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DISEASES
INFANTS AND CHILDREN. 
WOEKS BY THE SAME AUTHOR.
ON   THE  DISEASES   OF   WOMEN:

         INCLUDING  THOSE OP PREGNANCY  AND CHILD-BED.

                   A new American Edition, revised by the author.

                          Mitf) Notts anlJ gt&oitionjs

                     BY D.  FRANCIS  CONDIE, M. D ,
              Author of "A Practical Treatise on the Diseases of Children."

      In one handsome octavo volume, with wood-cuts, of about seven hundred page?.
  Former editions of this 'work hnve been noticed
in previous numbers of the Journal.  The senti-
ments of high commendation  expressed in those
nonces, have only to be repeated in this; not from
the fact that the profession at large are not aware
of the high merits which this work really pos-
sesses, hut from a desire to see the principles and
doctrines therein contained more generally recog-
nized, and more universally carried out in practice.
—N. Y. Journal of Medic int.
ON THE  THEORY  AND  PRACTICE  OF  MIDWIFERY,

              & iuio glnuriratt Ubitfon, im'ttj Notes anil gtbiittons

                    BY D.  FRANCIS CONDIE, M. D.

          WITH ONE HUNDRED AND THIRTY-NINE BEAUTIFUL ILLUSTRATIONS.

              In one very handsome octavo volume, of over 500 pages.
  Were we reduced to the necessity of having but
one work on midwifery, and vermilted to choose,
we would unhesitatingly take Churchill.—West-
ern Med and Svrg. Journal.
  Few treatises will be found better adapted as a
text-book for the student, or as a manusil for the
frequent consultation of the young practitioner.—
American Medical Journal.
  It is impossible to  conceive a more useful and
elegant manual than Dr. Churchill's Practice  of
Midwifery.—Provincial Medical Journal.
  In our opinion it forms one of the best, if not the
very best text-book and epitome of obstetric sci-
ence which we at present possrss in the English
language.—Monthly Journal of Medical Science.
ESSAYS   ON  THE   PUERPERAL  EEYER,
AND OTHER
                 DISEASES PECULIAR TO  WOMEN.

Selected from the Writings of British Authors prciious to the close of  the XVIII Century.

            In one neat oclavo volume, of ab)Ut four hundred and fifty pages. 
ON THE
DISEASES
OF
INFANTS  AND CHILDREN.
                 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.



          SECOND AMERICAN EDITION,

  ENLARGED AND REVISED BY THE AUTHOR.



          EDITED WITH ADDITIONS,


                 BY

     WILLIAM V. KEATING, M.D., A.M.,

PHYSICIAN TO ST. JOSEPH'S HOSPITAL; LECTURER ON OBSTETRICS AND DISEASES OF WOM: N
  IN THE PHILADELPHIA MKIHCAL ASSOCIATION | PHYSICIAN TO ST. JOSEPH'S ASVLCM
    FOR ORPHANS; FELLOW OF THE COLLEGE OF PHYSICIANS; MEMBER OF
       THE AMERICAN PHILOSOPHICAL SOCIETY, ETC. ETC. ETC.
         PHILADELPHIA:
B L A N C II A R D  AND  LEA.
              1856. 
IV5
I CO
         Entered according to the Act of Congress, in the year 1856, by

                      BLANCHARD AND  LEA,

in the Clerk's Office of the District Court for the Eastern District of Pennsylvania.
        PHILADELPHIA:

T. K. AXD P. G. COLLINS. PRINTERS. 
                    TO






     ROBERT  M.  HUSTON, M.D.,






          ISAAC HAYS, M. D.,





                    AND





   GEORGE SIIATTUCK, Jun.,  M. D.,






             THIS  WORK





               IS DEDICATED,




                   AS AN




       EXPRESSION OF THE HIGHEST ESTEEM




                  FOR THEIR




PERSONAL FRIENDSHIP AND PROFESSIONAL ATTAINMENTS. 
          PREFACE
                OF THE
AMERICAN  EDITOR.
  The American Publishers having confided to my care the Author's
revised  copy of the  present  work, I have bestowed every attention in
the revision of  the press to secure accuracy.  The difficulty of this has
been much enhanced by the fact that a large portion of the work was in
MS.  The extent of the additions made by Dr. Churchill is manifested
by the increase of a hundred pages in  the  volume, notwithstanding an
enlargement in the size of the page; and the special reference which
he  has  made to American authorities,  with a view of adapting the
work to the wants of American practitioners, has rendered  unnecessary
many additions  from me.  Such as  I  have considered  advisable  have
been generally introduced in brackets, to distinguish them from the  text.
  In its present improved form, the  work can hardly fail  to maintain
the high reputation previously acquired.

  Philadelphia, 111 South 4th Street,
           July, 18 .j 6. 
       AUTHOR'S  PREFACE
                      TO THE
SECOND  AMERICAN  EDITION.
  In preparing this Edition for the press, I have endeavored carefully
to add  all the information we have derived from recent researches.   I
have gone over every paragraph, with a view to correct any inaccuracy
and to remedy any indefiniteness of  expression.   I  have  cautiously
weighed every suggestion made  by those who have reviewed the work,
and where these seemed to me to be correct, I have adopted  them, and
made the requisite alterations,  and I  have added  several entire new
chapters,  as well as portions of  chapters,  so that I  hope that the
work may be deemed more  worthy of the kindness it  has received at
the  hands of  my American brethren, to whom once more I desire to
offer my sincere thanks for the  welcome they have accorded to this,
as well as my other volumes.

  15 Stephen's Greex, North Dublin,
        February, 1S50.
« 
* 
PREFACE.
   It is with much gratification  that I acknowledge  this volume to owe
its existence  to  the  solicitations of my excellent American publishers.
After making a  considerable collection of works on  Diseases  of  Chil-
dren, 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 recorded by
all the authors within  my reach, of which I have freely availed myself;
and, if it prove useful and acceptable to my American 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 complications 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. 
X
PREFACE.
  I have found it extremely difficult to lay down minute and specific
plans of treatment for individual cases,  or for the various modifications
of disease;  and, I fear, in this  respect, my book may be thought defi-
cient.  I have, however,  always indicated the principles, which must
guide us in the management  of the disorder ;  and I  have preferred
leaving  their adaptation to the sagacity and judgment of the  practi-
tioner.
  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 observ-
ed.   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 Green, Dublin, October, 1849. 
CONTENTS.
                           PART  1.

