel from Europe, in which several instances occurred during the voyage."2 In Australia, Van Dieman's Land, and New Zealand, it is unknown to this day. Sporadic cases of measles are observed at all seasons; but epi- demics, according to M. Andral, occur especially towards the end of winter and in the spring; so that the season of the year influences the latter, but not the former. I have already shown that the age of the child is so far a predis- posing cause, that more infants are attacked than children, and more children than adults ; and I endeavored to explain this without sup- posing a greater inherent liability. Nor is the foetus in utero exempt 1 Dublin Journal, vol. xxii., Sept. 1842, p. 26. 2 Diet, of Pract. Med., part ix. p. 822. MEASLES. 547 from the disease. Hildanus, Roesler, Vogel, Rosenstein, Osiander, Girtanner, Orfila, Billard, and others, witnessed cases of this kind.1 I saw a case in w7hich the eruption of measles appeared upon both mother and child the second day after delivery. In these cases, of course, the disease must have been communicated to the foetus through the blood of the mother, and so far are evidences of its contagion, analogous to the cases of inoculation. From the calculations of Emerson2 and Condie, it appears that 395 deaths occurred between the ages of one and two years, and only 468 between the ages of two and five years. Of 1293 deaths which oc- curred in London in 1842,3 93.8 per cent, occurred in children under five years, and 99 per cent, in those under ten years. Rilliet and Barthez met*with 25 cases between one and two years; 72 between three and five years; 50 between six and ten years; and 20 between eleven and fifteen years. 850. Diagnosis.—It is, of course, very difficult to pronounce upon the nature of the disease during the first stage, nor would it be very wise to do so. The sudden access of fever, the running of the eyes and nose, the hoarse voice, &c. may well excite our suspicions; but they will not be confirmed until the eruption appears. Then the semicircular or crescentic form of the eruption, mixed with papulae, their elevation and their course, will clear up our doubts. i. It may be distinguished from scarlatina by the distinctive form of the eruption, its elevation, and the greater disposition to affect the respiratory organs. In scarlatina, the eruption is diffused, and scarcely at all elevated—more, in fact, like a vivid blush than an eruption; the digestive organs are more affected, and the cellular tissue, as Ziegler has remarked. ii. Some cases of roseola strikingly resemble measles, and no doubt have been mistaken for them; but, in general, there is little or no running of the nose and eyes, no catarrh, less fever, the eruption is more fugitive, and no desquamation takes place. Moreover, when measles attacks one child of a family, it is generally communicated to others, which is not the case with roseola. 851. Prognosis.—The prognosis, in the mild uncomplicated form of measles, is almost alwrays favorable ; but, although a considerable number do recover, many others die. Percival states that 91 died out of 3807 cases; Watson, that 1 in 10 in one year, and 1 in 3 in an- other, died in the Foundling Hospital, London ; Home estimates the deaths at 1 in 12; M. De la Garde lost 3 per cent. We must, therefore, take other matters into consideration before forming our prognosis—the epidemic character, the type of the dis- ease, and its complications. The concurrence of pneumonia, croup, gastro-enteritis, or dysen- tery, whether they prevail epidemically or not, diminishes the chances of recovery very seriously. The typhoid form of the disease is also by 1 Ueber der Krankheiten des Fostus., by Grastzer, p. 46. 2 American Journal of Medical Sciences, 1827, vol. i. 3 West.on Diseases of Infancy and Childhood, p. 476, 548 MEASLES. far the most fatal. And children of broken-down constitutions are more likely to fall victims to the complaint than those who were pre- viously healthy. Upon the whole, measles are far less fatal than either scarlatina or small-pox. Of 167 cases, Rilliet and Barthez state that 77 were cured, and 90 died; and the conclusions they draw are as follows: 1. That normal primitive measles, simple, or with slight inflammation of the respira- tory or digestive organs, is very easily cured. 2. Normal primary, but complicated measles, is cured about as often as it proves fatal. 3. Anomalous measles, primary and complicated, is as often curable as mortal. 4. Simple, secondary, anomalous measles is fatal to half the cases; but the mortality depends upon-the primary affection, and not upon the measles. 5. Anomalous, complicated, secondary mea- sles is fatal in the great majority of cases.1 " The favorable indications which occur during the disease are a moderate eruption, with a mitigation of the fever; a disposition to an equable moisture on the skin; a moderate or slight cough, with a mucous and easy expectoration; a free and unembarrassed respira- tion ; a free state of the bowels, and moderate relaxation of them towards the close of the disease; hypostatic urine ; a regular succes- sion of the changes of the eruption ; and no appearance of any irregu- larity or complication with visceral affection, the existence of which often occasions a fatal result at a more or less remote period, owing to the tendency to disorganization being greater in the local affections occurring, than when taking place primarily."2 852. Treatment.—As the disease has a definite and regular course, we cannot attempt to interfere with that, but must content ourselves with correcting anything unfavorable in the type, and to subdue, if possible, the complications. In a simple case of measles, very little treatment will be necessary: the bowels must be kept free, plenty of diluent drinks allowed; the patient to be kept in bed, lightly covered, and only a very light diet permitted. The heat and prickling or itching of the skin, when the eruption appears, may be relieved by small doses of the liquor ammonia? ace- tatis and spiritus aetheris nitricL The catarrhal symptoms may be soothed by a mucilaginous mixture, with ipecacuanha, and a small quantity of morphia. Drs. Willan and Fothergill give emetics for this purpose, and they certainly seem to mitigate the fever. I quite agree with Dr. Armstrong, who observes : " From an impar- tial consideration of the facts which have come before me I am con- vinced that our plan of treating measles (in its regular form) is too uniformly active when the eruptive fever is developed • and that wre should be more fortunate in the main if we interfered les's with the operations of nature in cases of a mild and regular character.3 1 Mai. des Enfans, vol. ii. p. 744. 3 Copland, Diet, of Pract, Med., part ix. p. 821. 3 Practical Illustrations of Scarlet Fever, Measles, &c, p. 115. MEASLES. 549 Until the disease has subsided, the diet should be moderate; it may then be increased gradually; the child must live in warm, well-venti- lated apartments, and every precaution must be taken to avoid cold. 853. In the inflammatory form of the disease, when not only the surface, but the mucous membrane, and even the lungs, are in a state of extreme congestion or inflammation, more active measures will be necessary, and these of an antiphlogistic kind. Sydenham advises bleeding, when the fever is violent, with pulmo- nary symptoms. Cullen.thinks it rarely necessary early in the disease. Willan and Bateman prefer reserving it until a later period, if it should then be required by the cough, dyspnoea, pain in the chest, &c. There is no doubt that blood-letting is quite admissible in measles, if the symptoms demand it, but regard must be had to the character of the epidemic; and it is to the variations of this character that we must ascribe the difference of opinion in authors, each of whom speaks according to his experience. Thus, Hamilton, Murray, and others did not employ it, whilst Mead, Heberden, Home, Fergusson, Armstrong, &c. regarded it as a necessary part of the treatment. Dr. Dewees observes: " Therefore, regard must be had to the cha- racter the measles assumes, and must be treated accordingly. If fever be high, cough and oppression severe, blood should be drawn imme- diately, though these symptoms occur at rather an uncommon period of the disease, namely, in its forming stage; for such changes may be imposed upon the character of measles by some constitution of the air, or other cause, as to render this operation occasionally necessary."1 And he adds that he had only bled once that season, though he had prescribed for more than 100 patients. Drs. Stewart, Condie, and West advocate the employment of bleed- ing, when the inflammatory symptoms run high, or any pectoral com- plication exists. The quantity of blood to be taken must depend partly upon the in- tensity of the febrile or inflammatory action, partly upon the organs principally affected, and partly upon the stage of the disease and the constitution of the child. If the child be strong, the lungs conside- rably involved, with a quick pulse, sufficient blood should be taken to make a decisive impression upon the disease. On the contrary, at an advanced stage of measles, with delicate children, we must use great caution, and perhaps have recourse to leeches instead of venesection. Other antiphlogistic remedies must also be adopted : low diet, cool- ing, diluent drinks, saline effervescing draughts, &c, with a brisk purgative of calomel and rhubarb, or jalap, or castor oil. If there be no gastric irritation, we may give minute doses of tartar emetic with some expectorant, by which the cough will be relieved, and the general excitement lowered. If the skin be dry, James's powder, with a small portion of Dover's powder, may be given at bed- time, or twice in the day. Cold affusion has been strongly recommended, or sponging the 1 Diseases of Children, p. 570. 550 SCARLET FEVER. body with cold water; and we are assured that there is neither the risk one would suppose of suppressing the eruption, nor of exciting internal inflammation.1 Dr. Armstrong does not think it as suitable as in scarlatina ; but he has derived great benefit from tepid affusion.2 854. In the congestive form of measles, if we detect any organic inflammation, it may be found necessary to bleed; and it will gene- rally be found that* the pulse improves afterwards. Then we may have recourse to external counter-irritants, calomel and opium, &c. Warm baths will be found of great service in exciting the cuta- neous circulation, and so relieving the internal organs; and, more- over, they will favor the free development of the eruption. Diffusible stimulants are of use; carbonate of ammonia in almond milk affords great relief in congestion of the lungs. 855. In the typhoid or malignant form of measles, blood-letting will be out of the question. Our object must be to support and sti- mulate the vital powers, for which purpose we must give ammonia, camphor, bark, the alkaline carbonates, the chlorides, &c. Wine also may be necessary, and good diet. Guersent and Blache speak favorably of injections of bark, the use of rubefacients, mustard poultices, or blisters to the extremities, &c. 856. The practitioner, I must repeat, must always be guided in his treatment by the epidemic character of the season, and by the peculiarity of the epidemic of measles. Thus, purgatives must be cautiously administered when gastro-enteritis, or diarrhoea, or dysen- tery prevails ; blood-letting used warily wdien diseases have a typhoid or adynamic character. In inflammatory epidemics, such as that described by Mead, Arm- strong, &c, bleeding is highly beneficial; but in the one that pre- vailed in Paris in 1828, although it was frequently complicated with inflammation of the lungs and other organs, M. Biett states that it was not benefited by blood-letting.3 857. Special treatment will be required for each of the complica- tions, whether of the brain, lungs, or gastro-intestinal canal; but of this I have so fully spoken under the head of each of these diseases that I need not recapitulate the matter here. CHAPTER II. SCARLET FEVER.—SCARLATINA. 858. The second of the eruptive fevers I shall notice is scarlatina Like measles, it is preceded and accompanied by fever • and after 1 Bateman on Cutaneous Diseases, p. 61. 2 Practical Illustrations, p. 163. 3 Report in Journ. Hebdom., No. 42. SCARLET FEVER. 551 few days, a rash appears, which is general, and of a vivid red, with much irritation of the mucous membranes, especially of the throat and stomach ; it runs a definite course; occurs epidemically; may be pro- pagated by infection or contagion, and ordinarily attacks a person but once in a lifetime. Its cause and history have so much resemblance to measles, thatj for a long time, they were confounded; but the erup- tion is quite different in its general diffusion, and the digestive mucous membrane, rather than the pulmonary, is chiefly affected. It is a disease of infancy and childhood emphatically, and I be- lieve for the reason I have already mentioned, viz., that, being highly infectious as well as epidemic, the child takes it the first time it is ex- posed to its influence, which is pretty sure to happen before it has passed many years, in consequence of the frequent prevalence of the disease. Of 2614 cases recorded by Mr. Farre in his Fourth Report, 2419 w7ere children, 182 adults, and 13 aged persons. Dr. Copland says that it is doubtful whether scarlet fever was known to the Greeks or Romans. Ingrassias is said by Hildenbrand and Frank to have been the first to distinguish the disease. Cottyer pub- lished an account of an epidemic which resembled scarlatina, and which prevailed in Portiers in 1557. And Forestius states that the epide- mic at Amsterdam, in 1517, which was described by Tyengus, was this malady.1 Mercatus (1672), Heredia (1626), S&imbatus (1620), ^tius Clerus (1636), Sennert (1625), Sydenham, Sibbaid, Morton, Fothergill, Heberden, De Haen, &c. &c. have since described the dis- ease. It first appeared in Spain in 1610, in Naples in 1618, in London in 1670, and in Edinburgh in 1680. 859. We can only form an approximative estimate of the frequency of scarlatina. Dr. Copland has given the number of deaths from scarlatina, mea- sles, and small-pox, in the eleven years from 1838 to 1848 inclusive, and these are: from scarlatina, 20,962; from measles, 14,632; and from small-pox, 13,079. "In only three of these years have the deaths by measles been greater than those by scarlatina, and in only- two has the mortality from small-pox exceeded that of scarlet fever." Mr. Wilde observes that it is "the tenth most fatal of the epidemic class of diseases, and destroyed (in the ten years) 7886 persons, the sexes being in the proportion of 100 males to 95.97 females. With the exception of cholera, this disease has proved more fatal in towns, and among large and closely united masses of the population, than any other epidemic of this country, being one death in 24.63 of the epide- mic affections in the civic districts, and but 1 in 65.07 in those of the same class in the rural districts or open country. The deaths speci- fied from this cause are in the proportion of 1 in 150.56 of the total recorded mortality, and 1 in 48.34 of the entire epidemic or conta- gious diseases." . ..." In the years 1835-36, and part of 1837, 1 Diet, of Pract. Med., part xiv. p. 665. 552 SCARLET FEVER. the mortality from this disease rose from 620 to 840,1074, and 1040, being then the forerunner of the fever and small-pox which prevailed in 1837, 1838, and 1839, during the continuance of which diseases it fell, but again rose up, then declined in 1840.'" In the tables of mortality of Philadelphia, U. S., published by Dr. Emerson, it appears that, in twenty-four years, the mortality from scarlatina was 143 under twenty years of age; and, during the first twenty years of this period, there were 654 deaths from measles.2 During the ten years preceding 1845, Dr. Condie states that there were 2154 deaths from scarlatina, and only 574 from measles. Guersent and Blache have added together the cases collected in 1838-9, by Roger, Rilliet and Barthez, and Barrier, and find that there were 157 cases of scarlet fever, 264 of measles, and 213 of variola and varioloid.3 Dr. Gregory mentions that the deaths from scarlatina in 1837 in London were 2520; in 1838, 5802; in 1839, 10,325; and in 1840, 19,816. Thus, we cannot draw any accurate comparisons of the frequency of measles and scarlatina, or estimate precisely the frequency of either disease. The irregular occurrence of an epidemic of either disease, or its unusual severity, will effectually disarrange our statistical cal- culations. 860. Scarlatina may be either primary or secondary, normal or abnormal. By most writers it has been divided into three varieties; scarlatina simplex, scarlatina anginosa, and scarlatina maligna. I shall adopt the same plan as with measles, and first describe the ordinary form of scarlatina, and then the deviations or modifications. We may notice three periods of the disease. i. The Period of Invasion.—The term of incubation, from the moment of receiving the infection to the development of febrile symp- toms, varies in different patients; it may be only a few hours, or it may extend to ten or twelve days; in some cases of Dr. Maton's, it appeared to be twenty-four or twenty-five days. The earliest symptoms which manifest themselves are general uneasiness, lassitude, depression, aching in the back and limbs, rigors, loss of appetite, and thirst. Soon afterwards, the patient complains of stiffness and pain in the throat, with difficulty and pain in swallowing. The skin becomes very hot, the pulse quick and full; occasionally j there are nausea and vomiting; always pain in the loins, headache, and either drowsiness or sleeplessness. When the initiatory fever runs very high, there may be delirium or even convulsions. The face is congested, swollen, and red; the eyes injected, and sen- sitive to light. If the fauces and throat be examined, they will be found puffy, red, and inflamed, and the tonsils swollen. The tongue 1 Report on the Table of Deaths, p. 13. 3 American Journal of Medical Sciences, 1827, vol. i. 3 Diet, de Med., vol. xxviii. SCARLET FEVER. 553 is white or yellow, and loaded at the base, but red at the point and edges, with prominent papillae. The fever during this time seems rather to increase, the skin is hot and florid, the thirst intense, and the pulse very quick. The bowels are generally confined, the urine is scanty, high-colored, and voided frequently; sometimes it is albuminous, but more com- monly so at a later period. After these symptoms have continued for a time, varying from one day to four or six, the eruption makes its appearance. 861. n. Period of Eruption.—At first, there appear a number of minute red points, on a rose-colored ground, about the face or neck; sometimes on the trunk or extremities. These rapidly increase, spread, and coalesce into large patches, which increase and coalesce until the entire surface of the face, body, and limbs is covered. Or, the face and body may be occupied fully by the rash, whilst it exists in irre- gular patches on the limbs. Neither the minute red points, nor the large patches, nor the gene- rally diffused rash, have either tangible or visible prominence ; the skin feels rough if the finger be passed over it, and the surface of portions, as the face, may be swollen; but the characteristic appearance is that of a vivid scarlet color, like that of a boiled lobster, without papula?; very different from the irregular, semicircular or crescentic, somewhat elevated eruption of measles. Under pressure, the bright scarlet color disappears, and returns when the pressure is removed. The skin is burning hot, dry, and rough, resembling " goose-skin" to the touch; the itching is often intense, and the face, feet, and hands are considerably swollen. The pharynx is of a vivid red; the tonsils are red, swollen, and often covered with white pultaceous secre- tion in patches: the swelling of the tonsils may be perceived exter- nally, and the submaxillary glands are also enlarged. The coating of the tongue gradually peels off, until it presents the appearance peculiar to this affection; it is dark-red, dry, and shining as if varnished, with prominent papilla?, something like the surface of raspberry jam, if I may use so homely a comparison. On certain parts of the body, as the neck, axilla?, folds of the arm, &c, we find occasionally an eruption of miliary vesicles. The fever generally subsides some degrees upon the appearance of the rash, and continues at that point until it finally disappears. The heat of the skin during the eruption is very great; Hasse, Cuvier, Andral, and Rayer have found it to range from about 90° to 112° Fahrenheit. When the attack is severe, or during a paroxysm, the countenance is excited, but expressive of suffering; the eyes are bright; there is restlessness, agitation, or delirium, and the patient is generally sleep- less ; the respiration is hurried, and often impeded ; the constipation may be replaced by diarrhoea to a certain amount, accompanied with slight colic. It is chiefly during this period that the more serious complications are developed. 554 SCARLET FEVER. " After five, six, or eight days," Guersent and Blache observe, " that is, after a longer time than was required in measles, the exanthema gradually subsides; it assumes a violet tinge, then a pale rose, or slight copper color. Most commonly, the mucous membrane of the mouth remains red; sometimes it is at this period only that the tongue, throwing off its white coating, presents the prominent papilla? and the characteristic redness. The swelling of the parts diminishes simul- taneously, but gradually."1 862. in. Period of Desquamation.—Somewhere, then, between the fourth and ninth day desquamation commences. Should the attack have been severe, the fever high, and the eruption abundant, the process may commence before the disappearance of the rash; but, more generally, it is after its decline, during convalescence, or per- haps not until a week or two after its disappearance. It observes pretty much the order in which the eruption appeared ; the miliary vesicles drying first. When the eruption has been very slight, the desquamation is some- time scarcely perceptible ; in other cases, the epidermis is detached in very minute powdery particles, like flour: more frequently, however, it comes off in scales of varying sizes, or in strips from those parts where the epidermis is very thick, as the hands, fingers, soles of the feet, &c. The epithelium of the tongue is also cast off, leaving it of a vivid red color, and sometimes very tender. The hair commonly falls out in great quantities, and several writers have noticed the nails falling off. Dr. Graves mentions a case of this kind. This process may last from eight to fifteen days, or even longer, from thirty to forty ; but then we observe repeated exfoliations. Oc- casionally, the skin becomes universally sensitive during desquama- tion, and with some infants the slightest contact is very painful. Other children suffer from a kind of rheumatic pain in the limbs or joints, but chiefly in the wrists, during this or the preceding period, which does not, however, last as long as ordinary rheumatism. Sometimes between the fifth and eighth day, or sooner, if the attack be slight, we find the pulse become quiet, the surface cooler, though the skin is still dry and rough, and the affections of the digestive or respiratory mucous membrane diminish, and finally dis- appear. The throat ceases to be painful, the swelling of the tonsils subsides, and the pharynx and vault of the palate lose their scarla- tinous redness. Abundant alvine evacuations, profuse sweating, or, more rarely nasal hemorrhage, mark the critical termination of scarlatina. Thus, the entire duration of the disease will vary much, as well as each stage. In the mildest form, it may occupy five or six days ; in others, several weeks. 863. Modifications.—I have thus sketched a marked but simple ' Diet, de Med., vol. xxvih. p. 153. SCARLET FEVER. 555 case of scarlatina. Our next point is to notice the principal modifi- cations which may arise in the character of the eruption and its course, or in the type of the disease. a. The eruption may be partial, occupying only the face and hands, the neck and chest, or the flexures of the joints. Or, the redness may be in extremes, either very slight or very deep; or a number of violet-colored points may be interspersed, or a crop of miliary vesicles—the scarlatina miliformis of P. Frank: these vesicles are sometimes mixed with sudamina or papula?, but very rarely with pustules. " Reuss, Raimann, and Hildenbrand have observed, in rare in- stances, the eruption, on the second day of the efflorescence, of bullae, of a dark-red color, above the size of a nut, containing a yellowish serum, and resembling that produced by a blistering plaster. The cuticle breaks, and, the fluid being discharged, a sore remains, which follows the course of the constitutional malady."1 This is the scarla- tina pemphigoides of Hildenbrand. In the severe forms of the disease, the eruption may assume a dark- red or livid color, occasionally interspersed with petechia? of various sizes, or even large patches of sanguineous effusion, constituting the scarlatina purpura. Most writers have noticed the appearance of miliary vesicles. Rayer mentions having seen coincident eruptions of variola and chicken-pox.2 b. There may be also deviations from the usual course of the disease ; the initiatory fever may be either longer or more brief than usual, and the eruption consequently make its appearance after four, five, or six days, or almost simultaneously with the outbreak of the fever. The rash may die away unusually quickly, or remain longer than ordinary, or it may recede from especial causes. I have already men- tioned its recession and reappearance in some cases. Lastly, the desquamation may be scarcely perceptible, or may oc- cupy weeks. 864. It appears, also, from very good evidence, that a child may have .scarlatina without the eruption. Some have doubted this; but it is maintained by Huxham, Fothergill, Stoll, Dance, Guersent, Trousseau, and others. We may see the disease run its regular course with several members of a family, and perhaps one of them will exhibit all the constitutional symptoms, fever, sore throat, &c, without any rash upon the skin. We may perhaps go further; for Dr. Copland believes that "a child in the same house or family in which scarlet fever is unequivocally present, may have the constitutional affection, not only without the characteristic eruption, but even without the sore throat also; both these essential features of the malady being either entirely wanting, ' Diet, of Pract. Med., part xiv. p. 668. 3 Diet, de Med. et de Chir. Prat., vol. xiv. p. 541. 556 SCARLET FEVER. or so slight and so evanescent as to escape notice." This Dr. Copland believes to be true scarlatina, though latent. We find such occurrences more common in certain epidemics than in others, but it is always necessary to regard them carefully and cau- tiously; "for it should not be overlooked that sore throat and fever, both the local and constitutional affections being characterized by re- markable asthenia, amounting even to putro-adynamia, may occur sporadically or endemically, or even epidemically independently of any connection with scarlatina, and amongst persons and families who have already been the subjects of scarlatina. Of these occurrences, I have met with several instances; the greater part of a family, all of which had previously had scarlet fever, having been.thus attacked." 865. The modifications wdrich depend upon the type of the epide- mic, or perhaps upon the constitution of the patient, have been usually divided into three varieties: 1, the scarlatina simplex vel mitis; 2, scarlatina anginosa; and, 3, scarlatina maligna. Rilliet and Barthez give three forms, answering nearly to the above. In the first, the symptoms are very slight, as it were incomplete; in the second, the eruption is slight and benign, but the general symp- toms are severe, and run an irregular course; in the third, the typhoid character pervades all the symptoms. i. Mild Scarlatina may prevail in certain districts, or even epide- mically. Cases of it also occur during severe epidemics, and may be followed by dropsy or other of the ordinary sequelae. It is characterized by the moderate character of the symptoms I have already described. The initiatory fever is short and slight; the eruption moderate and brief; the fever mild; the throat but little distressing, although on ex- amination it exhibits its usual character; the desquamation trifling, perhaps inappreciable. The entire course of the disease is short, and patients recover from it rapidly and completely, unless from impru- dence some of the usual complications or sequela? should occur. n. Scarlatina Anginosa.—In this variety, the description I have already given of the disease is considerably aggravated. The fever is intense; the inflammation of the throat severe, and the tonsils much swollen, and covered with patches of whitish or grayish lymph; the temperature of the body often rises to 104, or even, according to Dr. Condie, to 112; the pulse is rarely under 120; the tongue is white, and loaded with enlarged papilla?. The eruption may appear upon the third day, or not till later; sometimes it disappears and returns • in some cases it is faint, but in most very well marked. The skin is burning, the thirst excessive, and the difficulty and pain of swallowing very considerable. Delirium is very common as the fever increases towards night. But the point of most importance, next to the inflammatory charac- ter of the fever and the severe affection of the throat, is the liability to internal complications, either of the brain, lungs, digestive organs or kidneys, &c, of which I shall speak presently. 1 Diet, of Pract. Med., part xiv. p. 868. SCARLET FEVER. 557 This form of the disease may characterize the epidemic or individual sporadic cases, nor is it the most dangerous form. 866. in. Scarlatina Maligna may commence like the latter variety, and may by degrees assume its peculiar typhoid character. It usually, however, presents an asthenic or typhoid character from the beginning, especially in autumn and winter, in patients of a debilitated consti- tution. "The patient is first affected with languor, lassitude, weak- ness, and vague pains through the body. These are succeeded by chilliness or shivering, followed by great heat. These latter alternate for several hours, until at last the heat becomes more constant and intense. The patient then complains of faintness, great pain in the head, and of violent sickness, with vomiting or purging, or both, es- pecially in children, more rarely in adults. Heat and soreness are felt in the throat, and stiffness and tenderness in the neck. The face soon appears red and flushed, swollen, or bloated, occasionally pale and sunk; the eyes are red, watery, heavy, or suffused. There are great fretfulness, restlessness, anxiety, lipothymia, or faintness, and remark- able dejection of spirits. The pulse, from the first, is quick, small, and fluttering; in some, soft and full, but weak and irregular, but always without that firmness and strength observed in inflammatory diseases. Dr. Johnston remarks that, if blood be taken from a vein soon after the attack, instead of forming a firm crassamentum, "it *" continues in the state of gelatinous texture." The urine at first appears crude, like whey; as the disease advances, it becomes yellowrer, as if bile were diluted with it, or turbid, scanty, high-colored; and some- times it contains dissolved or decomposed blood-globules. At the same time as, or soon after, the attack, the fauces, uvula, tonsils, and pharynx become red and swollen, and soon afterwards covered in parts by ash- colored or dark exudations, which appear as sloughs. The tongue is now deep red or brown, dry and glazed, and sometimes so tender and chapped as readily to bleed. The throat soon acquires a dusky red, brown, or livid hue, and the exudations on the fauces and tonsils are darker, and often cover gangrenous ulcers. The febrile or consti- tutional disturbance presents an extremely typhoid or asthenic charac- ter, or putro-adynamia. The skin is hot, but there is little thirst, although the mouth is dry; and the teeth and lips are covered by sordes, or by an acrid fluid from the excoriated or ulcerated sore throat. The breath is remarkably fetid and contaminating."1 It may, however, commence mildly, and to a certain extent pro- gress very favorably to all appearance, when suddenly the throat again becomes sore, and the parotid and submaxillary glands swollen and painful, and typhoid symptoms of the worst kind set in. Dr. Graves has given a very graphic account of this variety, to which, and to all his most valuable observations upon scarlatina, I beg to refer the reader.2 Dr. Armstrong observes that it is " in general only when the fever is protracted beyond the fourth day that the ulcers are converted into 1 Diet, of Pract. Med., part xiv. p. 670. - Clinical Medicine, vol. i. p. 318. 558 SCARLET FEVER. ill-conditioned, black, and fetid sloughs. At the commencement, the affection of the throat may be only pseudo-membranous pharyngitis, but at a more advanced stage, and in bad cases, ulceration takes place, and assumes a gangrenous character. The eruption may appear on the second or third day, or not until later; and then it has not its usual florid appearance, but rather re- sembles a dusky red stain. It may disappear and return, and it may be accompanied by petechia?, or some degree of oedema. The parotid and submaxillary glands are swollen and tender, and the neck and throat become cedematous, with great dyspncea. There is an acrid discharge from the nostrils and mouth, the angles and edges of which are excoriated by it, and the mouth often assumes an aphthous appearance. The gangrenous ulceration of the throat may extend up the Eustachian tube, and the tympanum and bones of the ear be de- stroyed by it, an acrid offensive discharge escaping from the ear. "When the disease has assumed a particularly violent character, collapse supervenes towards the middle or end of the second week. Great prostration of the vital energies now ensues ; the pulse becomes very frequent and feeble ; the heat of the surface sinks; the tongue is dark brown, or black ; exhausting diarrhoea often takes place ; and, in some cases, hemorrhages from various parts, and petechia?, occur towards the fatal termination of the complaint."1 The febrile excitement in children may run on into a low7 mutter- ing delirium, or perhaps more frequently into stupor and coma. "In the more violent cases, the efflorescence either disappears or becomes livid, the fauces are black, and the breath most offensive ; the eyes lose their lustre, and the swelling of the neck increases. The stools and urine are evacuated involuntarily; the former being fre- quent, watery, and most offensive, sometimes bloody; the latter putrid, brownish, or suffused. The surface becomes cool; the coun- tenance bloated, cadaverous, or cedematous ; the parts pressed upon excoriated or sphacelated; the tongue brown, hard, or dry; the breathing labored, or interrupted by singultus; and death follows with insensibility, congestion of the lungs, and great alteration of the state of the blood, and of all the circulating and secreted fluids."2 Death may occur as early as the second day, either from the laryn- geal or pharyngeal complications, or at a later period from the cere- bral or pulmonary complications, or from the morbid state of thp blood. This phase of scarlatina is distinguished from the others by the typhoid character of the fever, the malignant affection of the throat and the adynamic complications of the cerebral, thoracic or abdo- minal organs. As to the comparative frequency of the different forms, Dr. Willan states that, in 1786, he saw thirty-nine cases of malignant to 152 of the anginose variety; and Dr. Clarke, of Newcastle, had thirty-three cases of malignant to seventy-three of the anginose form. 1 Eberle, Diseases of Children, p. 449. 2 Diet, of Pract. Med., part xiv. p. 671. SCARLET FEVER. 559 867. Dr. Armstrong has described three varieties of malignant scarlatina ; the inflammatory, the congested, and the mixed. The first commences, like scarlatina anginosa, with considerable inflam- matory excitement: but, after a few days, collapse and a typhoid condition supervene ; the vital powrers sink, the throat becomes gan- grenous, and the other characteristic symptoms appear. It answers to the putrid variety of Richter. The second is characterized by a want of reaction : " The subjects of this modification are for the most part suddenly attacked. They become pale, faint, and sick, and chiefly complain of pain, load or giddiness in the head, extreme oppression, and much uneasiness in tlje region of the heart or at the pit of the stomach. Sometimes they at once sink, as if overcome by an uncommon shock, and lie in a state of confusion and oppression without making much complaint. At other times they walk about, pale and languid, for two or three days, and then take to their beds like persons completely worn out by some great fatigue or mental anxiety. When the attack has once decidedly occurred, the respiration is either quick and anxious, or slow and impeded. There is often a mixture of livor and paleness in the face ; the eyes are frequently dull, but sometimes glairy, and they acquire a fatuous, or inebriated expression in the course of the disease. The mind, at first alarmed, confused, or dejected, soon becomes dis- ordered with delirium; or an indifference to surrounding objects and a stupor succeed, under which patients finally expire. From the beginning, the pulse is generally low, quick, and irregular, and com- monly continues so to the last; but in those cases where there is a very slight degree of reaction, it sometimes has a short and rather sharp feel for a certain period, and finally grows weak and undulat- ing. At first, the tongue is commonly whitish in the middle, paler than natural, and covered with a slimy saliva; but towards the close, it often becomes rough and darkish, and then the breath is usually offensive. The bowels are commonly distended with flatulency, con- stipated or irregular in the first stage, but frequently loose in the last. The feces are sometimes darker, at other times lighter than natural. The stomach is often extremely irritable; yet occasionally it retains everything that is taken, though the deglutition becomes more diffi- cult as the disease advances. This form of the scarlet fever fre- quently runs its fatal course in two, three, or four days from the occurrence of the extreme general oppression, and there are almost always appearances of putridity in the last stage, such as oozings of blood from the mouth or nostrils, dark hemorrhages from the bladder or bowels, inky petechia?, or gangrenous spots upon the skin. A few- hours before death, there is o'ften a superficial glow of heat diffused over the body, accompanied with a darkly flushed face, high breath- ing, accelerated pulse, and partial or general sweats. But this mere semblance of excitement soon subsides ; the extremities grow7 cold, the face assumes a cadaverous hue, and when the skin is pale, it often has almost the smooth waxen appearance of the surface of a corpse."1 1 Practical Illustrations of Scarlet Fever, &c, p. 21. 560 SCARLET FEVER. In this form, the eruption is of a purplish or copperish color, deep- ening as the disease advances, and sometimes quickly disappearing. In some rapid and fatal cases, the throat is but slightly affected; in others, there are specks or sloughs on the fauces, but not dispropor- tioned to the amount of general disease. These varieties, as I have already observed, depend partly upon the condition of the child, and partly upon the character of the epi- demic; some assuming the form of scarlatina anginosa, and others of scarlatina maligna. 868. The last modification I shall notice is when the disease occurs a second time in the same person. No doubt, as I said of measles, that, in many cases which are popularly deemed a second attack of scarlatina, one of the affections was roseola; but there are undoubted cases on record of the recurrence of scarlatina, although they are rare. Willan observed no such case. Jos. Frank and M. Rayer each met with one case. Heberden says that such cases occur. Dr. Wood saw five in forty-five cases. Berton, Rilliet and Barthez, and Hey- felder, mention one case each.1 Dr. Burns mentions two instances. Dr. Bateman regards such cases as exceptions to a general rule. Bicker,2 Newman,3 and Burns deny that the susceptibility is in- variably removed by one attack. Richter observes that a second and even a third attack have occurred.4 Dr. Meigs', Jun., mentions the case of a person who had the disease two years previously under the care of his father.5 869. Complications.6—a. Affections of the Mouth.—When speak- ing of muguet, aphtha?, ulcerated sore mouth, and cancrum oris, I mentioned their occurrence during the course of scarlatina.7 In ordi- nary scarlatina anginosa, we may frequently perceive a disposition to the deposition of lymph upon the tonsils in the early stage of the disease; but, if the case be favorable, it extends no further into the mouth. But, in some of the severe cases of scarlatina maligna, in an advanced stage, aphthae, or ulceration may be observed in the mouth or about the gums; and these ulcers may take on a gangrenous cha- racter, and become converted into cancrum oris. Such a complication would probably itself insure a fatal termination, were it not that in most cases that is secured by the general typhoid form of the fever and the gangrenous condition of the throat. b. Pharyngitis.—In its moderate form, we can hardly call this c complication of scarlatina; it is rather a part of the disease itself It commences, during the preliminary fever, with redness and swelling of the fauces and throat, with soreness and difficulty of swallowing Soon afterwards, slight patches of false membrane appear upon the 1 Diet, de Med., vol. xxviii. p. 173. 2 Beschreibung eines Scharlachfiebers r> 1 fi9 • Aufsatze und Beobach, fur Aertze, p. 284. « Specielle Therapie vol 1. p^l J 5 Diseases of Children, p. 448. v' J' ** I would take the liberty of referring my readers to Dr. H. Kennedy's little v 1 scarlatina, as containing a valuable series of facts illustrative of almost all the ° "T °n tions of scarlatina, as they occurred for a number of years in this city carefuU^nmi and simply related. J' ? noted 7 Section iv. chapters 4, 5, 6, 7. a SCARLET FEVER. 561 tonsils, which may coalesce and extend to the neighboring parts; the submaxillary glands and tonsils are felt externally to be much enlarged and tender; deglutition is impeded; the fluids, or a portion of them, are regurgitated; and the speech is less clear than usual. If the complication be very extensive and severe, it will predominate over the other symptoms: " the febrile reaction becomes intense; the oppression great; respiration impeded; the cough frequent, rarely clear and sonorous, but also rarely hoarse or lost; the face is excited; but in some cases expresses prostration, anxiety, and suffering; and, the disease continuing to make progress, the patient dies when the angina has existed from five to ten days."1 But this pseudo-membranous pharyngitis is by no means the wrorst form of sore throat met with in the severe forms of scarlatina. Instead of the whitish patches lying upon the inflamed but unbroken mucous membrane, we may find ulceration of the tonsils, spreading to the pharynx, and exhibiting an unhealthy, grayish surface, which speedily assumes a gangrenous character. Or, we may find the pharynx, ton- sils, and fauces covered more or less with grayish or brownish patches, underneath which ulceration of an unhealthy character is going on; and by and by, when these membranous layers are thrown off partially or wholly, we may discover ulcers of various shapes and extent, but generally deep, which assume a gangrenous appearance. In whichever way it commences, we may have very shortly to deal with that very formidable and fatal affection, gangrene of the pha- rynx, or putrid sore throat, which I have heretofore described,2 and the danger of which is increased by its occurrence in the course of a typhoid form of disease. c. Gastro-enteritis.