      ON THE MANAGEMENT OF INFANCY AND CHILDHOOD.

                          CHAPTER  I.
                                                              PAGE
  PRELIMINARY OBSERVATIONS ON THE MANAGEMENT OF INFANCY AND CHILDHOOD.  15


                          CHAP TEH II.

                  MANAGEMENT OF THE INFANT AT BIRTH. .     .      .32


                         CHAPTER III.

                  THE FOOD OF INFANCY AND CHILDHOOD. .     .      .37


                          CHAPTER IV.

                            CLEANLINESS.

Dress    ..........   52

                          CHAPTER V.

                          AIR AND EXERCISE.    .      .     .      .58
Sleep..........63
Medicine ..........   65
                          PART  II.

           THE DISEASES OF INFANCY AND CHILDHOOD.


                           SECTION I.

           DISEASES OF  THE CEREBROSPINAL SYSTEM.

                          CHAPTER  I.

                  INTRA-UTERINE OR CONGENITAL DISEASES.
Convulsions     ......
Hydrocephalus  ......
Absence of Brain or Skull     ....
Hernia Cerebri.—Encephalocele
Spina Bifida.—Hydrorachitis   ....
71
71
72
73
75 
Xll
CONTENTS.
                            CHAPTER  II.
                                                                    PAGE
                CEPHAL2EMATOMA.—FRACTURES OF THE CRANIUM.    .      .   82
Sub-aponeurotie Cephalaematoma      .      .      .      .      .      .84
Sub-pericranial Cephalaematoma       .      .      .      .      .      .85
Sub-cranial Cephalhematoma   .       .      .      .      .             .87

                           CHAPTER III.
           IRRITATION OF THE NERVOUS SYSTEM.—TRISMUS NASCENTIUM.
Nervous Irritation      ........   90
Trismus Nascentium.—Nine-day fits   .      .       .      .      .      .94

                           CHAPTER IV.

                        CHOREA.—ST. VITUS' DANCE.      .      .       .  102

                            CHAPTER  V.

                              CONVULSIONS.     .      .      .       .114

                           CHAPTER VI.

        ACUTE MENINGITIS.—ACUTE ARACHNITIS.—ACUTE HYDROCEPHALUS.    .  134

                           CHAPTER VII.

                         CHRONIC HYDROCEPHALUS.       .      .       .  160

                          CHAPTER  VIII.

                       INFLAMMATION OF THE BRAIN.
Encephalitis    .      .      .      .     .      .      .      .       .176
Hypertrophy and Induration of the Brain    .      .      .      .       .178
Ramollissement, or Softening   .......  1S3
Abscess of the Brain   ........  184

                           CHAPTER IX.

            TUMORS OR TUBERCLES OF THE BRAIN AND SPINAL MARROW.

                            CHAPTER  X.

                  CONGESTION AND APOPLEXY  OF THE BRAIN.

                           CHAPTER XI.

                               PARALYSIS.       ....  202



                            SECTION II.

             DISEASES  OF THE  RESPIRATORY SYSTEM.

                            CHAPTER  I.

                         INTRA-UTERINE DISEASES.
Coryza  ......
Epistaxis       .....
.   186


.   195
.  213
.  213
.  215 
CONTENTS.
xm
                    CHAPTER II.
                                                           PAGE
SPASM OF THE GLOTTIS.—THYMIC ASTHMA.— LARYNGISMUS STRIDULUS. .   216

                   CHAPTER III.
                 PERTUSSIS.—HOOPING-COUGn.     .     .      .  229
                    CHAPTER IV.
               CROUP.—CYNANCUE TRACHEALIS.    .     .      .  259
                    CHAPTER  V.
                  ATELECTASIS PULMONUM. ....  292

                    CHAPTER VI.
                       BRONCHITIS.      ....  300
                   CHAPTER VII.
           INFLAMMATION OF THE LUNGS.— PNEUMONIA.     .      .  315
                  CHAPTER VIII.
                   PLEURISY.—PLEURITIS.  ....  341
                    CHAPTER IX.
                    PULMONARY PUTHISIS.  ....  35G
                           SECTION III.
                      DISEASES OF THE HEART.
                           CHAPTER  I.
                 MALFORMATIONS.—INTRA-UTERINE DISEASES.     .      .  376
Cyanosis .      .      .      •      •     •      •      •     •      .  3i7
                           CHAPTER II.
             INFLAMMATION OF THE PERICARDIUM.—PERICARDITIS.  .      .  385
                          CHAPTER III.
     INFLAMMATION OF THE LINING MEMBRANE OF THE HEART.—ENDOCARDITIS.  397
               SECTION IV.
   DISEASES OF THE DIGESTIVE  SYSTEM.
               CHAPTER  I.
INTRA-UTERINE DISEASES.—CONGENITAL MALFORMATIONS. .      .  405 
XIV
CONTENTS.
                               CHAPTER  II.
                                                                           PAGE
                                  DENTITION. .....  410


                              CHAPTER III.

             INFLAMMATION OF THE MOUTH.—ERYTHEMATOUS STOMATITIS.      .  426


                              CHAPTER IV.

                    MUGUET.—PSEUDO-MEMBRANOUS STOMATITIS.       .       .  427


                               CHAPTER  V.

                   APHTHA.--THRUSH.--FOLLICULAR STOMATITIS.     .       .   437


                              CHAPTER VI.

                 ULCERATED SORE MOUTH.—ULCERATED STOMATITIS.    .       .  442


                              CHAPTER VII.

       GANGRENE OF THE MOUTH.—CANCRUM ORIS.—GANGRENOUS STOMATITIS.  .  446


                             CHAPTER  VIII.

                 TONSILLITIS.—CYNANCHE TONSILLARIS.—QUINSY.    .      .  460


                              CHAPTER IX.

                   PAROTITIS.—CYNANCHE PAROTIDEA.--MUMPS.      .      .  464


                              CHAPTER X.

PSEUDO-MEMBRANOUS PHARYNGITIS.—DIPHTHERITE.—ANGINA PSEUDO-MEMBRANOSA. 468


                              CHAPTER XI.

        PUTRID SORE THROAT.—GANGRENOUS ULCERATION OF THE PHARYNX.   .   475


                             CHAPTER  XII.

                 ABSCESS BETWEEN THE PHARYNX AND THE SPINE.     .       .   481


                            CHAPTER  XIII.

                           DISEASES OF THE STOMACH.        .       .       ,   4g3


                            CHAPTER  XIV.

                  INDIGESTION.—VOMITING.--WEANING BRASH.       .       .   4gg


                             CHAPTER  XV.

           GASTRITIS.—INFLAMMATION AND SOFTENING OF THE STOMACH.      .  496 
Cholera Infantum
Enteritis  .
                  CONTENTS.



               CHAPTER XVI.          ,

                    DIARRHOEA.




              CHAPTER  XVII.

               DYSENTERY.—COLITIS.  .


              CHAPTER XVIII.

         HELMINTHIASIS.—INTESTINAL WORMS.  .


              'chapter  XIX.

I. JAUNDICE.—II. ENLARGEMENT OF THE LIVER, SPLEEN, ETC.


                C II A P T E R  X X.

                 TABES MESENTKKICA.


               CHAPTER  XXI.

                    PERITONITIS.
             SECTION  V.

       DISEASES OF THE SKIN.

             CHAPTER I.

STROPHULUS.—PRURIGO.--PTYRIASIS.--ROSF.OI
Strophulus, or Red Gum
Prurigo .
Pityriasis
Ruseola .       .      •
Herpes
Ki'zcma
Kupia
   CHAPTER II.

HERPES.—ECZEMA.—RUPIA.
                           CHAPTER III.

                           IMPETIGO.-—PORR1GO.

Impetigo       .      .       .      ■      •
Porvi^o, or Scald Head .       .      .      •
IWri^n  Scutulata, or Ringworm of the Scalp .
Porriim  Favosa  . 
XVI
CONTENTS.
          SECTION VI.
        ERUPTIVE FEVERS.

          CHAPTER I.
                                              PAGE
     MEASLES.—RUBEOLA.—MORBILLI.    .     .     .  589

         CHAPTER  II.
      SCARLET FEVER.—SCARLATINA.    .     .     .  610

         CHAPTER III.
  VARICELLA.—CHICKEN-POX.—SWINE-POX.      .     .  645
         CHAPTER  IV.
  SMALLPOX.—VARIOLA.—PETITE VEROLE.      .     .  649

          CHAPTER V.
         VACCINIA.—COWPOX.  ....  668
         CHAPTER VI.
(FDEMA OF THE CELLULAR TISSUE.—SCLEROMA.    .     .  677
    SECTION VII.
       FEVERS.
    CHAPTER I.
INFANTILE REMITTENT FEVER.     .      .     .  684
    CHAPTER  II.
     TYPHOID FEVER.    ....  695
   SECTION  VIII.
INFANTILE  SYPHILIS.    .     .      .705 
THE DISEASES OF CHILDREN.




            #-c. fyc. $C.
2 
 
PART  I.
                             ON THE

MANAGEMENT  OF  INFANCY  AND   CHILDHOOD.
                       CHAPTER  I.

                    PRELIMINARY OBSERVATIONS.

   1. A very limited acquaintance with statistics, or even a  moderate
experience, is quite sufficient to convince us of the high degree of mor-
tality 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 vari-
ous causes no inconsiderable proportion of those ushered into the world
are stillborn.   M.  Quetelet, in his very learned and  able work, thus
states, that in the principal cities of Europe1 the mean proportion of
stillborn children is one in every twenty-two births; and the number 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  between 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 entering 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 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."3

      1  Sur l'llomme et le Developpement de ses Facultes, &c, vol. i. p. 121.
      11 lb., vol. i. p. 167.
      s Combe on the Management of Infancy, p. 10. 
20
ON  THE  MANAGEMENT OF
  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 occurred
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 :—
Under 3 months			792 deaths.
Above 3 "	and under 6 months,		313 "
" 6 "	v "	9 "	319 "
" 9 "	n	12 "	311 «
" 1 year,	11	2 years,	802 "
« 2 "	(1	3 "	321 "
" 3 "	(1	4 "	183 "
« 4 «<	(<	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 certain
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
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 
INFANCY AND  CHILDHOOD.
21
at that age, out of 1000 of all  ages, scarcely exceed  180.*   Compare,
again, Manchester, Salford,  and  their  suburbs,  where  the  number
of deaths under two years of  age was 429.98 per 1000, with West-
moreland and Cumberland, where the proportion was only 276.35 per
1000.                                F  F              J
   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 con-
sequence of a parliamentary inquiry having taken place, the proportion
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 pro-
portions :—
                   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  in-
fants 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. Clark attributed to want of ade-
quate ventilation, which he proceeded to remedy with great success, for
of 8033 children born  after a free circulation of air had been secured,
only 419 died, that is, about 1 in 19-J-.
   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 respira-
tion ceased in a few seconds  after  birth, the proportion  of deaths  be-
comes trifling indeed."4
   7.  Foundling hospitals exhibit another instance of the connection be-
tween the management and the  rate  of mortality in  children.  In the

  1 Report, pp. 25,  44.                   2 On the Management of Children, p. 14.
  8 Transactions of the Royal  Irish Academy, vol. iii. Collias's Fractical Treatise, p.
514.
  1 Practical Treatise on Midwifery, p. 500. 
22
ON  THE  MANAGEMENT OF
Foundling Hospital of this city it appeared, on inquiry by Parliament,
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 state-
ment, as Dr. Hawkins observes, which at this moment seems incredible.1
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. Pe-
tersburg die during the first year, notwithstanding the  care and atten-
tion bestowed.
  8. Dr. Combe quotes an interesting illustration of the effects of im-
proved 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 man-
agement was in operation, from four to six children were constantly on
the sick list, and  sometimes more; one  or two assistant nurses were
necessary ;  a  physician was  in  regular  attendance twice  or  thrice a
wreek, and the deaths amounted in all to between thirty and forty, or
about one every month.  At  the end of this time an improved system
of treatment was begun, and notwithstanding the disadvantages insepa-
rable from the orphan state  of the  children, the results 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 were received, and two  of them
were idiots."2
  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 Lon-
don, made at the British Lying-in Hospital. " Several women who had
borne—
                                                   2
                                                   3
                                                   4
                                                   5
                                                   6
                                                   7
                                                   8
                                                   9
                                              8 and 10
                                             10 and 11
                                                 . 11
3 children had lost		as	many as
4	i <t		"
5	t a		t<
6	i (I		u
7	t it		c<
8	( <<		II
9	< <<		<<
10	I (<		t<
11	« <<		"
12	i a		it
14	i «<		t<
  "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
1 Medical Statistics, p. 130.         2 On the Management of Infancy, p. 22. 
INFANCY AND  CHILDHOOD.                  23
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, nothing
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 experience
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 stillborn; that another large proportion
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 manage-
ment 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  the nine months of gestation,
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.