—This is seldom a very formidable, though by no means a rare complication, unless it should prevail epidemically at the same time as scarlatina. Vomiting not unfrequently occurs during the first stage, or even the second, but rarely afterwards. Diarrhoea often marks the crisis when the disease is about to decline, and so far may be rather beneficial. Dr. Copland mentions that, in the cases in which this complication occurred, the eruption was either suppressed, partial, scanty, or pre- vented from appearing; the throat, moreover, being more or less affected. Dr. Graves noticed vomiting and purging, accompanied by abdo- minal tenderness, and he attributes it to cerebral irritation and con- gestion, as in hydrocephalus. Dr. Gregory speaks of a low7 degree of mucous enteritis accompa- nying the decline of scarlatina, and, in bad cases, ending in ulcera- tion of the mucous membrane, with bloody stools.3 But, in the scarlatina maligna, we have occasionally a very severe attack of diarrhoea at an advanced stage, with flatulence, tympanitis, and some degree of tension and tenderness. Although at this period, and in this form of disease, the gastro-enteric affection does not con- 1 Rilliet and Barthez, Mai. des Enfans, vol. ii. p. 604. ' Section iv. chap. 11, p. 425. 3 On Eruptive Fevers, p. 134. 36 562 SCARLET FEVER. stitute the principal danger, it certainly adds to it, and may hasten the fatal termination. 870. d. Coryza.—In some cases, the inflammation of the mucous membrane of the throat is extended to the nose, and there are irrita- tion, sneezing, &c, with a mucous or muco-purulent discharge. In the advanced stages of scarlatina maligna, there is an acrid discharge, which excoriates the edges of the nostril. But this complication is of no importance ; it is but a symptom, and has no bearing upon the issue of the disease. e. Laryngitis.—In some cases, though not very frequently, when there is much cedematous swelling of the neck, the glottis and neigh- boring parts participate in the affection; and, from the situation of the glottis, a sudden incursion of oedema may prove very serious ; in fact, the child may be choked very suddenly. We should, therefore, always be prepared for this occurrence, and watch the throat very carefully. It is, however, very rare. Simple laryngitis may also complicate scarlatina, though it is not common. It is much more probable that the diphtherite will extend to the larynx, and give rise to the symptoms of secondary croup.1 Such an addition to the original disease will, of course, add to its for- midable character. It rarely occurs during the period of invasion, but generally about the appearance of the eruption, or soon after. I do not know that there are any cases on record of gangrene of the larynx in scarlatina. I have never seen it; but I can easily suppose that the gangrene might extend from the pharynx to the larynx. f. Pneumonia.—In severe attacks of scarlatina anginosa, the lungs are much congested, or even occasionally inflamed ; but it does not appear to be at all so common as in measles. In the congestive form of scarlatina maligna, the lungs participate in the congestion of all the internal organs, and this congestion may run on into inflammation. During convalescence, if the child be exposed to cold, he may very probably suffer from an attack of pneumonia. g. Pleurisy.—This complication occasionally occurs in scarlatina, sometimes during the first or second stage, when inflammatory symp- toms run high, but more frequently when the eruption is declining or during convalescence. Both this secondary affection and pneu- monia are of such importance that we should be ever on the watch to detect their earliest symptoms. 871. h. Cerebral Affections.—1 have already mentioned that the child may be attacked by delirium, headache, stupor, convulsions coma, or paralysis. These may occur at any period ; headache and delirium occur generally during the first stage, and are but rarely permanent. However, they may assume a more serious character and prove fatal. MM. Guersent and Blache mention a case in which delirium, with loud cries, came on during convalescence with vomit- 1 Page 235. SCARLET FEVER. 563 ing, but no other symptom, and lasted some days. Rilliet and Bar- thez mention that cerebral complications proving fatal are more fre- quent in scarlatina than any other fever. I saw a case in which the head symptoms were relieved by bleed- ing, and the child wras apparently going on well; but, two or three days afterwards, without warning, convulsions attacked the child and proved rapidly fatal. Dr. Graves mentions several cases in which convulsions occurred on the first or second day, followed by coma, and ending fatally.1 Low, muttering delirium occurs in scarlatina maligna. During the desquamation and convalescence, the nervous symptoms which occur, the coma and paralysis which come on sud- denly, seem to be connected in many cases with the dropsy, of which I shall speak presently. On dissection, the cause of the cerebral symptoms is seen to be owTing sometimes to excessive congestion of the brain, and sometimes to inflammation of its membranes,2 or effusion into the ventricles. i. Glandular Swellings.—We have seen that the tonsils and sub- maxillary glands are more or less swollen, and in some cases the pa- rotids, one or both, participate in this enlargement, which may be very considerable. And not only that, but the entire neck maybe so much swollen from cellular cedema as to place the patient in great danger of suffocation, as in a case related by Dr. Kennedy.3 In some cases, an abscess may form, and the matter extend itself in dif- ferent directions, or point externally. Dr. West observes that, "in the majority of instances, however, the glandular swellings, which come on after the lapse of a w7eekfrom the commencement of the disease, though tedious and painful, yet do not endanger life. Occasionally, indeed, death occurs in consequence of the matter formed by the inflammation of the glands, or of the cellu- lar tissue around them, burrowing backwards behind the pharynx, instead of pointing externally. In these cases of retro-pharyngeal abscess, after more or less evident indications of inflammation in the neighborhood of the parotid or submaxillary glands, accompanied, in all probability, with a swelling on one or other side of the jaw, the patient begins to experience difficulty in deglutition, which goes on increasing until the attempt to swallow7 becomes quite impracticable. As the dysphagia increases, respiration also becomes very difficult, but the dyspnoea continues to increase progressively, and is not aggravated in paroxysms, as in cases of cynanche trachealis, though the effort to swallow will often bring on threatening suffocation. However, there is seldom any modification in the tone of the voice, such as occurs in croup, though the voice becomes by degrees whispering, and then extinct; while, if the throat be examined, the tonsils are observed to be free from swelling; and sometimes neither they nor the soft palate show the slightest increase in redness, or other token of inflamma- 1 Clinical Med., vol.i. p. 313. 2 Guersent and Blache, Diet, de Med., vol. xxviii. p. 161. Rilliet and Barthez, Mai. des Enfans, vol. ii. p. 620. 3 On Scarlatina, p. 78. 564 SCARLET FEVER. tion."1 I have already laid before the reader Dr. Flemyng's remarks upon the retro-pharyngeal abscess, with the mode of cure, and I must refer him to that chapter for fuller details.2 872. j. Dropsy.—JVephritis.—The dropsy which accompanies or follows scarlatina has been noticed from early times by all authors. It was a subject of special investigation to Plenciz, De Borsieri, Vieussieux, Meglin, &c, and is treated of by Underwood, Dewees, Eberle, Stewart, Condie, Maunsell and Evanson, Coley, West, Bar- rier, Rilliet and Barthez, Legendre, Johnson, Bush, Toynbee, Si- mon, &c.3 The complication is a very interesting one, and worthy of further details. M. Legendre thus describes the affection : " The anasarca which is developed during the desquamation of scarlatina is very dif- ferent in its mode of invasion, its course, and its symptoms, from that which results from a state of cachexia, or from an obstacle to the course of the blood. In the anasarca consecutive to scarlatina, the face is puffed, but tense, elastic, and does not preserve the impression of the finger; the eyelids themselves, which are often so much swollen that their separation is diminished, are resistent. The face does not present that dead paleness which is observable in passive anasarca; on the contrary, from the accompanying febrile action, there is gene- rally a red color in the cheeks. The enlargement of the trunk and members is equally characterized by a remarkable elasticity, so that pressure by the finger leaves no trace, and decubitus on the side does not determine a greater quantity of serum on the side in which the patient lies, nor does the skin assume the paleness and transparency of passive dropsy. "From these peculiarities, it is possible that the enlargement might be supposed to result from * embonpoint' by a person who had never seen the patient before; but this is not possible when the anasarca has lasted some time, and has increased rapidly under the influence of certain serious complications, for then the distension of the subcuta- neous cellular tissue becomes considerable, accompanied with paleness and transparency of the skin, and the serum, displaced by pressure of the finger, and obeying the laws of gravity, is accumulated on the side on which decubitus has taken place. "If the eruption of scarlatina has not been very slight, or if much time has not elapsed, the skin will present some traces of desquama- tion at the moment when the dropsy is developed ; if not on the trunk yet on the feet or palms of the hands. "The general symptoms which precede the anasarca commonly diminish after its appearance, leaving merely a degree of fever which in some infants, is perceptible only in the evening. Most frequently' after five or six days, these febrile symptoms disappear, either under the influence of treatment, or naturally; but when they are prolonged and accompanied by new symptoms, either cerebral, pulmonary, or 1 Diseases of Infancy and Childhood, p. 484. 2 Chapter xii 431 3 Med.-Chir. Trans., vols. xxix. and xxx. ' SCARLET FEVER. 565 abdominal, there is reason to fear some serious complication in either of these regions. '• Lastly, the urine presents in this anasarca peculiar characters, which have struck different observers, though in different ways. Some have mentioned the peculiar aspect of the urine; others have given their analysis."1 The extreme limits of the period at which the dropsy makes, its appearance after scarlatina are from ten to forty days. Borsieri, Wells, and others say between the twentieth and twenty-third day generally ; Rayer about the fourteenth or fifteenth, or later. It is sometimes preceded by vomiting, diarrhoea, abdominal pains, and fever, but not always; it may come on quite insidiously and slowly, or with suddenness and rapidity. It ordinarily commences in the face, and from thence extends over the body in the course of tw*o or three days. 873. Plenciz and Rosenstein were the first to notice that in this form of dropsy the urine was scanty, and resembled the water in which flesh had been washed. Dr. Wells, as the result of his researches, added, that the red color of the urine was owing to a mixture of blood, and that the action of heat determined a floury precipitate, of a dirty brown color, after the separation of which the urine became clear. Different opinions have been maintained in explanation of this con- dition of the urine, and its connection with the dropsy, and different views held of the condition of the kidneys in this disease. Seymour, Barlow, Spittal, Graves, and others regard the renal disturbance in the dropsy of scarlatina as functional, on account of its curability, whereas Bright's disease involves an organic change in the kidneys. Others, however, as Hamilton, Wood, Mateson, Constant, &c, con- sider the anasarca with coagulable urine as dependent upon Bright's disease of the kidney. M. Rayer regards the continuance of albu- minous nephritis as leading to the establishment of one of the three forms of Bright's disease. Lastly, MM. Guersent and Blache, although believing in the ex- istence of acute albuminous nephritis when the urine is coagulable after scarlatina, yet do not consider this nephritis as the cause of the dropsy, because of the great number of cases of dropsy in which the urine is not coagulable. The facts which appear to be certain are these: in some cases of dropsy with albuminuria, and which proved fatal, the kidneys have been found in a state of hyperaemia, resembling the first stage of Bright's disease, as in the instances related by Fischer,2 Hamilton,3 and others; and Bright, Christison, Guersent, and Blache have found the granulations so characteristic of albuminous nephritis in other more chronic cases. But, on the other hand, there are many cases of anasarca, without albuminuria, and also of albuminous nephritis 1 Recherches Anat. Path, sur plusieurs Mai. de l'Enfance, p. 343. a Hufeland's Journal, Feb. 1824. 3 Edinburgh Medical and Surgical Journal, 1833. 566 SCARLET FEVER. without dropsy, as Rilliet and Barthez have remarked, and as was the case in the epidemic at Berlin, described by Dr. Philip, and in some cases which occurred in Dublin, as noticed by Dr. H. Kennedy.1 874. M. Legendre, in his valuable memoir, has minutely reported fourteen cases, and I shall.be excused, I am sure, if I give in some detail the result of his observations. As to the color, when the ana- sarca had existed only three or four days, the urine was sometimes blackish, or perhaps only of a red color, more or less deep; after eight or nine days, this red color was superseded by a brown color, some- thing like muddy beer; and, as time elapsed, and the disease dimin- ished, the urine became of a lighter color, until, about the fifteenth or eighteenth day, it was paler than natural; and, when the renal affec- tion had ceased, it became quite natural. These different shades of color depended upon the presence of blood, as was easily ascertained by the microscope. Even after the urine became quite natural, color- less blood-globules could be detected by the same means. At the same time, the urine lost its usual transparency; muddy or troubled when first passed, it became clear after standing, and deposited at the bottom, of the vessel either small clots or reddish or brownish flocculi. The specific gravity was slightly diminished; less so than in Bright's disease. When heat was applied, or nitric acid added, there was in all the cases a more or less abundant precipitate of albumen, greater when the urine was blackish or brown, and less in proportion to its light color. This proportion of the coagulum to the blood pre- sent in the urine is, according to M. Legendre, a fundamental differ- ence between the albuminuria of scarlatina, and that in Bright's dis- ease. When the coagulum was deposited, the supernatant fluid assumed its natural color, and the precipitate appeared either of a brown or ash-gray color, and exhibiting under the microscope blood- globules, blanched, but quite recognizable. In certain cases, when death occurred from other diseases, M. Le- gendre found the kidneys enlarged and less brown than usual; in some parts, grayish. Divided lengthwise, it was evident that the increase depended upon swelling or puffiness of the cortical substance which presented a granular, "sandy or granitic" aspect, which seemed to arise from the glands of Malpighi being less colored than the sur- rounding parts. The cortical substance was more easily torn than usual, and was somewhat less firm. The tubular substance was un- changed. As to the nature of the renal affection, M. Legendre considers that inasmuch as the post-mortem appearances are those of congestion or simple nephritis, and as the coagulation of the urine is explained'bv the presence of blood, which escapes from the uriniferous canals we are not justified in assuming the identity of this disease with that of Bright, and that this difference is confirmed by the curability of the one and the incurability of the other. 1 Some Account of the Epidemic of Scarlatina which prevailed in Dublin from 1834 to 1842. SCARLET FEVER. 567 As to the connection between this condition of the kidneys and the scarlatina, he agrees with Guersent and Blache that it is a coincidence, or rather that they are two effects produced by the same cause, viz., the action of cold during the period of desquamation of scarlatina.1 875. Dr. West has thus described the severe cases of anasarca: "The swelling, after having undergone many apparently causeless fluctuations, becomes extreme as well as universal; the features are disfigured by dropsy; the legs greatly swollen, and the abdominal parietes much infiltrated, while the skin remains hot and dry. The quantity of water voided is very small indeed, and the pain in the back is often very severe. The chief suffering, howrever, is referred to the chest; the respiration is labored and accelerated, and the child is frequently unable to assume the recumbent posture, and is, more- over, distressed by a frequent short and hacking cough. Under these circumstances, life is sometimes prolonged for several days, though in a state of extreme suffering, remedies proving unable either to in- crease the action of the kidneys or to relieve the dropsy. Death is sometimes preceded by a sudden aggravation of the signs of disorder of the respiratory organs, which assume all the painful characteristics of oedema of the lungs; and, in other cases, a comatose condition comes on, such as often precedes death from Bright's disease in the adult. Sometimes a temporary improvement takes place, the ana- sarca abates, and the kidneys resume their functions; but the patient dies not long afterwards, from the effects of pleurisy or pericarditis, which had come on almost unnoticed during the acute stage of the affection." As to the concomitant change in the urine, he observes that, "in milder cases, it is transparent when passed, though of a deeper color than natural, and becomes turbid on cooling, when it deposits a more or less abundant precipitate. It has a strong acid reaction; somewhat exceeds the usual specific gravity of healthy urine; is at first rendered clear by the application of heat, but again becomes cloudy, as the albumen which it contains is coagulated, and falls down in a floccu- lent precipitate. If the attack be more severe, the urine, which is very scanty, is of a brown or smoke color, deep red, or coffee color, and throws down a deposit chiefly of a reddish-brown color, which, however, does not entirely disappear when heated, while albumen is present in extreme abundance. An examination, under the micro- scope, of the deposit that takes place spontaneously in the urine in these cases, discovers not merely crystals of the lithate of ammonia, but blood-globules, often very little altered, mucous corpuscles, and epithelium scales. These matters, however, disappear by degrees, as the urine regains its natural appearance, even though it may still be shown, by chemical reagents, not to be entirely free from albu- men."2 Dr. West does not state exactly what he considers to be the connection of the albuminous nephritis with the anasarca; but he has described what he considers the pathological stages of the former: 1 Recherches, &c, sur quelques Mai. de l'Enfance, p. 316. 3 Diseases of Infancy and Childhood, pp. 430, 431. 568 SCARLET FEVER. "The microscope has shown us that the morbid process begins in the cortical parts of the inflamed kidney, the urinary tubules of which are stimulated to an increased production of their epithelial lining, or even to a pouring out of solid fibrous matter into their cavities. The urine carries away with it some of these matters, and thus frees the tubules for a time; but, as these contents are reproduced in quantities too large to be thus eliminated, some of the tubules become plugged and impervious, sometimes even so over-distended that they give way, and are completely destroyed. Nor is this all; but the capillaries of the organ necessarily bear a part in the mischief. At first, from over- congestion, they become dilated and varicose, and afterwards (in part, probably, from the formation of fibrinous clots within them, in part as the result of a process of adhesive inflammation) they become ob- structed and even obliterated. Supposing this morbid process to have gone on to any considerable extent, the kidney must be left by it permanently and irreparably injured, while, even in its slighter de- grees, it must for a time seriously disturb the functions of the organ. In the earlier stages of the disease, the presence of albumen in the urine is in part due to the actual escape of blood from the overloaded capillaries of the kidney, and in part to the temporary suspension of its functions. If, at a later period, when the urine has lost its preter- naturally deep color, and has regained much of its healthy appear- ance, albumen should still exist in any quantity, there will be reason for apprehending that some abiding injury has been inflicted on the organ."1 Dr. Copland, in an admirable article, has gone fully into the con- sideration of the affections of the kidneys in scarlatina. He believes that they are frequently affected in the early stage of the disease, w7hen we find more or less oedema or anasarca, or dark-colored eruptions; the urine scanty and high-colored, muddy, brown, or red, from blood mixed with it; and further, that, from the interruption of the functions of the kidneys in the elimination of the excrementitious and unassimi- lated materials in the blood, the mortality in the early stages, is pro- bably owing to the renal complications: "For I have remarked " he says, "in many instances, as respects both the symptoms during life and the appearance of the kidneys after death, sufficient evidence to convince me that these organs are remarkably congested, and their secreting and tubular surfaces are the seats of a similar vascular injection or efflorescence to that existing in the vascular rete of the skin; and that this efflorescence on the surface of the uriniferous tubes, &c.,and the associated swelling and congestion of these organs during the early stages of the malady, either impede or interrupt, or altogether suppress the function of urinary excretion, and thereby oc- casion an accumulation of excrementitial and contaminating materials in the blood, and consecutively an increase of the poisonous action of the infected blood upon the nervous system, and on vital organs and parts, thereby producing further complications, &c."2 1 Diseases of Infancy and Childhood, p. 432. 3 Diet, of Pract. Med., part xiv. p. 673. SCARLET FEVER. 569 Dr. Copland subsequently notices the affection of the kidneys and dropsy, as occurring after scarlatina. The latter he considers as being chiefly caused by the former, although the state of the skin may assist; and he alone seems to have noticed, what I have no doubt is the case, that certain other sequela? of scarlatina are the re- sult of this condition of the kidneys, and of the imperfect performance of their functions, as, for example, effusion into the ventricles of the brain, into the cavities of the chest, diffuse inflammation, anaemia, and its consequences, &C.1 876. In addition to effusion into the serous cavities, M. Legendre2 has investigated, with his usual acuteness and care, a consequence of the anasarca which has been very much overlooked. I mean oedema of the lungs. This he believes to be dropsy of the interstitial cellular membrane of these organs, and not vesicular oedema; for whereas, in the latter, the lungs are of a grayish rose-color, contain air, crepitate, and float in water, in the former they are of a lilac color, entirely without air, and neither crepitate nor float in water. The disease is seldom recognized during life, unless extensive; but then it gives rise to characteristic symptoms, sometimes com- mencing by cough and some oppression in breathing when it pre- cedes general anasarca; after this occurrence,the cough and dyspncea increase greatly, and threaten suffocation. When oedema of the lung and general anasarca set in together, the child is suddenly attacked by cough and dyspnoea, so that it cannot lie down. There may be fever, agitation, and gastric disturbance. Generally speaking, there is heard a subcrepitating rale, without dulness, except towards the lower part of the chest, but the signs are not in proportion to the ex- tent of the mischief. The action of the heart is energetic, but the pulse weak and quick, from 120 to 160, whilst the respirations amount to 50, 80, or even 100 per minute. This is a much more dangerous form of disease than the vesicular oedema, both from the impediment which it offers to aeration of the blood, and from its occurrence at a time when the child is weakened, and is embarrassed by general anasarca. The antiphlogistic treatment, so useful for the general dropsy, appears equally successful in removing oedema of the lungs. 877. Now let us see to what our information amounts. We find that, in some cases, in the early stage, anasarca occurs, and that in these cases, and in others where there is no anasarca, the urine is scanty, discolored, albuminous, and contains blood-globules; in other cases, at a more advanced period, more extensive and general dropsy occurs, accompanied with a certain train of symptoms, and that in these also the urine is albuminous and contains red globules; that this change in the urine is owing to congestion or inflammation of the kidney, and seems in some way connected with the dropsy, either as cause and effect, or as a consequence of the same cause; that the 1 Diet, of Pract. Med., part xiv. pp. 779, 780. 2 Recherches sur quelques Mai. de l'Enfance, p. 324, 570 SCARLET FEVER. effect of this condition of the kidney upon the blood is to deprive it of red globules, to arrest the excretion of excrementitious matters and of miasmatic impurities, and, as a consequence, to induce certain other complications,1 and to leave the patient exposed to the effects of im- pure blood, of blood with the natural and healthy proportions of its constituent parts destroyed. I think we possess sufficient evidence to prove the existence of congestion or inflammation of the kidneys, but not enough to lead to the inference that the albuminuria accompanying scarlatinous anasarca is owTing to Bright's disease, nor that the state of this kidney is liable to. degenerate into Bright's disease. There are only two instances of which I am aware in which abscess was the result of scarlatinous nephritis; both are contained in a paper by Dr. Rose Cormack.2 878. k. Otitis.—Inflammation of the ear may occur as an extension of the disease of the throat, and may run on into ulceration, involving ultimately the "destruction of the small bones of the organ; inflam- mation, ulceration, and perforation of the tympanum; chronic otitis, with offensive discharge; inflammation and ulceration of the mem- brane lining the cochlea and semicircular canals; caries of the petrous portion or mastoid process, or other parts of the temporal bone ; and even the extension of inflammation, suppuration, or ulceration to the membranes and substances of the brain may supervene ; and, as respects these latter changes especially, not unfrequently at remote periods from the primary affection of the throat, and extension of lesion to the internal ear. When disease of the ear is so far ad- vanced as to implicate the bone in which the organ is lodged, the consequences are serious, not only as respects the organ itself, but also as regards adjoining vital parts, the affection of which often occa- sions great and protracted suffering, and ultimately fatal results."3 Otorrhcea is stated to be frequent, but of no importance, by Hey- felder; it is even regarded as favorable by Berndt, when the nervous system is much affected. Guersent and Blache haVe rarely met with it. I. Hemorrhages.—In addition to blood discharged from the kidneys, we occasionally meet with epistaxis occurring in the inflammatory stage or towards the end, in cases of angina maligna. Bleeding from the throat has also been noticed. Dr. Fothergill mentions that hemor- rhage from the nose or mouth has sometimes carried off the patient* and a similar result has occurred from bleeding from the ear.4 Dr' Graves mentions one case in which hemorrhage from the ear proved fatal, and another fatal result from epistaxis. m. I think I have noticed at sufficient length all the principal complications of scarlatina. There are undoubtedly other sequela? which occasionally occur, as Eberle remarks: "At times the disease 1 On the Dropsy following Scarlet Fever, by Dr. Scott Alison, Lond Journ of M„i No. iii. p. 227. ' * ■ueu-> 2 London Journ. of Med., No. v. p. 454. 3 Copland's Diet, of Pract. Med., part xiv. p. 678. 4 Works vol i p 37f SCARLET FEVER. 571 gives rise to various nervous affections, such as hysteria, spasmodic asthma, chorea, epilepsy, and neuralgic pains in the extremities; and occasionally it has been followed by strumous disorders, chronic cuta- neous eruptions, herpes, gutta serena, and rheumatic pains."1 Dr. Armstrong has noticed that the hair is very apt to fall out after scarlatina, and to be very imperfectly reproduced. Dr. Graves, Dr. H. Kennedy,2 and Dr. Gregory3 have alluded to cases in which either the cellular membrane of the orbit, or the eye- ball, was attacked by inflammation and sloughing. Dr. Huxham mentions "excoriation of the anus and buttocks;" and Dr. Graves relates a case in which aphthous ulceration of the anus occurred.4 879. Pathology.—-The appearances found after death, dependent upon scarlatina, but not resulting from the complications, are neither many nor of great magnitude. The eruption, if previously faint, may have disappeared from the surface of the body, or it may remain in patches of a livid hue, and, on dividing the skin, the vascular net- work is found unusually injected. The redness of the mouth, tonsils, and pharynx disappears when the attack has been slight, or when fatal in the early stage; but in severe cases the mucous membrane may be found softened, ulcerated, or gangrenous. The digestive mucous membrane is softened in the malignant cases. Brunner's and Peyer's glands are enlarged, and occasionally the me- senteric glands. Congestion of the brain or its membranes, of the liver, of the spleen, and of the kidneys, is by no means unusual, according to Rilliet and Barthez. 880. Each complication will, of course, furnish its peculiar morbid lesion; but it would be a waste of time to repeat them here. There are two or three points, however, on w7hich it is desirable to add a few words. Rilliet and Barthez consider the essential element of the disease— the point du depart—to be the condition of the blood; and they de- scribe it as varying in its state, sometimes being liquid and unusually fluid, black, or serous, and clear, with few clots, and those soft and easily crushed ; in other cases, the coagula were abundant, firm, solid, and in part fibrinous. Sometimes, it was effused profusely into the tissues; in other cases, the congestion was normal. Occasionally, cer- tain organs were pale, and contained little blood. Andral, Gavarret, and Lecanu analyzed the blood of persons in scarlatina; but the result did not differ much from that of healthy in- dividuals. Dr. Copland speaks of the blood in the malignant form of the disease being in the same state as in other malignant fevers. 881. Again, as the changes in the urine are so important in their practical bearing, I will just repeat the principal ones. During the early stages of the disease, it is always scanty, high-colored, and 1 Diseases of Children, p. 454. 3 On Scarlatina, p. 112. 3 On Eruptive Fevers, p. 128. 4 Clin. Med., vol. i. p. 341. 572 SCARLET FEVER. sometimes of a deep re/1 hue. In the mild and inflammatory forms, it has generally an acid reaction ; but, in the asthenic or malignant scar- latina, it is either neutral or alkaline, and very turbid, sometimes albu- minous, and containing blood-globules. In most cases, even early in the disease, it rapidly becomes ammoniacal; and in the malignant cases it deposits a viscid, whitish sediment, consisting of the earthy phosphates and mucus, and containing urate of ammonia and uric acid. "During the advanced stages of the mild and more sthenic form of scarlatina, the urine becomes more abundant, of greater specific gravity from the abundance of saline matters, and presents the characters usually observed, during the decline of inflammatory or continued fevers. In asthenic, septic, or malignant cases, the urine becomes, with the progress of the malady, of a dark brown or yellowish color, is very scanty, and of a specific gravity varying from 1020 to 1025. It has an alkaline reaction, with a disagreeable ammoniacal odor, and it occa- sionally contains blood and mucus, or partially dissolved haemato- globulin, either diffused or in flocculent deposits, but rarely any or much albumen. It throws down a dirty white sediment, consisting of earthy phosphates, urate of ammonia, urate of soda, and mucus, with other animal matters. In these cases particularly, and less rapidly in others, the urine becomes more decidedly ammoniacal and offensive."1 During the process of desquamation, the condition of the urine is a matter of dispute; some have found albuminuria with dropsical symp- toms or without, or dropsy with albuminuria. Solon found albumen in the urine of twenty-two out of twenty-three cases of scarlatina; but Phillipp, of Berlin, observed at least sixty cases in which there was no albumen. It is probable that, in very mild cases, there is little or no albumen; but, when fever is excited at this period, and anasarca supervenes, the urine generally becomes albuminous; and -when this occurs, we may expect that certain organic complications, to which I have before alluded, will take place. When, during its early or advanced stage, scarlatina is complicated with cerebral, pulmonary, or abdominal disease, the urine may either be suppressed altogether, or scanty, high-colored, bloody, and albu- minous. As regards the actual condition of the kidneys in the nephritis con- sequent upon scarlatina, in addition to the notice I have already given I may quote the description of Dr. G. Johnson: "The kidney " he says, "in these cases, is enlarged apparently by the deposit of a White material in the cortical substance ; the vessels in the cortical portion where they are not compressed by this new material, are injected and of a bright red hue; the medullary cones are of a dark red colo'r in consequence of the large red veins which occupy these portions of'the gland being distended with blood. The appearance of the entire organ is quite that of a part in a state of acute inflammation. When the 1 Copland's Diet, of Pract. Med., part xiv. p. 681. SCARLET FEVER. 573 kidney has been in a softened condition before the occurrence of the inflammatory disease, as often happens in elderly persons, the lobules on the surface appear larger and coarser than natural; the veins, being less compressed than when the natural texture of the kidney is firmer and more unyielding, are much distended with blood, so that the entire organ is of a dark slate color. On a microscopical examina- tion, the convoluted tubes are seen filled, in different degrees, with nucleated cells, differing in no essential character from those which line the tubes of the healthy gland. The Malpighian bodies are, for the most part, transparent and healthy; but the vessels of the tuft are sometimes rendered opaque by an accumulation of small cells on their surface. Some of the tubes contain blood, which has doubtless escaped from the gorged Malpighian vessels. There is no deposit exterior to the tubes."1 882. As scarlatina may occur in the course of other diseases, it becomes a matter of practical importance to ascertain what effect is thus produced upon the primary affection. Any affection of the mucous membrane of the mouth, pharynx, or digestive system, but especially the former, appears much aggravated by the incursion of scarlatina, which is what we might perhaps have anticipated. Trifling disorders become serious, and death may be the consequence. On the contrary, pulmonary inflammation seems rather benefited than injured: Rilliet and Barthez state that they have many times seen scarlatina supervene upon pneumonia, and that, unlike measles, it never exasperated the pulmonary disease ; nay, in one case, a slight pneumonia appeared to be cured by the eruptive fever alone. Hooping cough may be cut short, and chorea disappear, on the appearance of scarlatina. As to the influence of scarlatina upon measles, Rilliet and Barthez give the following conclusions as the result of their experience : " 1. That scarlatina rarely gives rise to tubercles. 2. That tubercu- lous children rarely take scarlatina, and when they do it is anomalous. 3. Children cured of tubercles are more liable to scarlatina than the preceding, and the eruption may be normal. 4. Those tuberculous children who do take scarlatina have but few crude tubercles, and very rarely any that are softened. 5. In those cases, the tubercles have a tendency to become cretaceous in a short time."2 883. Causes.—Among the predisposing causes, w7e may mention age, children being more frequently subjects of the disease than adults, and adults than old people. I have already stated that I do not be- lieve that children are more liable, but that they are exposed to the infection whilst children, and therefore take the disease before they grow up. Infants at the breast often escape the disease, although other mem- bers of the family may be suffering from it, probably because they are kept more apart from the rooms where the infection exists; and we 1 Cyclop, of Anatomy and Physiology, Art. Ren. 3 Mai. des Enfans, vol. ii. p. 634. 574 SCARLET FEVER. occasionally see a child enjoying a perfect immunity, even though associating with those affected. The foetus in utero may have the disease. Cases of this kind are collected by Gra?tzer; and Dr. Gregory mentions that a child of his own was born with it. Sex appears to exert no influence, males and females being equally liable. In London, in 1838, 747 males and 777 females died of it; in 1839, 1241 males and 1258 females; and throughout England and Wales, in 1840, 8927 males and 8935 females. Of 158 fatal cases, in 1839, in New York, 86 were males, and 72 females; and of 391 in 1840, 208 were males. Reid, Richter, and Steiglitz, however, believe that females are more liable to it than males. Scarlatina seems to be more prevalent in temperate climates ; and it is more severe, and propagated more extensively in warm, humid weather, and in low, marshy districts, and in the crowded, dirty, ill- ventilated portions of cities. Dr. Gregory mentions that Dr. Jackson could not recollect any cases deserving the name of scarlatina in India. Dr. Copland never met with a case between the tropics. It is as yet unknown in Australia and New Zealand. It was introduced into North America in 1735, and its progress was slow, but fatal. 884. The two principal modes of its communication are contagion or infection, and by the occurrence of an epidemic of the disease. Although the contagious nature of scarlatina has been doubted by Dewees, Daehere, Reich, Tortual, and others, yet so many and such conclusive facts daily occur, that few of the present day hold this opinion; and whatever doubt did exist must have been removed by the experiments of Sir B. Harwood, who succeeded in producing the disease by inoculation with the fluid from the vesicles which were intermingled with the eruption of scarlatina, although he was disap- pointed in producing a milder disease. Dr. Copland met w7ith a case in which the disease was excited by the contact of a small quantity of the discharge from the throat of a person affected with the malignant anginous scarlatina. M. Miquel de PAmboise succeeded in inoculation by means of the blood of a patient in scarlatina. The poison of scarlatina, by which it is communicated, consists in some miasma, of whose nature we are ignorant, either preserved and perpetuated by individual cases, or by fomites, or formed, de novo at different epochs. That it does emanate from persons laboring under the disease, and that the atmosphere of certain localities may become so impregnated with it as to communicate the disease to individuals visiting such places, we have sufficient proof: but it is very difficult to say whether the disease may originate spontaneously by any'com- bination of predisposing causes. The best writers think not and it seems to me unlikely. ' The media by which the disease is transmitted, in addition to sonal contact, are the atmosphere surrounding the sick, or substan G1> impregnated with the miasma from the sick. The distance to which SCARLET FEVER. 575 infection may be carried, and the duration of the infecting power pos- sessed by fomites, are very uncertain, and will be much modified by the freedom of access or exposure to pure air. Infection, as Dr. Sims has observed, may remain in a house some weeks, and it certainly may be transmitted in clothes to a considerable distance. Cazenave considers that the greatest activity of the contagion is during the desquamation. 885. But the extent and desolating fatality are more striking when we contemplate its spread as an epidemic. Many examples are on record; indeed, they are so frequent that it would be impossible to attempt an accurate enumeration of them. I may, however, mention some of the principal. An epidemic angina, with scarlet eruption, raged in Spain in 1610, from whence it passed to Naples in 1618. Laurent mentions an epi- demic in Germany in 1625, and Sydenham one in London in 1670 and 1675. Morton described that in London in 1689, and Sir Robert Sibbald that in Edinburgh in 1680. It prevailed in Saxony in 1695. An epidemic, which Mr. Wilde thinks was scarlatina, is mentioned by Dr. Rutty as prevailing in different parts of Ireland in 1743, 1744, and again in 1758, 1759, 1762, 1798, 1799, and 1800. It appeared in North America in 1746. Dr. Fothergill has given us the history of the London epidemic of 1747, 1748. It prevailed at La Haye in 1748, 1749; at Upsal in 1741 (Rosen); in Champagne in 1751; at Vienna in 1759 (Stark), and 1770, 1771 (De Haen, Kirchvogel); in the city of Cephalonga in 1763 (Zulatti); at Essen in 1763 (Franck); at Harcourt in 1744 (La Pecq. de la Cloture); at Heidelberg in 1775 (Zimmermann); at Copenhagen in 1777, and again in 1786; at Jersey and in New Eng- land in 1784; at St. Christopher's, West Indies, in 1787 (Stephens); at Langres in 1800; in Dublin in 1801, 1802, 1803, 1804, 1807; and at Caithness, in Scotland, and near Brignoles, in France, in 1807; at Marseilles in 1821, 1822; in Dublin from 1832 to 1834 (Graves); in Virginia, United States, in 1832; in England in 1838, 1839, 1840 (Gregory); in Dublin in 1840 (Lees); and in Philadelphia in 1841, 1842 (Meigs). Dr. Graves states that it has raged every winter and spring, with undiminished violence, in Ireland, from 1835 to 1846, resisting every kind of treatment, but that in 1847, 1848, it had be- come milder and less frequent. During the years 1841, 1842, Dr. Meigs states that it prevailed very extensively, and was very fatal in Philadelphia.1 In the year 1842, it occurred at Market Hill, an account of which has been given by Dr. Lynn.2 886. Diagnosis.—The characteristic symptoms of scarlatina are, violent preliminary fever, with sore throat, followed by the appear- ance of a general rash of an intensely red color, not elevated, and with disturbance of the renal functions. 1. It may be distinguished from ulcerated sore throat, by the occur- 1 Diseases of Children, p. 448. * Appendix to Dr. H. Kennedy's work on Scarlatina. 576 SCARLET FEVER. rence of the rash; but, when that is absent, as in scarlatina sine ex- anthemate, the distinction will be very difficult, if not impossible, unless scarlatina have attacked other members of the same family. 2. From measles, by the greater intensity and shorter duration of the initiatory fever, the sore throat, the absence of catarrhal symptoms, and the general and equable appearance of the rash, instead of the semicircular or crescentic form and elevated surface of the eruption of measles. The presence of albumen and blood in the urine, and the occurrence of dropsy at a more advanced period, will be an addi- tional evidence that the disease is scarlatina. 