               1 On the Diseases of Children, tenth edition, p. 85.
               2 On the Management of Infancy, &c, p. 25. 
24                  ON THE MANAGEMENT OF
  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 quickly 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 (which 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 meco-
nium 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 termi-
nation of gestation, plunged into the midst of excitement, and exposed
to influences  and impressions which act  rudely on organs hitherto un-
tried. " 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 con-
tact 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 re-
stored through means of the mother's system, must now be  oxygenated
by the child's own lungs.   The animal  heat once supplied to  it by an-
other source  must now be elaborated by the action of its own organs."1
  The first impression,  and  a most painful one, is that of cold, and the
first act  is to evince its  sufferings by  cries and struggles.   No doubt,
benefit is derived from this,  it assists in establishing perfect respiration,
and gives an impetus to the general circulation.
  The distress occasioned at first by cold is augmented by the compara-
tively 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  exposed to various
and confused sounds; and the brain and nervous system, so far used to

         1  Combe on the Management of Infancy and Childhood, p. 180. 
INFANCY AND  CHILDHOOD.
25
but few and simple impressions, become the centre of varied  and com-
plicated 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 ex-
ertions previously, but from  the small space in which it  was confined,
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 this organ was at all active during
gestation.
   15.  When we consider, therefore, that from a state of quiescence, and
simple organic nutrition, the infant at birth is roused into  a state of
functional and organic activity, with each sense exposed  to  vivid im-
pressions  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 when we reflect
upon the sympathetic interdependence of organs and systems, and re-
member how disorders of the one entail  disorders in another, and how
apt simple or complex disorders of  organs are  to entail serious disturb-
ance  in the nervous  system.  Under such circumstances, 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  imme-
diately 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 per-
fect 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 foetal blood may take place,
and individual organs or the growth of the child may suffer.
   Again,  it seems undeniable, though not to be established by anato-
mical research, that some kind  of nervous communication exists between
the mother  and child before birth;  at least it is certain that vivid im-
pressions, bodily or mental, upon the former, may be transmitted to the
latter, and injury or even death 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 
26
ON  THE MANAGEMENT  OF
importance, and appeals so directly  to  the most powerful feelings of
womanly nature, that it ought to be sufficient to insure an adequate  at-
tention 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 suf-
ficient nourishment without over-feeding, and only  a moderate use of
beer or wine should be allowed.   Exercise is necessary 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 abso-
lutely 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 Cfood Nurse very sensibly remarks: " When a
young woman acts from principles of reason and religion,  she will con-
sider 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 feel-
ing 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  decidedly of
opinion that if we suffer every trifling disappointment and cross-occur-
rence to ruffle and disturb us,  it is a certain  mode of corroding 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
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 exer-
cise, 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."3
   18.  But besides  the  indirect  sources  of  disease already mentioned,
another may be found  in  the temporary apparatus provided  for the

            1 The Good Nurse, p. 106.
            2 On the Management of Infancy and Childhood, p. 91. 
INFANCY AND  CHILDHOOD.
27
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 nourish-
ment of the foetus,  and, notwithstanding all  the compensating powers of
nature, the foetus will not infrequently suffer from disease as the conse-
quence.1   The same may be said of  any malformation 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 prac-
tice  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 diffi-
cult  labor it does not escape so well.  Pressure  of  the head, if beyond
a certain amount, may injure  the brain  or cranium; arrest of the circu-
lation, 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 vas-
cularity of their lining  membrane, and the  enormously increased circu-
lation in the lungs,  which have superseded  the  placenta in its function
of aerating the blood, afford ample grounds for the incursion 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 discomfort, may
be considered as violence applied to  the air-tubes, and anything which
quickens or renders irregular  the circulation in the lungs, may be said
to add an additional stimulus to diseased action in so delicate an organ.
Prolonged  decubitus has been  recently suggested as the principal cause
of the mortality in  the  Foundling Hospital of  Paris, from its effect in
producing inflammation  of the lungs, and it seems certain that change
of position and  gentle  movements  are  as necessary for the  health  of
internal organs  as for muscular development.
  21.  The digestive system is exposed to danger both from the quality
and quantity of the  food submitted to it.   The process of appropriating
Simpson on Diseases of the Placenta.  Edinburgh Med. and Surg. Journal. 
23
ON  THE MANAGEMENT OF
even the blandest food  increases the vascularity of the mucous mem-
brane 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 sensuous
impression is acutely felt, though  transitory, and obliterated probably
by the one  succeeding.   This  variety or succession of impressions is
advantageous, for the boundary between excitement and  irritation of
the nervous system  is so easily passed, that a deep or prolonged impres-
sion 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 concen-
trated  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 com-
municate 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 nervous
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
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 com-
pression  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  modification
which they subsequently possess, the natural food of each, the very pro- 
INFANCY AND  CHILDHOOD.
29
cess 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 injuri-
ous from its quantity or quality.
   The  intricate  and  extensive sympathies of  the  different systems,
slightly evident in health, but very marked in disease, are 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 management   ■
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 perform in
transmitting the blood through the lungs, acquires greater size.  The
pulmonary  bloodvessels are largely developed,  and are occupied in car-
rying 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 obli-
terated.  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 fol-
lows.   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
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 act-
ive 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 im-
perfectly 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 
30
ON  THE MANAGEMENT  OF
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 ac-
knowledging  that, to expect the vigorous generation  of animal heat in
such circumstances, would be very much like  expecting an oak to grow
without roots, or afire  to burn without air.   Notwithstanding this, how-
ever, it was once, or rather it still is, a matter of popular belief, that in-
fants have a great power of resisting external  cold, and are even invigo-
rated by it.   But Milne Edwards has now demonstrated that, in accord-
ance 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 natural
standard, and is very easily depressed still further by external exposure.
In one instance, of a seven months' child, the  thermometer stood at 89°
Fahr. instead of 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 necessary
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 ex-
haustion 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 proceed ra-
pidly.   Food, excitement, and  sleep, divide the life of infancy, but the
latter preponderate considerably in health.  By degrees the organs  of
life become used to their food and able  to  employ it beneficially ; 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 objects ;
he  hears, not sounds  simply, but sounds proceeding from something,
towards which  he endeavors to turn.   A light object  immediately at-
tracts  attention, and if it be moved  the infant will endeavor  to  follow
it with its 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