3. From roseola. The eruption in this disease is sometimes an admirable imitation of scarlatina; but, in general, there is much less fever, no sore throat, and the disease lasts a much shorter time. 4. From miliary fever. In this disease, there is an eruption of small, hard vesicles, containing clear water, as though water had been sprinkled in very minute drops, resembling, in appearance and touch, the drops on an ice plant, sometimes on a flushed surface; but there are few, if any, catarrhal symptoms, no sore throat, and subse- quently no desquamation. In scarlatina, the florid redness is general and equable, and, if any miliary vesicles are seen, they are compara- tively few; and the sore throat, intense fever, disordered urine, and desquamation, will sufficiently prove the nature of the disease. 887. Prognosis.—As a general rule, scarlatina is a more serious malady with children in proportion as they are young; infants under two years suffering more from it than after that age. But, in mild cases, there is little danger, if care be taken that the child do not take cold during the latter stages and convalescence. In scarlatina anginosa, when the inflammatory symptoms run high, where the throat is much affected, when internal organs are attacked, or when nephritis exists, the disease often proves very fatal. Scarlatina maligna is as fatal a disease as any to which children are liable; the typhoid character of the fever, the disposition of the sore throat to become gangrenous, the internal inflammations, and the renal complication, render it extremely diflicult to treat the case satis- factorily. The occurrence of an epidemic, and its peculiar character, must be taken into consideration in forming our prognosis. I have already shown the fearful increase of mortality in London in certain epidemics. They sw7eep down whole families occasionally, and during their pre- valence, even cases that commence mildly are by no means to be re- garded as safe. The mortality has varied from 1 in 6 to 1 in 40, according to the character of the epidemic. 888. Treatment.—1. Mild cases of scarlatina, when the fever is slight, the sore throat trifling, and the eruption favorable, require but little treatment beyond a dose of aperient medicine, a demulcent gargle, and a cool, well ventilated apartment. If there be much fever, the pulse quick, skin hot, urine scanty with pain in the back and limbs, an emetic will afford great relief SCARLET FEVER. 577 and its action should be promoted by diluent drinks, and subsequently by diaphoretics. W7hen the head is much affected in the preliminary stage, Dr. Arm- strong recommends the warm bath, strongly impregnated with salt, followed by a brisk purgative. The bow7els must be kept free, and the surface not too much heated by bedclothes. ii. Scarlatina anginosa will require a more active treatment. In the more sthenic form, we should commence with an emetic; nor will this be less beneficial if vomiting should have occurred, if there be pains in the back and scarcity of urine. If the pulse be full and quick, and there be much cerebral excite- ment, or pain in the region of the kidneys, with scanty and high- colored urine, it will be advisable to take some blood by cupping or leeches from the nape of the neck, behind the ears, or from the loins. Drs. Mackintosh, Armstrong, and others recommend general blood- letting in the early stage, and speak most highly of its beneficial effects in reducing the fever; but the more general opinion, in which I fully agree, is, that it is not ordinarily necessary, that it requires great dis- crimination in its use, and that it is mainly beneficial in cases where there is high fever, a full pulse, and a disposition to inflammation of some internal organ. In some epidemics, it is borne very well; in others, its effects are very pernicious. Whether cupping be necessary or not, the sore throat will be bene- fited by the use of a stimulating liniment; but we must take care that the skin be not too much irritated. Blisters are rarely, if ever, advis- able, on account of their disposition, in scarlatina, to run on into severe ulceration. Or the throat may be carefully fomented, or a poultice applied ex- ternally, and the steam of hot water inhaled. Cooling gargles, if the child be old enough to use them, will be found very soothing. They may be made of infusion of roses, or cin- chona, red wine and wrater, camphor, or rose water with nitrate of potass, &c. After the vomiting has ceased, a few grains of calomel may be placed on the child's tongue, to be followed in an hour by some gentle purgative of rhubarb and magnesia, infusion of roses, or senna, with manna and salts, or castor oil, &c, so as to evacuate the bowels com- pletely. Saline, diaphoretic, or diuretic mixtures may then be given, in a state of effervescence or not, as the patient pleases, although Dr. Bate- man doubts the success of the former, unless the heat of the skin have been previously reduced. Richter recommends the muriate of ammonia, and Steiglitz dilute sulphuric acid. When the heat of skin is great, Dr. Currie and others advise cold affusion ; but it would seem that it has been too indiscriminately used, and disappointed expectation. It is not without danger, except in the more sthenic cases, as it rather favors internal complications. Dr. Bateman observes: " We are possessed of no physical agent, so 37 578 SCARLET FEVER. far as my experience has taught me (not excepting even the use of blood-letting in inflammation), by which the functions of the animal economy are controlled with so much certainty, safety, and prompti- tude, as the application of cold water to the skin under the augmented heat of scarlatina and of some other fevers." " I have had the satisfac- tion, in numerous instances, of witnessing the immediate improvement of the symptoms, and the rapid change in the countenance of the patient, produced by washing the skin. Invariably, in the course of a few minutes, the pulse has been diminished in frequency, the^ thirst has abated, the tongue has become moist, a general free perspiration has broken forth, the skin has become soft and cool, and the eyes have brightened ; and these indications of relief have been followed by a calm and refreshing sleep."1 Dr. Armstrong speaks highly of tepid affusion four or five times in twenty-four hours, in the mildest form, and of cold affusion during the first three days, in scarlatina anginosa. Dr. Copland derived so little benefit from affusion, that he prefers a tepid bath, or cold or tepid sponging of the surface. Dr. Dewees thinks the sponging as effectual and safer than affusion. Some modification is necessary in the asthenic form of anginose scarlatina. General blood-letting is out of the question, and even local cupping or leeching seems to do more mischief, by weakening and depressing the patient, than good. We should commence with an emetic, followed by purgatives and diaphoretics, and have recourse to stimulating liniments to the neck and loins, if necessary. If the urine be scanty, we must give some diuretic, as the acetate of ammonia, or sweet spirits of nitre, or nitrate of potash, internally. So far, I have supposed the case to be uncomplicated, and these means, wisely used, may succeed in preventing complications in many cases. In others, they will fail; or some complication may have occurred before we were called to the patient, and our duty will be to treat each complication according to the rules laid down for the dis- ease, bearing in mind the distinctive individual or epidemic character of the scarlatina, and modifying our treatment accordingly. Leeches to the part affected, fomentations, embrocations, poultices, &c. may be used generally with benefit. hi. In scarlatina maligna, our treatment must vary moreover it must be very prompt, or we may lose our patient, on account of the rapidity of the disease. WTien it commences with high fever, full, quick pulse, Dr. Arm- strong advises cold affusion; and, if that fail in reducing the heat he recommends bleeding. This, however, will rarely be necessary or justifiable. " J Even local blood-letting, which seems called for by the symptoms is rarely of any use, and may be injurious, either by weakening the patient, or from diffuse inflammation attacking the leech-bites an 1 spreading to the neighboring parts. On Cutaneous Diseases, p. 81. SCARLET FEVER. 579 An emetic may be given immediately, with an ample supply of diluents, and a mercurial purgative; and the liniment, or a turpentine embrocation applied to the neck or loins, or both. But more than this must be attempted. The decoction of cin- chona should be given every three or four hours, with the carbonates of soda, potash, or ammonia, either in a state of effervescence, the alkaline being in excess, or with the alkaline carbonate only. If the acid be omitted, the fixed and volatile alkalies may be given at the same time, with the spiritus aetheris nitr., and tincture of serpentaria. "It is often difficult," Dr. Copland observes, "to determine whether or not the decoction should be given with an acid or an alkali, in the more malignant states' of scarlatina. The choice should depend, in some measure, on the state of the urine. If this secretion be not sup- pressed, and if it be alkaline, and contain phosphates, the cinchona should be conjoined with hydrochloric acid and hydrochloric ether; or the sulphate of quinia may be given in the infusion of roses, with dilute sulphuric acid and sulphuric ether, or the compound spirits of ether. When, however, the urine is suppressed, or nearly so, and when it presents an acid reaction, or is albuminous or bloody, after having recourse to emetics and terebinthinate epithems over the loins, I have generally preferred a combination of the decoction of cinchona, with the liquor ammonia? acetatis, or carbonate of ammonia, or with either of the alkalies, in a state of effervescence with a vegetable acid."1 At the same time, bark should not be given without discrimination. Dr. Armstrong regards stimulating and tonic remedies as "pernicious in the first stage, and most destructive in the second;" and so they may be, if inflammatory symptoms run high; but, after these have been subdued, and the disease shows itself in its true form, then assuredly tonics are beneficial. Dr. Garnett formerly recommended the chlorate of potass, and Dr. Clutton the hydrochloric ether, with or without decoction of bark, in malignant scarlatina. Dr. Peat and Dr. Stewart speak most highly of the sesquicarbon- ate of ammonia, as a stimulant, in doses of from two to four grains, in an emulsion with mucilage, for children from four to seven years of age. Infusion of serpentaria is useful from its being both a stimulant and a diaphoretic. Capsicum was recommended by Dr. Stevens as a powerful stimu- lant, and experience proves it to be of great value. He tried it in about four hundred cases with great success. If the symptoms be not ameliorated, the emetic must be repeated, and the other remedies continued. Chlorine and the chlorides have been strongly recommended in the severe cases. Powdered carbon alone, or in combination with quinine, cascarilla, 1 Diet, of Pract. Med., part xiv. p. 693. 580 SCARLET FEVER. or cinnamon, with the addition of camphor, creasote, and capsicum, have been beneficially employed by Dr. Copland. The flowers of arnica are recommended by Malfatte and Steiglitz. Reil speaks highly of large doses of musk when there is much rest- lessness with nervous irritation. The local applications are of various kinds. Externally, the lini- ment or the turpentine should be applied, as in the former variety; and internally, if the child be old enough to gargle, it may use a gar- gle of alum and water, port wine and water, chloride of lime and w7ater, decoction of bark, with nitric acid, and infusion of cayenne. Dr. Willan recommends fumigation with nitrous acid gas. Dr. Jackson applies iced water, or ice in a muslin bag, to the back part of the mouth. Dr. Eberle has found benefit from an infusion of the indigo plant, and from black wash. If not able to use a gargle, it must be applied with a sponge, or a dossil of lint on the end of a rod, three or four times a day. If the ulceration of the throat assume a grave character, we must have recourse to stronger caustics; and, after cleansing the parts, apply nitric acid or nitrate of silver freely, so as to check its progress by changing its character, as I recommended when speaking of putrid sore throat. The bowels must be kept moderately free, and it seems generally agreed that calomel acts most beneficially in this way; it maybe aided by castor oil, rhubarb, jalap, or a saline mixture. It will be necessary to be careful in giving purgatives during the collapse, as it may thereby be increased. Cool drinks should be permitted. Cold water, iced water, or water acidulated with lemon juice, dilute sulphuric or muriatic acids is exceedingly grateful and refreshing. In addition to the tonic and antiseptic remedies already mentioned it will be necessary, in many cases, to give wine or brandy freely, and such nutriment, by broth, beef tea, &c, as the patient can take.' The treatment I have thus shortly sketched will generally be'suffi- cient for each variety; but it must be modified according to the con- stitution of the child, the character of the epidemic, and any compli- cation that may exist. Of the suitable treatment for the latter, I have already spoken in the chapters treating of those diseases, to which I must refer the reader; but, on the treatment of the renal affection, I must say a few- words here. ^ 889. Something may be done in the way of prevention durino- the period of desquamation, by carefully avoiding cold, prohibiting the too free use of animal food and stimulating beverages and by or moting the healthy action of the skin by warm clothine- warm baths, &c. fining, warm But when the disorder actually exists, antiphlogistic remedies and diet must be adopted, unless the strength of the child be much duced, or the type of the scarlatina be typhoid. Bleeding cupping SCARLET FEVER. 581 the loins, or a few leeches, will generally afford relief, and it may be repeated, if necessary, and if the child can bear it. If the weakness be too great, we must content ourselves with ap- plying a blister to the loins, if the scarlatina have subsided ; or a liniment of oil and turpentine, or the compound camphor liniment, and the occasional use of the warm bath. Internally, diaphoretics should be administered, and gentle purga- tives. Dr. West speaks highly of tartar emetic, in nauseating doses, given every three or four hours, combined with a solution of the acetate of ammonia; and aftenvards mild diuretics, as the acetate of potash, extract of taraxacum, spirits of nitrous ether, &c. I have seen the amount of blood in the urine checked by the use of gallic acid in doses of one-third or one-half of a grain three times a day. The disappearance of the blood and albumen, and the resumption of its healthy color by the urine, will be the best evidence of the di- minution of the renal disease. Fortunately, the treatment I have advised for the affection of the kidneys is equally calculated to benefit the anasarca connected with it, which supervenes during the period of desquamation or conva- lescence. General bleeding, if the pulse be full and the child strong, as ad- vised by Sydenham, Richter, and others, or cupping or leeching with diaphoretics, diuretics, and baths, are the remedies upon which we must chiefly rely; but I am anxious to recommend the vapor bath especially, from the great benefit I have seen derived from it. It may be easily administered without the usual expensive apparatus. Take a cane-bottomed chair, suspend a pan of hot water underneath, near to the floor, and place under it a spirit-lamp, and then cover the seat and legs of the chair with a blanket, so as to prevent the hot steam from scalding the child; then place the child, naked, upon the seat, and envelop the chair and the child (except his head) in a blanket. In a few minutes, the child will have a comfortable and complete vapor bath, which is far less exhausting than a common warm bath, and has a more beneficial effect upon the anasarca. When, after the nearly complete disappearance of the oedema, and the return of the urine almost or altogether to a healthy state, Jhe child still continues pale, and languid, and feeble, the tincture of the sesquichloride of iron is the best tonic that can be administered, and under its use any traces of albumen that previously existed in the urine will be altogether removed.1 890. The diet of the child, during the simple and anginose scarla- tina, should be restricted, and of a bland character; in angina ma- ligna, we may have to give broths, beef tea, jelly, or even wine and brandy. During convalescence, we must be careful that the child be not too 1 West, Diseases of Infancy and Childhood, p. 434. 582 SCARLET FEVER. highly fed, under the plea of recruiting its strength, as this may ex- cite disorder of the kidneys. During the height of the disease, the child should be moderately covered with clothes, the room be kept cool and well ventilated. We must remember that, during convalescence, the sequela? of the disease arise, and therefore great care should be taken that the child be warmly clothed and not exposed to cold or damp. 891. Prophylactic Treatment.—Many plans have been suggested for preserving individuals from scarlatina. Dr. Withering recom- mends the frequent expectoration of the mucus that collects upon the mucous membrane of the fauces and nose, and that, when the infection has been imbibed, the person should take an emetic, wash the mouth with soap-lyes diluted with water, and promote sneezing, then go to bed and take wine whey with spirits of hartshorn. He advises that, when a family or school is attacked, the members should not be dis- persed, but, " allotting apartments on separate floors to the sick and healthy, choosing for nurses the older parts of the family, or those who had already had the disease, and prohibiting any more communication between the sick or their attendants and the healthy, with positive orders to plunge into water all the linen, &c, used in the sick cham- bers, have universally been found sufficient to check the further pro- gress of the infection." Dr. Sims thinks the best precaution to be to take so much rhubarb every morning as will produce a loose motion in the day. Dr. Wil- liams thinks this precaution as effectual as that of Hahnemann, if not much more so. Hahnemann recommended a minute portion of belladonna to be taken twice a day. Ettmuller, Berndt, Korrff, and Hufeland believe in its good effects. Salzer and others have found it useless ; and Hil- denbrand and others treat it writh ridicule. Dr. Stievenart of Valenciennes tried it upon 200 individuals during an epidemic of scarlatina near Valenciennes, and all escaped the dis- ease. "In an epidemic which occurred in South Carolina, Dr. Irwin made a very extensive trial of the prophylactic properties of belladonna. Three grains of the extract were dissolved in one ounce of cinnamon water, and two or three drops of the solution were given morning and night to a child under one year old, and one drop more for every year above that age. Of 250 children who took the belladonna, less than half a dozen had the disease, and but very mildly. After eight or ten days' use of the medicine, there occurred an eruption over most of the surface, in some cases profuse and troublesome from itching Those families who did not take the preparation had the disease with scarce an exception."1 Dr. M'Kee made a similar trial with success Dr Condie found it of no use. Guersent and Blache, Rilliet and Barthez think it deserving of further trial. Calomel has been recommended by Kreysig and Slig ; Theussink 1 Condie on Diseases of Children, p. 441. VARICELLA. 583 calomel and the golden sulphuret of antimony; Eichel, emetics, fol- lowed by diaphoretics. Others have recommended the mercurial acids, or capsicum, quinine, camphor, &c. Whether there be any special prophylactic or not, I cannot say. I am sure that good food, fresh air, exercise, ventilation, cleanliness, &c, by promoting the health, may either preserve from the disease, or will tend to diminish its severity. CHAPTER III. VARICELLA.--CHICKEN-POX.--SMALL-POX. 892. This is a trifling disorder, hardly worthy of the name of an eruptive fever. It was confounded with small-pox until Dr. Heberden published his Memoir,1 and ever since there have been controversies as to whether or not it is not a modified variola. Valuable descriptions have been given by Frank of Vienna, WTillan, Heim, Mohl, Thomp- son, Gregory, &c. Dr. Gregory defines the disease as " a slight disorder, the off- spring of a specific miasm, which, without irritating fever, throws out an eruption of confluent vesicles, which mature in three days, and desiccate into granular scabs, which speedily fall off. Little or no fever accompanies the matured stage, and no secondary fever fol- lows. The disorder chiefly prevails among children, and occurs but once in life."2 The period of incubation is very short-^from four days to a week; and Heberden, Plenk, Rayer, and Gregory speak of it as latent, affording no symptoms; but Dr. Willan states that occasionally the patient complains of languor and somnolency, with a furred tongue, hot skin, and quick pulse, with sore throat, and rheumatic pains. Dr. Bateman says that " some degree of fever generally precedes the eruption of varicella for a couple of days, which occasionally continues to the third day of the eruption. This is sometimes very slight, so that it is only recollected as having been previously indicated by fret- fulness, after the eruption appeared."3 I have seen the eruption appear without preliminary fever; but I have also seen it preceded by irritability, discomfort, dislike of exer- tion, and fever. Whether ushered in by fever or not, at the end of a few days the eruption appears, sometimes preceded, for a few hours, by a general erythematous rash, or a few7 red patches here and there, upon which there appear simple vesicles filled with clear transparent serum, as if the skin had been blistered with boiling water. Many of the vesicles * Trans, of College of Physicians, London, vol. i. * On Eruptive Fevers, p. 225. 3 On Cutaneous Diseases, p. 213. 584 VARICELLA. appear upon the skin with no surrounding redness ; but the clear vesicle upon the white skin. It usually commences on the breast and back, then on the face and scalp, and lastly on the extremities, and it appears in successive crops for a few days, the old ones dying away whilst the new ones are forming. The eruption is accompanied with a degree of itching and tingling, and the child generally rubs off the head of the vesicle, and the ex- posed surface becomes irritated and sore; occasionally, they become inflamed and a kind of pustule forms, which has led to some confusion. If the vesicles remain unbroken for twenty-four hours, they become opaline and then opaque, and by degrees they dry and form small granular scabs. There are few7 or no constitutional symptoms accompanying the eruption; the little disturbance that preceded it generally subsides on its appearance; the tongue is pretty clean, the pulse quiet, the skin cool, and the appetite good. After a few days, the scabs fall, and all traces of the disease disappear. The entire course may be completed within a fortnight. 893. The modifications of the disorder have reference principally to the form of the vesicles. Willan described three varieties: the len- ticular, conoidal, and globate, which are thus characterized by Dr. Bateman: "The lenticular appears on the first day of the eruption in the form of small red protuberances, not exactly circular, but tending to an oblong figure, having a nearly flat and shining surface, in the centre of which a minute transparent vesicle is speedily formed. This, on the second day, is filled with a whitish lymph, and is about the tenth of an inch in diameter. On the third day, the vesicles have undergone no change, except that the lymph is straw-colored. On the fourth day, those which have not been broken begin to subside, and are puckered at their edges. Few7 of them remain entire on the fifth day; but the orifices of several broken vesicles are closed, or ad- here to the skin so as to confine a little opaque lymph within the puckered margin. On the sixth day, small brown scabs appear uni- versally, in place of the vesicles. The scabs on the seventh and eighth days become yellowish, and gradually dry from the circum- ference towards the centre. On the ninth and tenth days, they fall off, leaving, for a time, red marks on the skin without depression. Sometimes, however, the duration of the disease is longer than the period just stated, as fresh vesicles arise during two or three succes- sive days, and go through the same stages as the first. "In the conoidal varicella, the vesicles rise suddenly, and have a somewhat hard and inflamed border: they are, on the first day of their appearance, acuminated, and contain a bright, transparent lymph On the second day, they appear somewhat more turgid, and are sur' rounded by more extensive inflammation; the lymph contained in many of them is of a light straw color. On the third day the vesi- cles are shrivelled; those which have been broken exhibit'at the top slight gummy scabs, formed by a concretion of the exuding lymph VARICELLA. 585 Some of the shrivelled vesicles which remain entire, but have much inflammation round them, evidently contain on this day purulent fluid: every vesicle of this kind leaves, after scabbing, a durable cicatrix or pit. On the fourth day, these dark brown scabs appear intermixed with others which are rounded, yellowish, and semi-transparent. These scabs gradually dry and separate, and fall off in four or five days. A fresh eruption of vesicles usually takes place on the second and third day; and, as each set has a similar course, the whole dura- tion of the eruptive stage in this species of varicella is six days; the last-formed scabs, however, are not separated till the eleventh or twelfth day. "In the swine-pox or hives (for in the south the former appellation is applied to both the second and third species), the vesicles are large and globated; but their base is not exactly circular. There is an in- flammation round them, and they contain a transparent lymph, which, on the second day of the eruption, resembles milk whey. On the third day the vesicles subside, and become puckered and shrivelled, as in the two former species. They likewise appear yellowish, a small quantity of pus being mixed with the lymph. Some of these remain in the same state till the following morning; but, before the conclusion of the fourth day, the cuticle separates, and then blackish scabs cover the bases of the vesicles. The scabs dry and fall off in four or five days."1 894. There seems to be no doubt that the disease is both contagious and epidemic; we constantly see it communicated successively to every member of a family or school. Dr. Bateman mentions that varicella may be propagated by inocu- lation with the lymph of the vesicles, and that it may be introduced whilst the constitution is under the influence of vaccination, without modification of either disease: "that small-pox, inoculated during the eruptive fever of varicella, proceeds regularly in its course without occasioning any deviation in the lattt*r; but that, when variolous and varicellous virus is inserted at the same time, the small-pox proceeds through its course, while that of the chicken-pox is in a great degree interrupted."2 Mr. Bryce, of Edinburgh, made many attempts to propagate the disease by inoculation, but failed in all.3 895. I have already mentioned that, up to the time of Heberden, the disease was confounded with small-pox. Since that time, many persons have regarded it as a modification of small-pox; and recently Dr. Thompson has maintained this opinion, mainly because, as he states, varicella prevails where variola prevails, and never without, and that, therefore, the generating miasma must be the same in both; and that chicken-pox is never witnessed in children who have had small-pox. As to the first, Dr. Mohr states that, from 1809 to 1823, chicken-pox was observed annually at Copenhagen without variola, ' Bateman on Cutaneous Diseases, p. 210. 3 Willan on Vaccination, p. 97. 3 Thompson on Varioloid Diseases, p. 74. 586 SMALL-POX. M. Eichhorn mentions varicellous epidemics without variola, and Mr. Burnes relates a similar occurrence at Carlisle in 1826. Dr. Gregory has also shown that children may take chicken-pox after cow-pox, or the reverse, or may have both at the same time. Fur- ther, the inoculation of chicken-pox never produced either variola, varioloid, or vaccinia. M. Rayer agrees with Dr. Thompson, and suggests that the chicken- pox, which occurs some time after an epidemic of small-pox, may be " a last effort of the variolic medical constitution."1 M. Alibert does not believe that the miasm of varicella can give rise to variola; and he mentions that chicken-pox occurs not merely in those who have been vaccinated, but in those who have had small- pox.2 MM. Guersent and Blache regard varicella as a disease sui generis, and have refuted the positions of Dr. Thompson.3 896. Diagnosis.—The very slight fever, or its entire absence, the vesicular eruption, the clear, watery contents of the vesicles, and the insignificant character of the attack, distinguish it from all other eruptive fevers. There is some resemblance between it and that variety of small- pox which has been termed varioloid ; but in the latter there is more fever; the eruption is partly vesicular and partly pustular, and the contents of the vesicles are never the clear, transparent lymph we find in varicella. 897. Treatment.—Little or none is necessary. The child should be kept within doors for a few days, abstain from animal food and heating drinks, and take a gentle purgative once or twice. CHAPTER IV. SMALL-POX.--VARIOLA.--PETITE VEROLE. 898. This is the most distressing and most fatal of all the eruptive fevers. It may be defined as a pustular disease, preceded by fever which subsides, but is again excited at a more advanced stage • and which terminates in a scab. It is contagious and epidemic and attacks a person but once in his lifetime. M. Hahn, Dr. Willan, and Dr. Barow believe that the disease was known to the Greeks and Romans. Dr. Mead, Dr. Friend Dr. Gre- gory, and others maintain the contrary. It was first described by Rhazes, and after him by Avicenna, and by innumerable writers since, among whom Sydenham decidedly holds the first rank not 1 Diet, de Med., vol. xv. 2 Monographie des Dermatoses, vol. ii. p. 342. 3 Diet, de Med., vol. xxx. p. 548. SMALL-POX. 587 merely as an accurate observer, but as having applied his sound judgment to the improvement of the treatment. Of the period when it was first introduced into Europe, or even into England, we know little. Dr. Hillary1 says that Gilbertus An- glicus (1280) and John of Gaddesden (1310 or 1320) allude to the disease as one well known. Dr. Monro mentions that some authors have maintained that it was introduced into Europe in the eighth century, on the invasion of the Saracens, and into England in the ninth ; but Dimsdale, Mead, and others place it two centuries later.2 In the year 1721, inoculation was introduced into England by Lady Mary Wortley Montague, from Constantinople, and was, at that time, a great improvement in the history of the disease, in consequence of the diminished mortality which it insured. This has been superseded by the glorious discovery of Dr. Jenner, and is now abolished by act of Parliament. Mr. Wilde has shown satisfactorily the antiquity of this disease in Ireland; he observes that "the time at which this disease first made its appearance in Ireland has not been as yet fully determined ; it must have been in existence long prior to the date of the English and Latin authors of the fifteenth and sixteenth centuries; for the Irish manuscripts refer to it at the beginning of the fifteenth century; it is described in the Book of O'Shiel under the name of bolgach, which means, literally, blisters or pustules containing matter; but water-blisters (vesicles or bulla?) are generally termed clog. One of the Irish translators in the fifteenth century states that small-pox and measles (which in the manuscripts are generally mentioned together) form in pustules all over the body, and are generated from a vitiated state of the red blood and humors; but that the small-pox is pro- duced from a vitiated state of the red blood alone, and measles from a depraved condition of the humors. The work of Bernard on the small-pox and measles is mentioned in the Book of O'Shiel." "The total number of deaths from this cause during the ten years amount to 58,006, in the proportion of 100 males to 96.45 females." "The proportion of this to the general mortality appears from the returns to be 1 in 20.46, and, compared with all of the epidemic class, 1 in 6.57; being, next to fever, the most fatal epidemic affection in the country."3 Small-pox has been divided into discrete and confluent, mild and malignant, with several subdivisions. I shall first describe the dis- ease as we ordinarily see it, and then its modifications. 899. Symptoms.—For the facility of description I shall, as in the case of measles and scarlatina, divide the disease into periods or stages. i. Period of Incubation.—After exposure to contagion, a certain period elapses before the child shows any symptoms of being affected, beyond, perhaps, some uneasiness, an unwillingness to play as usual, 1 A Practical Essay on the Small-pox, 1740, p. 19. 3 Monro on the Small-pox, p. 48. 3 Report upon the Tables of Deaths, pp. 11, 12. 588 SMALL-POX. and an "unquiet silence," as M. Alibert expresses it. It is not easy to fix the length of this period: Boerhaave and Stoll say six or seven days; Dr. Gregory from ten to sixteen days. ii. Period of Invasion.—At the termination of the period of incuba- tion, the early symptoms of fever show themselves; the child is chilly, shivering, creeping to the fire; complains of headache; is uneasy, cross, and hard to please. This state is succeeded by heat and dryness of skin,'and a quick and full pulse; the appetite is lost; there is nausea, with occasional vomiting; generally constipation, rarely an attack of diarrhoea. The tongue becomes loaded, but red at the point and edges, and there is great thirst; the child is completely prostrated, and complains of aching in the limbs, the back, the epigastrium, and in various other parts. The pain in the loins is so unusually severe that Dr. Gregory and others have regarded it as peculiar to small-pox, and aiding in its diagnosis in this stage. In some cases, there is lachrymation, with injection of the conjunc- tiva, redness and swelling of the amygdalae, sore throat, and pain and difficulty in swallowing. In others, there is precordial oppression, dyspncea, dry cough, with a sense of heat and soreness in the larger bronchial tubes, flying pains in the chest, and palpitation. Or this period may be marked by the predominance of nervous symptoms, agitation, restlessness, sleeplessness, or a sudden waking from sleep with a start and crying, but nothing more formidable. In more severe cases, the child may become delirious, or pass into a state of stupor and coma, or be attacked by convulsions resembling epilepsy. Sydenham regarded these epileptic attacks as characteristic, where there was no irritation from teething, and states that he has foretold in such cases the appearance of the eruption of small-pox.1 Rayer mentions that these cerebral attacks may prove fatal even before the eruption appears, or soon after.2 The duration of this period is generally about three days; occasion- ally, the eruption appears on the second day, or not till the sixth or seventh. Generally, the eruption is earlier in confluent and severe cases than in those where it is discrete and slight. In twenty-six cases of normal variola, Rilliet and Barthez state that the duration of this stage was one day in one case; two days in eleven cases; three days in nine cases; four days in four cases- and six days in one case. Of thirty-five abnormal cases, it was a few7 hours in one case; one day in four cases; thirty-one hours in one case- two days in twelve cases; three days in five cases; four days in six cases.3 m. Period of Eruption.—-This stage dates from the first papular appearance to the time when the pustules are filled with pus. At the first, we observe small, round, isolated spots, which soon become full 1 Works, vol. ii. p. 153. » Traite des Mai. de la Peau vol i n m r » Mai. des Enfans, vol. ii. pp. 441, 442. ' '' x" P' 51G' SMALL-POX. 589 solid, and prominent papulae, of a more or less vivid red color, which disappear under pressure to re-appear immediately. We observe them first on the face, then on the neck, and by degrees upon the limbs, body, hands, and feet. These papula? gradually increase in size and change their character. The epidermis on each is slightly elevated by a drop of serum, of a yellowish-white color, not so transparent as that of varicella. The time of this change is not the same for all the papula?, inasmuch as they appear in successive crops on different parts of the body, and the earlier ones become vesicular the first, then the others in the order of their succession, occupying from twenty-four hours to two or three days in the process. Rilliet and Barthez think that the length of this period is inversely as the length of the prodromi. At first, the vesicles are small, especially upon the papula? which were acuminated ; but by degrees they become flattened at the top, and spread out laterally until they cover the papula and are much larger than it. They lose their semi-transparent character, and be- come opaline. The vesicles are surrounded by an inflamed base, some- times flat, in other cases somewhat elevated above the level of the skin: if the vesicles be not too distant, their areola? are in contact, so that the skin is of a bright red color between the vesicles. The vesicles themselves vary in number, and, when numerous, may run into each other, constituting wdiat is called " confluent small-pox," and exhibiting just such severity of symptoms as might be expected from the extent of inflamed and suppurating surface. This conflu- ence may occur in patches of different sizes over the surface, but especially upon the face, which is now more severely affected than any other part. On the body and limbs the vesicles are generally distinct, and when they are universally so, it is called "discrete small-pox." The papulae assume the character of vesicles about the second day ; sometimes, though rarely, a day later, and in about t\vo or three days more they again change and become pustular. The vesicle, which had spread out and become flatter, now becomes depressed in its centre, leaving the borders round and elevated ; the serum, which had become opaque, now becomes purulent, and the eruption has the pustular appearance, at first on the face, then the neck, body, limbs, &c, just in the order in which it appeared. This observance of a regular order of succession is remarkable; in consequence of it, wre may see in the same case papula? and vesicles, or vesicles and pustules, but never papula? and pustules, because the time required to convert the vesicles into pustules has been sufficient for the transformation of all the papula? into vesicles. The duration of this period is from four to six days. The fever and general disturbance we noticed during the period of invasion continue for a short time after the appearance of the erup- tion, and then either disappear or are considerably reduced in severity; but as the disease assumes its true character we find considerable irritation of the mucous membrane of the mouth, pharynx, and larynx, 590 SMALL-POX. Sometimes the tongue is much swollen, and there is a profuse dis- charge of saliva. The face also—especially the eyelids,—and the neck, are swollen. iv. Period of Suppuration.—It is somewhere about the fifth or sixth, or, according to Sydenham, the eighth day, that suppuration com- mences; the liquid in the vesicles, from semi-transparent, becomes opaque, then of a dull white, and lastly of a yellow color; at the same time the pustules increase in size, the depressed centre is again raised, and they become more spherical. On the extremities, we occasionally find pustules which retain their opaline character during the whole of this period, and others which assume a livid appearance, as if from the effusion of blood. On the surface of the pustules themselves, at the beginning of this stage, we may observe small semi-transparent gray or yellow points,1 the former, owing to an arrangement of the epidermis, the latter to new matter deposited under the epidermis. Rilliet and Barthez call these "pointilles de couleur." They are generally seen upon the pustules of the face, or on the body and thighs, and they disappear about the seventh or ninth day of the eruption, when the pustules are completed, or perhaps just as desiccation commences. On the pus- tules of the hands, feet, and arms, instead of these points, we may observe concentric circular marks, gray and semi-transparent, or clear yellow, alternately. When two pustules touch, the outer yellow circles of each are broken and confused. The gray circles are broader at the commencement, but the yellow ones increase until they occupy the entire pustule. The process of pustulation follows exactly the same order as the development of the papula?; those on the face, which appeared first, being first perfected, then those on the neck, body, limbs, hands, and feet. The more advanced the eruption, the more confluent it appears; and the more abundant the crop of pustules, the more confluent they become, because this gradual increase which we noticed brings them into contact with each other; and many parts, which were very dis- tinct at the beginning, end by becoming quite confluent. The period of suppuration lasts from four to six days, and it is marked by a return or an increase of the fever; but in this stage it is called the suppurative or secondary fever. Its amount or intensity is generally in proportion to the extent and confluence of the eruption • slight in discrete small-pox, it acquires great severity in the confluent form ; the pulse ranges from 100 to 140, full, strong, and regular • the skin is very hot and dry; there rarely is any perspiration. The face is enormously swollen, the eyelids quite closed, and the aspect utterly changed and frightful. In addition, the mucous membrane of the fauces, pharynx air tubes, and digestive passages, is in a state of great congestion'and irritation, if not of inflammation. 1 Rilliet and Barthez, Mai. des Enfans, vol. ii. p. 449, SMALL-POX. 591 " In a large .portion of confluent and in some semi-confluent cases, the mucous membrane of all these parts to which the atmospheric air gets access (the nose, mouth, and trachea), is occupied with the erup- tion, sometimes distinct, more generally confluent. The only symp- toms occasioned by this mucous complication are as follows: numer- ous white points appear on the tongue, palate, and velum pendulum. Hoarseness and alteration of voice indicate that the same condition extends to the mucous membrane of the larynx and trachea. There are great pain and swelling, and, in bad cases, cough and dyspncea. The cough is at first dry and teasing; as the disease progresses, there is expectoration; about the eighth day, a copious viscid secre- tion takes place from all the affected structures."1 In many cases there are delirium, agitation, coma, &c, so that, at a later period of the disease, we seem to have its first acute febrile and inflammatory character reproduced, and this continues until the de- siccation has fairly set in. This secondary fever is supposed to result from absorption of the purulent matter, and its mixture with the blood. If the eruption be limited, the quantity of purulent matter absorbed is small, and the result is fever, without complication; but in very confluent cases, the amount of purulent matter absorbed is sufficient to taint the whole system, and to produce all those phenomena which result from such a" poison, analogous to those which arise from phlebitis, such as typhoid or ataxic fever, metastatic abscesses in the lungs, liver, and cellular tissue: arthritis with effusion, &c. Sydenham seems to allude to this result when speaking of the epi- demic of 1674: "Of this I am certain, that the present small-pox exactly resembled that of the preceding constitution, only it seemed to be of a grosser nature, and attended with a much greater degree of putrefaction. And from these two causes it followed that, when the eruptions were very confluent, it destroyed abundance more than any other sort I had yet seen, and in my opinion proved as fatal as the plague itself," &c.2 " Often, indeed," says Dr. West, "it assumes a typhoid character; the pulse becomes extremely frequent and feeble; the tongue dry and brown; and the patient dies delirious. In other instances, the matu- ration of the pustules goes on for a day or two, with very slight re- action ; and were it not that this extreme mildness of the secondary fever, in cases where the eruption has been abundant, is itself a sus- picious circumstance, we should be disposed to express, without hesi- tation, a most favorable opinion as to the patient's condition. Sud- denly, however, the pulse begins to falter, the pustules, which before seemed full, collapse; the extremities grow cold ; and in a few hours the patient dies. This fatal change is sometimes ushered in by a fit of convulsions; at other times, it is preceded by a condition of ex- treraest restlessness, which contrasts remarkably withthe extreme quietude of the child's manner for the two or three previous days."3 1 Gregory on Eruptive Fevers, p. 47. 3 Works, vol. ii. p. 322. 3 Diseases of Infancy and Childhood, p. 468. 592 SMALL-POX. v. Period of Desiccation.—Like the other phases of the disease, this further process commences in the face first, so that this part may be covered with crusts at a time when the pustules are but just ar- rived at maturity upon the limbs. The tumefaction diminishes, the pustules dry up, and the crusts which result form a mask over the entire face. The features are hidden by a thick, brown incrustation, which falls off about the fifth or sixth day after its formation, to be succeeded by furfuraceous scabs, which fall, and are renewed several times before the skin is clear. The more confluent the disease, the more humid are the crusts. But when the pustules ulcerate, which is very common in confluent small-pox, some blood may escape, which will give to the crusts a black color; and when they fall off, we find the skin irregularly destroyed, so as to form pits, seams, or cicatrices, which give to the countenance a very frightful appearance. These pits or seams are much more frequent on the face than in any other parts of the body, because it is there that the eruption is more abundant and confluent, and that the inflammation, being more in- tense, is more liable to run on into ulceration of the cutis. The odor from the patient during this period is most offensive and sickening; the tenderness of the surface is so great, that it is impos- sible to observe great cleanliness; and the accumulation of purulent matter, the extent of suppurating surface, the fetid breath, occasion a disgusting and impure atmosphere around the patient. A very distressing itching accompanies the formation of crusts, the more annoying as rubbing or scratching the parts is attended by pain, and leads to still greater disfigurement. M. Rayer,1 Rilliet and Barthez, and others, mention that, in some cases, there is neither desquamation nor formation of crusts; the pus- tules become flat in the course of forty-eight hours, owing, probably, to the absorption of the pus; and that, coincident with this change, there is a sudden prostration and other phenomena analogous to those observed in animals into whose veins pus has been injected. Rilliet and Barthez have described several modes in which this desiccation takes place.2 i. In the first, the epidermis of the pustule cracks in the centre or circumference, and the pus and false mem- brane, being exposed to the air, concrete into a yellow crust at first moist, then dry, rough and unequal at first, occupying only a portion of the pustule, but afterw7ards occupying the whole: it is connected with the neighboring ones at its circumference. n. In other cases, a small, dry, yellow7, semi-transparent crust is formed occupying the entire pustule, and if we detach it, the surface underneath will be found red, moist, elevated, and perhaps bleeding- when the crusts fall, they leave a red, uniform, level surface which gradually loses the red color, and exhibits no cicatrix. in. A small scale may form in the centre of the pustule, surrounded by purulent ^ matter, the epidermis having desquamated and being detached. This mode leaves no mark. ° ' Mai. de la Peau, vol. i. p. 520. 3 Mai. des Enfans, vol. ii. p. SMALL-POX. 593 iv. Lastly, the pustules do not break, but become gradually flat- tened from the absorption of the pus, and the epidermis, smooth and softened, is separated from the cutis by a layer of false membrane, which forms a thin crust of a yellow color, and which, with the epi- dermis, dries and falls off in large scabs, leaving a smooth and slightly red surface underneath. 900. Let us now inquire as to the eruption upon the mucous mem- branes. Small elevations, surrounded by a circle of inflammation, may be observed in the mucous membrane of the mouth and fauces, and at the end of two or three days these change color, and become white or gray, and on their surface there is a small patch of false membrane, which is detached after a few days, leaving a slight erosion, or superficial ulceration, which is not followed by a cicatrix. In the pharynx and oesophagus, pustules are occasionally observed, somewhat modified by the structure of the part, and pustules have also been observed at the rectum. Death may take place at any stage; before the appearance of the eruption, during its course, or after desiccation. In 168 fatal cases mentioned by Dr. Gregory, death occurred between the third and seventh days in 32; between the eighth and twelfth in 83; between the twelfth and twentieth in 39; and between the tw7enty-second and thirty-eighth in 16 cases. 901. Modifications.—The preceding description embraces only ordinary cases of small-pox ; but we find in practice that in many cases the disease, in its appearance and course, deviates widely from the ordinary standard, and in others, whether normal or anomalous, it is very seriously complicated with some organic affection. Let us in- quire a little into each of these phases. a. It sometimes, though rarely, occurs, that there are either no pre- cursory symptoms, or that they are unusually short in duration. On the other hand, we sometimes see the fever lasting several days, with no other symptom, or with only diarrhoea. Much depends, no doubt, upon the previous state of health, and whether the variola is primary or secondary. 6. The eruption may appear irregularly, showing itself first upon the body or arms, and thence spreading to the face; or it may appear full on the face and very sparingly upon the body. In some cases, the eruption scarcely assumes the true pustular cha- racter, or, whilst some of the spots go through their proper course, others remain vesicular, with clouded serum instead of pus. c. In some very severe and fatal cases, the pustules are red, livid, or filled with blood (hemorrhagic variola, or black small-pox of Sy- denham). In other cases, we may find petechia? or ecchymoses in different places, with hemorrhage from the kidneys, bowels, &c, speedily carrying off the patient. My friend, Mr. Smyly, has given me the notes of two such cases, and it is remarkable that in such cases the eruption is seldom, if ever, fully developed; it may remain either papular or vesicular. As this form of the disease is comparatively rare now, it may be 38 594 SMALL-POX. worth w7hile extracting the following graphic description from Dr. Hillary's work:— "The bleeding small-pox is the very worst sort, and seems to pro- ceed from a conjunction of several of these causes in their most violent degree. The infection is probably the most pernicious, the habit of the person unfavorable, and strongly disposed to receive the infec- tion." "The invasion is mostly attended with convulsive, racking, lancinating pains in the lower part of the back and loins, so intole- rable that at every spasmodic shoot the patient cannot refrain from starting and crying out as if he were stabbed with a sw7ord ; he has also a violent shooting pain in his head; his eyes are extremely in- flamed ; he breathes very quick, short, and laboriously, and his pulse is quick, weak, and frequent: though sometimes the purple spots and hemorrhages will come on without any other symptoms than the last two, though not often. The sick have first a flushing in their faces, breasts, and backs, and shortly after a redness like that in the scarlet fever appears all over the body; the pustules do not rise, but stand in the skin like a flat, continued, red swelling; after this redness, an infinite number of small red or purple petechia? will appear all over the body and limbs, which afterwards turn to a dusky brown, livid, or black color, and sometimes spread very broad: the pustules, likewise, are spotted or turn black in the middle, which dimple in and do not rise. Sometimes a colliquative profuse salivation comes on thus soon, which is afterwards often mixed with blood."1 d. Again, the vesicles and pustules may be either unusually small or unusually large. In the latter case, they are flattened and not dis- tended, and the false membrane has not its usual character. Occasionally, large bulla? are seen on the limbs, wrists, ankles, &c, but never on the face, filled with serum, and, when dried, forming large scales. This was noticed by Sydenham in the epidemic of 1670. e. The fever, which ordinarily subsides very much, if not com- pletely, when the eruption appears, in other cases continues unabated in intensity. /. Suppuration may not take place satisfactorily; it maybe in- complete or excessive, or mixed with hemorrhagic blotches. The fever may take a typhoid type, and very formidable complications occur. g. Varioloid.—A modified kind of small-pox, which is termed varioloid, occurs occasionally either after vaccination, inoculation or casual small-pox, and it is more frequent after the age of fourteen than before, perhaps from the vaccine influence having worn out. The precursory symptoms are not generally severe, though in some cases there is a smart febrile attack. The eruption is ordinarily not very extensive, and chiefly occupies the face and trunk. It does not assume the flattened pustular form, but is more spherical and is filled with yellow serum or pus. After a few days, the vesicles or pustules dry up and form small round scabs, which fall off, and leave no indent- 1 On the Small-pox, p. 123. SMALL-POX. 595 ation after them. The fever subsides as soon as the eruption appears, and there is no secondary fever. The extent of pustulation varies much; some have only ten or twenty spots; others, as I have seen, are pretty well covered by them.1 It rarely happens that any complication aggravates the attack. It is undoubtedly contagious, and it has been remarked that it may reproduce true small-pox in another person. It is doubtful whether an attack of varioloid affords protection from small-pox subsequently. h. Ordinarily, small-pox attacks an individual but once in his life; there are, however, well-authenticated cases on record where it oc- curred a second or even a third time, though in general these assume the form of varioloid.2 i. " During the prevalence of epidemic small-pox, numerous cases of a febrile affection frequently occur, marked by tenderness of the epigastrium, pain in the back and limbs, some degree of soreness of the throat, salivation, profuse perspiration from which no relief results, and not unfrequently petechia?. This has been denominated variolous fever without eruption. This fever generally begins and ends with the variolous epidemic. We have repeatedly met with such cases, as well in the unprotected as in those who have been vaccinated, or who had previously had the small-pox. That the disease results from the same infection as the small-pox, we have no doubt; how- far it affords subsequent immunity from the latter, we have had no means of judging."3 902. Complications.—i. The nervous system is frequently more or less involved. I have already stated that headache is an accompani- ment of the fever, and that we may also have delirium, agitation, stupor, coma, or convulsions, in the period of invasion. We 'have seen how characteristic Sydenham thought the epileptiform attacks, and, I may add, that head symptoms are by no means uncommon in the suppurative stage of bad cases. Dr. Condie observes that " the same affection of the brain that fol- lows the destruction of large portions of the skin by burns or scalds, often occurs. The symptoms are severe : repeated rigors, followed by general tremors ; a quick, thready, and tremulous pulse ; a dry, brown tongue; collapse of the features; cold extremities ; subsultus tendinum, and death."4 Of 112 patients who died of the disease in 1825, M. Guersent did not find a single example of meningitis or encephalitis, but occasion- ally a kind of passive injection of the membranes. I need not add that any cerebral attack is a most formidable com- plication, and may, in itself, prove rapidly fatal. n. Coryza.—Epistaxis.—A sero-sanguinolent discharge from the 1 Monro on Small-pox, p. 233. 3 Gregory on Eruptive Fevers, p. 73. Monro on Small-pox, p. 77. 3 Condie, Diseases of Children, p. 450. 4 Diseases of Children, p. 449. 596 SMALL-POX. nostrils is by no means unfrequent, owing to the inflammation and pustulalion of the mucous membrane of the nose. in. Laryngitis.—Croup occurs occasionally in the course of small- pox, but not very frequently. e iv. Bronchitis alone, is rare, and not very important, but it is not unfrequently complicated with pneumonia. It rarely occurs before the tenth day. v. Pneumonia.—Inflammation of the lungs is not very uncommon, and it has a serious influence upon the result of the variola. Accord- ing to Rilliet and Barthez, " the pneumonia of variola commences either during the first days of the eruption, or during convaslecence. In the first cases, the variola was secondary and anomalous, two pa- tients having varioloid, one normal, the other abnormal, so that it may be questioned whether the irregularity depended upon the pri- mary disease, or upon the pulmonary complications. We think that both causes may have contributed to produce this effect. On the contrary, in the second series, the variola was primitive and normal; the complication had no influence upon the eruption. With one, only, of our patients the pneumonia occurred at an intermediate pe- riod, i. e. on the eighth day of the eruption ; the variola was abnor- mal; the effect of the pneumonia was to discolor it almost instant- ly, and to add to the previous irregularity a remarkable paleness. "Pneumonia, rare, and without bronchitis, may be overlooked in our investigation. When more extensive, it is only by auscultation and percussion that it is known, and these methods are sometimes difficult to use ; the disgusting odor, the necessity of interposing seve- ral layers of linen between the sufferer and the ear, occasion us to overlook the pneumonia until the autopsy. The cough hardly draws attention to the pulmonary organs, inasmuch as it may be caused by the pharyngo-laryngitis: but when, at the period of desiccation, the symptoms increase instead of diminishing, we may suspect some pul- monary disease, and call to our aid auscultation for its detection. The prognosis of variolous pneumonia is very serious ; but the mortal- ity is greater in the irregular forms of variola. The pneumonia is less serious when it occurs during convalescence, and particularly when it is lobar."1 Fabre states that lobar is more common than lobular pneumonia. vi. Salivation.—Muguet.—In some cases, we find a continual dis- charging of a viscid, limpid, and frothy fluid from the mouth. It generally occurs from the fourth to the eleventh day, but Rilliet' and Barthez have seen it come on on the eighteenth ; and chiefly about the age of six years or after. It attacks those who recover as well as those who die, and most frequently in the anomalous and confluent variola. It may, perhaps, be owing to the inflammation or pustulation ex- tending up the salivary ducts, or, perhaps, to sympathetic irritation Pseudo-membranous inflammation of the gums, mouth, or pharynx 4 Mai. des Enfans, vol. ii. p. 503. SMALL-POX. 597 may occasionally be observed, and, in a very few cases, gangrene of the mouth. vn. Gastro-enteritis.—Entero-colitis.—We have seen that small- pox may be accompanied with great irritation of the stomach, vomit- ing, &c. This may continue some days, and then cease, and it may return at a later period. The digestive functions are, of course, sus- pended during the disease. Dr. Gregory states that " small-pox is singularly exempt from all abdominal complications;" but that mu- cous enteritis sometimes occurs. But the lower portion of the intestines is much more commonly affected in variola, as Guersent and Blache have observed, and this is one of the most common complications of the eruptive disease. In the normal form, it commences from the eighth to the tw7enty-fourth day, and rarely before, but in the abnormal it may show itself on the first or second day. Diarrhoea is the symptom which is present in almost all these cases of entero-colitis, sometimes after constipation, with swelling, tension, and tympanitis of the abdomen, and some- times without. It is always a very serious, often a fatal, compli- cation. vni. Hemorrhages.—In severe typhoid cases of small-pox, we occasionally find a discharge of blood from different organs, epistaxis, bleeding from the gums, petechia? on the skin, hemoptysis, hematuria, and hemorrhage from the intestines. None of these are very common, but all are of importance, either in themselves when extensive, or as indicating a very deteriorated condition of constitution. All these attacks have been noticed by Sydenham, and others since his time. ix. Ophthalmia.—No portion of the mucous membrane shows more distinctly or more frequently its participation in the pustular eruption; not merely is the conjunctiva inflamed, but the deeper tissues are in- flamed, softened, and ulcerated; especially the cornea. Rilliet and Barthez have noticed different degrees of keratitis. In the first, there were slight spots upon the cornea, surrounded by a red circle, and with great congestion of the vessels of the conjunctiva. In the second, ulceration had taken place ; in some to a limited extent, and followed by recovery; in other cases, the eye was lost. Hernia of the iris may result in such cases, or the transparent cornea become hopelessly opaque. This affection of the eye is generally observed at an advanced period of the disease. x. Otitis.—Less common than ophthalmia, we now and then do meet with cases of inflammation of the external meatus, or internal ear, terminating by resolution most frequently, or in abscess with severe suffering. It generally occurs towards the decline of the disease. xi. Abscess.—Subcutaneous abscesses are sufficiently frequent, and as the patients in whom they occur generally recover, they have been regarded by some writers as critical. In some cases, they appear independently, as the result of the violent inflammation which the skin has undergone, and in others they are 598 SMALL-POX. probably connected with rheumatism. Rilliet and Barthez observe: " Besides these patients, six others had abscesses, more or less nume- rous, in different parts of the body, and particularly around the arti- culations. Two out of twelve or fifteen of these abscesses followed upon considerable swelling of the subcutaneous tissue. In fact, the children had at this period severe pains, which diminished with the general swelling. But the local tumefaction continued, and soon after, fluctuation became perceptible. "In other cases, the first evidence of suppuration between the thir- teenth and thirty-second day, was pain, accompanied by swelling, heat, and redness in some part of the body, and when near an articulation, simulating very accurately articular rheumatism. However, in a few days, suppuration w7as evidently established, and the abscess being opened gave exit to pus, sometimes sanious, sometimes thick and healthy, and then cicatrization took place after a longer or shorter time. " Two patients alone had a single abscess; the others had two, three, or four, in different parts of the body. We observed them on the chin, at the anterior iliac spine, in the parotid, but more frequently around the shoulder, the elbow, and the joints of the thigh or foot. In all cases except one, cicatrization was sufficiently speedy. Of the six patients, five recovered, and one died."1 xn. Rheumatism.—The preceding paragraph will show that ar- ticular rheumatism occurs occasionally, though not very frequently. Rilliet and Barthez remark: "Four patients exhibited symptoms which resembled those of articular rheumatism, i. e. tumefaction and pain about several joints, sometimes with redness. These symptoms were of short duration, and in two cases there was metastasis from one joint to another, although it is true that, in one of these cases, there was an interval of twenty-twodays between the inflammation of the twojoints." " Of ten cases of arthritis, or of abscess, six had normal variola ; three abnormal variola, and one varioloid. Of the entire, eight were cured ; one died during suppuration ; and another a long time after the disappearance of the rheumatism." " It is impossible, with such facts before us, not to regard these inflammations and abscesses towards the end of variola as a critical symptom of favorable augury "2 xm. Eruptions.—I have already mentioned the occurrence of petechia?, resembling those of purpura hemorrhagica, and of bulla? both unfavorable symptoms, and occurring only in the worst kind of cases. Guersent and Blache mention having seen the favi of porrigo form upon the pustules of small-pox. Rayer, and Rilliet and Barthez ob- served mercurial erythema follow the use of mercurial plasters But, what is more remarkable, measles and scarlatina may occur either along with small-pox, just previously, or immediately after ' Sydenham mentions that the irregular black small-pox was in'tro- ' Mai. des Enfans, vol. ii. p. 495. a jk-j SMALL-POX. 599 duced by an epidemic of measles, in 1670, and also the singular variety which appeared in 1674-5. xiv. Other complications have been] observed, but less frequently than those I have noticed. Anasarca occurs occasionally at the be- ginning or during the desiccation, and oedema of the lung. Pleurisy and pericarditis have been sometimes observed, but neither of these is of frequent occurrence. 903. Pathology.—A post-mortem examination reveals considerable congestion of almost all the organs of the body. The muscles are of a deeper red color than usual; the vessels of the brain and its mem- brane are distended; the lungs, liver, spleen, and kidneys are more or less congested or inflamed. The blood is a good deal changed ; it is almost entirely fluid, of a dark color, and unusually serous ; or, if there be coagula, they are small, soft, and of a dark color. From the eruption being more abundant where the cutaneous follicles abound, MM. Petzholdt, Rilliet and Barthez, regard them as the true seat of the pustules of small-pox. This pustule, at its origin, is but a macula resulting from the vas- cular injection of the mucous tissue of Malpighi. Shortly afterwards, the surface becomes raised, and a pustule is gradually formed; in its interior, there is a circular false membrane which is attached, by a threadlike process, to the cutis on the one hand, and to the epidermis on the other, and this it is which causes the depressed centre of the pustules. Beneath this membrane, there are small cells containing a serous fluid, and without intercommunication. At a late period, when pus is formed, it penetrates between the epidermis and the membranous disk, ruptures the adhesions, and gives a globate form to the pustule, which has thenceforward only one sub-epidermic cell. If we divide a fully-formed pustule, we may perceive at its base the pseudo-membranous disc, underneath which the cutis is red and often inflamed. Cotugno thus enumerates the tissues to be seen in a pustule divided vertically: 1. A white line formed by the thickened epidermis; 2. Beneath, a purulent layer; 3. Still lower, a red line, formed by the in- flamed rete mucosum ; 4. Underneath which is the unaltered chorion; 5. In the centre of the pustule a small white body, whose superior filiform extremity is implanted in the centre of the depression (um- bilicus), whilst the inferior is attached to the inflamed corpus re- ticulare. MM. Rilliet and Barthez do not agree with M. Rayer1 as to the formation of the umbilical depression, because it exists when there is no membranous disc. They prefer M. Petzholdt's2 explanation, who attributes it to the traction excited upon the epidermis by the excre- tory ducts of the cutaneous glands.3 They have thus stated the different degrees of suppuration in dif- ferent parts of the body: 1. In the face, and sometimes on the limbs, the ulceration extends to the chorion more or less deeply, with a true 1 Mai. de la Peau, vol. i. p. 529. 3 Archives Gen. de Med., 1838, vol. ii. p. 314. » Mai. des Enfans, vol. ii. p. 450. 600 SMALL-POX. suppuration, and followed by persistent cicatrices. 2. On the limbs most frequently, and sometimes on the face, there is inflammation of the sub-epidermic layer, with erosion and suppuration, but no cicatrix. 3. If the cutis be not eroded with inflammation of the sub-epidermic layer, there will be a serous secretion at first, then one of plastic lymph, but no cicatrix. 4. The serous secretion may be deficient, and then the false membranes will not be abundant, and the pustules will be flat, &.C.1 904. The mucous membrane of the mouth, larynx, pharynx, and, in short, any portion possessing epithelium, is the seat of pustules, but which are modified in some degree by the peculiarities of the struc- ture, and when the epithelium has been removed, exhibiting super- ficial ulcerations which may be increased in extent by the junction of several. Pustules are also observed in the oesophagus, but not so frequently. It is a matter of dispute whether any true pustules have been found in the stomach. M. Guersent believes that he has seen them several times in the stomach, and in the small and large intestines. M. Rostan2 found them in the large intestines and in the rectum, and Cotugno3 observed them upon the mucous membrane of a pro- lapsus ani. Rayer, and Rilliet and Barthez deny that they exist in the intes- tines, and attribute the appearance which has been mistaken for them to the development of the mucous follicles. Dr. Condie mentions that, in the epidemic of 1823-4, at Philadel- phia, in almost every case, the stomach and upper portion of the small intestines were diseased. The larynx, trachea, and principal bronchial tubes exhibit the variolous pustules upon their mucous membranes, and in common withthe gastro-intestinal surface, present appearances of congestion and inflammation. 905. Causes.—Among the predisposing causes, are age, sex, and seasons. It occurs at all ages, nay, even before birth,4 as has been ob- served by Mead, Jenner, Laird, Hosack, and others, and undoubtedly children are more subject to it than adults, and adults than old peo- ple. For a reason I have mentioned before, I attribute the predomi- nance of the small-pox among young children to the fact of their taking it the first time they are exposed to the contagion, rather than to any greater susceptibility in children than in adults. Rilliet and Barthez have remarked that the anomalous variety is more common among young infants, and the normal form among older children The disease is not so frequent apparently, among very young infants' as measles and scarlatina. ' It does not appear that the one sex is more liable to the disease than the other. Small-pox, when it prevails epidemically, commences, accordinp- to Sydenham, about the vernal equinox, and is prolonged during sum- ' Mai. des Enfans, vol. ii. p. 453. » Diet, de Med., vol. xxi. p. l 908. Diagnosis.—Perhaps there is no disease whose diagnosis is more easy when it is fully formed. The intense fever, subsiding on the appearance of the eruption, the character of that eruption, rapidly running on from papula? to vesicles and pustules, their confluent cha- racter, and the formation of scabs, serve at once to distinguish it from any other eruptive fever. it is true that, at a very early period, we may be in doubt whether the child be about to have measles or small-pox, but a day or two will decide; and in some of the anomalous cases we may have to determine that it is small-pox, by proving that it can be neither measles nor scarlatina: but in general we shall find but little difficulty. Prognosis.—Our prognosis must be founded upon the character of the disease. If it be discrete and normal, the majority of cases re- cover; when confluent, but normal, there is more danger, but still it is often cured; but when confluent, complicated, and abnormal, it proves very fatal. M. Rayer remarks: "The gravity of the prognosis is in proportion to the number of pustules, the degree of inflammation of the skin of the face and mucous membranes, and especially of that of the air passages, the temporary or permanent character of the complications, the presence of the petechia?, and the amount of passive hemorrhage. It is unfavorable in infants during dentition. "If the eruption is successive in confluent variola, the danger is in general less imminent; if, on the contrary, the pustules appear at once on the face, neck, trunk, and limbs, the disease is one of the most serious to which the human frame is liable, and death often terminates it. Variola, with cerebral symptoms at its commencement, or in its course, is very dangerous. Ecchymoses and petechia? indicate often a fatal change in the blood, and approaching death. " Laryngo-tracheitis, croup, and pseudo-membranous bronchitis, render the prognosis more and more serious. " Obstinate ophthalmia, otitis, caeco-colitis, abscess, or other affec- tions, augment the danger during convalescence."3 It has always been one of the most fatal diseases of children. Be- fore the introduction of inoculation, the mortality was said to be 25 per cent. In London, before the discovery of vaccination, the deaths by small- pox were to the total deaths as 8 to 100; and in the last century 199,665 persons died of it. In Germany, Heim states the mortality to be 20 per cent. At the Small-pox Hospital, the average mortality for twenty-five years (from 1 On the Weather, Seasons, and prevailing Diseases of Dublin 1770 ' Dublin Journal, July, 1841, vol. xix. p. 429. » Mai. de la Peau, vol. i. p. 539. SMALL-POX. 603 1776 to 1800) was 32£ per cent. From 1800 to 1825, it was 30 per cent. In Philadelphia, from 1786 to 1802, the average relative mortality was 1 in 14, or 7.28 per cent.; from 1807 to 1811, 4 per cent.; from 1816 to 1841, after the prohibition of inoculation, about 1.66 per cent. Throughout England and Wales, the deaths now amount to about 12,000 annually, and Dr. Gregory considers that 1 in 6 may be con- sidered as about the average mortality of those attacked. As might be expected, the younger the child the more fatal the disease. Of 3022 deaths of children from this cause, in Philadelphia, in 40 years, 1810 occurred in those under ten years of age, and 555 in those under one year. Of 9762 who died in England in 1837-8, 7340 were under five years of age. 909. Treatment.—Fortunately, in the present day, we are rarely called upon .to treat small-pox, compared with former times; but even now we occasionally meet with the disease, and our treatment must be regulated by the severity of the attack, the stage of the com- plaint, and the state of the patient's constitution. The old method of close, hot rooms, w7arm clothing, and hot drinks may be considered as abolished since the time of Sydenham; expe- rience having shown that cool, well-ventilated apartments, comfortably cool bedclothes, and cooling drinks, are both more pleasant and more successful. As we cannot prevent the disease from running its course, our aim must be to mitigate such symptoms, in each stage, as may threaten to become dangerous. During the stage of incubation, we can do little or nothing, beyond having recourse to the ordinary hygienic rules ; but, during the second stage, we may endeavor to moderate the febrile excitement. When we have reason to suspect the patient of having taken small-pox, if the fever be moderate, there is little to be done beyond confinement to bed, cool drinks, a dose or two of purgative medicine, and a warm bath. But suppose the fever to be intense, are w7e to resort to blood-letting? Not simply on that account, it would appear; at the commencement, an emetic ; afterwards, purgatives and cool drinks, with low diet, will generally be sufficient, unless some complication should develop itself. If there be evidences of much cerebral excitement, of pulmonary or gastro-enteric inflammation, &c, and especially if the type of the epi- demic be inflammatory, we must have recourse to venesection or leeches. For this, we have the sanction of the highest authority, although others have objected. Dr. Gregory observes, "I can give you no rules as to the quantity of blood to be drawn. Consider the circumstances of each case, and be guided by them. Your object is to unload and relieve the lungs, the liver, or the brain. Whenever, therefore, these organs are gorged, and their functions impeded by a load of stagnant or inflamed blood; when intense headache, extreme irritability of the stomach, oppressed breathing, with a full laboring pulse, give evi- dence of such general or local congestion; draw blood, and let the 604 SMALL-POX. quantity drawn be such as to relieve the urgent symptoms. In some cases, when headache predominates, with suffusion of the eyes, leeches applied to the temples afford all the relief which is required to take off the strain from the vessels."1 Saline effervescing draughts, small doses of James' powder, &c, by promoting the cutaneous secretion will moderate the heat of the skin. Nitrate of potash has been recommended as a refrigerant by Henke and others. Lemonade, made with cream of tartar, is a pleasant beverage, and these salts also act benefically upon the kidneys. We must take care, however, not to carry the cooling regimen to excess, or the patient may be attacked by some organic disease ; and in giving acid drinks, we must have consideration for the state of the bowels. Dr. Condie recommends that the hair should be cut short, not merely for the sake of cleanliness, which it will promote,.but as dimi- nishing the tendency to cellular inflammation of the scalp, sore eyes, &c. If there be much soreness of Ihe mouth and fauces, an acidulated gargle will be useful ; if the child be too young, we may use honey with a slight proportion of borax, or sponge the mouth with an acidu- lated lotion. 910. As soon as the eruption appears, the fever generally subsides, and if there be no complication, we shall scarcely need to interfere beyond assuring ourselves of the state of the bowrels, continuing the antiphlogistic regimen, and guarding against cold. If there be any organic disturbance or inflammation, then our treatment must be carefully directed for its relief, with such modifica- tions as the presence of so severe an eruptive disease may impose. 911. During the stage of maturation or suppuration, if the disease be mild and the eruption discrete, there will be little for us to do. The cool drinks should be continued, and some slight stimulant allowed if the patient be weak, such as wine whey, weak wine and water, &c. Gargles will still be necessary in most cases, or a linctus if the infant be young. Small doses of camphor or ammonia are sometimes beneficial, and in consequence of the irritation and restlessness pro- duced by so large an extent of suppurating surface, it may be advis- able to give an anodyne, so as to quiet the nervous system, and pro- cure sleep. From the relief often afforded by a critical diarrhcea, some authors strongly advise purgatives during this period. In severe cases of confluent small-pox, where the fever assumes a typhoid type, stimulants must be freely given during this stage. Wine or brandy, chicken broth or beef tea, according to circumstances and in such quantities as the case may demand. Camphor, ammonia musk, &c. may also be administered liberally. ' On Eruptive Fevers, p. 83. SMALL-POX. 605 In petechial or hemorrhagic cases, vegetable or mineral acids are recommended, as the sulphuric, chloric, hydrochloric, and lemon- juice, either alone or in combination with quinine. Dr. Gregory thinks that these cases admit of no essential relief by medicine. The complications, which are so apt to arise at this period, will require great watchfulness to detect them, and great skill in the adaptation of the suitable treatment, which I have heretofore detailed. We must have regard not merely to the organ affected and the inten- sity of the attack, but to the present condition of the child and its future prospects. 912. The tumefaction of the face and the state of the eyelids will require great attention. Fomentations of warm water, decoction of poppy heads, or the vapor of warm water, will be very soothing. If the eyelids be closed, in addition to bathing them carefully and fre- quently, warm water should be thrown between them by means of a syringe, so as to cleanse them from the discharge. Acetate of lead in water, or decoction of poppy heads, is a very suitable application, provided there be no ulceration of the cornea; if there be, it will leave a white spot, which nothing will remove. On this account it should never be employed, unless we can ascertain the state of the cornea. In order to prevent the face from being marked, it has been pro- posed by Velpeau, Meyrick, and others to open the pustules, and touch them with nitrate of silver; and Rilliet and Barthez state that, though painful, it is effectual in preventing cicatrices. MM. Serres and Oliffe propose to paint the eruption, before it assumes the pustular form, with a strong solution of the nitrate of silver, from fifteen to forty-five grains to the ounce. Medaraine employed frictions wTith sulphur ointment. Dr. Ste- venson and others, the close application of linen spread with mercurial ointment. Of the latter, Drs. Condie and West speak favorably. Dr. Crawford, of Montreal, and Dr. Jackson, of the United States of America, state that they have been successful by pencilling the erup- tion with tincture of iodine. 913. During the stage of desiccation, after the secondary form has subsided, it will be necessary to support the strength by a gradually improving diet, wine, tonics, &c. Much care must be taken that the patient shall not take cold, or by imprudence expose himself to the secondary affections, which occur at this time. A warm bath, repeated twice a week, will be of use, not merely in cleansing the surface and in allaying the itching, but in so restor- ing the skin to its natural condition, that the troublesome rheumatic affections and abscesses may be prevented. As the itching at this time is very troublesome, we must adopt some measures to relieve it, and to restrain the child from increasing the disfigurement by scratch- ing or picking itself. Cold cream, oil, or spermaceti are recommended ; but the best remedies I know are the zinc cream, black wash, or a decoction of poppy heads, with sugar of lead. 914. The only prophylactic treatment is either inoculation or vac- 606 VACCINIA. cination: the former is prohibited by law in these countries, as it would be a foolish risk, when a better and safer remedy is at our command. I have, therefore, not entered upon the question; but those who are anxious for information may consult Dr. Thompson's work on the small-pox, or any of the older works on the subject. CHAPTER V. VACCINIA.--COW-POX. 915. If he who makes two blades of grass grow7 where one grew before be a benefactor of mankind, what shall we say of him whose genius has stayed one of the most desolating plagues of mankind, who has been the means of saving millions of human lives, who has contributed to the preservation of families, who has enlarged and ren- dered more secure the social circle, who has given permanency to holy ties, who has indirectly increased the manhood of nations and added to them more wealth and strength? It is trifling with realities to talk of the glory which involves destruction in presence of the greater glory of preservation. In the long list of earth's benefactors, very few if any will take precedence of Edward Jenner, when the true importance of things is clearly discovered. After having learned, in the last chapter, the frequency and destruc- tive extent of the epidemics of small-pox, its proportionate and abso- lute mortality, we are well prepared for appreciating the value of the remedy now to be considered. It appears that, in certain districts of dairy farms, it had been ob- served that the cows were subject to an eruption on the teats, and that the hands of the milkers frequently took this eruption from the cows—were inoculated, in fact. Those who did so regarded themselves as secure from the small-pox, and I believe were so. But although this fact was open to the investigation of every one, nay, though it had been pressed upon the notice of the provincial medical men they could or would see nothing in it. In the year 1770, when Dr. Jenner went to study in London he mentioned this popular opinion, and on his return to Berkeley in Gloucestershire, he applied himself to the investigation of its truth or falsehood. Nothing can be more interesting and instructive than the records of his labors; the patient, unwearied industry; the energy in over- coming obstacles, the acuteness in distinguishing differences the candor and honesty and strength of mind in dealing with opponents__ all convey a lesson by which we may well profit, and the relation of which I should gladly undertake for the benefit of my junior readers if I had space and time. As it is, I must content myself by saying VACCINIA. 607 that, having satisfied himself of the truth of the popular opinion, he conceived the grand idea of propagating the cow-pox by inoculation as a prevention of small-pox. This was about 1780, and he continued his inquiries yet sixteen years longer before he made his first experi- ment. On the 17th of May, 1796, a boy was vaccinated, and tested with small-pox on the 1st of July of the same year, and found unsus- ceptible. This was the hour of triumph for Jenner, and the reward of near 30 years' labor. The rest of his life was spent in furthering the spread of vaccination by his personal influence, writings, &c, and he sank to rest with the consciousness of having been made a blessing to all mankind. I shall not enter into any detail as to the subsequent history of vaccination; the objections that were made, the obstacles that were raised; nor into the successful efforts of its advocates and friends. It is sufficient to know, as all do now, that it did triumph, that it has spread from nation to nation throughout the civilized world, and that it has, in these countries, the sanction of law; for by an Act of Parlia- ment passed in 1840, propagating small-pox by inoculation is prohi- bited and vaccination prescribed to all. 916. Dr. Gregory thus describes the regular course of cow-pox: " On the third day from the insertion of the virus, the wound will be perceived red and elevated. By aid of the microscope, the efflo- rescence surrounding the inflamed point will be distinctly perceived even on the second day. On the 5th day, the cuticle is elevated into a pearl-colored vesicle, containing a thin and perfectly transparent fluid in minute quantity. The shape of the vesicle is circular or oval, according to the mode of making the incision. On the 8th day, the vesicle is in its greatest perfection ; its margin is tinged and sen- sibly elevated above the surrounding skin. In color, the vesicle may be yellowish or pearly,—the quantity of fluid which it contains will be found to vary very much. When closely examined, the vesicle will exhibit a cellulated structure. The cells are eight or ten in number, by which the specific matter of the disease is secreted. The vesicle possesses the umbilicated form belonging to variola. On the evening of the 8th day (counting from the day on which the incision was made), an inflammatory circle, or areola commences at the base of the vesicle. The skin becomes tense, red, and painful for a considerable extent around. The figure of the areola is perfectly circular. In some cases, the subjacent cellular membrane participates in the inflamma- tory action, and occasionally the glands of the axilla swell. The areola continues to advance during the 9th and 10th days. On the 11th day it begins to fade, leaving, in its decline, two or three concentric circles of a bluish tinge. The vesicle by this time has either burst spontaneously or been opened by the lancet of the sur- geon. Its contents now become opaque. The vesicle itself begins to dry up, and a scab forms of a circular shape and a brown or mahogany color. By degrees this hardens and blackens, and at length, between the 18th and 21st day, drops off, leaving behind it a cicatrix of a form and size proportioned to the prior inflammation. A perfect 608 VACCINIA. vaccine scar should be of small size, circular, and marked with radia- tions and indentations. These show the character of the primary inflammation, and attest that it had not proceeded beyond the desirable degree of intensity. Many of the perfect scars disappear entirely as life advances."1 There is very little constitutional disturbance attendant upon vac- cination; occasionally, after the 7th or 8th day, the child becomes restless, uneasy, and feverish, with loss of rest and diminished appe- tite. This disappears, after lasting for a few days. Now and then we see a child suffer during the entire course of the disease; and, on the other hand, many children go through it with no fever at all. 917. Modifications and Irregularities.