  1  Combe on the Management of Infancy, p. 119.  This  is an excellent little  work,
which I would strongly recommend to  the notiee of all interested in the management of
■children. 
INFANCY AND  CHILDHOOD.
31
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 together
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 grasping them,
and the  mind has thus opened  to it another  source of information,
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  difficulty and uncer-
tainty,  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 command, and mental  or  cere-
bral 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
or power of imitation.   Voice or  sounds the child has produced from its
birth, but it was expressive of two  sensations merely, distress and  plea-
sure ; now, however, that the ear  has acquired a certain amount of
knowledge, and the muscles of the mouth and larynx a certain degree
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 persevering endea-
vors a  simple  sound is divided  and rendered distinct by the lips, and
the child's first words, " pa-pa," " mam-ma," are uttered.   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 increases 
32
MANAGEMENT OF
with considerable rapidity, single words are accumulated, complex  ones
are formed, two  or  more  are joined, so as to form an imperfect  sen-
tence, 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 impres-
sions to another.   The influence of mind upon speech  is very well illus-
trated in the case of idiots, who always learn to speak very imperfectly,
and often not at all.
  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 to 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 progress 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 bis limbs than when
he learns to walk without  first creeping.
  Be this as  it may, by one means or another he  acquires all  the mus-
cular 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, how-
ever, the power of balancing himself  and the courage to do so are at-
tained, 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.
                      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 flan-
nel and laid  upon the bed, or  taken to the  fire until the  nurse is at
liberty to attend it.  Common sense would teach us, as instinct teaches 
INFANT AT  BIRTH.
33
animals, that for some considerable time after  birth great care should
be taken to keep the infant  warm, and  observation only confirms this
necessity by showing that the change of locality at birth involves  a dif-
ference of at least  twenty degrees.  Dr.  Edwards'  experiments 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 be washed and dressed immediately.  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
Bimple 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 yelk of an egg is  equally
effectual.2   Both lay great stress upon  the necessity of its complete re-
moval.  Now, without going so far in the  opposite extreme as  the Ger-
man professor referred to by Dr. Dewees, who  advised its being allowed
to dry and drop off  spontaneously, I do think  that to prolong the ope-
ration of washing unduly for this purpose  is unnecessarily exposing the
child to cold  and irritation.   Let the nurse apply the  lard, and  after-
wards, 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 care-
fully 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
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  ne-
cessary, 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, axillae,  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, or
lycopodium, 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.3  I cannot say I

    1  Diseases of Children, p. 71.                2 Diseases of Children, p. 18.
    s  Diseases of Children, p. 21.
        3 
34
MANAGEMENT OF TnE
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 precau-
tion, 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.1  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 to separate as
early  as the second day, and, on the other hand, to 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 limbs, than it is
clapped  again  into confinement.  It is swathed, its head  is  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 fortunate 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  themselves; for
the helpless infant is not at liberty to turn its head  to facilitate the
discharge."2
   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

    1 Dewees, Diseases of Children, p.  81.        2 Histoire Nat., vol. iv. p.  190. 
INFANT AT  BIRTH.
35
sake of warmth, and if the parent possess common sense, she will not
adopt  the  cruel fashion of short sleeves.  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
sporge 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 bias been evacuated.   It is better to take a
middle course; to allow a few  hours' rest  after washing  and dressing,
and then,  if the  bowels  are not spontaneously moved, to give a  tea-
spoonful of castor  oil in a little warm water and sugar.  I think the oil
a better medicine  than either calomel, 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 beneficial.
   33.  For some hours the child will  not  require food;  its  first necessity
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  awaking it will generally be found  to have passed water, and per-
haps to  have  evacuated the bowels, and as it  will  then feel  hungry, 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 generally
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 simplest,

   1 On  Diseases of Children, p. 34.
   2 Raulin (De la Conservation des Enfans,  vol. ii. p. 177) in 1769, and Deleurye (La
M6re 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 
36           MANAGEMENT OF THE  INFANT  AT  BIRTH.
most natural, and healthy nutriment, and the mother may be thus saved
from uterine hemorrhage,1 mammary congestion, and milk fever, which
latter are 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 ducts will be  freed, and the  secretion quick-
ened.   So long as the supply is inadequate, the deficiency must be  sup-
plied 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 may 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 se-
creted for two or three days.2   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, in-
flamed, and  excoriated.3   The  child should be fed, and only once or
twice a day placed  to the breast.

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
nutriment; gradually the milk is more plentiful, the exertions of the infanf 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.
   1 Underwood, Diseases of Children, p. 29.
  2 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, the late Dr. Graves, very successful. Order some "milk powder,"—a few
grains of some innocuous or inert substance, e. g., Pulv. Contrayervse,—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 play, and in the
majority of cases your "powders" will have the credit of success.
   3 Few things occasion greater suffering than cracked or ulcerated nipples, and it is not
always possible to avoid them.  I have found a modification of Professor Osiandcr's me-
thod the best means of avoiding them.  For a month or six weeks before confinement 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 preg-
nancy."—p. 54 
THE FOOD OF INFANCY AND CHILDHOOD.          37
                      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  excep-
 tions, the imperative duty of the mother to supply it.
   To  the  credit  of those who  are below or  above  the influence of
 fashion—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 affection,
 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 adduced
 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 mortality
 among dry-nursed children is not quite so great  as in London, 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 undoubtedly
the mother.   But then it may be asked whether this rule  is universal,
Underwood, Diseases of Children, p. 13. 
38          THE FOOD OF  INFANCY AND CHILDHOOD.
and without exception ?—whether  all mothers  can and  ought to nurse
their children?  The answer is simply that there are exceptions to this
rule  as to  every other, depending upon constitution, 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 prominent,
or so much tucked in, that the infant cannot seize it.  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. Dewees, 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.  I  have  seen  one case, but only one, in which the ducts
were imperfect  or impervious ; for, notwithstanding that the  breasts
were distended  with  milk, not a drop could be obtained by the infant or
by an  older child, or by  the  breast  pump.  The lady  has  had three
children, and was equally unable to nurse with  all.
  II. 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 nothing
capable of restoring  the secretion in such cases.
  III.  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 infant,
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, with-
out 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 appearance,
and they suffer so much distress that  they are not unlikely to cause in
this way the very danger they fear.
   Moreover, in women of  this temperament  the constitutional disturb-
ance excited by nursing is too great for their own health or that of the
child, especially with first children.  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 
THE FOOD OF INFANCY AND  CHILDHOOD.          39
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, epi-
lepsy, scrofula, syphilis, mental  disturbance, &c.  Nay,  even a known
tendency towards some of these diseases, their occurrence in any mem-
ber 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 constitu-
tions 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 disagree
temporarily;  but if pregnancy  takes 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.
   VII.  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
mothers, who cannot give up their amusement, do not add to their folly
by attempting to nurse.
   vni. Lastly, great  mental emotion,  such  as grief for the loss  of
relatives 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 appa-
rently suffer.
   I have met with  an instance  of two  sisters, who continued to nurse
their infants during a time  of severe domestic trial, and although the
children were both  healthy previously, yet, shortly after,  one  was
attacked 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 
40          THE FOOD OF INFANCY AND  CHILDHOOD.

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.   A recent author  has attributed the  excoriation  to the
action of the infantile saliva upon  the tender skin of the  nipple, and
has recommended  washing  with water after each  application  of the
infant.
  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 the natural supply from any cause,  it  may not suffer.  As the child
grows older, and  its  appetite  increases,  the mother  may not have
sufficient, and the feeding must be increased in quantity and frequency,
at the same time it  ought to have the benefit  of all  the 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  medical
attendant should be extremely careful  in his
                        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
two points, not strictly medical, which are  of importance, and should be
inquired into.   For instance, her temper,  habits  of  life, and any pecu-
liarity  of her position, may be serious inconveniences.   If she be liable
to fits  of passion  and ill-temper, or indulge any vicious propensities, 
THE FOOD OF  INFANCY AND CHILDHOOD.          41
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 subse-
quently.
   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  sufficiently
recovered from  the effects of parturition, to undertake the duties  gene-
rally 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 perfect,
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 promi-
nent, and we should  observe whether the milk escapes involuntarily, or
only when demanded by the infant.2
   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 a while, covered
with cream.
   It may also be subjected  to  chemical and microscopical analysis, if

  1 Underwood, Diseases of Children, p. 71.
  2 " 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
'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 examiner 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.
  Dr. Peddie has  published  a  valuable paper on the mammary ducts, in the Edinburgh
Monthly Journal for Aug. 1848, in  which he has shown the value of the  microscope for
showing the poverty or richness of the milk, and also  for detecting certain of its patholo-
gical conditions.  I would strongly recommend its careful perusal. 
42          THE FOOD OF  INFANCY AND CHILDHOOD.

there be any doubt, but ordinarily the characteristics  mentioned above
will be sufficient.
  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  fre-
quently propagated, as to become familiar to the observation  of every-
body ;  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 wdiich the father and mother, three
children, the maid servant, and two clerks, were infected with venereal
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  attendant 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 por-
tion 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  ob-
tained 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  comparative idleness,
having little to do but to attend to the infant.   It cannot be surprising
that such a change should in many  cases be unfavorable  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 regi-
men.   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 bedtime ; 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 exer-
1 Dewees, Diseases of Children, p. 68. 
            THE FOOD OF INFANCY AND  CHILDHOOD.          43

cise in the open air is essential, a good smart walk will promote diges-
tion and favor the secretion of milk, if she take care not to overheat
herself.   The bowels should be moved every day,  if not spontaneously,
then by means of medicines.
  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."1
  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 air and good diet, exercise, and occupa-
tion, 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 arid porter,
and it is  very likely that  in so  doing she will  defeat  her own  object.
Dr.  Dewees 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 suitable remedies, that the secretion of milk
again becomes  more  abundant.  Upon this  principle  we have  fre-
quently prescribed evacuants and abstinence to  promote the secretion
of milk.2
   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 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 occasions
of irritation, and exert all the self-control she possesses.
   I  may as well mention here  that  Dr. McWilliam has introduced to
the notice of the profession the leaves of the castor oil plant as  a galac-
1 Maternal Management of Children, p. 33.
2 On the Diseases of Children, p. 99. 
44          THE FOOD OF INFANCY AND CHILDHOOD.

tagogue.  The leaves of the white bofareira are to be boiled in water,
and the breasts are to be bathed with this decoction for fifteen or twenty
minutes.  Part  of the  boiled leaves are then to  be  spread over the
breasts, and allowed to remain till dry.   This  operation of foments and
poulticing is to be repeated, at  short intervals, until the milk is pro-
duced or increased.  Dr. Tyler Smith tried it  in several cases, which, I
think, afford ground for believing that  it may be useful.  A consider-
able amount of uterine or ovarian irritation seems  to be produced,  and
menstruation or leucorrhoea occurred, so that, perhaps, the application
may be successful  as an emmenagogue as well as a galactagogue.   From
Dr. Rose Cormack's experiments, however, it  appears doubtful whether
the effects result from some special property of the leaves, or from the
heat and moisture of the poultice.
  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 ; Mr. Stephens mentions that the
Mexicans adopt the practice, and the lower orders occasionally practise it
to avoid pregnancy, but with only a partial success ;  for we find from the
investigations of Dr.  Laycock and  Mr. Roberton, that a lagre propor-
tion of females of the lower  classes become  pregnant  while nursing.
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 the breast 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
Dr. Ashwell on Prolonged Lactation. 
THE FOOD OF INFANCY AND CHILDHOOD.          45
emptiness is at times felt  at the region of the  stomach ; the mind
becomes disturbed and tormented often with an intense dread of dying,
or a constant apprehension of some dreadful accident.   A last delirium
and even mania sometimes supervene."1
   Dr. Gooch, in his valuable work, alludes to mental  affections caused
by nursing.   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
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 great measure prepared the child; and if  the frequency be in-
creased 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, bow-
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 or 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."2
1 Eberle, Diseases of Children, p. 64, et sea.
8 On Diseases of Children p. 75. 
46          THE FOOD  OF INFANCY AND CHILDHOOD.
                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 mor-
tality 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.   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 8.35 6.50 0.45 87.98	4.02 3.32 5.28 0.58 86.80	4.50 4.20 5.00 0.68 85.82
Total.....	100.00	100.00	100.00 12.02	100.00 13.20	100.00
Solid substances	12.98	8.35			14.38
  From  this analysis we learn  that  women's  and  ass's milk  are  the
poorest of all, but that they contain most saccharine matter,1 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  dif-
ferences  in that we do  take.  Thus a large proportion  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