—Let us first notice those cases in which these deviations do not impeach the validity of the vaccine. i. The vaccine vesicle may be tardy in its appearance ; in some cases, it shows no appearance until the 6th or 8th day, and then runs through its course ; in other cases, the delay seems to be in the ma- turation ; the inflamed spot appears at the proper time, but the vesicle is not complete until the 10th or 12th day, or even longer. Dr. Labatt has met cases where no inflammation occurred till the 12th day; Mr. Bryce, where others were deferred a fortnight; Mr. Pearson, one case where it did not appear for 20 days; Mr. King, in one instance, saw no appearance before the 46th day. We can understand that a co-existing disease, such as measles, scarlatina, diarrhoea, &c, may modify the course of vaccinia, but in many cases no such cause exists, and it is quite impossible to explain the delay. n. In some cases, on the first appearance of the vesicle, it gets rubbed, or the child scratches off the head, and the character of the vesicle is changed. It loses its proper form, and is more conoidal; its contents, too, are rather thicker and more yellow than usual, and it has near the appearance of a pustule. There is an areola around the base, and the scab is small and drops off prematurely. " When all the previous appearances have been well marked, it will occasionally happen that, at the desiccating period, pus shall be formed. When any pus is formed, it is probably the effect of local irritation. If the crust be torn off, or mechanically injured, an ulcer is often formed, which frequently, especially in scrofulous constitu- tions, proves difficult of cure."2 in. In other cases, the inflammation is very intense the areola occupies two or three times its usual extent, is of a deep-red color and resembles erysipelas. The vesicle, instead of drying, is con- verted into an ulcer involving the entire thickness of the cutis and leaving behind a deep pit as large as a sixpence or shilling.' In these cases, the suffering is considerable, and the fever sometimes runs very high. I have noticed this occurrence particularly in chil- dren beyond ten years of age and young persons, and I attribute it to rubbing during sleep for the relief of the itchiness. * On Eruptive Fevers, p. 189. « Labatt on Cow-pox p. 83 VACCINIA. 609 iv. During the course of the vaccine vesicle, we may sometimes observe a lichenoid eruption on the child's body, with a crop of vesicles here and there. It apparently arises from the peculiar irri- tability of the skin in some infants, and it may occasion uneasiness to the parents, for which, however, there is no ground. Dr. Labatt has referred to several similar examples. 918. There are other deviations from the normal course of vaccine, which are either unsatisfactory or quite inefficacious. i. The same vaccine virus may succeed with one child and fail with another, without any appreciable cause. Many children require to be vaccinated several times before we succeed, others, though rarely, resist every attempt. Mr. Bryce Vaccinated a child ten times, and failed. Mr. Elkington was himself inoculated for small-pox five times, and three times for cow-pox, but in vain. I have vaccinated one child seven times before it took the infection, and in obstinate cases, I allow a considerable interval to elapse before repeating the vaccination. In other cases, doubtless, the failure may be accounted for, either because the lymph has been taken from a spurious vesicle, or at too late a period, or upon a rusty lancet, or it has been injured by heat, exposure or moisture, or on account of some coincident disease.1 n. Occasionally, we find the inflamed spot on the third or fourth day as it ought to be in appearance, but instead of progressing in the usual manner, a smaller acuminated vesicle forms without or with very slight areola, and soon dries up into a minute scab, which falls off in a day or two. in. "Sometimes the insertion of vaccine lymph is followed by a slight inflammation, gradually increasing to the fifth or sixth day, when a pustule is formed containing opaque matter. Every now and then, the inoculated part proceeds regularly for a few days, when a watery discharge takes place, followed by a crustaceous sore, and about the eleventh day the part is usually covered by a dark-colored crust. I should distrust such cases."2 iv. Dr. Labatt has laid down the characters of spurious cow-pox so succinctly, that I cannot do better than quote them. "There are two kinds of spurious vesicles; the first bears a strong resemblance to the true in several respects; its edges are commonly elevated; its contents nearly limpid, and it continues the usual time, but it com- mences with a creeping scab of a pale brow7n or amber color, making a long slow progress, sometimes unattended by any efflorescence; the vesicle is more transparent .and the pellicle is generally thinner and easily torn. This Dr. Jenner has particularly noticed, and he ascribes it to the virus used for inoculation having been exposed to a degree of heat capable of decomposing it. "The second kind appears early and increases rapidly; is elevated in the centre and globular, with more or less of the appearance of a 1 Monro on Small-pox, p. 109. 3 Labatt on Cow-pox, p. 88. 39 610 VACCINIA. common phlegmon, and when punctured there issues opaque fluid re- sembling what is produced in any other festering sore. It is more easily ruptured: at the sixth or seventh day it generally runs into a perfectly purulent state. The areola is irregular or notched, resem- bling a large blotch; has a fiery or livid aspect; is not shaded off'into the surrounding skin, and as Dr. Cuffe observes, seems rather to be under than upon its surface, while at the same time it is less exten- sive, nor is the hardness around it so evident. A ragged scab pre- maturely covers the vesicle, or when the black crust, should form a yellowish sore appears, drying and breaking out again, with an oozing from under it. Imperfect vesicles are in general smaller, more glo- bular than the true vaccine; they have not the tinged convex margin; but a somewhat puckered base, appearing to slope off into the sur- rounding skin; they have not a cellular structure; contents not a clear, transparent lymph, but a straw7-colored, opaque, and purulent fluid; the areola not defined nor of so vivid arose tint, but ragged and diffuse, appearing about the seventh or eighth day, or earlier: on the fifth or sixth of a dark-red color, with less hardness than the true areola, and disappearing sooner; the succeeding crust is smaller, of a light lemon or amber color, irregular and friable, forms earlier, se- parates sooner, and leaves an indistinct and not pitted cicatrix."1 v. Small-pox and cow-pox may sometimes exist 'together, without any sensible modification of either, or they may each restrain or mo- dify the other. If the variola has preceded the vaccine, and the fever be high, the latter will be as it were blighted. 919. In an enormous majority of cases, the vaccine vesicle not only runs its proper course, but vaccination is successful and the child is protected against the small-pox. We have seen that the practice of inoculation was attended by a greatly diminished mortality, but not to be compared with the immunity conferred by vaccination. Not- withstanding the prevalence of natural small-pox and (until lately) of inoculation, it has been found that the mortality has gone on diminish- ing since the time of Jenner; and it is hardly too much to attribute, with Dr. Monro, the great increase of the population which took place between 1801 and 1811 compared with the previous ratio, to the lives saved by vaccination. 920. It has, however, been supposed, that its protective power may be exhausted in time, and, certainly, there is so much evidence in favor of this opinion, that in a number of cases where a genuine vesicle was formed in childhood, small-pox or varioloid has occurred in after life. Whether the number of such cases is increasing I cannot say, but for many years they were not numerous. In the report of the College of Surgeons, it is stated that of 164,381 persons vaccinated by members, only 56 or about one in 3000 were afterwards afflicted with small-pox.2 Dr. Monro thinks that such cases are more frequent than here stated. In Dr. Barow's report, I find that, between 1825 and 1832 1 Labatt on Cow pox, p. 90. » Monro on Small-pox, p. 147. VACCINIA. 611 86,646 patients were vaccinated at the National vaccine establish- ment, and of that number only tw7o deaths from small-pox after vacci- nation are mentioned. Mr. Dodd reports 201 cases of small-pox in the year 1837, of which 114 were, after repeated vaccination, 91 cases were mild, 23 severe, and two fatal. At the Royal Military Asylum, Chelsea, between 1803 and 1833: of 2533 who had small- pox before admission, 26 had small-pox again, and three died; of 3688 who were vaccinated before or after admission, 27 caught small- pox, and none died.1 It is to meet such cases that certain persons have recommended vaccination after the interval of a number of years, or periodically, every seven years. In Prussia, several extensive revaccinationshave been practised, and even among those who took it some few cases of small-pox occurred. The late Dr. Labatt, whose high standing and experience all will admit, objects to revaccinations as being unneces- sary, considering the small proportion of variola after vaccination, and also as not being valid as a test of the former vaccination or as a safeguard for the future.2 921. But granting, that a certain number of such cases occur, or even supposing them far more numerous than they are, it ought not to shake our confidence in vaccination, considering the millions who pass through life with perfect immunity from small-pox: nor would it prove that, even in those cases, vaccination was of no use. For those exceptional cases seldom or never take the genuine variola, but that modified form of it which is called varioloid, an infinitely milder disease, and one almost never involving either danger or disfigurement. 922. There is still a very interesting question remaining, viz. W7hat is cow-pox, and what relation does it bear to small-pox ? Are they simply different and incompatible diseases, or is the one a sub- stitute for the other, having some relations; or are they modifications of the same disease and identical in nature ? Dr. Jenner thought the latter, and further experiments have confirmed his opinion. A disease resembling variola prevails among animals during epi- demics of small-pox ; this can be communicated from one animal to another by inoculation, and be thus rendered milder, that it may be communicated to human beings producing a mild disease. On the other hand, human small-pox may be communicated to the cow by inoculation, producing a mild form of the disease; and if matter be taken from these pustules and a human being inoculated thereby, a disease identical with cow-pox will result, "thus inevitably proving," as Dr. Barow observes, "Dr. Jenner's fundamental proposition that cow-pox and small-pox are not bona fide dissimilar, but identical; and that the vaccine disease is not the preventive of small-pox but the small-pox itself, the virulent and contagious disease being a malignant variety." . 923. Diagnosis.—The character of a true vaccine vesicle is that it begins to appear on the third or fourth day after the insertion of the ' Labatt on Cow-pox, p. 14. ' Ibid> P- 141- 612 VACCINIA. virus, that it increases for three or four days more, until, on the eighth day, it is round or slightly oval, depressed in the centre (like a pus- tule) with elevated edges, and containing clear transparent lymph, which becomes afterwards opaque; that it has a well-marked areola, and that a brown circular scab forms, and falls off, leaving a circular depression. Dr. Labatt remarks, " I have seen the areola very faint, but seldom entirely absent; nor should 1 be satisfied with any case unattended with areola, and the normal circumscribed hardness, which I consider indicative of constitutional vaccine affection, and i" know of no other certain proof of perfect vaccination"1 Mr. Bryce, in 1802, proposed a test of the vaccination, founded on the fact, that when fresh vaccine virus is reinserted on the fourth, fifth, or sixth day from the first vaccination, but not later, the vesicles of the second form rapidly, and are hurried forward in their course, so as to overtake the first and to maturate and scab at the same time. This plan was very popular at first, but seems now to have fallen into disuse. Dr. Labatt, however, is quite in favor of this test; he says, "when correctly conducted, it will, in my opinion, give every security against future attacks of small-pox which it is in the power of vaccination to afford, but if the second inoculation be postponed beyond the sixth, or beginning of the seventh day in the ordinary course of the affection, the characteristic test will not be obtained &c.2 Dr. Gregory thinks that if there be any doubt of the perfect success of the first vaccination, it is better to repeat it after an interval of months or years. 924. Mode of Operating.—Before proceeding to the actual opera- tion, let me say a word about the lymph, and the best method of se- lecting it. i. First, then, we should be very particular in taking the matter from healthy children only. It is a popular belief that various dis- eases, and certain morbid conditions of the body, may be transmitted through the medium of vaccine lymph, and, although I do not believe this, yet I would never outrage a prejudice of the kind. Healthy children are sufficiently common, and it is a satisfactory assurance to a parent that she has no injury to fear, from this source for her child. ii. The day on which lymph is ordinarily taken, is the eighth, but it may be taken earlier, and used successfully, and it will answer at a later period. Even the scabs, when powdered and dissolved in water, will succeed, but they are not so certain. Dr. Gregory's experience is thus stated: "The younger the lymph is, the greater its intensity. The lymph of a fifth day vesicle, when it can be obtained, never fails. It is, however, equally powerful up to the eighth day, at which time it is also most abundant. After the formation of the areola, the true specific matter of cow-pox becomes mixed with variable proportions of serum, the result of common in- flammation, and diluted lymph is always less efficacious than concen- 1 On the Cow-pox. p. 81. a Ibid., p. 102 VACCINIA. 613 trated virus. After the tenth day, the lymph becomes mucilaginous and scarcely fluid, in which state it is not at all to be depended on. Out of a dozen incisions made with such viscid lymph not more than one will prove effective. The scabs of cow-pox ground to powder, and moistened w7ith lukewarm water to the consistence of mucilage, will sometimes reproduce the disease in all its purity, &C."1 But the lymph may vary in purity in different persons at the same period ; every vesicle does not necessarily contain equally efficacious lymph. It is more effectual from infants than from adults, and from primary than from secondary vaccinations. in. The usual methods of conveying the lymph are on the point of a lancet, on small pointed slips of ivory or quill, or on small squares of glass. The first is undoubtedly the best; but it is even better, when we have it in our power, to vaccinate one child from the arm of another. iv. The incisions are to be made w7ith the point of a lancet inserted into the skin, or a few scratches made upon the surface. Blood must be drawn, but too much is inconvenient, as it dilutes the lymph and is apt to run down the arm. As to the number of vesicles to be raised, different opinions have been held. At an early period, one vesicle was considered sufficient —then three, four, or six, were recommended. Some of the Germans insert twTenty or thirty, as they hold that no reliance can be placed upon the vaccination unless some constitutional effect be produced. Dr. Gregory advises that five vesicles should be produced. In this country it is, I believe, the custom generally to make two punctures, nor is it found less effectual than five. For some years I have only made one, on account of the severe inflammation which sometimes results from two or more; nor have I had any reason to suppose that my object was not as completely attained. ' On Eruptive Fevers, p. 195. SECTION VII. INFANTILE REMITTENT FEVER.—WORM FEVER.—GASTRIC FEVER. 925. This is a species of fever to which children from one year old to ten or twelve are very liable, characterized by one or more exa- cerbations and remissions, by pain of the belly, and sometimes, also, of the head, and by an unnatural state of the alvine discharges.1 Such attacks w7ere always attributed to worms by the older writers, nor do I mean to deny that, in some cases, worms may be present; but after what I have stated in the chapter on w7orms, the reader will be prepared for my rejection of them as the cause of this disease. Dr. Joy has given an excellent summary of the opinions of many writers as to the influence of worms in producing disease, and I must refer those who are curious on the subject to his paper. Dr. Butter, who has written the best essay on this subject, divides the disease into three varieties: the acute, the slow, and the low re- mittent;2 others, into the acute and chronic. In fact, the varieties differ merely in the duration of the disease, and the modifications impressed upon it by the peculiar constitution of the patient or the prevalent epidemic influence. 926. Symptoms.—The disease may commence suddenly by a severe febrile paroxysm in the night, with heat of skin, quick pulse, flushed countenance; and the thirst is intense, the tongue dry, and furred ; there are restlessness and agitation, and sometimes delirium ; the child complains, if old enough, of headache, intolerance of lio-ht, and soreness of the abdomen. Nausea and vomiting sometimes occur and the matter vomited is yellow or greenish, and has a sour smell. These symptoms abate towards morning; the skin becomes cooler the pulse quieter, and the tongue more moist. Still the skin remains dry, the tongue loaded, and the pulse quicker than natural. The child is uneasy and fretful, the abdomen tender and sore and the urine scanty and high colored, often depositing a white sediment. During the day there is a still further improvement; the child becomes more lively, although we may discern the remains of indisposition in the occasional languor and uneasiness. Towards evening, the parox- ysm returns, with fever, uneasiness, headache, &c, as before to be succeeded by a remission in the morning. 1 Cyclopaedia of Pract. Med. art. Fever, Infantile Remittent, by Dr. Joy vol ii p 239 3 A Treatise on the Infantile Remittent Fever, 17S2. ' ' v' INFANTILE REMITTENT FEVER. 615 Or the attack may come on more gradually, preceded several days by indisposition. The child looks unwell, is uneasy and fretful, picks his nose, and has offensive breath, short dry cough, loss of appetite, pain in the head and abdomen, and occasionally tympanitic enlarge- ment of the latter. The sleep is uncomfortable, and interrupted by starting, moaning, and grinding the teeth. The urine is scanty, milky soon after it has passed, and deposits a whitish sediment. The bow-els are generally in extremes, either costive or too free. Soon after this the fever is developed, ushered in sometimes by a cold fit, with rigors, sometimes stealing on so gently that its com- mencement is not marked. The paroxysm comes on in the evening, with hot skin, quick pulse, thirst, flushed face, &c, lasts during the night, and is followed by more or less complete remission in the morning and during the day. When the fever is very severe, the remissions are shortened, and sometimes are hardly perceptible. During the exacerbations, all the symptoms are aggravated ; the child is drowsy, but sleeps uneasily; it moans, starts, and talks incoherently, or may wake with a scream; the skin is hot; the pulse quickened, varying from 140 to 160 ; the respiration rapid ; a dry cough, and uneasiness in the bowels, with flatulence. Nausea and vomiting occur occasionally. During the remissions, all the symptoms are mitigated; the child is tolerably lively and cheerful; his skin cooler; the pulse from 100 to 120; and, if he sleeps, he does so quietly. Ordinarily, these paroxysms occur once in the twenty-four hours, in the evening; but they may be more frequent. Dr. Joy mentions that there are sometimes three in the twenty-four hours; one in the morn- ing, another at noon, and a third in the night, the longest and most severe of all. This daily paroxysm, with remission, characterizes the disorder, and continues during its entire duration ; but some changes take place in other symptoms, and the fever makes more or less impression on the child. The headache, which is generally felt at the beginning during the exacerbations, gradually ceases, unless in the cases of cerebral com- plication. The cough continues longer; but, if there be no pulmonary dis- ease, it is only occasional, not very troublesome, and by degrees di- minishes. The respiration is always hurried during a paroxysm, and is hardly as quiet as usual during the intervals. The breath has a peculiar sickly odor, and is often very offensive. The local affection, which is frequently developed the first—or, if not, which certainly persists the most obstinately—is disorder of the intestinal canal. The bowels are frequently constipated in the be- ginning, and then attacked by diarrhoea; or, they may be too free from the commencement, and afterwards the diarrhoea may continue or alternate with constipation. Most frequently, I think the bowels are too much moved. The amount discharged each time varies; 616 INFANTILE REMITTENT FEVER. sometimes there are copious evacuations; at others, very little fecal matter, w7ith much wind. The character of the stools is unhealthy, and highly offensive; they may be clay-colored, dark and slimy like tar; or mixed with mucus occasionally, and a little blood. In the latter cases, the attack as- sumes somewhat of the appearance of dysentery. The abdomen feels very hot to the touch, and somewhat tender on pressure; and the child now and then complains of pain in its bowels. In some cases, the abdomen is distended with flatus ; but I think it is more frequently flat, or even concave. Worms are sometimes dis- charged by stool; sometimes, but very rarely, by vomiting; and oc- casionally they crawl out of the anus spontaneously. The urine, which at first was whitish, becomes yellow and very transparent. Dr. Condie has noticed a rose-colored, lenticular eruption upon the abdo- men or inner surface of the thighs, and occasionally sudamina upon the abdomen, or along the front and sides of the neck. 927. Thus, the disease may go on from day to day for an indefinite time, without any very bad symptoms arising, but without any ad- vance being made towards cure ; the child becoming weaker and thinner, until it is so reduced in flesh and strength that recovery seems improbable; and yet from this state it rallies astonishingly, if no complication take place. By degrees, the bowels become more quiet and regular; the discharges more natural; the urine again de- posits a copious sediment; then the tongue cleans, and the pulse falls. A gentle moisture appears on the skin, the sleep is quiet and refresh- ing, and the daily exacerbation does not appear. The pulse, however, in some cases, remains quicker than natural after the other symptoms have disappeared. On the other hand, the child may sink from mere exhaustion, or the intestinal affection may become more serious, presenting the charac- teristics of entero-colitis or colitis, and, in its reduced state, speedily prove fatal to the child; or, lastly, the nervous system may become implicated, and the child be carried off by coma or convulsions. The duration of the disease is very uncertain ; it may last from a w7eek to a month, and it does not terminate by a crisis. 928. Not only is the duration variable, but the rate of progression also, if I may use the expression, and this is probably a sufficient explanation of Dr. Butter's slow variety; in which we remark that the disease comes on slowly and unnoticed ; the child slowly declines • the appetite diminishes, then fails altogether; the breath offensive' and the abdoimen enlarged. One daily exacerbation occurs in the evening, and lasts until morning, succeeded by a profuse sw7eat During the day, the skin is dry and harsh, and there is a hectic flush upon the cheeks. The pulse ranges from 100 during the remissions to 140 during the exacerbations. The child is sleepy, dozino- un- easily, with starting and moaning; and, when awake, he picks his nose and fingers until they are sore. The tongue is white, loaded and moist; there is no appetite, and but little thirst; the urine is of INFANTILE REMITTENT FEVER. 617 a deep yellow color, and in the morning contains a sediment. The stools are unhealthy, and of the same kind as in the former variety. This form of disease may be developed very slowly, and may last for one or two months, reducing the child as much, but less rapidly, than the other form. Dr. Condie has given a description of a chronic form of the disease, which answers pretty accurately to this slow variety of Dr. Butter. "The exacerbations," he says, " are of longer duration, but marked by symptoms of less intensity than in the more acute attacks of the dis- ease ; the remissions are also less distinct. The abdomen is usually tender and hot, and generally tympanitic ; the bowels are often affected with diarrhoea, the dejections being always unhealthy in appearance and fetid. The tongue is thickly coated on its upper surface with a yellowish or brownish mucus, and red and dry at its point and edges; the teeth are often covered with sordes, and the lips parched and cracked; the urine is scanty and high colored, throwing down a co- pious white sediment, particularly during the remissions; the skin is dry, harsh, and of a sallow or dirty hue ; the countenance is contracted and wrinkled, presenting the appearance of premature old age. The appetite is often unimpaired, and in some cases it is even voracious ; in general, howrever, it is altogether lost. The child is very generally affected by a short, hacking, and frequent cough. Most commonly, there is urgent thirst. There is always more or less fretfulness, with the usual indications of suffering; and the patient exhibits a disposi- tion to pick almost constantly at some portion of its face or body, or at the bedclothes, or at the face and arms of its attendants. If there be an accidental pimple on the skin, this will usually be picked until a sore be produced, the edges of which are still more eagerly attacked, so that the fingers are constantly stained with blood. This picking is by many considered to be one of the diagnostic symptoms of infantile remittent fever ; it is, howrever, a common phenomenon in all the chronic affections of childhood, and is often observed when no disease whatever is present."1 929. Yet, again, the symptoms and course of the disease may be varied by the constitution of the individual, or perhaps by the atmo- spheric constitution at the time, to produce what has been termed the low form of infantile remittent; and I gladly avail myself of the sum- mary which Dr. Joy has given us: " The low infantile fever begins suddenly, and for the first week perfectly resembles the acute, save that the head is more affected, and delirium sometimes occurs. After this, the low state succeeds, the child becoming quiet, indifferent to surrounding objects, and indisposed to answer questions. He rarely asks for anything, but takes his food or drink when it is offered to him : the trunk and lower extremities generally remain fixed in one posture, but the arras and hands are almost always in motion when he is aw7ake; sometimes he flings them about, and at other times picks not only his nose and lips, but even his tongue, eyes, and other parts 1 Diseases of Children, p. 250. 618 INFANTILE REMITTENT FEVER. of his face till they become sore. At the height of the disease, the difficulty of replying to questions, arising from debility, terminates in a temporary loss of spirits and voice, and the jaws are occasionally locked together. He slumbers much during the exacerbations, and in the remissions performs with his hands the gesticulations above described. When the low stage sets in, the eyes are reddish, dull, and inattentive; the countenance is expressive of distress; and the tongue, teeth, and lips are covered with a blackish fur. The patient is particularly uneasy before stools, or the escape of flatulence. The urine and stools, which are of an unnatural appearance, are involun- tary; yet he is quite sensible. The pulse, which is about 100 in the remissions, rises to 120 in the exacerbations. W7hen the disease takes a favorable turn, the exacerbations become shorter ; the child is less drowsy; the eyes are clearer, and more observant; the counte- nance is placid, and the tongue cleaner; the pulse is calmer, and the appetite returns. The voice is regained, and, though weak at first, soon becomes stronger, and is frequently exercised, as he cries when- ever he is disturbed or wants anything, or if he feels himself unable to reply to questions; or to put out his tongue when desired. The strength, the flesh, and color are gradually recovered; and he yawns, sneezes, or coughs, which he was previously unable to do. The urine, which is of a straw color, is still, for a considerable period, passed involuntarily. The crying and fretfulness long continue. The stools at length become natural, and there is no complaint made but of weakness. The pulse occasionally continues accelerated till the recovery is complete. The duration of this fever is from a month to six weeks or even longer."1 In practice, various modifications both of the symptoms and course of the disease are observed, all of which cannot easily be enumerated. One of these has been noticed by Huxham, who says, " In the fevers of children, the face is sometimes drawn to one shoulder. I have often seen this, but never knew it continue long after the fever was cured." Underwood has noticed this also; and Dr. Joy adds, "A tenderness and intolerance of pressure in the upper part of the spine, with this a general increase of the sensibility of the whole surface of the body, seem sometimes to coexist, so that the child can scarcely bear to be touched in any part." Dr. Pemberton observes "that the intestines seem to be in a manner paralyzed ; they exert no action on the food, for it passes off like a mass of putrid animal and vegetable matter which had been some time subjected to heat and moisture, without its havino- the smallest resemblance either in appearance or smell to those feces where the powers of digestion have been exerted."2 930. Complications.—No doubt, the child may die from exhaustion in this disease; but, I am sure, all whose fortune it has been to see much of the disease will agree with me that the chief danger is from * Cyclop, of Pract. Med., vol. ii. p. 241. 3 On the Diseases of the Abdominal Viscera, p. 165. INFANTILE REMITTENT FEVER. 619 the complications to which it is liable in some part of its course. Of these, I shall notice the three principal ones :— 1. Convulsions, or Meningitis.—We rarely, if ever, see convul- sions in the beginning of the disease ; it is only after it has lasted some time, and whilst reducing the strength of the child has quickened the susceptibility of the nervous system, that the attack is to be feared. Sometimes, the child is attacked by one or more convulsions, occa- sional staring, twitchings of the muscles, &c.; or these symptoms may come on gradually without a convulsion. WTe may find the hands clenched, the thumbs and great toes turned in, the eyes staring or twinkling, suppressed breathing, and then a sigh, followed after a time by jerking of the limbs, convulsions or paralysis of one side, with incessant aimless motion or convulsion of the other; in short, by the symptoms of meningitis already enumerated, but in a subdued degree ; for the child is too generally weak to develop the new disease fully, and indeed is generally carried off before it has time. This attack appears to arise from irritation of the cerebro-spinal system, in consequence of the continued irritation of the intestines. It is a very fatal complication, and in remittent fever is always to be feared. No visit should take place without a careful scrutiny into the condition of the brain, nor a moment lost when any suspicious symptom arises. 2. Entero-colitis, or Colitis.—That remittent fever is always ac- companied with more or less gastro-enteric irritation is quite evident; but it may be doubted whether this amounts to inflammation in ordi- nary cases. In certain other cases, how7ever, this complication does take place, and it may occur at any period, either early, or, more commonly, at a more advanced stage. Enteritis will be evidenced by an increase of all the abdominal symptoms, pain, tenderness, tympanitis, diarrhoea, &c. Colitis, or Dysentery, by the frequent desire to go to stool, and the substitution of small quantities of mucus and blood for the former un- healthy discharges, and by the other general and local symptoms ■which I formerly described. 3. Bronchitis, or Pneumonia.—From the beginning there is often a dry troublesome cough, owing probably to some sympathetic irritation of the mucous membrane of the bronchial tubes, which may, at any period, degenerate into an attack of bronchitis, or, descending still lower, give rise to lobular pneumonia. 931. Pathology.—A post-mortem examination reveals in all cases a certain amount of disease of the intestinal canal. Evidence of in- flammation varying in extent, sometimes in the stomach and small intestines, sometimes in the ileum chiefly, or in the ileum and colon. The mucous membrane is reddened in patches, or exhibits red striae or points, and it may be thickened, softened, or ulcerated. The iso- lated follicles are generally enlarged, as well as the patches of follicles in the small intestines, and they are sometimes softened or ulcerated.1 1 West, Diseases of Infancy and Childhood, p. 454. 620 INFANTILE REMITTENT FEVER. When the patient has been carried off by entero-colitis or colitis, the usual morbid lesions are found. , oevorv The mesenteric glands are frequently enlarged, sometimes very considerably ; and, if the disease be of long standing, they may be in a state of suppuration, or converted into a cheesy matter. In some rare cases, there are evidences of peritonitis, and the peri- toneum may be studded with minute tubercles. The liver is enlarged from congestion, very rarely changed in texture. _ The usual appearances of meningitis or tubercular meningitis will be found in those whose disorder has been thus complicated ; and the same may be said of bronchitis and pneumonia. 932. Next comes the question as to the nature of the disorder. Is it a fever depending upon worms or a gastro-enterite, or a fever with gastro-enteric complication, but not caused thereby? 3 We may, I think, dismiss the first opinion, although backed by those who were great authorities in their day. In a very large ma- jority of cases, no worms are evacuated, and they are rarely, if ever, detected after death; the evidence, therefore, is insufficient. For the second opinion, we have the authority of almost all the writers upon the subject. m Dr. Underwood considers it to arise merely from an affection of the prima? via?. Dr. Eberle agrees with those who attribute it to irritation located in the stomach and bowels, with disordered functions of the biliary- organs. Dr. Stewart, that the great cause is excitement of the intestinal mucous membrane. Dr. Condie considers it, in every case, as " the result of inflamma- tion, most commonly subacute, of the digestive mucous membrane." Dr. Pemberton regards the fever as merely symptomatic of derange- ment in the intestines. Dr. Joy regards it merely as a variety of gastric fever, modified by the irritable constitution of infancy. Sir H. Marsh observes that "its characteristic symptoms, if closely analyzed, will be found, all of them, to point to the mucous surface as the "original seat of morbid action;"1 with which opinion, Maunsell and Evanson concur. The French authorities are nearly unanimous in regarding the dis- ease as gastro-enteritis, and the fever as symptomatic. At the same time, if we take and carefully examine the simpler and milder cases, I think we may find ground to doubt the existence of any inflamma- tion, and be rather more inclined to look upon the gastric symptoms in some cases as a complication rather than as being essential to the disease. We must necessarily discard the evidence of morbid anato- my, because our obtaining any may be a consequence of some com- plication foreign to the disease. 933. Causes.—Cold and teething are two principal causes of remit- 1 Dub. Hosp. Reports, voL iii. p. 316. INFANTILE REMITTENT FEVER. 621 tent. Another is irregular or unwholesome food, excess, and neglect of the bowels. I am not sure whether over-dosing with purgatives may not also give rise to it. It has been supposed, but I believe without any truth, to be propagated by contagion. That it prevails epidemically, seems beyond doubt. Dr. Butter speaks of it as either sporadic or epidemic; and Dr. Sims has described an epidemic which occurs at the same time with the prevalence of a low nervous fever among adults. " It was called," he says, "by some a worm fever, though I believe worms were seldom the cause; yet, as that lay apparently in the stomach and intestines, the error did not mate- rially affect the practice." 934. It may also occur as a secondary affection in the course of hooping-cough, or disease of the pulmonary mucous membrane, after the sudden cure of an eruption, or as one of the sequela? of an erup- tive fever ; or as a termination of dysentery. 935. Diagnosis.—The great difficulty is in the diagnosis of remit- tent fever from meningitis; and, no doubt, it is often a very difficult point. Nay, more, towards the end of the disease it may be impossi- ble because of the supervention of certain head symptoms ; such as drowsiness, staring, starting from sleep with screaming, &c, which may be either functional disturbance, the result of irritation merely, or the commencement of hydrocephalus. In such cases, time and the result of treatment are our only helps. In other cases, it may assist us to remember that, in remittent, there are no distinct stages, no changes in the pulse such as we noticed in meningitis; that there is a distinct remission, which there is not in meningitis; that the disease lasts for a much longer time; that the heat of the head is not specially increased ; that there is not generally clenching of the thumbs and toes, or twitchings ; that the head is not rolled or tossed about; that, except at the first, there is no intolerance of light or sound; that the intellects are not obtuse; and that, unless complicated, there is no convulsion. Further, although there maybe occasional vomiting, there is sufficient gastro-enteric irritation to account for it, and very much more than is usual in hydrocephalus. 936. Prognosis.—Notwithstanding the lengthened nature of the attack, and the great extent to which the child is reduced, if there occur no complication, the prognosis is by no means unfavorable. The majority of such cases recover, and those who die either sink from exhaustion, or, more commonly, are carried off'by some compli- cation. Convulsions or hydrocephalus coming on after the disease has lasted some time, are almost invariably fatal. Pulmonary or in- testinal inflammation, though not so certainly mortal, is frequently so, and requires not merely great care and skill, but a strong constitution on the part of the child to enable it to struggle through. The dimi- nution of the exacerbations, the return of healthy evacuations, of sleep, appetite, and a quiet pulse, are all favorable signs; whilst, on the other hand, an increase of fever, with either abdominal, pulmo- nary, or, still more, cerebral symptoms, is highly unfavorable. 937. Treatment.—Very active treatment is out of the question in 622 INFANTILE REMITTENT FEVER. any variety, and a good deal of our success will depend upon the regimen adopted. The child will either be in bed, or should be placed and kept there, lightly clothed, and in a well-ventilated apart- ment. The gums should be carefully examined, and, if the least swollen, they should be divided freely. Suppose we see the child soon after the commencement of the attack; if the bowels are consti- pated, we should order a purgative powder of calomel and rhubarb, or jalap or calomel alone, followed by a moderate dose of castor oil. Dr. Butter preferred sulphate of potash or some of the neutral salts as a purgative. Dr. Sydenham gave an infusion of rhubarb in beer. Dr. Hosack preferred infusion of senna with supertartrate of potash and manna. If the bow-els are purged, or in a very irritable state, our first ob- ject must be to quiet them either by chalk mixture with a drop or two of laudanum, or a mixture of mucilage, syrup, caraway-seed water, and a little laudanum in proportion to the age of the child. Having freed or quieted the bowels, we may next give small doses of the hydr. c. creta, with Dover's powder or ipecacuanha; or calo- mel and antimonial powder, as Dr. Cheyne advises. He remarks, " Antimonials, in combination w7ith cathartics and more especially calomel, have appeared to me very useful in those cases of infantile remittent fever in which the sensorial functions are much oppressed, as also in the commencement of febrile attacks of a less definite na- ture which are liable to degenerate into hydrocephalus. In such cases, I prescribe a pill of calomel and antimonial powder three times a day, interposing between every two pills a moderate dose of the com- mon purgative mixture." WThen the bowels are irritable, calomel will often not be borne, and I have then given the gray powder, with Dover's powder and some- times with ipecacuanha, with great benefit. Two grains of gray powder, with half a grain of each of the others, may be given three times a day to a child of five years old. Dr. Butter gave hemlock when diarrhoea was present: he dissolved five grains of conium in four ounces of water, and gave two tea- spoonfuls for a dose to children of five years of age. He thought it both checked the looseness and relieved the fever. A saline diaphoretic mixture may also be given with great benefit if it do not act upon the bowels. Warm baths, fomentations, or poultices to the abdomen are of great use; the latter I sometimes direct to be made of linseed meal with one-third flour of mustard. Dr. Merriman remarks: " Some practitioners seem to rely upon purgatives alone; but the saline mixture, nitre, and antimonials assist so much in abating the disease that they ought not to be omitted • and, in cases of great irritability, small doses of the milder narcotics are to be employed; nor ought the advantages to be overlooked which may be gained by pediluvia, fomentations to the abdomen and ablu- tions with tepid water. As the disease advances, bitters ammonia bark, the mineral acids, &c, may be required." INFANTILE REMITTENT FEVER. 623 If the cough be troublesome, we must order a mixture with ipe- cacuanha, syrup of squills and almond milk, with a little paregoric. When the fever is intense, and the exacerbations very severe, Eberle and Condie recommend the abstraction of a small quantity of blood from the arm, or the application of a few leeches to the abdo- men. The former, I think, will scarcely ever be necessary; but, if there be much tenderness of the abdomen, two, three, or four leeches to the most painful part, followed by poultices, will be of great service. 938. WThen the disease has lasted for some time—but the precise moment must be left to the judgment of the practitioner—we may have recourse to mild tonics. Dr. Pemberton, indeed, gave a light infusion of cascarilla three times a day throughout the whole disorder. Minute doses of quinine may also be given; and Dr. Clarke is an advocate for their early employment. After giving an emetic and a purgative, he at once began with the bark. "By this means," he says, "the nervous symptoms which so frequently accompany fevers in the delicate habits of children are for the most part happily obviated." Dr. West speaks favorably of the following prescription, if there be no abdominal irritation, viz., four minims of dilute hydrochloric acid, eight of the compound spirit of sulphuric ether, and three drachms of camphor mixture every six hours for a child of five years old. The diet should be very moderate or even low7 at first. Milk in every form, arrowroot, sago, gruel, tea, &c, may be permitted, with plenty of cold water if the child be thirsty. WTien, from the duration of the disease, weakness and exhaustion have resulted, we must improve the diet, and allow chicken broth, beef tea, &c. In some cases, it is absolutely necessary to give wine and water or wine whey; nor have I found the tendency to cerebral complications at all increased thereby, if it be given in small quantities frequently- repeated. During convalescence, also, great care must be used, in returning to the usual diet, not to over-feed the child ; and, in resuming its usual habits, that it shall not be exposed to cold. Of the treatment of the complications, I need say nothing, having entered fully into the subject under their proper heads. INDEX OF AUTHORS AND WORKS REFERRED TO IN THIS VOLUME. Abercrombie, J., M. D. Pathological and Practical Researches on Diseases of the Brain, &c.: Amer. edit., Philada., 1843. Abernethy, J. On Diseases of the Brain. Albert, Dr. Hufeland's Journal der Practische Heilkunde, Aug. 1830. Albert, Mich., M. D. De Tussi Infantili Epidemica: Halle, 1728. Alcock, Dr. Dublin Medical Journal. Alcock, Thos., M. D. Lectures on Surgery: London, 1830. Alderson, Dr. Med.-Chir. Transactions, Pathology of Hooping Cough, 1830. Aldis, Dr. Medical Gazette. Alison, Scott, M. D. On Dropsy following Scarlet Fever: London Journal of Medicine, No. 3, 1849. Andral, M. Mai. de 1'Abdomen, in Clinique Mddicale. Armstrong, Geo., M. D. An account of the Diseases most incident to Children: London, 1783. Ashburner, J. On Dentition and some coincident Disorders: London, 1834. Ashwell, Samuel, M. D. Diseases of Females: Amer. edit., Philada., Lea and Blanchard, 1847. Baffos, M. Cooper's Surgical Dictionary. Bailly and Legendre, MM. Archives Generates de Mddecine, January and Feb- ruary, 1844: Nouvelles recherches sur quelques Maladies des Poumons. Bard, S., M. D. Transactions of the American Philosophical Society. Barnard, Dr. Lancet. Baron, Ch. De k, Pleur^sie dans l'Enfance: These, Paris, 1841. Barrier, F. Trait6 Pratique des Maladies de l'Enfance: 2d edit., Paris, 1845. Barthez, M. Archives G6n. de Med., July, 1838. Bateman, Dr. Edinburgh Med. & Surg. Journal. Bateman, Thos., M. D. Practical Synopsis of Cutaneous Diseases: London, 1817. Battersby, Dr. Dublin Journal, Nov. 1847. On Hare Lip. Baudelocque. Lancette Francaise, 1837, Art des Accouchemens. Baumes, J. B. T. Trait6 de l'Ict6rus ou Jaunisse des Enfans de naissance: Paris, 1805. Bedor, M. Dictionnaire de MSdecine de Fabre. Bennett, J. H., M. D. Des Vegetaux qui croissent sur 1'Homme et sur les Ani- maux vivans, 1847. Bennett, Henry, M. D. Lancet, December 30, 1843. Bernhardi. Preuss. Med. Zeitung. B6rard, M. Manuel d'Anatomic Berton, E. A. J. TraitS des Maladies des Enfans: 2d edit., Paris, 1832. 40 626 INDEX OF AUTHORS AND WORKS REFERRED TO. Berzelius, J. J. Traite de Chimie: Paris, 1829. Biett; in AbregS Pratique sur les Maladies de la Peau, by Cazenave & Schedel: Paris, 1828. Amer. edit., Philada., 1829. Bigger, Dr. Dublin Medical Press. _ w Billard, C. M. Traite des Maladies des Enfans Nouveaux-nes: Paris, 183/. Amer.edit., by Jas. Stewart: New York, 1845. Blache. Dictionnaire des Sciences M6d. Blache. Archives Generates. Blancard, S. Collect. Phys. Med.: cent. 1, obs. 75. Blane, Sir Gilbert. Lectures on the Structure and Physiology of the Bones: London Lancet. Blaud de Beaucaire. Nouvelles recherches sur la Laryngo-trachSite: Paris, 1824. Bouchut, E. Manuel Pratique des Maladies des Enfans Nouveaux-n6s et des Enfans a la mamelle: Paris, 1845. Bouillaud, J. Traite des Maladies du Coeur: Paris, 1835. Brendel. Prog, de Tussi Convuls.: Gotting. 1747. Breschet, G. Dictionnaire des Sciences Medicales. Bretonneau, P. Des Inflam. Sp6ciales du Tissu Muqueux et en particulier de la Diphtherite: Paris, 1826. Brewerton, Mr. Ed. Med. and Surg. Journal. Brunet, F. Memoire sur la Pneumonie lobulaire, in Journal Hebdomadaire des Sciences Medicales, 1833. Buffon. Histoire Naturelle. Bull, Thos., M. D. Maternal Management of Children. Amer. edit., Philada., 1849. Burgess, Dr. Eruptions of the Face, Head, and Hands. Burrows, Dr. Medico-Chirurgical Transactions. Butter, W. A Treatise on Kink-cough: London, 1773. Butter, Dr. Treatise on Infantile Remittent Fever: London, 1782. Campbell, Dr. A. B. Northern Journal of Medicine. Carmichael, Mr. Transac. of the Association of Physicians of Ireland. Caspar. "Wochenschrift. Cazenave, P. L. A. Legons sur les Maladies de la Peau. Charcelay, M. Recueil de la Soc. Med. d'lndre et Loire. Chaussier. Bull, de la Faculte de Med., 1821. Chelius, Max. Jos. Handbuch der Chirurgie: Heidelberg, 1829. Amer. edit. translated and edited by South: Philada., Lea & Blanchard, 1848. Cheyne, Dr. J. Essay 2, On "Bowel Complaints. Essays on the'Diseases of Children: Edinburgh, 1801. J Cheyne, Dr. J. On Acute Hydrocephalus, 2d edit.: Dublin, 1809. Cheyne, Dr. J. Pathology of the Larynx and Bronchia: Edinburgh 1809 Chomel & Bouillaud, MM. Clinique, vol. ii. Churchill, F., M. D. Theory and Practice of Midwifery. Amer. edit by R M. Huston, M. D.: Philada., Lea & Blanchard, 1848. ' Clark, Sir James. On Consumption. Amer. edit., Philada. 1835. Clark, James. On Yellow Fever: London, 1798. Clarke, Dr. John. Commentaries on Diseases of Children: London 1798 Clarke, Dr. Joseph. Transactions of the Royal Irish Academy ' Cogswell, Dr. N. Y. Med. Repository. ' Coley, John Milman. Practical Treatise on the Diseases of Children : London Collins, Dr. Practical Treatise on Midwifery. Amer. edit Philada Condie, D. F., M. D. On Diseases of Children: 3d edit., Philada 1850 Constant, M. Gazette des HSpitaux. *' Constant, M. Gazette Medicate. Combe, Dr. A. On the Management of Infancy and Childhood A mo* ara* by J. Bell, M.D.: 1840 Amer. edit., Cooper, S. Surgical Dictionary. Copland, Jas. Dictionary of Medicine. INDEX OF AUTHORS AND WORKS REFERRED TO. 62% Cormack, Dr. Rose. London Journal of Medicine. Cotugno, D. De Sedibus Variolarum: Neapoli, 1775. Crisp, Mr. London Medical Gazette, Dec. 1846. On Infantile Pleurisy. Cruveilhier, J. Anatomie Pathologique du Corps Humain: Paris, 1832. Cullen, W., M. D. First Lines of the Practice of Physic. Amer. edit.. Philada., 1822. Cumming, T. Observations on Peripneumonia of Children, in Transactions of Assoc, of College of Physicians in Ireland, vol. v. Danz, F. G. Versuch einer Allgemeine Geschichte des Keichhustens: Mar- bourg, 1791. Darwall. Plain Instructions for the Management of Children. Davis, Dr. D. On Acute Hydrocephalus : London, 1840. Dease, W. Observations on Midwifery: Dublin, 1785. Deleurye. La Mere selon l'Ordre de la Nature. Dendy, W. C. Portraits of the Diseases of the Scalp. Denis, R. S. Recherches Anatomiques et Physiologiques sur quelques Maladies des Enfans: Paris, 1824. Deschamps. Journal de M6decine. Desruelles, H. M. J. Trait6 Theoriqae et Pratique du Croup: Paris, 1822. Desruelles, H. M. J. Traite de la Coqueluche: Paris, 1827. Dessault, P. Traite des Mai. Chirurg.: Paris, 1795. Dewees, W. P., M. D. A Treatise on the Physical and Medical Treatment of Children: 9th edit., Philada., 1847. Dieffenbach, M. Abscessus Capitis Sing. Neonatorum, in Rust's Handbuch der Chirurgie: Berlin, 1830. Dubois, M. Nouv. Dipt, de Medecine. Duges, A. Recherches sur les Maladies les plus importantes et les moins con- nues des Nouveaux-n6s: Paris, 1821. Duges, A. Diet, de M6d. et de Chir. Pratiques, Art. Gynaecologie. Duges, A. Manuel d'Accouchemens. Duncan, Dr. Dublin Quarterly Journal of Med. Science : 1845. On the Epi- demic Ulceration of the Gums in Children. Dunglison, Dr. Robley. On Diseases of the Stomach and Bowels in Children: London, 1824. Dupuytren, Le Baron. Legons orates de Clinique Chirurgicale: Paris, 1832-4. Eberle, John, M. D. On Diseases of Children: Cincinnati, 1833. Edwards, "W. F. S. On the Influence of Physical Agents upon Life : American edition, Philadelphia, 1838. Elsasser, Dr. Die Magenerweichung der Sauglinge: Stuttgard, 1846. Engelmann, M. Archives G6n6rales de Medecine, June, 1838. On the Treat- ment of Hydrencephalus by Compression. Fabre, M. Bibliotheque de Medecine Pratique. Fedran, M. Memoires de l'Acad. de Chirurgie. Ferguson, Prof. Transactions of the Royal Medical and Surgical Society. Ferguson, Prof. London Journal of Medicine, 1849. Ferriar, S. John. Medical Histories and Reflexions : Manchester, 1795. Ferrus, M. Dictionnaire de Medecine. Fisher, Dr. On Cerebral Auscultation, in American Journal of the Medical Sciences, March, 1838, and October, 1843. Fleischmann. Die Entzvindung. Fleischmann. De Vitiis Congenitis circa Thoracem et Abdomen. Fleming, Dr. Dublin Medical Journal. Fortin, M. C6phalaematome sous pericran. Francis, Dr. New York Medical and Physical Journal. Fried. Extrait. des Theses de Halter. Friedleben & Fleisch, MM. Zeitschrift fur Rationelle Medicin, 1846. On the Pathology of the Intestinal Mucous Membrane in Young Infants. Fyfe, Dr. Provincial Medical and Surgical Journal, June 16, 1847. 628 INDEX OF AUTHORS AND WORKS REFERRED TO. Gendrin, A. N. Translation of Abercrombie. Gerhard, Dr., W. W. Lobular Pneumonia of Children: in American Journal of the Medical Sciences, 1834. Geoghegan, Dr. Medical Press, March 8, 1848. Gintrac, E. Observations et Recherches sur la Cyanose: Paris, 1824. Gintrac & Breschet, MM. Repertoire G6n. d'Anatomic Gooch, R., M. D. Diseases of Women. Good, J. M., M. D. Study of Medicine: American edition, by Dr. Doane: New York, 1843. Golis. Treatise on the Hydrocephalus Acutus, translated by R. Gooch, M. D.: London, 1821. Golis. Practische Abhandlungen. Grsetzer, J. Die Krankheiten des Fotus: Breslau, 1837. Graves, Dr. R. J. Clinical Lectures : second American edition, Philada., 1848. Green, Dr. Lancet. Green, Dr. Med.-Chir. Transactions, vol. xxv. On Tubercle of the Brain in Children. Gregory, Dr. G. On Eruptive Fevers. Grisolle, A. Traite Pratique de la Pneumonie aux differens ages : Paris, 1841. Gruner. Var. Antiq. ab Arab. Guersent. Dictionnaire de M6decine; Art. Croup. Guibert, H. Recherches sur la Croup et la Coqueluche : Paris, 1824. Gumprecht. Medico-Chirurgical Transactions. Hache, M. Maladies des Enfans. Haine, M. Ranking's Abstract. Hall, Marshall, Dr. Diseases and Derangements of the.Nervous System: Lon- don, 1836. Halter, A. De Monstris: Gotting. 1751. Hamilton, Dr. Jas., Jr. On Diseases of Infants : London, 1809. Harris, Dr. W. De Morbis Acutis Infantum: London, 1705. Hawkins, F. Bisset. Elements of Medical Statistics: London, 1829. Hayes, Pliny. Braithwaite's Retrospect, vol. ix. Hegewisch, Dr. Rust's Magazin. Heim, M. Hufeland's Journal. On Revaccination. Henke, A. A. Handbuch der Kinderkrankheiten : Frankfort, 1621. Herrich & Popps. Der Plotzlichen Tod aus inneren Ursachen. Hess, Prof. Ranking's Abstract. Heyfelder. Beobachtungen liber der Krankheiten der Neugebornen 1822. Heyfelder. Studien in Gebiete der Heilwissenschaft. Hillary, W., M. D. On the Small-pox: London, 1735 Hird, M. Lancet, Dec. 1846. Hoere, G. F. De Tumore Cranii recens natorum sanguineo, &c.: Berlin 1824 Home, Dr. Medical Facts and Experiments, 1759. Hood, P. Practical Observations on the Diseases most fatal to Children &c • London, 1845. ' Hope, J., M. D. On Diseases of the Heart: second American edition Phila Horner, W. E., M. D. American Journal of the Medical Sciences 1829 1831 On the Pathology of Cholera Infantum and Infantile Convulsion*' Hughes, Dr. Guy's Hospital Reports, Nos. 3 and 4, 1844 Hutchinson, A. C. Surgical Dictionary. Isenflamm. Archives Generates de Medecine. Jackson, S., M. D. (of Northumberland). American Journal of tha tu^j- i Sciences, Aug. 1834. On Gangrsenopsis. f the Medlcal Jaeger. Hufeland's Journal, 1811. On the Softening of the Stomach in Chil- Jahrbericht iiber die Leistungen des Unentzeldlischen Kinderkranken In t' INDEX OF AUTHORS AND WORKS REFERRED TO. 629 Jervis. Journal G6n. de Mddecine. Johnson, C. On Hooping Cough, in Cyclopaedia of Practical Medicine. Joy, Dr. Cyclopaedia of Medicine, Art. Fever, Infantile Remittent. Keilmann. Prodrom. Act. Havn. Kennedy, Dr. H. Some account of the Epidemic of Scarlatina which pre- vailed in Dublin from 1834 to 1842: Dublin, 1843. Kerkring, Thos. Spicilegium Anat., obs. 57 : Amsterdam, 1670. Krukenberg. Jahrbiicher des Ambulatorischen Klinik zu Halle, 1824, 2 vols. Labatt, Dr. On Cow-pox. Laennec, R. T. H. De 1'Auscultation Mediate: 3me edit., Paris, 1831. Lallemand, Prof. On Softening of the Brain. Latham, P., M. D. Lectures on Diseases of the Heart: Amer. edit., Philada., 1848. Lee, C. A., M. D. New York Medical and Physical Journal. Legendre, M. Recherches, &c. sur quelques Maladies de l'Enfance. Paris, 1846. Leger, V. Essai sur la Pneumonie des Enfans: These, Paris, 1823. Lelut. Archives G6nerales de Medecine. Ley, Dr. Hugh. On Laryngismus Stridulus: London, 1836. Linnaeus, C. Diss. Exanth. viv.; in Amoenitat. Lindsley, Dr. American Journal of the Medical Sciences, vol. xxiv. 1839. On Cholera Infantum. Lion, Dr. Ranking's Abstract. Liston, R. Practical Surgery: Amer. edit., Philada., 1848. Louis, P. C. A. Memoires et Recherches Anatomico-pathologiques: Paris, 1826. Louis, P. C. A. Recherches Anat. Path, sur le Croup considere chez l'Adulte: Paris, 1826. Malespini. Archives Generates de Medecine. Malgaigne, M. Bull, de Therap., 1840. Marcus, A. F. Der Keichhusten: Lips., 1816. Marcus, A. F. Traite de la Coqueluche, 1816: trad, par M. Jacques. Marley, Miles. On Diseases of Children: London, 1830. Marsh, Sir H. Dublin Hospital Reports, vols. iii. v. Martin. Rec. Period, de la Soc. de Med. de Paris: April, 1840. Marthey. Seance pub. de la Soc. Roy. de Paris. Matuszinski, M. Gazette Med., 1837. Mauran. Philada. Medical Journal, Aug. 1827. Mauthner. Die Kranken des Geherns und Ruckenmarks bei Kindern, Vienna, 1844. Mayne, Dr. Dublin Quart. Journal of Med. Science, May, 1844, and August, 1846. •McClean, Mr. Visit to St. Kilda. . Meckel, J. F. Manuel d'Anatomie Generate, &c.: Paris, 1825. Amer. edit., by Dr. Doane: Philada., 1832. Meigs, J. Forsyth, M. D. Practical Treatise on Diseases of Children: Philad,, 1848. Meine, Dr. Osteomalacia et ejus in partum actione. Michaelis. Ueber eine eigene Art. von Blutgeschwulsten. Michaelis. London Medical Transactions, de Angina polyposa: Gottingen, 1778. Millar. Obs. on Asthma and Hooping Cough: London, 1769. Mills, Dr. On Hydrocephalus, Transactions of the King and Queen's College of Physicians in Ireland, vol. v. Moncrieff, in A. Monro, tertius, Morbid Anatomy of the Brain. Mondiere. L'Expenence, June 25. On Intra-arachnoidean Hemorrhage. Monro, Dr. On the Morbid Anatomy of the Brain, vol. i.: Lond. and Edin., 1827. Monro, A. L. On the Small-pox: Edinburgh, 1818. -«,.,. Montgomery, Dr. Dublin Journal, vol. ix. On the Sudden Death of Children from Enlargement of the Thymus Gland. 630 INDEX OF AUTHORS AND WORKS REFERRED TO. Morgagni, J. B. De Sed. et Causis Morb. Epist.: Paris edit., 1820-23. Morton, E., M. D. Observations on the Healthy and Diseased Condition oi the Breast, Milk, &c: London, 1831. Moscati & Palletta. De Abscessu Sang. Capit. Mediol. Moss, W. On the Management and Nursing of Children: London, 1182. Naegele. Erfahrungen und Abhandlungen. Naegele, H. F. Lehrbuch der Geburtshulfe: Mainz, 1843. Neligan, Dr. Eruptive Diseases of the Scalp. Neligan, Dr. Medicines and their Uses: Amer. edit. North, John. Practical Observations on Convulsions of Infants: London, 1826. O'Ferrall, Dr. Dublin Hospital Gazette. Ollivier, C. P. Traite de la Moelle Epiniere, et de ses Maladies: Paris, 1824. Orfila. In Graetzer, Krankheiten des Fotus. Osiander. Handbuch der Entbindungskunst. Paget, John. On the Congenital Malformations of the Heart: Edinburgh Medical Journal, vol. xxxvi. Paldam, V. H. L. Der Stickhusten: Halle, 1805. Palmer, Dr. Medico-Chirurgical Journal, 1816. Panarola. Obs. Med. Pentecost. Papavoine. Journal des Progr6s, 1830. On Tubercles and Convulsions in Infants. ParentrDuchatelet and Martinet. Recherches sur 1'Inflammation de l'Arach- noide Cerebrate et Spinale: Paris, 1819. Parrish, Jos., M. D. On Infantile Convulsions arising from Spasm of Intestines. N. Amer. Med. & Surgical Journal, 1827. Pearson, Mr. Med.-Chir. Transactions. Penada, G. Memoria Sulla Tussa Convulsiva: Verona, 1815. Pereira, Jonathan. A Treatise on Food and Diet. Amer. edit.,by C. A. Lee: New York, 1843. Petzholdt, M. Archives G6n. de Medecine. Piet. Thesis, 1836. Pigne, M. Journal Hebdomadaire. Piorry, P. A. De l'lrritation Encephalique des Enfans : Paris, 1823. Porter, W. H. Surgical Pathology of the Larynx and Trachea: Dublin, 1837. Purefoy, Dr. Dublin Journal, May, 1846. Qugtelet, A. Sur l'Homme, et le Developpement de ses Facultes: English edit. Edinburgh, 1842. Ramel, Journal de Medecine, de Chirurgie, et de Pharmacie, 1778. Ramisch. De Gastromalacia et Gastropathia Infantum: Prague, 1824. Ramsbotham. London Med. and Phys. Journal. Rau. Handbuch der Kinderkrankheiten. Raulin. De la Conservation des Enfans. Recherches sur Plusieurs Maladies. Reece, Dr. Med.-Chir. Review. Report of the Royal Infirmary for 1846. Reports of the Registrar-General. Reveille-Parise, M. Gazette Medicate. Richerand, le Baron. Nosographie Chirurgicale: Paris, 1815. Rigby, E., M. D. A System of Midwifery. Amer. edit., Philadelphia, 1840 Rilliet and Barthez. Traite Clinique et Pratique des Maladies des Enfans • Paris, 1843. Ringland, Dr. . Dublin Journal, July, 1841, vol. xix. Riverius. Obs. Commun: London, 1840. Roe, Geo. H. Treatise on the Nature and Treatment of Hooping Coueh • London, 1838. s s : Rogers, Dr. Jos. An Essay on Epidemic Diseases: Dublin, 1734, INDEX OF AUTHORS AND WORKS REFERRED TO. 631 Roman, M. Ann. de la Soc. M6d. Prat, de Montpellier. Romberg, Dr. Wochenschrift fiir die gesammt. Heilkunde, 1833 ; UberMagen- erweichung. Rosenvon Rosenstein. On the Diseases of Children. English edit., London 1776. ' Rostan, M. Dictionnaire de MSdecine. Roux. De Carditide Exsudativa. Rudolphi. Abhandlungen der Konigl. Acad, zu Berlin. Rufz, F. Journal des Connoissances Medico-Chirurgicales, 1835. Rusaeus. De Extract. Foetus. Rush, B., M. D. Med. Obs. and Inq.: Phila. 1800. On Dropsy of the Brain. Rutty, John. On the Weather, Seasons, and Prevailing Diseases of Dublin: Dublin, 1770. Saillant. Memoires de la Soc. de Mddecinc Salleneuve, M. M6m. de l'Acad. de Chirurgie. Sanson. Dictionnaire de Med. et de Chir. Pratique, art. Hemic Sauvage. Nosolog. Method. Schmidtmann, Albert. Observationes Medicae, vol. ii. Schneider, Dr. Edinburgh Med. and Surg. Journal. Schbller. Medicinische Zeitung. Schultz. M. N. C. Dec. 1, An. 6, 7. Schwarz, L. W. Siebold's Journal, B. 7. Schweinger. Uber Tuberculose als die gewbhnlichste Ursache der Hydroce- phalus acutus. Segerus. M. N. C. Dec. 1, An. 3, obs. 160, p. 291. Seitz, Dr. Ranking's Abstract. Sentin. Beitrage zur ausiibenden Arzneiwissenschaft. Sestie & Cazalis, MM. Bull, de la Soc. Anat.: 1832. Sherwood, Dr. Medical Repository. Siebold, J. A. Journal fur Geburtshulfe. Simpson, J. Y. Edinburgh Med. and Surg. Journal. Smith, H., M. D. On Hydrocephalus. Stewart, J. On Diseases of Children: New York, 1841. St. Hilaire, Geoffroy Isidore. Histoire G6n6rale et Particuliere des Anoma- lies de l'Organisation, &c.: Paris, 1832. Stokes, Wm., M. D. Diseases of the Chest: American edition, Philadelphia, 1844. Struve. On the Physical Management of Children: Berlin, 1776. Suiron, M. Ranking's Abstract. Swagemann. Ontleed. Heilkund. Verhandl. Sydenham. Opera Universa: London, 1726. Taupin. Journal des Connois. Med.-Chir., 1830-1840. On Typhoid Fever in Infants. Taupin. Recherches sur le Diagnostique des Mai. de la Poitrine chez les Enfans. Thompson. London Medical Repository, Jan., 1814. Thore, M. Archives G6n6rales de Medecine, 1846. De la PSritonite chez les Nouveaux-nes. Todo, Dr. Jas. Medical Gazette, Dec. 25,1846. Tonnelte. Maladies des Enfans. Tretis, Dr. Medical and Physical Journal. Trousseau, M. Journal des Connois. Med.-Chir. Underwood, Mich., M. D. A Treatise on the Diseases of Children: American edition, by J. Bell, M. D. : Philadelphia, 1842. Uwins, David. Med. and Phys. Journal, August, 1810, and Sept., 1819. Valentin, Louis. Sur le Croup: Paris, 1812. Valleix, F. L. J. Clinique des Maladies des Enfans Nouveaux-n§s: Paris, 1838. Vauthter, Dr. Arch. Gen. de Medecine, May, 1848. 632 INDEX OF AUTHORS AND WORKS REFERRED TO. Velpeau, A. A. L. M. Nouveaux Elements de Medecine OpSratoire : Paris, 1832. Velpeau, A. A. L. M. Trait6 des Accouch.: edit, de Bruxelles. Veron. Recherches des Maladies des Nouveaux-ne's : Paris, 1821. Veron. Seance de l'Acad. Roy. de Med., June 28, 1825. Waddington, Mr. Lancet, June 21, 1845. Walther, M. Ranking's Abstract. Watson. Lectures on Principles and Practice of Physic, by Condie: Philada. Lea & Blanchard, 1847. Watt, R. Treatise on the History and Treatment of Chin-cough: Glasgow, 1813. Webster, Dr. London Med. and Phys. Journal. Weisberg. Dissertatio de Praeternaturali et raro intestini recti cum vesica urinaria coalitu, &c, 1779. West, Chas., M. D. Lectures on the Diseases of Infancy and Childhood: Philada., Lea & Blanchard, 1850. Whitlock, Nicholl, Dr. Practical Remarks on Disordered States of the Cerebral Structures, occurring in Infants: London, 1821. Wilde. Report upon the Tables of Deaths. Willan. Diseases of the Skin. Willey, Dr. American Medical Repository. Williams, C. J. B. Pathology and Diagnosis of Diseases of the Chest: Amer. edit., Philada., Haswell, Barrington, & Haswell, 1839. Willis. Opera Omnia: Amst. 1682. De Morb. Convulsiv. Puerorum, &c. Wilson, Mr. Philosophical Transactions. Wooton, Dr. Transactions of the College of Physicians of Philada. Wrisbey, H. A. Descriptio Anat. Embryon., 1764. Zeller, Ch. Thesis de Cephalaematomate: Heidelberg, 1822. INDEX. A. Abscess between thepharynx and spine,431. diagnosis of, 433. symptoms of, 432. treatment of, 433. Air, importance of pure, 68. Angina, pseudo-membranosa, 418. Anus, imperforate, 365. Apoplexy, 180. causes of, 184. cerebral, 181. diagnosis of, 184. meningeal, 180. spinal, 186. Aphthae, 388. causes of, 391. pathology of, 389. prognosis of, 391. treatment of, 393. Artificial feeding, 45. Asthma, thymic, 192. B. Bathing, importance of, 51. Brain, abscess of, 168. absence of, 72. congestion of, 179. hypertrophy and induration of, 162. inflammation of, 160. pathology of tubercles of, 173. Bronchitis, 268. diagnosis of, 281. modifications of, 276. pathology of, 274. prognosis of, 281. treatment of, 281. varieties of, 269. C. Calorification, state of in infancy, 30. Cancrum oris, 397. Caput succedaneum, 82. Carnification of the lung, 299. Cathartics for removal of the meconium, 35. Cephalaematoma, sub-aponeurotic, 84. sub-pericranial, 84. sub-cranial, 87. pathology of, 87. termination of, 88. treatment of, 88. Cerebro-spinal system, diseases of, 71. Chicken-pox, 583. Cholera infantum, 457. Chorea, 99. causes of, 105. complications of, 102. diagnosis of, 106. 41 Chorea, pathology of, 103. prognosis of, 107. symptoms of, 100. treatment of, 107. Cleanliness, importance of, 50. Cleft-palate, 362. Clothing of the infant, 34-53. Colitis, 473. Condition of foetus in utero, 24. Congestion of the brain, 179. Convulsions, 71-110. causes of, 111. diagnosis of, 120. prognosis of, 121. symptoms of, 116. treatment of, 122. Coqueluche, 205. Coryza, 189. causes of, 190. treatment of, 191. Cow pox (see Vaccinia). Cranium, fractures of the, 81. Croup, 235. causes of, 249. complications of, 250. pathology of, 243. prognosis of, 255. prophylactic treatment of, 268. stages of, 238. symptoms of, 237. tracheotomy in, 262. treatment of, 256. Cyanosis, 329. pathology of, 333. Cynanche parotidea, 414. tonsillaris, 410. trachealis, 235. Dance of St. Guy, 99. Dentition, 368. Diarrhoea, 454. varieties of, 455. Digestive system, diseases of, 357. Disease, intra-uterine, 189. Dress, changes in, 55. materials of, 54. Dry-nursing, fatal effects of, 37. Dysentery, 473. causes of, 478. diagnosis of, 478. morbid anatomy of, 477. treatment of, 478. Eczema, 515. 634 INDEX. Encephalitis, 160. causes of, 161. diagnosis of, 161. symptoms of, 160. treatment of, 162. Encephalocele, 73. diagnosis of, 74. treatment of, 75. Endocarditis, 349. diagnosis of, 355. morbid anatomy of, 354. prognosis of, 355. results of, 354. symptoms of, 349. treatment of, 356. Enteritis, 460. causes of, 465. diagnosis of, 466. treatment of, 467. Epistaxis, 191. treatment of, 192. Exercise, importance of during childhood, 57. precautions in regard to, 57. F. Fever, infantile remittent, 614. causes, 620. complications of, 618. diagnosis of, 621. pathology of, 619. prognosis of, 621. symptoms of, 614. treatment of, 621. Foetus, sources of disease in the, 25. Food of infancy and childhood, 37. of new-born infant, 36. Flannel, importance of in the clothing of children, 54. Fractures of the cranium, 81. G. Gangrene of the mouth, 397. causes of, 405. diagnosis of, 407. pathology of, 401. prognosis of, 407. symptoms of, 397. treatment of, 407. Gangrenous ulcerations of the pharynx, 425. Gastric fever (see Fever, infantile remittent). Gastritis, 447. causes of, 451. diagnosis of, 452. morbid anatomy of, 449. symptoms of, 447. treatment of, 452. Glottis, spasm of the, 192. Growth of the infant, 29. H. Hare-lip, 358. treatment of, 358. Heart, diseases of, 326. anomalies as to the number of, 328. malformations of, 328. Helminthiasis, 482. Hernia cerebri, 73. Herpes, 514. Hooping cough, 205. Hydrocephalus, 71. acute, 127. causes of, 141. diagnosis of, 143. historical notice of, 128. pathology of, 139. prognosis of, 145. stages of, 129. terminations of, 145. treatment of, 146. chronic, 151. causes of, 155. diagnosis of, 156. historical notice of, 151. pathology of, 154. symptoms of, 153. treatment of, 157. Hydrorachitis, 80. operations for, by puncture, 81. Hypertrophy of the brain, 165. causes of, 165. diagnosis of, 165. pathology of, 165. prognosis of, 166. treatment of, 166. I. Imperforate anus, 365. Impetigo, 518. Incontinence of milk, 38. Indigestion, 439. causes of, 444. diagnosis of, 444. morbid anatomy of, 443. symptoms of, 439. treatment of, 445. Infancy, effects of poverty upon the mortality in, 22. Infancy and childhood, food of, 57. statistics of mortality in, 19. Infant, management of at birth, 33. Infantile remittent fever, 614 (see Fever). Infants, peculiarities of the nervous system in, 29. peculiarities of the digestive system in, 29. times of feeding new-born, 40. Inflammation of the pericardium, 336. of the pleura, 311. Influenza, 278. Intestinal worms, 482. causes of, 486. treatment of, 487. varieties of, 482. Intra-uterine diseases, 71. Irritations arising from severe dentition, 375. of the nervous system, 90. J. Jaundice, 490. causes of, 492. pathology of, 491. prognosis of, 492. treatment of, 493. Keichhusten, 205. K. L. Lancing the gums, 373. INDEX. Laryngismus stridulus, 192. Ligature of the cord, 34. Light, importance of in infancy, 61. Liver, enlargement of, 493. Lobar pneumonia, 205. duration of, 289. physical signs of, 287. Lobular pneumonia, 289. duration of, 292. physical signs of, 290. Lungs, gangrene of, 300. inflammation of, 284. M. Malformation of the nipple, effects of, 38. Management of the infant at birth, 33. Measles, 531. causes of, 545. complications of, 539. diagnosis of, 547. modifications of, 535. morbid anatomy of, 544. prognosis of, 547. symptoms of, 532. treatment of, 548. Medicine, use of in infancy, 64. Meningitis, tubercular, 136. Milk, analysis of different kinds of, 46. effects of organic disease upon, 39. influence of mental emotions upon, 39. influence of menstruation upon, 38. Mortality in infancy, statistics of, 19. effects of poverty upon, 22. Mouth, inflammation of, 377. Muguet, 379. diagnosis of, 386. pathology of, 380. prognosis of, 386. symptoms of, 379. treatment of, 387. Mumps, 414. N. Nervous irritation, 90. causes of, 92. symptoms of, 91. treatment of, 92. Nine-day fits, 94. causes of, 95. symptoms of, 94. treatment of, 97. Nursery, location and furniture of the, 65. regulation of the, 65. temperature of the, 66. Nurses, 66. Nurse, domestic qualifications of the, 41. duties of the, 43. Parotitis, 414. causes of, 415. symptoms of, 414. treatment of, 416. Pericarditis, 336. causes of, 345. morbid anatomy of, 344. symptoms of, 339. treatment of, 347. Peritonitis, 497. causes of, 499. Peritonitis, diagnosis of, 500. morbid anatomy of, 499. prognosis of, 500. terminations of, 506. treatment of, 500. Pertussis, 205. causes of, 222. complications of, 212. diagnosis of, 224. pathology of, 218. prognosis of, 225. symptoms of, 207. treatment of, 226. Pharyngitis, pseudo-membranous, 418 causes of, 422. complications of, 422. diagnosis of, 423. morbid anatomy of, 421. prognosis of, 423. symptoms of, 418. treatment of, 424. Pityriasis, 512. Pleuritis, 311. causes of, 319. diagnosis of, 320. morbid anatomy of, 318. prognosis of, 321. symptoms of, 312. treatment of, 321. Pneumonia, 284. complications of, 294. diagnosis of, 306. lobar, 205. lobular, 289. primary, 293. prognosis of, 307. secondary, 294. treatment of, 307. Porrigo, 520. Porrigo favosa, 525. Porrigo scutulata, 521. Prurigo, 511. Putrid sore throat, 425. causes of, 430. diagnosis of, 430. morbid anatomy of, 428. prognosis of, 431. symptoms of, 426. treatment of, 431. Quinsy, 410. Q. R. Ramollissement of the brain, 167. diagnosis of, 168. pathology of, 167. Respiration in the infant, 29. Roseola, 513. Rubeola, 531. Rupia, 517. Scald-head, 520. Scalp, abscess of the, 86. Scarlatina, 550. Scarlatina anginosa, 577. Scarlet fever, 550. causes of, 573. 636 INDEX. Scarlet fever, complications of, 560. diagnosis of, 575. Scarlatina maligna, treatment of, 578. Scarlatina, pathology of, 571. periods of, 552. prognosis of, 576. prophylaxis of, 582. treatment of, 576. Senses, progressive education of the, in the infant, 31. Serum, Breschet's analysis of, 155. Shower-bath, tonic effects of, 52. Skin, diseases of the, 510. Skull, absence of the, 72. Sleep of infants, 62. Small-pox (see Variola). Spasm of the glottis, 194. causes of, 202. diagnosis of, 202. pathology of, 196. prognosis of, 203. symptoms of, 194. treatment of, 203. Spleen, enlargement of the, 496. Spina bifida, 75. Spinal marrow, tubercles of, 176. Spoon feeding, 45. Staphyloraphe, 362. State of muscular action in the infant, 31. Stomach, diseases of the, 434. inflammation of the, 447. pathological changes in the mucous membrane of the, 438. softening of the, 447. Stomatitis, 377. treatment of, 378. Strophulus, 510. St. Vitus's dance, 99. Thrush, 388. Thymic asthma, 192. Tonsillitis, 410. causes of, 412. diagnosis of, 412. symptoms of, 410. treatment of, 412. Trismus nascentium, 90. Tubercular meningitis, 137. symptoms of, 137. Tubercles of the brain, 170. causes of, 174. diagnosis of, 175. treatment of, 176. of the spinal marrow, 176. treatment of, 178. U. Ulcerated sore mouth, 393. pathology of, 395. symptoms of, 394. treatment of, 396. Vaccinia (history of), 606. course of, 607. diagnosis of, 611. modifications and irregularities of, 608. mode of operating, 612. Varicella, 583. diagnosis of, 586. modifications of, 584. symptoms of, 583. treatment of, 586. Varieties of food, and modes of administra- tion, 40. Variola, 586. causes of, 600. complications of, 595. diagnosis of, 602. modifications of, 593. pathology of, 599. period of incubation, 587. invasion, 588. eruption, 588. suppuration, 590. desiccation, 592. prognosis of, 602. symptoms of, 587. treatment of, 603. Varioloid, 594. Veitstanz, 97. Vernix caseosa, 33. W. Washing infants, mode of, 33. Walking, precautions in teaching, 59. Water-stroke, 138. Weaning, 44. Weaning-brash, 439. Worm fever (see Fever, infantile remittent). # THE END. I / j.; ';.> „\ ,- CATALOGUE OF MEDICAL AND SURGICAL BOOKS, PUBLISHED BY LEA AND BLANCHARD, PHILADELPHIA, AND SOLD BY ALL BOOKSELLERS. TO THE MEDICAL PROFESSION. 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Robertson on the Teeth, 1 vol.8vo.,230 pp., pts. Sargent's Minor Surgery, 1 vol. royal 12mo., 380 pages, 128 cuts. A new work, 1848. MATERIA MEDICA AND THERAPEUTICS. Ghnstison's and Griffith's Dispensatory, 1 large vol. Svo., 216 cuts, over 1000 pages. Dunglison's Materia Medica and Therapeutics, a new ed., with cuts, 2 vols. 8vo., 986 pages. Dunglison on New B.emedies, 5th ed., 1 vol. 8vo., 653 pages. Ellis' Medical Formulary, 9th ed., much improv- ed, 1 vol. 8vo., 268 pages. Griffith's Medical Botany, a new work, 1 large vol. Svo., 704 pp.', with over 350 illustrations. Mayne's Dispensatory and Formulary, by Griffith, 1 vol. 12mo., 330 pages. A new work. Mohr, Redwood, and Procter's Pharmacy, 1 vol. 8vo., 550 pages, 500 cuts. Pereira's Materia Medica, by Carson, 2d ed., 2 vols. Svo., 1580 large pages, 300 cuts. Royle's Materia Medica and Therapeutics, by Carson, 1 vol. 8vo., 689 pages, many cuts. OBSTETRICS. Churchill's Theory and Practice of Midwifery, by Huston, 3d ed., 1 vol. 8vo., 526 pp., many cuts. Dewees' System of Midwifery, 11th ed., 1 vol. 8vo., 660 pages, with plates. Lee's Clinical Midwifery, 12mo., 238 pages. Meigs' Obstetrics; the Science and the Art; 1 vol. 8vo., 686 pages, 121 cuts. Ramsbotharn on Parturition, with many plates, I large vol. imperial 8vo., 520 pages. Smith (Tyler) on Parturition, 1 vol., 400 pages. CHEMISTRY AND HYGIENE. Bowman's Practical Chemistry, 1 vol. 12mo., 97 cuts, 350 pages. Brighamon Excitement,&c, 1 vo!.12mo.,204pp. Dunglison on Human Health,2d ed.,8vo., 464 pp. Fowne's Elementary Chemistry for Students, 2d ed., 1 vol. royal 12mo., 460 pages, many cut:'. Gardner's Manual of Medical Chemistry, 1 vol. l2mo., cuts. A new work, 1848, 400 pp. Griffith's Chemistry of the Four Seasons, 1 vol. royal 12mo., 451 pages, many cuts. Knapp's Chemical Technology, by Johnson, Vol. I., 8vo., 504 pp., 214 large cuts. Vol. II., 8vo., 426 pp., 246 cuts. Simon's Chemistry of Man, 8vo., 730 pp., plates. MEDICAL JURISPRUDENCE, EDUCATION, &c. Bartlett's Philosophy of Medicine, 1 vol. 8vo., 312 pages. Bartlett on Certainty in Medicine, 1 vol. small 8vo., 84 pages. Dunglison's Medical Student,2d ed.l2mo.,312pp. Taylor's Medical Jurisprudence, by Griffith, 1 vol. 8vo., 540 pages. Taylor on Poisons, by Griffith, 1 vol. 8vo., 688 pp. Traill'sMedical Jurisprudence, lvol.8vo.,234pp. NATURAL SCIENCE, &c. Arnott's Elements of Physics, new edition, 1 vol. 8vo., 484 pages, many cuts. Ansted's Ancient World, Popular Geology, in 1 12mo. volume, with numerous cuts, 382 pages. Bird's Natural Philosophy, 1 vol. royal 12mo., 402 pages and 372 wood-cuts. Brewster's Optics, I vol. 12mo.423 pp.many cuts. Broderip's Zoological Recreations, 1 vol. 12mo., pp. 3-;6. «• Coleridge's Idea of Life, 12mo., 94 pages. Carpenter's Popular Vegetable Physiology, 1 vol. . royal 12mo., many cuts. Dana on Zoophytes, being vol. 8 of Ex. Expedi- • tion, royal 4to., extra cloth. Atlas to "Dana on Zoophytes," imp. folio, co-- lored plates. Hale's Ethnography and Philology of the U. S.. Exploring Expedition, in 1 large imp. 4to. vol. Herschel's Treatise on Astronomy, 1 vol. 12mo.w 417 pages, numerous plates and cuts. Introduction to Vegetable Physiology, founded or De Candolle, Lindley,&c, 18mo., paper,25 cts„ Kirby on Animals, plates, 1 vol.8vo., 520 pages. Kirby and Spence's Entomology, 1 vol. 8vo., 600 large pages; plates plain or colored. Muller's Physics and Meteorology, 1 vol. 8vo., 636 pp., with 540 wood-cuts and2 col'd plates. Philosophy in Sport made Science in Earnest, 1 vol. royal 18mo., 430 pages, many cuts. Roget's Animal and Vegetable Physiology, with 400 cuts, 2 vols. Svo., 872 pages. Small Books on Great Subjects, 12 parts, done up in 3 handsome 12mo. volumes, extra cloth. Somerville's Physical Geography, 12mo., cloth. Weisbach's Mechanics applied to Machinery and Engineering/Vol. 1.8 vo., 486 pp. 550 wood-cuts. Vol. II., 8vo., 400 pp., 340 cuts. VETERINARY MEDICINE. Clateraud Skinner"s Farrier, lvol. 12mo.,220pp Youatt's Great Work on the Horse, by Skinner^. 1 vol. 8vo., 448 pages, many cuts. Youatt and Clater's Cattle Doctor, 1 vol. 12mo., 282 pages, cuts. Youatt on the Dog, by Lewis, 1 vol. demy 8vo., 403 pages, beautiful plates. Youatt on the Pig, a new work with beautiful il- lustrations of all the different varieties, 12mo. npond of Practical Medicine, Surgery, Anatomy, Midwifery, Dis- uses of Women and Children, Materia Medica and Therapeut.es, Physiology, Chemistry, and Pharmacv, with numerous illustrations, 1 vol. 12mo., 900 pages. 350 illustrations. MEDICAL BOOKS IN PRESS. ,. , c • „i Ar.ot^mv imnpriil nnarto 64 plates. West on the Diseases of Infancy. (Publishing in MB£1B?' W.ndffiTBBrW of Medicine. In one vol. Svo. 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THE GREAT AMERICAN MEDICAL DICTIONARY, NEW AND ENLARGED EDITION.—Lately Issued. MEDICAL "LEXICON; A DICTIONARY OF MEDICAL SCIENCE, CONTAINING CONCISE EXPLANATIONS OF THE VARIOUS SUBJECTS AND TERMS, WTTH THE FRENCH AND OTHER SYNONYMES; NOTICES OF CLIMATE AND OF CELEBRATED MINERAL WATERS; FORMULA FOR VARIOUS OFFICINAL AND EMPIRICAL PREPARATIONS, ETC. BY KOBLEY DUNGLISON, M. D., &c. SEVENTH EDITION, CAREFULLY REVISED AND GREATLY ENLARGED, In One very large and beautifully printed Octavo Volume of over Nine Hundred Pages, closely printed in double columns. Strongly bound in leather, unth raised bands. This edition is not a mere reprint of the last. To show the manner in which the author has la- bored to keep it up to the wants of the day, it may be stated to contain over SIX THOUSAND WORDS AND TERMS more than the fifth edition, embracing altogether satisfactory definitions of OVER FORTY-FIVE THOUSAND WORDS. Every means has been employed in the preparation of the present edition, to render its me- chanical execution and typographical accuracy in every way worthy its extended reputation and universal use. The size of the page has been enlarged, and the work itself increased more than a hundred pages; the press has been watched with great care; a new font of type has been used, procured for the purpose; and the whole printed on fine clear white paper, manufactured expressly. Notwithstanding this marked improvement over all former editions, the price is retained at the original low rate, placing it within the reach of all who may have occasion to refer to its pages, and enabling it to retain the position which it has so long occupied, as THE STANDARD AMERICAN MEDICAL DICTIONARY. We have examined the Lexicon for alarge number of words, including such terms as Anaesthetic, Otiatria, Pyelitis, Mastitis, and Stomatitis, which are not commonly met with in medical dictionaries, and on which medical readers occasionally require information; and we have found them with an explanation of their classical prigin, and the signification under which they are employed. Dr. Dunglison's Lexicon has the rare merit that it certainly has no rival in the English language for accuracy and extent of references. The terms generally include sliort physiological and pathological descriptions, so that, as the author justly observes, the reader does not possess in this work a mere dictionary, but a book, which, while it in- structs him in medical etymology, furnishes him with a large amount of useful information. That we are not over-estimating the merits of this publication, is proved by the fact that we have now before us the seventh edition. This, at any rate, shows that the author's labors have been properly appreciated by his own coun- trymen ; and we can only confirm their judgment, by recommending this most useful volume to the notice of our cisatlantic readers. No medical library will be complete without it.— The London Med. Gazette,T>ec. 1848. It is certainly more complete and comprehensive than any with which we are acquainted in theEnglish language. Few, in fact, could be found better qualified than Dr Dunglison for the production of such a work. Learned, industrious, persevering, and accurate, he brings to the task all the peculiar talents necessary for its successful performance: while, at the same time, his familiarity with the writings of the ancient and modern '•masters of our art," renders him skilful to note the exact usage of the several terms of science, and the va- rious modifications which medical termino'ogy has undergone with the change of theories or the progress of improvement.—American Journal of the Medical Sciences. One of the most complete and copious known to the cultivators of medical science.—Boston Med. Journal. This most complete medical Lexicon—certainly one of the best works of the kind in the language.— Charleston Medical Journal. ° The most complete Medical Dictionary in the English language.— Western Lancet. Dr. Dunglison's Dictionary has not its superior, if indeed its equal, in the English language — St Louis Med and Surg. Journal. Familiar with nearly all the medical dictionaries now in print, we consider the one before us the most complete, and an indispensable adjunct to every medical library.—British American Medical Journal Admitted by all good judges, both in this country and in Europe, to be equal, and in many respects superior to any other work of the kind yet published.—Northwestern Mtdualand Surgical Journal Januarv 1849 We repeat our former delaration that this is the best Medical Dictionarv in the English iansruaee— Western Lancet. December, 1848. 6 5- «> f We have no hesitation to pronounce it the very best Medical Dictionary now extant —Southern Mediral and Surgical Journal, December, 1848. aoumern meaieal The most comprehensive and best English Dictionary of medical terms extant.— ButTaln Mprt Tn„r*,nl Whence the terms have all been derived we find it rather difficult to imagine. We can£nlv mv ih^i Xr inkinc for everv new and stranee, word we. pcmU\ think nf we hn ve hm hJl„ a:____:_7 . . ' ' l?al> auer Dr. Dunglison's masterpiece of literary labor.—N. Y. Journal of Medicine. ' HOBLYN'S IvliDTfS^MTDTcTION ARY A DICTION"ARY OP THE TERMS USED IN* IVTEDICTlvrT AND THE COLLATERAL SCIENCES ***•»■*•• BY RICHARD D. HOBLYN, A. M., Oxon REVISED, WITH NUMEROUS ADDITIONS, FROM THE SECOND LONDON EDITION BY ISAAC HAYS, M. D., &c. In one large royal 12mo. volume of 402 pages, double columns We cannot loo strongly recommend this small and cheap volume to the librarv of everv afn yc of Physiology within their reach.-JV. Y. Journal of Medicine. exposition of the present condition! The work, as it now stands, is the only treatise on Physiology in the Enelish !»„„„,„ u- . .... clear and connected, and comprehensive view of the present condition of that acienf? Sr'« 3flch exJ1,^lt? a burgh Monthly Journal. aBl sc,ence.—London and Edin. The standard English treatise on Physiology.—London Medical Gazette. Dr. Carpenter's productions justly hold the first rank in Physiology, and should be rearf h„ nn u keep pace with the rapid advances of the slu^y.