  1  In the 7th vol. of the Dublin Journal, p. 275, Dr. Mone reports an interesting series
of experiments, from which he deduced the conclusion, that " the casein of human milk forms,
with most acids, two sets of compounds: the one when a certain quantity of acid is used'
soluble in water; the other, when a different quantity of acid is used, insoluble in water'
and that according as each experiment has formed the soluble or insoluble compound, he
has  reported the milk on which he operated to be incapable or capable of evaporation with
acids," &c. 
            TnE FOOD OF INFANCY AND  CHILDHOOD.          47

Bhould 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."3
   51.  Various kinds of food are in daily use, many of which are very
valuable.
   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  sometimes diarrhoea; but
with an occasional variation, it is one of the best, as it is  the most com-
mon kind of food for infants.
   II. A very nice kind of food may be made from  biscuit powder, pre-
pared rusks, or " tops and bottoms,"  by  steeping them in  water boiling,
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 cool-
ing 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. Arrowroot, 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 Mr. 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 ten-
1 Diseases of Children, p. 91. 
48          THE FOOD OF  INFANCY AND CHILDHOOD.
93.
dency 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
  VII. In some  cases of illness, to be hereafter noticed, rennet whey or
white wine whey are useful  temporary additions or  substitutes  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.
  VIII.  I am  indebted to a writer in the Med.-Chir. Revieiv  for  the
knowledge of  another species  of food, viz: carrot-pap, which has been
strongly recommended  to the profession  by Dr.  Gumprecht, of Ham-
burgh.   It is used in Wallachia and  Turkey ; and at the request of Dr.
Gumprecht, it has been tried, and is highly commended  by Miiller, of
Hamburgh, Manthner, of Vienna, and Miitchmeyer, of  Luneburg.  The
reviewer states that " Wakenroder gives  the following analysis of the
expressed and inspissated juice of the carrot:—
            Oil,  fatty,   "I 1 0()                Sugar,     1
            Oil,  ethereal, /  '  '                Malic acid, I
            Albumen, vegetable, 4.35.           Starch,    J
            Karrotin, 0.34.                    Lime.
                                           Alumina.
                                           Oxide of iron.

  " But as the scraped root of the carrot contains  other matters than
the above, especially a large quantity  of  ligneous  substance which
cannot be digested :  and which will often  remain two  or three   days in
the intestinal  canal before being discharged,  and  being highly detri-
mental to the mucous membrane  of children, it becomes  important to
separate that which will be useful from that which will not.   Gumprecht
advises an ounce of finely scraped full grown carrot to be mixed with two
cupfuls of cold soft water, and allowed to stand for twelve hours, being
frequently stirred during  this period.  The fluid portion is then to  be
strained  off, what remains  being pressed to yield  some  more.  The
fluid is then to  be  mixed with  the proper  quantity of biscuit  powder
or bruised crust  of  bread or arrowroot,  &c,  and the pap placed over  a
slow fire until it  begins to bubble.  Care  must be taken that the heat-
ing be not  pushed so far  as to cause boiling, or  the albumen will  co-
agulate.   After  its  removal from the fire,  it  is  to be sweetened with a
due amount of white sugar.   Dr.  Gumprecht states that by mixing the
carrot juice with biscuit, crust of bread  or arrowroot and sugar, we
obtain all the farinaceous and nutritious elements required, viz: albumen
and gluten, starch, sugar, fat, and the phosphates of lime and magnesia.
This food is  more  particularly adapted  for children who have been
suckled  and are  being weaned.  For those who  are brought up by hand
the  following preparation  is deemed more advisable: an ounce of very
finely scraped  yellow carrot, and two drachms of biscuit powder  are
to be mixed with two cupfuls of cold soft water.   This must stand in
a covered vessel,  in a cool  place for twelve  hours, to be frequently stirred
during that time.  It is then  to be  drawn  off or  strained  through a
1 Underwood on Diseases of Children, p. 64. 
THE FOOD  OF INFANCY AND  CHILDHOOD.          49
fine linen cloth.    Some sugar-candy and  a pinch of  salt are to be
added  to  the fluid, which may then  be administered by means of a
sucking bottle, care being taken that the food is at  the proper tem-
perature."
  Wi.  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
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 thick-
ened as the child grows  older.   The nurse should place the infant 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 f(*)fi  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  bet-
ter, 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 infant, 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
Tai :s,  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