-Southern Medical and SureicalTJ.il iY ll who Wlsh to Second to no work extant upon the subject of which it treats.-//*, and IndMediZ^fi c • , . We know 01 no work m our language from which the recent views on Physiolo^ p»„ k Sur^le°} Journal. nor any in which the subjects are so ably discussed.-St. Louis Medical and SurJiWr 80 wel1 obtai«ed, Peculiarly adapted to the Medical Student.-Medical Examiner. *™gical Journal. We have much satisfaction in declaring our opinion, that this work is th* h*«t =„=. Physiology in our own language, and the best adapted to the student in any lanmaJL ^"emMie treatise on Review. .. , "»"guage.—Medico Chururgical A work to. which there has been none published of equal value in the deDartmpnt ~e r. • ,. • Dr. Black's Retrospective Address. uepartraent of which it treats.— From Professor Caldwell, of Louisville, Ky. ■'■ I have already recommended it, and will continue to do so, to my class, as onp of t>.„ • \. est repositories of physiological knowledge now in the English or any other lan„.?,,?T and '"und- Teading." B ' lner langiiage t am capabl ^ LEA & BLANCHARD'S PUBLICATIONS.—(Physiology.) 9 COMPENDIUM OP MULLER'S PHYSIOLOGY. A MANUAL OF~PHYSIOLOGY, FOR THE USE OF STUDENTS. BY WILLIAM SENHOUSE KIRKES, M. D., Assisted by JAMES PAGET, Lecturer on General Anatomy and Physiology iii St. Bartholomew's Hospital. In One Handsome Yolume, Royal 12mo., of Five Hundred and Fifty Pages. ILLUSTRATED WITH UPWARDS OF ONE HUNDRED WOOD ENGRAVINGS. This is. certainly, a most able manual of Physiology. The student will find in it, not a meagre outline, a bare skeleton of the leading particulars embraced in the science, but a very complete and accurate—though at the same time, concise—account of the facts and generally admitted principles of Physiology ; forming an admirable introduction to the study of that science, as well as a useful compendium for consultation by those who are preparing for an examination. The whole of the illustrations are very excellent, and calculated to render the description of the objects ihey represent clear and precise. To those who stand in need of a Manual of Physiology—and works of this description have now become, in a certain sense, indispensable portions of the apparatus of study—we can very confidently recommend the present one as well for its com- prehensiveness as for its general accuracy.—American Journal of the Medical Sciences, April, 1649. An excellent work, and for students one of the best within reach.—Boston Medical and Surgical Journal. A work very much wanted, bringing modern Physiology more within the student's grasp than its prede- cessors.—Dublin Medical Press. One of the best little books on Physiology which we possess.—Braithwaite,s Retrospect. The authors have succeeded in producing a work well adapted for students.—Monthly Journal and Retro- spect of the Medical Sciences. Particularly adapted to those who desire to possess a concise digest of the facts of Human Physiology.— British and Foreign Med.-Chirurg. Review. One of the best treatises on Physiology which can be put into the hands of the student.—London Medical Gazette, March, 1849. We conscientiously recommend it to our readers as an admirable "Handbook of Physiology."—London Journal of Medicine. As an introduction to the study of the larger works, or as a reference for those who desire to "brush up" their knowledge, we most cordially recommend the manual of .Kirkes and Paget to both practitioner and stu- dent, with the firm conviction that they will not be disappointed in the end they desire to attain.—The Medical Examiner. CARPENTER'S ELEMENTS. ELEMENTS OF PHYSIOLOGY, Including Physiological Anatomy.—For the use of the Medical Student. BY WILLIAM B. CARPENTER, M. D., F. R. S., Fullerian Professor of Physiology in the Royal Institution of Great Britain, &c. With one hundred and eighty Illustrations. In one octavo volume of 566 pages. Elegantly printed, to match his " Principles of Human Physiology." The author has shown singular skill in preserving so marked aline of distinction between the present Manual and the " Principles of Physiology" previously published by him. They are both on precisely the same subject; but the one is neither a copy, nor an abstract, nor an abridgment of the other. In one thing, however they are exactly alike—in their general excellence, and in their perfect adaptation to their respec- tive purposes.—British and Foreign Medical Review. SOLLY ON THE BRAIN. THE HUMAN BRAIN; ITS STRUCTURE, PHYSIOLOGY, AND DISEASES. WITH A DESCRIPTION OF THE TYPICAL FORM OF THE BRAIN IN THE ANIMAL KINGDOM. BY SAMUEL SOLLY, F. R. S., &c, Senior Assistant Surgeon to the St. Thomas' Hospital, &c. FROM THE SECOND AND MUCH ENLARGED LONDON EDITION. In One Octavo Volume; with One Hundred and Twenty Wood-cuts. The most complete account of the anatomy, physiology, and pathology of the brain that *ias hitherto ap- peared. We earnestly advise all our professional brethren to enrich their libraries with this admirable treatise.—Medico- Chirurgical Review. HARRISON ON THE NERVES.—An Essay towards a correct theory of the Nervous System. In one octavo volume, 292 pages. M ATTEUCCI ON LIVING BEINGS.—Lectures on the Physical Phenomena of Living Beings. Edited by Pereira. In one neat royal 12mo. volume, extra cloth, with cuts—388 pages. ROGET'S PHYSIOLOGY.—A Treatise on Animal and Vegetable Physiology, with over 400 illustrations on wood. In two octavo volumes, cloth. ROGET'S OUTLINES.-Outlines of Physiology and Phrenology. In one octavo volume, cloth-516 pages. ON THE CONNECTION BETWEEN PHYSIOLOGY AND INTELLECTUAL SCIENCE. In one 12mo. volume, paper, price 25 cents. TODD & BOWMAN'S P»™^^ co^o^ the comDletion 10 LEA & BLANCHARD'S PUBLICATIONS —(Pathology.) "WILLIAMS' PRINCIPLES—New and Enlarged Edition. PRINCIPLES OF MEDICINE; Comprising General Pathology and Therapeutics, AND A f Brief general view of Etiology, Nosology, Semiology, Diagnosis, Prognosis, and Hygienic* BY CHARLES J. B. WILLIAMS, M. D., F. R. S., Fellow of the Royal College of Physicians, ice. Edited, with Additions, BY MEREDITH CLYMER, M. D., Consulting Physician to the Philadelphia Hospital, Ac. &c THIRD AMERICAN, FROM THE SECOND AND ENLARGED LONDON EDITION. In one volume, octavo, of 440 pages. The best exposition in our language, or, we believe, in any language, of Rational Medicine, in its present improved and rapidly improving slate— British and Foreign Medico-Chirurg. Review. We recommend every part of Dr. Williams' excellent Principles of Pathology to the diligent perusal of every physician who is not familiar with the accessions which have been made to medical science withiq the last few years.— Western Journal of Medicine and Surgery. From Professor Thayer, of Boston. It fills the place for which it was intended better than any other work. From Professor S. H. Dickson, of New York. I shall be truly glad to know that a copy of it is in the hands of every member of our profession. As a public teacher, I know not how I could dispense with it. MANUALS ON flHE^LOOD AND URINE: CONSISTING OF I. A Practical Manual, containing a description of the General, Chemical, and Microscopical Char- acters of the Blood and Secretions of the Human Body, as well as of their compounds, including both their healthy and diseased states; with the best method of separating and estimating their ingredients. Also, a succinct account of the various concretions occasionally found in the body, and forming calculi. BY JOHN WILLIAM GRIFFITH, M. D., F. L. S., &c. II. On the Analysis of the Blood and Urine in health and disease, and on the treatment of Urinary diseases. BY G. OWEN REESE, M. D., F. R. S., &c. &c. III. A guide to the examination of the Urine in health and disease, for the use of students. BT ALFRED MARKWICK. The whole forming one large royal 12mo. volume, of four hundred and sixty pagea, With about one hundred figures on five plates. Although addressed especially to students, it contains almost all the information upon these matters which the practitioner requires.—Dublin Medical Press. The chemical processes recommended are simple, yet scientific; and the work will be very useful to the medical alumni for whom it is intended.—Medical Times. The author must be admitted to have attained his object in presenting a convenient bedside companion.— Dr. Ranking's Abstract. THE PATHOLOGICAL ANATOMY OF THE HUMAN BODY. BY JULIUS VOGEL, M. D., &c. TRANSLATED FROM THE GERMAN, WITH ADDITIONS, BY GEORGE E. DAY, M. D., &c. Illustrated by upwards of One Hundred Plain and Colored Engravings. In one neat octavo volume. It is decidedly the best work on the subject of which it treats, in the English language,- and Dr. Day whose translation is well executed, has enhanced its value by a judicious selection of the most important figures from the atlas, which are neatly engraved.—The London Medical Gazette. ° ALISON'S PATHOLOGY.—Outlines of Pathology and Practice of Medicine; containing Preliminary Ob- servations, Inflammatory and Febrile Diseases, and Chronic or non-Febrile Diseases In one neat Svo volume, pp. 420. * ABERCROMBIE ON THE STOMACH—Pathological and Practical Researches on Diseases of the Stomach, Intestinal Canal, &c. Fourth Edition. One small 8vo. volume, pp. 320. ABERCROMBIE ON THE BRAIN.—Pathological and Practical Researches on Diseases of tt,* w,*;.. .„j Spinal Cord. A new edition, in one small 8vo. volume, pp. 324. me Brain *UM| BURROWS ON CEREBRAL CIRCULATION.-On Disorders of the Cerebral Circulation ard on »K» Connection between Affections of the Brain and Diseases of the Heart. In one Svo. vol. with color I I t BLAKISTON ON THE CHEST—Practical Observations on certain Diseases of th« n,«.f j •. Principles of Auscultation. In one volume, 8vo., pp. 384. *,ne«, and on the BILLING'S PRINCIPLES.—The First Principles of Medicine. From the Fourth London Editio I volume. Svo., pp. 304. caiuon. in one BIRD ON URINARY DEPOSITS.—Urinary Deposits, their Diagnosis, Pathology, and Th.ran.n.;.., t j- cations. In one volume, 8vo., pp. 228. 6 6y' ana "erapeutical Indi- IIASSE'S PATHOLOGICAL AN ATOMY.-An Anatomical Description of the Diseaseaof !)„„;„,■ Circulation. Translated and Edited by Swaiue. In one volume, Svo., pp. 379. BCU!""80' "espirauon and HUGHES ON THE LUNGS AND HEART.-Clinical Introduction to the Practice of An«r.,int;«„ other modes of Physical Diagnosis. Intended to simplify the study of the Diseases of the Hear ».. 1 ?' &ni In one 12mo. volume, with a plate, pp. 270. c ncttrl anu ^ung». WALSHE ON THE LUNGS—Physical Diagnosis of the Diseases of the Lungs. In one 12mo vol. pp 311) LEA & BLANCHARD'S PUBLICATIONS.—(Practise of Medicine.) 11 DUNGLISON'S PRACTICE OF MEDICINE. ENLARGED AND IMPROVED EDITION. THE PRACTICE OP MEDICINE; A TREATISE ON SPECIAL PATHOLOGY AND THERAPEUTICS. THIRD EDITION. BY EOBLEY DUNGLISON, M. D., Professor of the Institutes of Medicine in the Jefferson Medical College; Lecturer on Clinical Medicine, <$•«. In Two large Octavo Volumes of Fifteen Hundred Pages. In Dr. Dunglison's volumes, there is a kind of pervading exactness on every page, that is at once recognized; and, in fact, the medical public has long since decided that implicit reliance may be placed in any work which he permits to appear with his name upon the title-page. A third edition of his treatise on Special Pathology and Therapeutics has just been published. It has pass- ed through so many careful examinations, and received so many improvements, under the vigilant eye of the indefatigable man who first gave it existence, that it would be an anomaly in medical literature if it had not grown better and better. The student of medicine will find, in these two elegant volumes, a mine of facts, a gathering of precepts and advice from the world of experience, that will nerve him with courage, and faithfully direct him in his efforts to relieve the physical suf- ferings of the race.—Boston Medical and Surgical Journal. Upon every topic embraced in the work the latest information will be found carefully posted up. Medical Examiner. Professor Dunglison's work has rapidly passed to the third edition, and is now presented to the profession as probably the most complete work on the Practice of Medicine that has appeared in our country. It is especially characterized by extensive and laborious research, minute and accu- rate pathological, semeiological, and therapeutical descriptions, together with that fulness of detail which is so important to the student. The present edition has been considerably enlarged; indeed the indefatigable author seems to have explored all of the labyrinths of knowledge, from which important facts and opinions could be gleaned, for the instruction of his readers. We cheerfully commend the work to those who are not already familiar with its merits. It is certainly the most complete treatise of which we have any knowledge. There is scarcely a disease which the student will not find noticed.—Western Journal of Medicine and Surgery. One of the most elaborate treatises of the kind we have.—Southern Medical and Surg. Journal. The work of Dr. Dunglison is too well known, to require at our hands, at the present time, an analysis of its contents. The call for a third edition within five years from the appearance of the first, is, of itself, a sufficient evidence of the opinion formed of it by the medical profession of our country. That it is well adapted as a text-book for the use of the student, and at the same time as a book of reference for the practitioner, is very generally admitted; in both points of view, for accu- racy and completeness, it will bear a very advantageous comparison with any of the numerous co- temporary publications on the practice of medicine, that have appeared in this country or in Europe. The edition before us bears the evidence of the author's untiring industry, his familiarity with the various additions which are constantly being made to our pathological and therapeutical knowledge, and his impartiality in crediting the general sources from which his materials have been derived. Several pathological affections, omitted in the former editions, are inserted in the present, while every portion of the work has undergone a very thorough revision. It may with truth be said, that nothing of importance that has been recorded since the publication of the last edition, has escaped the attention of the author; the present edition may, therefore, be regarded as an adequate exponent of the existing condition of knowledge on the important departments of medicine of which it treats.—The American Journal of the Medical Sciences. The Physician cannot get a better work of the kind than this, and when he masters its contents, he will have mastered all that such treatises can afford him.—St. Louis Med. <$■ Surg. Journal, June, 1848. , . v , In the volumes before us, Dr. Dunglison has proved that his acquaintance with the present facts and doctrines, wheresoever originating, is most extensive and intimate; and the judgmeot, skilL and impartiality with which the materials of the work have been collected, weighed, arranged, and ex- posed, are strikingly manifested in every chapter. Great care is everywhere taken to indicate the source of information, and under the head of treatment, formulae of the most appropriate remedies are everywhere introduced. In conclusion, we congratulate the students and junior practitioners of America on possessing in the present volumes a work of standard merit, to which they may con- fidently refer in their doubts and difficulties.—Brit, and For. Med. Review. Since the foregoing observations were written, we have received a second edition of Dunglison's work, a sufficient indication of the high character it has already attained in America, and justly attained.—Ibid. DAY ON OLD AGE-Now Ready. A PRACTICAL TREATISE ON THE DOMESTIC MANAGEMENT AND MORE IMPORTANT DISEASES OF ADVANCED LIFE. With an Appendix, containing a series of cases illustrative of a new and successful mode of treating r Lumbago, and other forms of Chronic Rheumatism BY GEORGE E. DAY, M. D. In One Octavo Volume. A more satisfactory and truly rational train of excellent suggestions have not been ushered into being for along lime than are contained in this work.—Boston Med. % Surg. Journal. 12 LEA & BLANCHARD'S PUBLICATIONS.—(Practice of Medicine.) WATSON'S PRACTICE OF MEDICINE—New Edition. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. DELIVERED AT KING'S COLLEGE, LONDON, BY THOMAS WATSON, M.D., &c. &c. Third American, from the last London Edition. REVISED, WITH ADDITIONS, BY D. FRANCIS CONDIE, M. D., Author of a Work on the " Diseases of Children," &c. In One Octavo Volume, Of nearly ELEVEN HUNDRED LARGE PAGES, strongly bound with raised bands. To say that it is the very best work on the subject now extant, is but to echo the sentiment of the medical press throughout the country.— N. O. Medical Journal. Of the text-books recently republished Watson is very justly the principal favorite.—Holmes'1 Report to Nat. Med. Assoc. By universal consent the work ranks among the very best text-books in our language.—III. and Ind. Med. Journal. Regarded on all hands as one of the very best, if not the very best, systematic treatise on practical medi- cine extant.—St. Louis Med. Journal. Confessedly one of the very best works on the principles and practice of physic in the English or any other language.—Med. Examiner. As a text-book it has no equal; as a compendium of pathology and practice no superior.—N. Y. Annalist. We know of no work better calculated for being placed in the hands of the student, and for a text-book. On every important point the author seems to have posted up his knowledge to the day.—Amer. Med. Journal. One of the most practically useful books that ever was presented to the student—indeed, a more admirable summary of general and special pathology, and of the application of therapeutics to diseases, we are free to say, has not appeared for veTy many years. The lecturer proceeds through the whole classification of human ills, a capite ad calcem, showing at every step an extensive knowledge of his subject, with the ability of com- municating his precise ideas in a style remarkable for its clearness and simplicity.—N. Y. Journal of Medi- cine and Surgery. A careful examination of this volume has satisfied us that it merits all the commendation bestowed on it in this country and at home. It is a work adapted to the wants of young practitioners, combining, as it does, sound principles and substantial practice. It is not too much to say that it is a representative of the actual state of medicine as taught and practised by the most eminent physicians of the present day, and as such we would advise every one about embarking in the practice of physic to provide himself with a copy of it.— Western Journal of Medicine and Surgery. We have for several years considered this one of the best wotIcs extant on the Principles and Practice of Medicine. Its style is adapted to all classes of readers, and the views of the author are sound and practical. —Mo. Med. and Surg. Journal. Whoever owns this book will have an acknowledged treasure, if the combined wisdom of the highest au- thorities is appreciated.—Boston Med. and Surg. Journal. It has now become, beyond all question, the standard work on the subject of which it treats; it is in the hands of every physician, surgeon, and senior medical student in every country in which the English lan- guage is spoken; it has passed scathless through the perils of criticism. Never, within the memory of authors or publishers, has a medical work in two thick octavo volumes attained the enormous circulation of Watson's Lectures, a third edition having been called for within the space of five years, and being, we believe, already nearly exhausted ;,and, in addition to this, it must be recollected that these lectures also appeared in the Medi- cal Gazette, and have been reprinted in America. We mention these facts as affording a sufficient reason why, in attempting to do tardy justice to the merits of this work, our notice of it will be comparatively brief. A work that has passed through so many editions, and that is already so widely diffused through the profes- sion, is in one point of view, that is to say, in so far as any opinion of ours can influence its popularity be- yond the critic's province.—Edinburgh Monthly Journal and Retrospect of the Medical Sciences. Much Enlarged Edition of BARTXETT ON FEVERS. THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEYERS OF THE UNITED STATES BY ELISHA BARTLETT, M. D., Professor of the Theory and Practice of Physic in the Medical Department of Transylvania University &c. In One Octavo Volume of 550 Pages, Beautifully printed and strongly bound. We regard it, from the examination we have made of it, the best work on fever extant in oiir ii„» and as such cordially recommend it to the medical public—Si. Louis Med. and Surg. Journal Z"^' The most complete, methodical, and satisfactory account of our fevers anywhere to h* m«t »,-«i. m._ i ton Med. Journ. and Review. ' ""*mel wuh-— Charles- CLYMER AND OTHERS ON FEVERS. FEVERS; THEIR DIAGNOSIS, PATHOLOGY, AND TREATMENT. PREPARED AND EDITED, WITH LARGE ADDITIONS, FROM THE ESSAYS ON FEVER IN TWEEDIE's LIBRARY OF PRACTICAL MEDICINE BY MEREDITH CLYMER, M.D. ' In One Octavo Volume of Six Hundred Pages. One of the best works we have on fevers, and especially adapted to the wants of the American Dhvsioian —IU. and Ind. Med. and Surg. Journal. *"»jr»ician. ________^^ ** DLai^nAitua PUBLICATIONS.—(Practice of Medicine.) 13 THE GREAT MEDICAL LIBRARY. THE CYCLOPEDIA OF PRACTICAL MEDICINE; COMPRISING Treatises on the Nature and Treatment of Diseases, Materia Medica, arid Thera- peutics, Diseases of "Women and Children, Medical Jurisprudence, &c. &c. EDITED BT JOHN FORBES, M. D., F. R. S., ALEXANDER TWEEDIE, M. D., F. R. S., AND JOHN CONNOLLY, M. D. Revised, with Additions, BY ROBLEY DUNGLISON, M. D. THIS WORK IS NOW COMPLETE, AND FORMS FOUR LARGE SUPER-ROYAL OCTAVO VOLUMES, Containing Thirty-two Hundred and Fifty-four unusually large Pages in Double Columns, Printed on Good Paper, with a new and clear type. THE WHOLE WELL AND STRONGLY BOUND, WITH RAISED BANDS AND DOUBLE TITLES. Or, to be had in Twenty-four Parts. This work contains no less than FOUR HUNDRED AND EIGHTEEN DISTINCT TREATISES, BY SIXTY-EIGHT DISTINGUISHED PHYSICIANS. The most complete work on Practical Medicine extant; or, at least, in our language.—Buffalo Medical and Surgical Journal. For reference it is above all price to every practitioner.— Western Lancet. One of the most valuable medical publications of the day—as a work of reference it is invaluable.— Western Journal of Medicine and Surgery. It has been to us, both as learner and teacher, a work for ready and frequent reference, one in which modern English medicine is exhibited in the most advantageous light.—Medical Examiner. We rejoice that this work is to be placed within the reach of the profession in this country, it being unques- tionably one of very great value to the practitioner. This estimate of it has not been formed from a hasty ex- amination, but after an intimate acquaintance derived from frequent consultation of it during the past nine or ten years. The editors are practitioners of established reputation, and the list of contributors embraces many of the most eminent professors and teachers of London, Edinburgh, Dublin, and Glasgow. It is, indeed, the great merit of this work that the principal articles have been furnished by practitioners who have not only devoted especial attention to the diseases about which they have written, but have also enjoyed opportunities for an extensive practical acquaintance with them,—and whose reputation carries the assurance of their , competency justly to appreciate the opinions of others, while it stamps their own doctrines with high and just authority.—American Medical Journal. WILLIAMS ON RESPIRATORY ORGANS. A PRACTICAL TREATIs"FoN DISEASES OF THE RESPIRATORY ORGANS. INCLUDING DISEASES OF THE LARYNX, TRACHEA, LUNGS, AND PLEURA, BY CHARLES J. B. WILLIAMS, M. D., &c. WITH NUMEROUS ADDITIONS AND NOTES, BY MEREDITH CLYMER, M. D. With wood-cuts. In one octavo volume, with 508 pages. BENEDICT'S CHAPMAN.—Compendium of Chapman's Lectures on the Practice of Medicine. One neat volume, 8vo., pp. 258 BUDD ON THE LIVER.—On Diseases of the Liver. In one very neat 8vo. vol., with colored plates and wood-cuts, pp. 392. CHAPMAN'S LECTURES.—Lectures on Fevers, Dropsy, Gout, Rheumatism, &c. &c. In one neat 8vo. volume, pp. 450. ESQUIROL ON INSANITY.—Mental Maladies, considered in relation to Medicine, Hygiene, and Medical Jurisprudence. Translated by E. K. Hunt, M. D., &c. In one 8vo. volume, pp. 496. THOMSON ON THE SICK ROOM.—Domestic management of the sick Room, necessary in aid of Medical Treatment for the cure of Diseases. Edited by R. E. Griffith, M. D. In one large royal 12mo. volume, with wood-cuts, pp. 360. HOPE ON THE HEART.—A Treatise on the Diseases of the Heart and Great Vessels. Edited by Pen- nock. In one volume, 8vo., with plates, pp. 572. LALLEMAND ON SPERMATORRHOEA.—The Causes, Symptoms, and Treatment of Spermatorrhoea. Translated and Edited by Henry J. McDougal. In one volume, 8vo., pp.320. PROUT ON THE STOMACH.—On the Nature and Treatment of Stomach and Renal Diseases. In one volume, 8vo., with colored plates, pp. 466. PHILIP ON INDIGESTION.—A Treatise on Protracted Indigestion. In one volume, 8vo., pp. 210. PHILIPS ON SCROFULA.—Scrofula: its Nature, its prevalence, its Causes, and the Principles of its Treatment In one volume, 8vo., with a plate, pp. 350. WHITEHEAD ON ABORTION, &c—The Causes and Treatment of Abortion and Sterility; being the Result of an Extended Practical Inquiry into the Physiological and Morbid Conditions of the Uterus. In one volume, 8vo., pp. 368. BENNET ON THE UTERUS.—A Practical Treatise on Inflammation, Ulceration, and Induration of the Neck of the Uterus. In one small 12mo. volume, pp. 146. 14 LEA & BLANCHARD'S PUBLICATIONS —(Materia Medica, &c.) ILLUSTRATED ENCYCLOPEDIA OF MATERIA MEDICA. THE BIiEBffEPJTS OF MATERIA MEDICA ANO THERAPEUTICS. COMPREHENDING THE NATURAL HISTORY, PREPARATION, PROPERTIES, COMPOSITION, EFFECTS, AND USES OF MEDICINES. BY JONATHAN PEREIRA, M. D., F. R. S. and L. S., Member of the Society of Pharmacy at Paris: Examiner in Materia Medica and Pharmacy in the University of London; Lecturer on Materia Medica at the London Hospital, &c. &c. Second American Edition, Enlarged and Improved. WITH NOTES AND ADDITIONS, BY JOSEPH CARSON, M. D. In two volumes octavo, containing Fifteen Hundred very large pages, illustrated by Two hundred and Seventy five Woodcuts. Notwithstanding the large size of this work, and the immense quantity of matter contained in its closely printed pages, it is offered at a price so low as to place it within the reach of all. An Encyclopaedia of knowledge in that department of medical science—by the common consent of the pro- fession the most elaborate and scientific Treatise on Materia Medica in our language.— Western Journal of Medicine and Surgery. This Encyclopaedia of Materia Medica, for such it may justly be entitled, gives the fullest and most ample exposition of Materia Medica and its associate branches of any work heretofore published in the English lan- guage.— N. Y. Journal of Medicine. The work will be found an invaluable storehouse of information for the physician and medical teacher, and we congratulate the profession of this country that it is now placed within their reach.—Amer. Med. Journal. An authoritative and unerring pharmacological guide.—Medical Examiner. Any quotations from a work so well known as this, and which has deservedly become one of the highest authority in the department of medical science to which it relates, would be superfluous. The untiring in- dustry of the author, and his extensive researches into the medical literature of every country, aTe impressed upon the mind of the reader in each page of the volume. Not a fact of any importance, bearing directly or indirectly upon his subject, is allowed by the author to escape. All are chronicled with accuracy and order; and, instead of th<> dry hisioryof a drug, the reader finds himself instructed in philology, natural history, bota- ny, physiology, or chemistry, so that he can seldom refer for information on one point without acquiring some knowledge on others which had hitherto escaped his notice. This work shows that Dr. Pereira is not only an extensive reader, but a practical man. He has studiously endeavored to bring the present edition up to the scientific level of the day, and m this we need hardly say he has succeeded.—London Med. Gazette. Beyond dispute, the best work on Materia Medica.—Lancet. April, 1849. The work will be found an invaluable storehouse of information for the physician and medical teacher, and we congratulate the profession of this country that it is now placed within their reach.—Amer. Med. Journal. ELLIS'S MEDICAL FORMULARY. Improved Edition. Now Ready. 1849. THE MEDICAL" FORMULARY: BEING A COLLECTION OF PRESCRIPTIONS, DERIVED FRO« THE WRITINGS AND PRACTICE OF MANY OF THE MOST EMINENT PHYSICIANS OF AMERICA AND EUROPE. TO WHICH IS ADDED AN APPENDIX, CONTAINING THE USUAL DIETETIC PREPARATIONS AND ANTIDOTES FOR POISONS. THE WHOLE ACCOMPANIED WITH A FEW BRIEF PHARMACEUTIC AND MEDICAL OBSERVATIONS. BY BENJAMIN ELLIS, M. D., NINTH EDITION, CORRECTED AND EXTENDED, BY SAMUEL GEORGE MORTON, M.D. In one neat octavo volume, of 268 pages. In preparing the new edition of this popular and valuable work; great care has been taken to bring it up to the advanced science of the day. The size of the page has been increased, thus enlarging the work without extending its bulk, while the price is kept at the former rate. A chapter has been added on Ether and Chlo- roform, the subject of poisons has been rewritten and enlarged, and many new formulas interspersed through- out the volume. DUNGLISON ON NEW REMEDIES. NEW EDITION. NEW REMEDIES, BY ROBLEY DUNGLISON, M. D., &c. &c. Fifth edition, with extensive additions. In one neat Octavo volume. A work like this is obviously not suitable for either critical or analytical review. It is, so far a* it goes a dispensatory, in which an account is given of the chemical and physical properties of all the articles recently added to the Materia Medica and their preparations, with a nonce of the diseases for which they are pre- scribed, the doses, mode of administration, ice—The Medical Examiner. LEA & BLANCHARD'S PUBLICATIONS -(Materia Medica, tf-c.) 15 ciiristisojy a* Griffith's dispensatory, .wu> Ready. A DISPENSATORY, OR COMMENTARY ON THE PHARMACOPEIAS OF GREAT BRITAIN AND THE UNITED STATES: COMPRISING THE NATURAL HISTORY, DESCRIPTION, CHEMISTRY, PHARMACY, ACTIONS, USES AND DOSES OF THE ARTICLES OF THE MATERIA MEDICA. BY ROBERT CHRISTISON, M.D., V.P.R.S.E., PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH, PROFESSOR OF MATERIA MEDICA IN THE / UNIVERSITY OF EDINBURGH, ETC. Second Edition, Revised and Improved, WITH A SUPPLEMENT CONTAINING THE MOST IMPORTANT NEW REMEDIES. WITH COPIOUS ADDITIONS, AND TWO HUNDRED AND THIRTEEN LARGE WOOD ENGRAVINGS, BY R. EGLESFELD GRIFFITH, M.D., AUTHOR OF "A MEDICAL BOTANY," ETC. In One very large and handsome Octavo Volume of over One Thousand closely printed Pages, with numerous Wood-cuts, beautifully printed, on fine white paper. Presenting an immense quantity of matter at an unusually low price. It is enough to say that it appears to us as perfect as a Dispensatory, in the present state of pharmaceuti- cal science, could be made. If it omits any details pertaining to this branch of knowledge which the student has aright to expect in such a work, we confess the omission has escaped our scrutiny. We cordially recommend this work to such of our readers as are in need of a Dispensatory. They cannot make choice of a better.—The Western Journal of Medicine and Surgery. In conclusion, we need scarcely say that we strongly recommend this work to all classes of our readers. As a Dispensatory and commentary on the Pharmacopoeias, it is unrivalled in the English or any other lan- guage.—The Dublin Quarterly Journal. We earnestly recommend Dr. Christison's Dispensatory to all our reader?, as an indispensable companion, not in the Study only, but in the Surgery also.—British and Foreign Medical Review. It is exactly the work we would give to the student for daily reading, or to the practitioner for regular refer- ence. Without being encumbered with unnecessary detail or research, it is sufficiently explicit in its litera- ture to render it an ample encyclopajdia of its subject; and at the same time, its practical information is so condensed and summary, yet without a sacrifice of even the least important fact, that to the student it cannot but be a text-book invaluable in its kind. Had we said less concerning this volume we should have been wanting in common duty ; but it is not necessary that we should say more to convince our readers that we consider it to be the best English work extant upon the subject it embraces.—Medical Times. There is not in any language a more complete and perfect Treatise.—N. Y. Annalist. As nearly complete as possible— a work of great authority and usefulness.—Charleston Medical Journal. One of the standards of the day, and as such must meet the favor it deserves.—Am. Jour, of the Med. Sciences. In advance of most that has been written on the subject —Buffalo Medical Journal. As perfect as such an undertaking can well be—Southern Medical and Surgical Journal. We can heartily recommend this work as one of the very best of its kind.—Northwestern Medical Journal. It should occupy a conspicuous place in the bureau of every physician and apothecary.—N. O. Medical and Surgical Journal. The most accurate, the best arranged, and the cheapest work of the kind.—London and Edinburgh Jour- nal of Medical Science. To those who do not possess Wood $ Bache, we would say procure Christison <$• Griffith; and to those who do possess the former, that it would be well to procure the latter as soon a3 convenient.—St. Louis Medical and Surgical Journal. From Professor Rayburn, of St. Louis. The most valuable, in my opinion, of all the Dispensatories yet published. DINGHSOIt'S THEIUPEUTICS. New and mnen Improved Edition. GENERAL THERAPEUTICS-AND MATERIA MEDICA. With One Hundred and Twenty Illustrations. ADAPTED FOR A MEDICAL TEXT-BOOK. BY ROBLEY DUNGLISON, M. D., Professor of Institutes of Medicine, &c. in Jefferson Medical College ; Late Professor of Materia Medica, &c. in the Universities of Virginia and Maryland, and in Jefferson Medical College. Third edition, revised and improved, in two octavo volumes, well bound. The most complete and satisfactory exponent of the existing state of Therapeutical Science, within the moderate limits of a text-book, of any hitherto published.—N. Y. Journal of Medicine. Our junior brethren in America will find in these volumes of Professor Dunglison, a "Thesaurus Medica- minum," more valuable than a large purse of gold.—London Medico-Chirurgical Review. No medical student on either side of the Atlantic should be without these volumes.—British and Foreign Medical Review. 16 LEA & BLANCHARD'S PUBLICATIONS.—(Materia Medica, $c.) ROYLE'S MATERIA MEDICA, MATERIA MEDICA AND THERAPEUTICS; INCLUDING THE Preparations of the Pharmacopeias of London, Edinburgh, Dublin, and of the United States. WITH MANY NEW MEDICINES. BY J. FORBES ROYLE, M. D., F. R, S., Professor of Materia Medica and Therapeutics, King's College, London, &c. &c. EDITED BY JOSEPH CARSON, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy, &c. &c. WITH NINETY-EIGHT ILLUSTRATIONS. In one large octavo volume, of about Seven Hundred Pages. Being one of the most beautiful Medical works published in this Country. This work is, indeed, a most valuable one, and will fill up an important vacancy that existed between Dr. Pereira's most learned and complete system of Materia Medica, and the class of productions on the other ex- treme, which are necessarily imperfect from their small extent.—British and Foreign Medical Review. Of the various works on the plan of the one before us, there is none more deserving of commendation. Every one who can afford it, should possess this excellent work.—Medical Examiner. We cannot too highly recommend this valuable work, both to the student and practitioner.—Southern Jour- nal of Medicine and Pharmacy. This work is ably done—the botanical part with great skill; and the chemical, natural history, and thera- peutic department most perfect and complete.—Edinburgh Medical Journal. The subject is well treated, the matter practical and well arranged, and we do not hesitate to recommend it ;is a most useful volume to the student and practitioner.—Medical Gazette. The wood engravings by which the crystals, the vegetable products, and the medicinal animals are illus- trated, are better than anything hitherto attempted in Materia Medica, and must prove a great assistance to ihe student, appealing as they do more powerfully to the mind than the most careful verbal descriptions taken alone could do.—Lancet. Each substance is considered in reference to its history, its physical and chemical properties, preparations, tests, action, uses, and doses. All of these are briefly sketched in a concise and lucid manner, and in a way to show that a master-hand was employed in the task.—N. O. Medical and Surgical Journal. JVEW JUYIt COMPLETE JtlEOIClZ, BOTAJV1T. Lately Published. MEDICAL- BOTANY, OR, A DESCRIPTION OF ALL THE MORE IMPORTANT PLANTS USED IN MEDICINE, AND OF THEIR PROPERTIES, USES, AND MODES OF ADMINISTRATION. BY R. EGLESFELD GRIFFITH, M. D., &c. &c. In one large octavo volume, of 704 pages, handsomely printed, with nearly three hundred and fifty illustrations on wood. By far the most comprehensive and complete work upon the subject which has been issued from the Ame rican press, filling a great vacancy in the medical literature of the country .-HI. $ Ind. Med. and Surg. Jour An admirable work.—Boston Medical and Surgical Journal. u»ig.<»»j. One of the greatest acquisitions to American medical literature. It should by all means be introduced at the very earliest period, into our medical schools, and occupy a place in the library of every physician in the land.—Southwestern Medical Advocate. J * v ' oi*-1B"'" «*e Admirably calculated for the physician and student—we have seen no work which Promises (rreater »H vantages to the profession— N. O. Medical and Surgical Journal. promises greater ad- One of the few books which supply a positive deficiency in our medical literature — Western Tn«^t We hope the day is not distant when this work will not only be a text-book in every medica"school and college in the Union, but find a place in the library of every private practitioner.-JY: 5■ tour of Med£ine GRIFFITH'S UNIVERSAL FORMULARY.-To be Ready in August THE UNIVERSAL FORMULARY- A SYNOPSIS OF THE raABMA^IA^DIWENBATOEIES, AND FORMULARIES OF With numerous Magisterial Formulas from various sources BY R. E. GRIFFITH, M. D., &c. &c, Author of "Medical Botany," &c. &c. In one octavo volume. This work is intended to embrace all that is of practical importance in the numerous Pv,«,m„ • „ ularies, and Dispensatories of Europe and of this country, as well as such formula* »T* «™ jPiElas' Form- notice in the Medical Journals, Treatises of Medicine, &c. &c, together with manv mh ! ■ deserving of vate sources, which have never been hitherto published. It will therefore include all iw • nv?,d fron» pri- Redwood's Edition of Gray's Supplement to the Pharmacopoeias, in Jo'urdan's PharmnVnlwl-8 real1I>r useful in works of Ellis, Fee, Paris, Thomson, Beasley, Cottereau, Cooley, Bouchardat &e a , • ' the 8evera' its title of a Universal Formulary it will not be confined solely to medical formulas thJ.'n n. ?.c*:orda'",("e with the numerous scientific receipts embraced, will render it of much practical imnortn'nV.A ;« .{. £™ hope ,hat Manufacturer. It will contain nuance to the Chemist and UPWARDS OF SIX THOUSAND FORMULAS alphabetically arranged, with copious indexes, pointing out the diseases in which the nrennrminn. », . t used, &c. &c, and thus combining the advantages of all the different modes of arrangement and ?efere ________LEA & BLANCHARD'S PUBLICATIONS.—(Materio Medica, v adds much to its value.-SouMem Journal of Medicine and Surgery. *ieusive analytical index Appended to Chelius is an analytical index of unusual length; this was essential, and will be found mow useful in enabling the inquirer to consult any part of the work without trouble or loss of time —MediralTVm.. One of the most complete works in surgical literature.— Western Journal of Medicine and Sureeru Members of the profession who reside at a distance from the metropolitan centres or in the colon \e« il,™ who are or purpose to be, connected with our military or naval departments; indeed, all who mav X«i™ />t who, from their posiUon may find it necessary to have a book of reference at hand, which thev L,„„j as an authority, will derive much assistance from this work, as supplying a desideratum lonir want«H in ,k« profession.—Medical Times. ""*» wa"iea in tue COOPER (SIR ASTLEY) ON THE AN^^TOmTaNeTtREATMENT OF ABDOMWAT pPPW„ 1 large vol., imp. 8vo., with over 130 lithographic figures. ml" ALj H^R«IA. COOPER ON THE STRUCTURE AND DISEASES OF THE TESTIS, AND ON THt? to™,,t0 GLAND. 1 vol., imp. 8vo., with 177 figures on 29 plates. ntd 1HYMU8 COOPER ON THE ANATOMY AND DISEASES OF THE BREAST, WITH twpntv ttt™ MISCELLANEOUS AND SURGICAL PAPERS. 1 large vol., imp. 8vo., with 252 figures on 36 "nl T^ COOPER ON DISLOCATIONS AND FRACTURES OF THE JOINTS.-Edited bvBranshv r™„ 1 J. C. Warren. 1 vol. 8vo., with 133 cuts. 600 pp. y Urans°y Cooper and DURLACHER ON CORNS, BUNIONS, Icc.-A Treatise on Corns, Bunions, the Diseases of v«ii. .^ the General Management of the Feet. In one 12mo. volume, cloth. 134 pp. diseases of IV ails, and GUTHRIE ON THE BLADDER, &c.-The Anatomy of the Bladder and Urethra, and the Treatment „f tk- Obstrucuons to which those Passages are liable. In one vol. 8vo. 156 pp. ' e lrealmenl°ftha LEA & BLANCHARD'S PUBLICATIONS.—(Surgery.) 23 THE STUDENT'S TEXT-BOOK OF SURGERY. JYew and Improved Edition. Just Issued. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. BY ROBERT DRUITT, Fellow of the Royal College of Surgeons. A New American from the last and improved London Edition. EDITED BY E. W. SARGENT, M. D.; Author of "Minor Surgery," &c. Illustrated with One Hundred, and Ninety-three Wood Engravings. In one very handsomely printed octavo volume of 576 large pages. In preparing the new edition of this popular text-book, every care has been taken so to improve it in every respect as to raise it still higher in the estimation of the profession. The edition from which this is printed has large and important additions by the author; while the present editor, Dr. Sargent, has added whatever appeared necessary to render the book a correct exponent of the present state of surgical science in this country. The illustrations have been entirely remodelled j numerous new ones added by both author and editor ; and many superior ones substituted for those rejected. The amount of these changes may be estimated from the fact, that of the 193 wood-cuts at present in this volume, more than one-half have appeared in no former American edition. In mechanical execution, also, the work will be found much improved; in clear type, white paper, and handsome printing, it will compare favorably with the best executed works published in the country, while the price is still kept so low as to place it within the reach of all. An unsurpassable compendium, not only of Surgical, but of Medical Practice.—London Medical Gazette. No work, in our opinion, equal* it in presenting so much valuable surgical matter in so small a compass.— St. Louis Medical and Surgical Journal. The author has fully succeeded in producing a complete system of surgical science and practice in the smallest practicable compass, and at the cheapest possible price.—Edinburgh Monthly Medical Journal. It is the most accurate and ample r6sum6 of the present state of surgery that we are acquainted with.— Dublin Medical Journal. This is the best work of its size, on the subject of surgery, that has made its appearance on our desk. For the use of the general practitioner, it may be preferable to many of the larger works, as it has the important facts he wants, in a more condensed form, from which he can get his information with less labor and time, if not with clearer views of the subject—The Northwestern Medical and Surgical Journal. Admirably adapted to the wants of the student.— Provincial Medical and Surgical Journal. A better book on the principles and practice of surgery has not been given to the profession.—Boston Medi- tal and Surgical Journal. SARGENT'S MINOR SURGERY. A NEW WORK. ON BANDAGING, AND OTHER POINTS OF MINOR SURGERY. BY P. W. SARGENT, M. D. In one handsome volume, royal 12mo., with nearly 400 Pages, and 128 Wood-cuts. The very best manual of Minor Surgery we have seen —Buffalo Medical and Surgical Journal. Admirably adapted to the use of the student — Charleston Medical Journal. We can unhesitatingly recommend this volume as one of the very best of its kind.—American Med. Journal. We will adopt it as a text-book for the use of our own pupils, and we must recommend our fellow practi- tioners in all partsofthe country to do likewise.— IV. V. Journal of Medicine. Nothing perhaps in the whole routine of practice redounds more decidedly to the upbuilding of a young sur- geon's reputation, and certainly none contributes more to the comfort of the suffering patient, than dexterity ui the performance of the minor surgical operations, and the neat and skilful arrangement of dressings. In view of these facts, it is a matter of some degree of astonishment that a due consideration of this subject should have been deferred so long. We strongly recommend Dr. Sargent's treatise to all our readers, believing that it will prove abundantly useful to those who consult its pages for information upon the important subjects therein discussed.—The Ohio Medical and Surgical Journal. LISTON AND MUTTER'S SURGERY. LECTURES ON" THE OPERATIONS OP SURGERY, And on Diseases and Accidents requiring Operations. DELIVERED AT UNIVERSITY COLLEGE, LONDON. BY ROBERT LISTON, Esq., F. R. S., &c. EDITED, WITH NUMEROUS ALTERATIONS AND ADDITIONS, BY T. D. MUTTER, M. D., &C &C In one large and handsome octavo volume of 566 pages, with 216 Wood-cuts. It is a compendium of the modern practice of Surgery as complete and accurate as any treatise of similar dimensions in the English language.— Western Lancet. LAWRENCE ON RUPTURES—A Treatise on Ruptures, from the fifth London Edition. In one 8vo. vol. sheep. 480 pp. MAURY'S DENTAL SURGERY.—A Treatise on the Dental Art. founded on Actual Experience. Illus- trated by 241 lithographic figures and 54 wood-cuts. Translated by J. B. Savier. In 18vo. vol., sheep. 286 pp. ROBERTSON ON THE TEETH.—A Practical Treatise on the Human Teeth, with Plates. One small volume, 8vo. 230 pp. DUFTON ON THE EAR.—The Nature andTrealmentof DeafnessandDiseasesof theEar; andtheTreat- ment of the Deaf and Dumb. One small 12mo. volume. 120 pp. 24 LEA & BLANCHARD'S PUBLICATIONS.—(Surgery.) FERGUSSON'S OPERATIVE SURGERY. NEW EDITION. A SYSTEM OF PRACTICAL SURGERY. BY WILLIAM FERGUSSON, F. R. S. E., Professor of Surgery in King's College, London, &c. &c. THIRD AMERICAN, FROM THE LAST ENGLISH EDITION. With Two Hundred and Seventy-four Illustrations, from Drawings by Bagg, Engraved by Gilbert tf Gihon. In one large and beautifully printed octavo volume, of six hundred and thirty pages. It is with unfeigned satisfaction that we call the attention of the profession in this country to this excellent work. It richly deserves the reputation conceded to it, of being the best practical Surgery extant, at least in the English language.—Medical Examiner. Professor Fergusson's work, we feel persuaded, will be as great a favorite as it deserves, for it combines the powerful recommendations of cheapness and elegance, with a clear, sound, and practical treatment of every subject in surgical science. The illustrations, by Bagg, are admirable—inhis very best style.—Edinburgh Journal of Medical Science. MILLER'S PRINCIPLES OF SURGERY. THE PRINCIPLES OF SURGERY. BY JAMES MILLER, F. R. S. E., Professor of Surgery in the University of Edinburgh, &c. SECOND AMERICAN EDITION, In one octavo volume of five hundred and thirty-eight pages. BY THE SAME AUTHOR. THE PRACTICE OF SURGERY. SECOND AMERICAN EDITION. In one octavo volume, of five hundred pages. These two works are printed and bound to match, forming together a complete System of Surgery. Taken together they form a very condensed and complete system of Surgery, not surpassed, as a text-book by any work with which we are acquainted.—III. and Ind. Medical and Surgical Journal. Mr. Miller has said more in a few words than any writer since the days of Celsus.—JV. O. Med. and Sure Journal. s LIBRARY OF OPHTHALMIC MEDICINE AND SURGERY. A TREATISE ON THE DISEASES OF THE EYE. BY W. LAWRENCE, P. R. S., Surgeon Extraordinary to the Queen, Surgeon to St. Bartholomew's Hospital &c. &c. A NEW EDITION. With many Modifications and Additions, and the introduction of nearly two hundred Illustrations BY ISAAC HAYS, M. D., In one very large 8vo. vol. of 860 pages, with twelve plates and many wood-cuts through the text. This book contains all that is necessary for the student or practitioner to know.—Dublin Medical Press The work of Mr Lawrence, with the numerous additions of the American Editor, is allowedly one of if not the best. The library of no medical man can be complete Without it.—JV. Y. Journal of Medicine. JONES ON THE EYE. THE PRINCIPLE? AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY. BY T. WHARTON JONES, F. R. S., &c. &c. EDITED BY ISAAC HAYS, M. D., &c. In one very neat volume, large royal 12mo. of 529 pages, with four plates, plain or colored and ninety-eight well executed wood-cuts. » From Professor Mott, of New York. The work on Ophthalmic Surgery, by Jones, is undoubtedly the best on that subject in the Fnai;«t, i=„ It will give me pleasure to aid in its circulation in every way in my power. ^"o"»n language. Mr. Jones'Manual is a very elaborate compilation, and will, in this age of condensing »nif«™u; manualizing, doubtless occupy the foremost place.—Medico-Chirurgical Review. "' cPll0mizlng) and BRODIE'S SURGICAL LECTURES.—CHnic^alL^cmres^S^ery. 1 vol. 8vo., cloth 350 nn ' BRODIE ON THE JOINTS.-Pathological and Surgical Observations on the Diseases of the Joints. 1 vol BRODIE ON URINARY ORGANS.-Lectures on the Diseases of the Urinary Organs. 1 vol. 8vo., cloth %*TSurglcafwoff»m780pp.had nCatly b°Und t°gether' foming *large volume of "Bro°ie'» LEA & BLANCHARD'S PUBLICATIONS.—(Chemistry.) POWNES' CHEMISTRY FOR STUDENTS. New and Improved Edition. ELEMENTARY CHEMISTRY, THEORETICAL AND PRACTICAL. BY GEORGE FOWNES, Ph. D., Chemical Lecturer in the Middlesex Hospital Medical School, &c. &c. With Numerous Illustrations. Second American Edition. Edited, with Additions, BY ROBERT BRIDGES, M. D., Professor of General and Pharmaceutical Chemistry in the Philadelphia College of Pharmacy, &c. &c. In one large royal 12mo. volume, of 460 pages, sheep or extra cloth. We know of no treatise in the language so well calculated to aid the student in becoming familiar with the •*" numerous facts in the intrinsic science on which it treats, or one better calculated as a text-book for those at- tending Chemical lectures. * * * * The best text-book on Chemistry that has issued from our press.—Ameri- can Medical Journal We again most cheerfully recommend it as the best text-book for students in attendance upon Chemical lectures that we have yet examined.— HI. and Ind. Medical and Surgical Journal. A first rate work upon a first rate subject.— St. Louis Medical and Surgical Journal. No manual of Chemistry which we have met, comes so near meeting the wants of the beginner.— Western Journal of Medicine and Surgery. We know of none within the same limits, which has higher claims to our confidence as a college class book, both for accuracy of detail and scientific arrangement.—Augusta Medical Journal. GARDNER'S MEDICAL CHEMISTRY—Now Ready. MEDICAL CHEMISTRY, FOR THE USE OF STUDENTS AND THE PROFESSION; BEING A MANUAL OF THE SCIENCE, WITH ITS APPLICATIONS TO TOXICOLOGY, PHYSIOLOGY, THERAPEUTICS, HYGIENE, &c. &c. BY D. PEREIRA GARDNER, M. D., Late Professor of Chemistry in the Philadelphia College of Medicine, &c. In one handsome royal l2mo. volume of 400 pages, with illustrations. By far the greater number of medical students will find this work of Dr. Gardner better adapted to their wants than any other with which we are acquainted.— Ohio Medical and Surgical Journal. Admirably adapted to the end and design. We shall be much disappointed if it is not adopted as a text- book in all our American Colleges.—JV. Y. Journ. of Medicine. An excellent work—one likely to be of great use to the student, and of no small value to the practitioner. — Charleston Medical Journal. it is an admirable exposition of the facts of Chemical science in their application to practical medicine in Jts various branches. The work is sufficiently extended, and very accurate in its details, and cannot fail to prove most useful as a book of study or of reference.—The Lancet, March 10,1649. We know of no work exactly like it by any English author. The reader will find here, in a concise form, information for which he would otherwise have to seek in many elaborate and expensive treatises.—London Medical Gazette, March, 1849. BOWMM'S PRACTICAL. CHEMISTRY. JVow Ready. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. By JOHN E. BOWMAN, Demonstrator of Chemistry, King's College. In one handsome volume, royal 12moM of over 300 pages. WITH NEARLY ONE HUNDRED ENGRAVINGS ON WOOD. One of the most complete manuals that has for a long time been given to the medical student.—Athenceum. We regard it as realizing almost everything to be desired in an introduction to Practical Chemistry, it is by far the best adapted for the Chemical student of any that has yet fallen in our way.—British and Foreign Medico- Chirurgical Review. The best introductory work on the subject with which we are acquainted.—Edinburgh Monthly Journal February, 1849. AN IMAL CHEMI STRY, WITH REFERENCE TO THE PHYSIOLOGY AND PATHOLOGY OF MAN. BY DR. J. FRANZ SIMON. TRANSLATED AND EDITED BY GEORGE E. DAY, M. A. & L. M. CANTAB., &C. With plates. In one octavo volume of over seven hundred pages, sheep. No treatise on physiological Chemistry approaches this in fulness and accuracy of detail.— Western Journal of Medicine and Surgery. New Edition, Preparing.—THE ELEMENTS OF CHEMISTRY, INCLUDING THE APPLICATION OF THE SCIENCE TO THE ARTS. WITH NUMEROUS ILLUSTRATIONS. BY THOMAS GRAHAM, F. R. S., L. & E. D. With Notes and Additions, by ROBERT BRIDGES, M. D., &c. &c In one very large 8vo. vol. 26 LEA & BLANCHARD'S PUBLICATIONS. TAYLOR o.v roisojYS. ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE BY ALFRED S. TAYLOR, F. R. S., &c. Edited, with Notes and Additions, BY R. E. GRIFFITH, M. D. In one large octavo volume, of 688 pages. The most elaborate work on the subject that our literature possesses.—Brit, and For. Medico- Chirur. Review. One of the most practical and trustworthy works on Poisons in our language — Western Journal of Med. It contains a vast body of facts, which embrace ail that is important in toxicology, all that is necessary to Ihe guidance of the medical jurist, and all that can be desired by the lawyer.—Medico-Chirurgical Review. It is, so far as our knowledge extends, incomparably the best upon the subject; in the highest degree credit- able to the author, entirely trustworthy, and indispensable to the student and practitioner.—N. Y. Annalist. TAYLOR'S MEDICAL JURISPRUDENCE. MEDICAL JURISPRUDENCE. BY ALFRED S. .TAYLOR, Lecturer on Medical Jurisprudence and Chemistry at Guy's Hospital, &c. With numerous Notes and Additions, and references to American Practice and Law. BY R. E. GRIFFITH, M. D. In one octavo volume of five hundred and forty pages. We recommend Mr. Taylor's work as the ablest, most comprehensive, and, above all, the most practically useful book which exists on the subject of legal medicine. Any man of sound judgment, who has mastered Ihe contents of Taylor's "Medical Jurisprudence," may go into a court of law with the most perfect con6- denceof being able to acquit himself creditably.—Medico-Chirurgical Review. The most elaborate and complete work that has yet appeared. It contains an immense quantity of case« lately tried, which entitle it to be considered what Beck was in its day.—Dublin Medical Journal. TRAILL'S MEDICAL JURISPRUDENCE—Outlines of a Course of Lectures on Medical Jurisprudence, Revised, with numerous Notes. In one small octavo volume of 234 pages. DUJYGLISOJY OJY HUMAJY HEALTH. HUMAN ~HEALTH, OR THE INFLUENCE OF ATMOSPHERE AND LOCALITY, CHANGE OF AIR AND CLIMATE, SEASONS, FOOD, CLOTHING, BATHING, EXERCISE, SLEEP, &C. &C. &C., ON HEALTHT MAN, CONSTITUTING ELEMENTS OF HYGIENE. Second Edition, with many Modifications and Additions. BY ROBLEY DUNGLISON, M. D., &c. &c. In one octavo volume of 464 pages. MITCHELL ON THE ORIGIN OF FEVERS—A New Work-Just Ready. ON THE CRYPTO&AMQUS ORIGIN OF MALARIOUS AND EPIDEMIC FEVERS. BY J. K. MITCHELL, M. D., Professor of Practical Medicine in the Jefferson Medical College of Philadelphia, &c. In one small volume of 138 pages, extra cloth. BARTLETT OJY CERTAIJYTY MY MEDICMYE—J\^w Ready. AN INQUIRY INTO THE DEGREE OP CERTAINTY IN MEDICINE AND INTO THE NATURE AND EXTENT OF ITS POWER OVER DISEASE ' BY ELISHA BARTL.ETT, M. D., Author op " Fevers of the United States," " Philosophy of Medical Science." In One small Volume of 84 pages, crown 8vo., extra cloth. AN ESSAY ON THE PHILOSOPHY OF MEDICAL SCIENCE BY ELISHA BARTLETT, M. D., Author of « Fevers of the United States." In one handsome octavo volume of three hundred and twelve pages. _____ A NEW EDITION OF THE MEDICAL STUDENT; Or, Aids to the Study of Medicine. A REVISED AND MODIFIED EDITION. BY ROBLEY DUNGLISON M. D In one neat l2mo. volume. LEA AND BLANCHARD'S PUBLICATIONS. 27 MAITUALS FOR EXAMINATION. Now Ready. an analtti^ITcompendtum: OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE, FOR THE USE AND EXAMINATION OF STUDENTS. BY JOHN NEILL, M. D., DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA. LECTURER ON ANATOMY IN THE MEDICAL INSTITUTE OF PHILADELPHIA, ETC., FRANCIS GURNEY SMITH, M.D., LECTURER ON PHYSIOLOGY IN THE PHILADELPHIA ASSOCIATION FOR MEDICAL INSTRUCTION, ETC. ETC. Forming One very large and handsomely printed Volume in royal duodecimo, of over Nine Hundred large Pages, with about Three Hundred and Fifty Wood Engravings, strongly bound in leather, with raised bands. While this work is not offered as a substitute for the regular text-books, for the purpose of study, its convenient form, and the amount of information condensed in its pages, together with the ful- ness of its illustrations, render it eminently suited as a work of reference for the office table of the practitioner. To render it more convenient for the student, it is divided into seven por- tions, corresponding to the leading divisions of medical and surgical science. These are paged separately, and may be had done up in stout covers, each being perfect in itself, and forming con- venient volumes to carry in the pocket to the lecture room, or fitting them to be sent by mail. It will thus be seen that this work affords, at a price unprecedentedly low, a series of digests of the medical and surgical sciences, clearly and conveniently arranged, and forming a complete set of HANDBOOKS FOR STUDENTS, as follows:— ANATOMY; 180 large pages, with 157 Illustrations. Price 75 Cents. PHYSIOLOGY) 134 pages, with 40 Illustrations. Price 60 Cents. SURGERY; 122 pages, with 51 Illustrations. Price 60 Cents. OBSTETRICS; 114 pages, wilh 37 Illustrations. Price 50 Cents. MATERIA MEDICA AND THERAPEUTICS: 116 pages, with 29 Illustrations. Price 50 Cents. CHEMISTRY; 94 pages, with 19 Illustrations. Price 40 Cents. THE PRACTICEOF MEDICINE; 152 pages, with 3 Illustrations. 50 Cmts. Any one of which may be had separate; or, the whole will be done up and mailed, v/ith the postage prepaid, on the remittance of $4; or, if $5 is remitted, The Medical News will be sentin addition. It should be noticed that the amount of matter on a page is unusually large, thus making these Handbooks not only low priced, but extraordinarily cheap. We do not share in the opinion entertained by some, that compendiums of science are not desirable or with the still smaller number, who esteem them useless. On the contrary, when well executed, they are of essential service to the student; and so far as we have seen, most of them have contained an amount of in- formation which older individuals—even they who disparage them—may be presumed to be far from pos- sessing. Taking the work before us, we can cenainly say that no one who has not occupied himself with the different scientific treatises and essays that have appeared recently, and has withal a rare memory, could pretend to possess the knowledge contained in it; and hence we can recommend it to such—as well as to students especially—for its general accuracy and adequacy for their purposes; and to the well informed practitioner to aid him in recalling what may easily have passed from his remembrance. We repeat our favorable impression as to the value of this book, or series of books; and recommend it as decidedly useful to those especially who are commencing the study of their profession.— The Medical Examiner. We have no hesitation in recommending it to students.— Southern Medical and Surgical Journal, Dec.lP48. Books of this description are most erroneously denounced, from the supposition that they are intended to lake the plaee of elaborate treatises; but their object is raiher to assist the student in mastering the elements of medicine, and to aid the practitioner by refreshing his recollection of former studies. In short, a manual or compendium is to the standard text-books in medicine and surgery what " the finder" is to the telescope of Ihe astronomer. It gives to the inquirer a key to the object of his pursuit, and enables him to trace out those parts which require to be especially studied. We have looked through this compendium,and we find that the authors have really succeeded in compressing a large amount of valuable information into a very small com- pass. VVe recommend this work especially to the notice of our junior readers. To those who are about to commence their studies in a medical school it will be found a serviceable guide.—London Medical Gazette. It aims to give a condensed account of every question touching the several branches of medicine, and on Hits account will arrest the attention of every candidate for his doctorate. It is not simply a work for the in- itruction of the novices.it maybe consulted by tbegeneral practitioner with infinite advantage. The different departments of which it treats are illustrated by handsome plates, and will serve to impress the mind of the ■tudent wilh clear and definite ideas on the various subjects comprehended in the work. It is, we think an excellent book of the kind, and will no doubt become highly popular with the students throughout the United Suues. To the medical student it may be confidently recommended as well as to the general prac- titioner, whose constant occupation will not allow him the necessary leisure to read more elaborate and comprehensive works — The New Orleans Medical and Surgical Journal. It will materially -assist the student and practitioner in refreshing his knowledge on points previously ac- quired, but upon which he may have become in a measure, rusty—for this purpose it is admirably adapted und we believe will not only prove acceptable to the student of medicine,,but also to the profession at lar°-e! — N. Y. Journal of Medicine. The airungeinent adopted will be found at once concise and clear; while its mechanical execution, its co- pious pictorial illustrations in the. branches of anatomy, physiology, surgery, obstetrics, materia medica and chemistry, together with iis neat, cheap and convenient form, will recommend it to all such students and practitioners who may desire to avail themselves of what cannot fail to prove, if kept within its proper sphere a convenient and use'lul remembrancer.—American Journal of the Medical Sciences. 28 LEA & BLANCHARD'S PUBLICATIONS. LIBRARY OF ILLUSTRATED SCIENTIFIC WORKS. UNDER THIS TITLE LEA & BLANCHARD ARE PUBLISHING A SERIES OF BEAUTIFULLY ILLUSTRATED WORKS, ON VARIOUS BRANCHES OF SCIENCE, BY THE MOST DISTINGUISHED MEN IN THEIR RESPECTIVE DEPARTMENTS. Printed in the handsomest style, and embellished in the most efficient manner. H"7*No expense has been or will be spared to render this series worthy of the support of the scientific pub- lic, while at the same lime it is one of the handsomest specimens of typographical and artistic execution which have appeared in this country. Specimens of the Engravings and style of the volumes may be had on application to the publishers. MULLER'S FHYSICS-LATELY ISSUED. P RIN CI P L E S OF PHYSICS AND METEOROLOGY. BY PROFESSOR J. MULLER, M. D. EDITED, WITH ADDITIONS, BY R. EGLESFELD GRIFFITH, M. D. In one large and handsome octavo volume, with 550 wood-cuts, and two colored plates. This is a book of no ordinary or ephemeral value. It is one of a series, now republishing in London, on the different branches of science, which from its thorough character and extended range, is much needed in this country. Its design is to render more easily accessible an extensive knowledge of the general principles of physics and meteorology; and the distinguished author has certainly realized the design to a wonderful extent. The subjects treated upon are very numerous— statics, hydrostatics, dynamics, hydrodynamics, pneu- matics, the laws of the motions of waves in general, sound, the theory of musical notes, the voice and hearing, geometrical and physical optics, magnetism, electricity and galvanism, in all their subdivisions, heat and meteorology. The size is nevertheless convenient—one handsome octavo volume, of six hundred pages— in clear, bold type, and profusely illustrated. In the execution of the illustrations we have rarely seen any thing equal to this American edition.— N. Y. Commercial. This is a large, elegant and most admirable volume—the first of a series of scientific books now passing through the press in London, knd which cannot fail to commend themselves to the favor of all who take any interest in the progress of science among the great mass of the people. The author is one of the most distin- guished scientific men in Germany, and these works have been prepared with the utmost care, and are put forth in a form admirably adapted to secure that wide circulation and universal favor which they deserve.__ N. Y. Courier and Inquirer. The Physics of Muller is a work superb, complete, unique: the greatest want known to English Science could not have been better supplied. The work is of surpassing interest. The value of this contribution to the scientific records of this country may be duly estimated by the fact that the cpst of the original drawings and engravings alone has exceeded the sum of £2,000.—Lancet. A work of which all parties may be proud.— Colonization Herald. An excellent work, fully and elegantly illustrated.—Silliman's Journal. At the present day it can hardly be requisite to speak of the absolute necessity for a well-educated physi- cian to be conversant wilh Natural Philosophy. At every turn he is met with the need of a knowledge of its principles; and, in proportion as he is well instructed in these, caeteris paribus, will he be prepared to prac- tice successfully and with advantage to himself. No surgeon, thoroughly imbued with the laws of Phvsics can ever be at a loss in the application of his various apparatus, to meet the continually changing requisitions of his art; without a practical knowledge of the same, he must ever be a novice and a bungler The number and beauty of the woodcuts struck us at once. They are unsurpassed in distinctness of outline and clearntss of delineation. We sincerely wish success to the undertaking, believing, when finished, that the whole series will form a valuable scientific library.— The Medical Examiner. ' From Professor Renwick, of Princeton University. I have been much gratified with the style in which the work is got up. It is not only highly creditable tn the publishers, in comparison with other American books of a similar character, but will stand nn Z>.iitv wilh the best foreign editions. cquauiy From Professor W. H. Bartlett, IT. S. Military Academy, West Point I deem this work a most valuable addition lo the educational facilities of the country and a rich m„,.o „, information to the general reader, as it is truly an elegant specimen of typography. source oi NOW READY. PRACTICAL PHAEMACY. COMPRISING THE ARRANGEMENTS, APPARATUS, AND MANIPULATION nv Tur PHARMACEUTICAL SHOP AND LABORATORY. BY FRANCIS MOHR, Ph. D., Assessor Pharmacia? of the Royal Prussian College of Medicine Coblentz ■ AND THEOPHILUS REDWOOD, Professor of Pharmacy in the Pharmaceutical Society of Great Britain. EDITED, WITH EXTENSIVE ADDITIONS, BY PROFESSOR WILLIAM PROCTER, Of the Philadelphia College of Pharmacy. In one handsomely printed octavo volume, of 570 pages, with over 500 engravines fcj- For fuller Advertisement, see p. 17. In preparation, works on Metallurgy, Food, the Steam Engine, Machines Rural Economy, A'c. Of.tk BLANCHARD'S PUBLICATIONS. 29 Library of Illustrated Scientific Works. (Continued.) KNAPP'S CHEMICAL TECHNOLOGY. TECHNOLOGY; OR, CHEMISTRY APPLIED TO THE ARTS AND TO MANUFACTURES. BY DR. F. KNAPP, Professor at the University of Giessen. Edited, with numerous JYotes and Additions, by DR. EDMUND RONALDS and DR. THOMAS RICHARDSON. First American Edition, with Motes and Additions, By Professor WALTER R. JOHNSON. In two handsome octavo volumes, printed and illustrated in the highest style of art. Volume One, lately published, with two hundred and fourteen large wood engravings. Volume Two, just ready, with two hundred and fifty wood engravings. One of the best works of modern times.—New York Commercial. We think it will prove the most popular, as it is decidedly the best of the series. Written by one who has for many years studied both theoretically and practically the processes which he describes, the descriptions are precise, and conveyed in a simple unpretending style, so that they are easily understood, while they are sufficiently full in detail, to include within them everything necessary to the entire comprehension of the operations. The work is also carefully brought down to include the most recent improvements introduced upon the continent of Europe, and thus gives us full descriptions of processes to which reference is fre- quently made in other works, while many of them are, we believe, now for the first time, presented in a com- plete state to the English reader.—Franklin Institute Journal. In addition to the valuable scientific matter contained in the original work, very extensive American addi- tions have been made to it by the editor, which are exceedingly valuable, and of much interest to the general reader. The publishers have spared no pains in bringing out a work of superior mechanical execution and rare excellence, with numerous skilfully engraved cuts, designed to illustrate the various subjects treated in this work. We feel confident that, as a truly useful publication, it will be eagerly sought after and highly appreciated —N. Y. Farmer and Mechanic. We had the pleasure of noticing, in a former number, the first volume of this excellent work, and of ex- pressingour high sense of its value. We need say little more, therefore, of its continuation, than that it fully sustains the character of its predecessor, both in regard to the value of the original treatise, and the number and importance of the additions which have been made to it by the English editors.—The British and Foreign Medico- Chirurgical Review. When we say that this volume begins another of the superb "Library of Illustrated Books," republished from the London series by Lea& Blanchard, of which Muller's Physics and Meteorology, and Weisbach's Mechanics and Engineering (the first volume of the latter), have already appeared; that the present work is on a subject coming home to the business and bosoms, because to the economic interests of Americans; that its American editor is Prof. Walter R. Johnson, who has enriched it with numerous valuable additions, the results of his own industrious researches in the technological sciences; and that it is illustrated and printed in the same superb style which marked the previous works;—we have sufficiently explained to our readers the value of a work which will not need any other commendation— North American. No mechanic, student of chemistry, miner, or manufacturer should omit purchasing this work. It will be found useful, interesting, and instructive to all—Pittsburgh Commercial Journal. ■WEISBACH'S MECHANICS. PRINCIPLES OF THE MECHANICS OF MACHINERY AND ENGINEERING. By Professor JULIUS WEISBACH. TRANSLATED AND EDITED BY PROFESSOR GORDON, OF GLASGOW. First American Edition, frith Additions By Professor WALTER R. JOHNSON. IN TWO OCTAVO VOLUMES, BEAUTIFULLY PRINTED. Volume One, with 550 illustrations, just issued. Volume Two, with 350 illustrations, nearly ready. The second volume of this work embraces the application of the Principles of Mechanics to Roofs, Bridges, Platform Scales, Water Powers, Dams, Water Wheels, Turbines, Water Engines, &c. &c. This work is one of the rrost interesting to mathematicians that has been laid before us for some time ; and we may safely term it a scientific gem.—The Builder. The most valuable contribution to practical science that has yet appeared in this country.—Athenceum. Unequalled by anything of the kind yet produced in this country—the most standard book on mechanics, machinery and engineering now extant—N. Y. Commercial. In every way worthy of being recommended to our readers.—Franklin Institute Journal. What the " Me'chanique Celeste" is to the astronomer, a treasury of principles, facts, and formulas on which he may draw on almost any and every occasion, that can be conceived to arise in the field either of demon- stration or operation.—Methodist Quarterly Review. From Charles H. Haswell, Esq., Engineer in Chief, U. S. N. The design of the author in supplying the instructor with a guide for leaching, and the student with an aux- iliary for the acquirement of the science of mechanics, has, in my opinion, been attained in a most success- ful manner. The illustrations, in the fullness of.their construction, and in typographical execudon, are without a parallel. It will afford me much pleasure to recommend its use by the members of the profession with which I am connected. 30 LEA & BLANCHARD'S PUBLIC A ON THE HORSlf YOUATT «fc SKINNER'S GREAT WORK THE HORSE. By William Youatt. A NEW EDITION, WITH NUMEROUS ILLUSTRATIONS: Containing a full account of the Diseases of the Horse, with their mode of treatment; his Ana- tomy, and the usual operations performed on him; his Breeding, Breaking, and Manage- ment; and hints on his Soundness, and the Purchase and Sale. TOGETHER WITH A GENERAL HISTORY OF THE HORSE; A Dissertation on the American Trotting Horse, how Trained and Jockeyed, an account of hia remarkable performances; and AN ESSAY ON THE ASS AND THE MULE. BY J. S. SKINNER, Assistant Postmaster-General, and Editor of the Turf Register. In one large and handsome octavo volume, with numerous wood-cuts. This edition of Youatt's well-known and standard work on the Management, Diseases, and Treatment of the Horse, has already obtained such a wide circulation throughout the country, that the Publishers need say nothing to attract to it the attention and confidence of all who keep Horses or are interested in their improv<»- CLATER'S FARRIER. EVERY MAN HIS OWN FARRIER: CONTAINING THE CAUSES, SYMPTOMS, AND MOST APPROVED METHODS OF CURE OF THE DISEASES OF HORSES. BY FRANCIS CLATER, Author of "Every Man his own Cattle Doctor," AND HIS SON, JOHN CLATER. FIRST AMERICAN, FROM THE TWENTY-EIGHTH LONDON EDITION. WITH NOTES AND ADDITIONS BY J. S. SKINNER. In one 12mo. volume, cloth. CLATER'S CATTLE DOCTOR. EVERY MAX HIS OW1Y CATTEE DOCTOR. Containing the Causes, Symptoms, and Treatment of al l Diseases incident to Oxen, Sheep, and Swine ; and a Sketch op the Anatomy and Physiology of Neat Cattle. BY FRANCIS CLATER. Edited, Revised, and almost Rewritten, by William Youatt. With Numerous Additions, em- bracing an Essay on the Use of Oxen, and the Improvement in the Breed of Sheep, by J. S. Skinner, Assistant Postmaster-General. In one duodecimo volume, cloth, with numerous illustrations. YOUATT ON THE PIG. THE! FIG: A Treatise on the Breeds, Management, Feeding, and Medical Treatment of Swine, with Directions for Salting Pork, and Curing Bacon and Hams. By WM. YOUATT, V. S., Author of " The Horse," "The Dog," "Cattle," "Sheep," &c. &c. ILLUSTRATED WITH ENGRAVINGS DRAWN FROM LIFE, BY WILLIAM HARVEY. In one handsome duodecimo volume, extra cloth, or in neat paper cover, price 50 cents. YOUATT ON THE DOG. THE DOG. By William Youatt, Author of "The Horse," &c. WITH NUMEROUS AND BEAUTIFUL ILLUSTRATIONS. EDITED BY E. J. LEAVIS, M.D., &c. &c. In one beautifully printed volume, crown octavo. JOHNSON AND LANORETH ON FRUIT, KITCHEN, AND FLOWER GARDENING. A DICTIONARY OF MODERN GARDENING. By George William Johnson Esq Author of the '• Principles of Practical Gardening," "The Gardener's Almanac," &c. With one hundred and eitrhtv wood-cuts. Edited, with Numerous Additions, by David Landreth, of Philadelphia. In one lar"e roval duodecimo volume, extra cloth, of nearly six hundred and fifty double-columned pages " THE COMPLETE FLORIST. A MANUAL OF GARDENING: containing Practical Instructions for the Management nfRr„„u„- Plants, and for the Cultivation of the Shrubbery, the Flower Garden, and the Lawn • whh nL,,i„ „ , those Plants and Trees most worthy of Culture in each Department. With Addition* and Aml„i . adapted to the Climate of the United Slates. In one small volume. Price only twenty five cems THE COMPLETE KITCHEN AND FRUIT GARDENER A SELECT MANUAL OF KITCHEN GARDENING, and the Culture of Fruits- containing v r Directions for the most approved Practice in each Department, Descriptions of man'v vnl„M,iT!■ taimI"" a Calendar of Work to be performed each Month in the Year. The whole adaptedI to th..pit ruitsva,'n United States. In one small volume, paper. Price only twenty-five cents. inmate of lha LANDRETH'S RURAL REGISTER and ALMANAC for 1848, WITH NUMEROUS ILLUSTRATIONS. Still on hand, a few copies of the REGISTER for 1847, with over one hundred wood-cuts This work h 150 large 12mo. pages, double columns. Though published annually, and containing an almanac the nr• cipal part of the matter is of permanent utility to the horticulturist aad farmer. ' P'la' 1 * 9 CONTENTS OF THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. April, 1849. ORIGINAL COMMUNICATIONS. Memoirs and Cases pp. 277-410. Art. I. Leidy on the Intimate Structure and History of the Articular Cartilages. (With two plates.) U. Jackson's Observations on Hydrophobia, with cases, in one of which chloroform was administered with a favorable result. III. Meigs' History of Five Cases of Pseudo-membranous Laryngitis or true Croup; in three of which the Operation of Tracheotomy was performed, and in two successfully. IV. Parkman's Ex- tracts from the Records of the Boston Society for Medical Improvement. V. Sargent's Report of the Cases 01 Small-Pox received into the Philadelphia Cay Hospital in 1845 6. VI. Peaslee's Case of Ovarian Dropsy. VII. Warren on the Effects of Chloroform as a Narcotic Agent. VIII. Bond's Cases of Retroversion of the Uterus, with a description of a New Instrument for its Restoration. (With two wood-cuts.) IX. Ruschenber- ger's Cases of Extraction of a glass goblet from the Rectum—Fracture of the Penis. (With a wood-cut.) Reviews, pp. 411-441. X. Obstetrics, the Science and the Art. By CD. Meigs, M. D. With 121 cuts,8vo. pp. 685. XI. Reports on Lunacy. Bibliographical Notices, pp. 442-464. XII. Ames on Epidemic Meningitis. XIII. Manley's Anniversary Discourse. XIV. Stevens's Plea of Humanity in Behalf of Medical Education. XV. Kirkesand Paget's Manual of Physiology. XVI. Bowman's Introduction to Practical Chemistry, including Analysis. XVII. Morfit and Muckle's Chemical and Phar- maceutical Manipulations XVIII. New York Report on the subject of Asiatic Cholera. XIX. Philadel- phia Report on Public Hygiene. XX. Summary of the Transactions of the Col lege of Physicians of Philadel- phia, from September 16,1848,to January 2,1849, inclusive. QUARTERLY SUMMARY OF THE IMPROVEMENTS AND DISCOVERIES IN TIIE MEDICAL SCIENCES. FOREIGN INTELLIGENCE. Anatomy and Physiology, pp. 465-467. 1. Paget on the Blood Corpuscles of the Human Embryo. 2. Schiff on the Changes in the Lungs after Di- vision of the Pneumogastric Nerves. 3. Hamernik on the Mechanism of the Head. Organic Chemistry, pp 467-470. 4. Lehmann on the Nature of the Gastric Juice. 5. Wohler and Frerichs on the Changes of Organic Sub- stances on their passage into the Urine. 6. Regnault and Reiset on the Chemical Changes of Respiration. 7. Dr. Bernard on the Source of Sugar in the Animal Economy. Materta Medica and Pharmacy, pp. 470-476. 8. Pereira on Cod Liver Oil. 9. Bouchardat and Stuart-Cooper on the Physiological and Therapeutic Ac- tion of Atropia. 10. Chavannes on the advantages of Chloride of Gold as a Caustic. 11. Millon on th« Nutritive Properties of Bran. 12. Donovan on Vegetable Infusions. Medical Pathology and Therapeutics and Practical Medicine pp. 476 499. 13. Dr. Mombert's Case of Hydrophobia Spontanea. 14 Valleix on Muscular Rheumatism. 15. Solon or Bilious Pneumonia. 16. Rilliet on Melaena Neonatorum. 17 Elam on Chorea. 18. Schneider on Sangui- nous Perspiration. 19 Dr. Pickford's Case in which the Physical Signs of the position of the Heart were de- ceptive. 20. Jaksch on the Signs of Diseased Heart afforded to the hand laid over the Praecordium. 21. Bellingham on Polyform Concretions in the Cavities of the Heart. 22. O'Ferrel on Pleuritis simulating Pericarditis. 23. Greene on Encysted Tubercles in the Lungs. 24. Mayne on Phthisis in the Infant. 25. M. Levy on Acute Tubercular Meningitis in the Adult. 26. Patterson's Case of Variola in which the Eruption was found in the Mucous Membrane of the Colon. 27. Watson on Intra-Uterine Small-Pox. 28. Gamberini on Nocturnal Neuralgia of the Forearm. 29. Bennet on Spontaneous cure of Ovarian Dropsy, by meansof an Ulcerative Opening of the Cyst into the Bladder. 30 Delasiauve on the Treatmentof Epilepsy. 31. Melsens on Iodide of Potassium in Saturnine Affections. 32. Wilige on the external use of Iodine in Croup. 33. Koreffon Spigelia Marylandicain Pruritus Ani. 34. Owen. Reese on Lemon Juice in Rheumatie Gout. 35. Nevins on the employment of Nux Vomica in the Diarrhcea of Exhaustion. 36. Dr. Pickford on the Beneficial Effects of Coffee in Infantile Cholera. 37. Palsy of the Tongue cured by galvano-puncture. 88. Manzolini and Quaglino on the Injection of various substances into the Veins. Scrgical Pathology and Therapeutics and Operative Surgery, pp. 499-508. 39. Guthrieon Hospital Gangrene. 40. Toynbee's Pathological Researches into the Diseases of the Ear. 41. Tilt on Ovarian Dropsy. 42. Hancock on Aneurism of the Axillary Artery. 43. Cooper on Ligature of Subclavian followed by incessant Cough. 44. Willis on Inguinal Aneurism—Ligature of the left external Iliac Artery. 45. Tufnell on Femoral Aneurism—Compression tried without success—Ampuiation. 46. Blandin on Wound of the Right Kidney successfully treated. 47. Sewell on Lateral Transfixiure of the Chest by a Scythe Blade, followed by complete recovery. 48. Neuhold and Hasserbronc on the Employment of Sugar of Lead in Strangulated Hernia. 49. VidaVs New Method of Treating Urethral Pains following Gonorrhoea. 50. Thevenot and Boyer on Luxation of the Astragalus inwards ; Reduction. 51. Mendoza on Vertical Dislocation of the Patella. 52 Greenhow on Excision of the Oa Calcis. 53. Syme on Excision of the head of the Femur in Morbus Coxarius. 54. Christophers'1 new mode of removing Naevi. Ophthalmology, pp. 508-509. 56. Mackenzie's Case of Cysticercus Cellulosa in the Human Eye 56. Dixon's Case of Foreign Body in the Eye. Midwifery, pp. 509-517. 57. Rowth on the Causes of the Endemic Puerperal Fever of Vienna. 58. Burdon on the Influence of the Mother's Imagination upon ihe Production of Monstrous Children. 59. Mitchell on Ulceration of the Os and Cervix Uteri treated with Solution of Gun-Cotton. 60. Webster on the Statistics, Pathology, and Treatment of Puerperal Insanity. 61. In what ca*es (other than of Contracted Pelvis) is itproperto induce abortion or Premature Labor. By Dubois. 62. Scanzoni on the Cause of Hemorrhage in the latter months of Preg- nancy in Cases of Placenta Prse via. 63. Ducrest on Cerebral and Meningeal Phlebitis in Puerperal Women. Cholera, pp. 517-534. 64. Taylor on the Chemical Examination of the Liquid Vomited during Cholera. 65. Boehm on the Micro- scopic Examinations of the Mucous Membrane of the Stomach and Bowels in Cholera 66. Lamprey on Terchlonde of Carbon as a Remedy for Cholera. 67. Little on Quinine in Cholera. 63. Robertson on Blood- Letting in Cholera 69. Robertson on the. Injection of Saline Solution into the Veins in Cholera. 70. Fretten- bacher's Conclusion respecting the mode of Propagation of Cholera in Russia, in 1B47-48. Anesthetic Agents, pp. 524-530. 71. Malgaigne on the Action of Chloroform 72. Deaths from Chloroform. 73. Nunneley on the Chloride of OlefiantGas as an Anrcsihelic 74 Simpson on Naphtha as an Anaesthetic 75. Higginson on Anaesthesia frora the local application of Chloroform. 76. Snow on Chloroform in Midwifery. Medical Jurisprudent and Toxicology, pp. 530-532. 77. Boucheton the Lunatic A.-ylum Names. 78. Smith on Early Menstruation and Pregnancy. Miscellaneous, p.532. 70 Dr. Spengleron Influenza and Ozone. (For remainder of Contents, set next page.) Two Medical Periodicals for Fi%e Dollars. ( THE AMERICA^ JOURNAL OF THE MEDICAL SCIENCES, EDITED BY ISAAC HAYS, M. D., . Is Published Quarterly ON THE FIRST OF JANUARY, APRIL, JULY AND OCTOBER. Each Number contains about Two Hundred and Eighty Large Octavo Pages, And is appropriately Illustrated with Engravings on Copper, Stone, Wood, &c. The variety and extent of its contents may be estimated from the very condensed summary of the Number for April, 1849, on the preceding page. THE MEDICAL NEWS AND LIBRARY Is Published Monthly, and consists of THIRTYVTWO VERY LARGE OCTAVO PAGES, Containing the Medical Information of the day, as well as a Treatise of high character on a prominent department of Medicine. WATSON'S LECTURES ON THE PRACTICE OF PHYSIC, BRODIE'S CLINICAL LECTURES ON SURGERY, AND TODD & BOWMAN'S PHYSIOLOGY Have thus appeared in it, and the work at present publishing is WEST ON THE DISEASES OF INFANCY AND CHDLDHOOD. Which will be completed in the present year. TERMS. THE SUBSCRIPTION TO THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES IS FIVE DOLLARS PER ANNUM. When this amount is paid in advance, the subscriber thereby becomes entitled to the MEDICAL NEWS AND LIBRARY FOR ONE YEAR. Without further charge. For the small sum, therefore, of FIVE DOLLARS, the subscriber can obtain a Quarterly and a Monthly Journal of the highest character, presenting about FIFTEEN HUNDRED LARGE OCTAVO PAGES, With appropriate Illustrations: Or, for TEN DOLLARS, the Publishers will furnish TWO COPIES OP THE JOURNAL, AND THREE OP THE NEWS- Or, for TWENTY DOLLARS, FIVE COPIES OF THE JOURNAL AND FIVE OF THE NEWS Presenting strong inducements to Clubs, and rendering these among THE CHEAPEST OF AMERICAN MEDICAL PERIODICALS When the News is ordered separately, the price is One Dollar per annum, invariably in advance. CONTENTS OP JOURNAL. (Continued from preceding Page.) AMERICAN INTELLIGENCE. ,m . „ Original Communications, pp. 633-536. Clement's Case of Trismus Nascentium, illustrative of the influence of position nT ti.- «-«• Case of Ovarian Dropsy cured by the long Abdominal Incision in 1701. patient Houstoun's Domestic Summary, pp. 536-552. bryo of the Human Subject. (With two wood-cuts.) Eve on Lithotomy-117 ?r£?~i "* B?ne ln lhe Em- successfully removed. Van Buren's Case- of Inguinal Aneurism-Compressinn7,LWeiS ung *** ounces, Ligature of the Artery. Holster on Trephining for Epilepsy. Whitmire on Iodine in "l®" wltl»out success- bites. Fenner on Cholera in New Orleans, Iron Rod weighing 13i pounds driven ,11 r«atment of Snake- covery. By Dr. Harlow. Hamilton on Death from presfure of^an enlarged Thv£M lhf Hei»d-Re- Superfcetation and Mixed Births. Jackson's Case in which a large quantity of Ch\r>ZZc Uiand- Taylor on on Local Anaesthesia in Neuralgia. Stille on Chloroform in Nephritic Colic Am?J^rm Was used- HaV* Table of Contents, Index, &c, 20 pages. v Army Surgeons. ■SK»*r*JP^pWk., immm*~*«.....mhuw. &'*>. .. ■ k "Sftfy /frMfL: p;