                  1 Underwood, Diseases of Children, p, 59.
       4 
50          THE FOOD OF  INFANCY AND CHILDHOOD.
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 accompanies
spoon-feeding, and  without the risk of a sour nipple from the  careless-
ness 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 sub-
stance as  the child advances in age, and then  the  sucking-bottle must
be laid aside.   If  possible, at  any rate in the daytime, the food should
be  fresh  made each time, and the vessels used carefully washed  after-
wards.  In order  that these  matters  be properly attended  to, it is
absolutely necessary that the  mother  should keep  a  vigilant  super-
vision  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 variety.
Until the child is prepared with teeth  to  masticate solid food, we may
fairly conclude that such is  not its  natural  food, and whatever is  un-
natural is certainly mischievous with children.   Dr. John Clarke 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  ani-
mals are designed by the  Creator for the same sort  of food.   If the
mastication of solid food, whether animal or vegetable,  and a  due ad-
mixture of saliva,  be necessary for digestion, then solid food cannot be
proper where there is no power  of mastication."   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 necessary
to  satisfy the first  demands of the appetite;  afterwards,  at a convenient
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 mut- 
THE FOOD  OF INFANCY AND CHILDHOOD.          51
ton 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 con-
sist of the same food as the breakfast;  and  very soon afterwards  the
child should be put to bed.
   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 exceptions.
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 rea-
sonable 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 children, but yet it  is quite pos-
sible 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  sweetmeats 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  suffer-
ing.
   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 circum-
stances,  should be  prohibited to  children  under fifteen  or  sixteen
years of age.   I mean wine or malt liquor.  Neither are at all  neces-
sary,  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  conse-
quences. 
52
CLEANLINESS.
                      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  skin
from  impurities, and prevent the irritation which  might arise, but it is
in itself of the greatest value in promoting health.   " I consider bath-
ing," remarks Struv&, " 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 ad-
vanced  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  armpits, the creases of the neck, &c.  &c.;  after  drying
 them well, they are to be powdered with  starch or lapis calaminaris  or
lycopodium.   Very little soap will  be necessary, and it should  not  be
applied to the face at  all, because of  the  risk of its getting  into the
eyes.   Great gentleness  is  necessary in both washing  and drying, as
the   skin  is  extremely  tender,  and  easily  irritated.   Properly em-
ployed, friction along  the back and limbs  is both pleasant and bene-
ficial.
   In addition to these regular and stated washings, the  nates  should
be  washed and powdered after each movement of the bowels, in order
1 Underwood on Diseases of Children, p. 27. 
CLEANLINESS.
53
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, excoria-
tion, 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 unques-
tionably the only one that influences upon this subject, when the 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  offensive
odor."1
   I would wish to add  a word with regard to the powder, lycopodium,
which I have recommended, and which  I have found  most useful.   Its
peculiar quality is that,  when dusted over a surface, water runs off from it
without wetting the surface, so that, for some time at least, perfect dry-
ness is  preserved.   For children with delicate skin, liable to excoriation,
nothing can be  better,  and I have repeatedly seen  severe excoriation
disappear in a few days under its use.
   59. For  the first few days, care must be  taken not to disturb the
remains of the navel-string during washing.  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 pro-
bably be unmanageable, and even fatal.  It will fall naturally about the
fifth or sixth day, and then a little scorched rag, or spermaceti spread on
linen, may be applied.   If the navel be red  and swollen, a little  bread
poultice may be applied.
   GO. 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 winter, that
 a proper degree of reaction takes place immediately after, and that the
child is not frightened.   I know of no good  to compensate for the con-
vulsive  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 temperature, and how  slowly-
they regain it, we shall view the cold bath  as  one of those measures
1 Dewees, Diseases of Children, p. 88. 
54
CLEANLINESS.
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  termi-
nating at the upper part in a narrow  tube;  when  put  into water it be-
comes 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 weather, and the  season.   It should  be
warm or tepid for  infants at first; afterwards it may be used  a  little
cooler.  Its tonic effect may be augmented by the addition of bay salt,
and  by much active rubbing.   The first few baths may be quite warm,
and make a sort of commencement, until the infant is  familiar with the
little shower.   It may gradually be made a remedy."1
   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
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 qud 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  yelk of
an egg, which is much better, and  leaves the hair beautifully 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 irri-
tation it causes: the best  means  I know is  rubbing  a little  pomatum
gently over it at night, and washing  it off with mild soap and water or
oatmeal 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, pro-
vided 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.
1 Underwood, Diseases of Children, p. 33. 
DRESS.
55
                               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 em-
ployed 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
being  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
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 im-
mediately 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 sus-
pected."
   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 appa-
rently enfeeble their brain in after life. 
56
DRESS.
  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 society
for  the use we make of our power.
  64.  It is obvious that the materials of dress ought to vary according
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 difference
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 delicate
skin of an infant, and unless it be changed every day, as the inner gar-
ment 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 move-
ment as is necessary.   The  sleeves of the frock should also  be 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 higher, 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  produced by
the  bed and its coverings renders unnecessary  the same  amount of gar-
ments  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
1 Diseases of Children, p. 43, 4th edit. 
DRESS.
57
a greater or less extent by the clothes, being retained too  long in con-
tact with it."1
  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 before 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."2
  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 short-
ened ;  and at the end of the year they may be 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 framework 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 cors-ets, 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 develop-
ment."3

  1  Condie on Diseases of Children, p. 43, 4th edit.    2 Diseases of Children, p. 97.
  s  Underwood on Diseases of Children, p. 38. 
58
AIR  AND EXERCISE.
                       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
bed-chamber, and that should  be well ventilated; the second  or third
week it may be taken into the nursery during  the day, and subsequently
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
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 infant
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 ventilated, 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.  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.
   60. 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 exposure.
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. 
AIR AND EXERCISE.
59
  We may  leave  such arguments as  these, and  attend to  the  ex-
perience of  Dr.  John  Clarke and Dr. Merriman, who have been more
conversant with  the habits and  diseases of children than most  of their
contemporaries.   The former observes: "It  is a subject of  very com-
mon 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 ex-
posed to cold in winter are generally most  healthy, whilst  those 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 treat-
ing children; and  many fall sacrifices to  pulmonary consumptions 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, sup-
ported 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 hardening
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 car-
1 On the Diseases of Children, p. 9.
z Underwood, pp. 43, 44. 
60
AIR AND EXERCISE.
ried  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 position.
When  the child acquires  sufficient strength, it  may be allowed to  sit
up, and take  its exercise in this posture.   The nurse  should  be  ac-
customed  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 consists
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 exer-
cise, 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 violently, 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.
  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 armpit, and  so raise
the infant.
   71.  When  the infant  is a  few  months old,  it  will voluntarily  ex-
tend  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 walking' 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  benefited.   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 own 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 leave
the child  to its own direction,  and it will very rarely hurt itself by its
own  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
1 On the Management of Infancy, &c, p. 269. 
AIR AND EXERCISE.
61
  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 or 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.  Remembering
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  chil-
dren attain the latter very slowly, and if they are forced, the fear  of
falling will prevent their making the attempt, and will  only serve  to
distress  them.   I would say,  then, that  the child should itself  decide
upon the different steps of its progress; and a little watchfulness 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  backwoods  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 ac-
 customed 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 as-
sistance, 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."1
    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 apartments 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;

  1  Combe on the Management of Infancy, p. 272.  Eberle on Diseases of Children, p. 50. 
62
AIR  AND 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 unfortunate 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 account
 of its delicacy, by means of a donkey or pony,  with amusement and
 gentle excitement in addition.  Exercise on horseback is particularly
 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 exer-
 cise, 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 prema-
 turely confined.  The time, however, will come  when the association of
 brothers  and  sisters will, to  a great  degree, be  broken.  Boys,  how-
 ever, 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 con-
 fined 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  bois-
 terous 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 beino- well
 developed  and  allowed free play, easy and natural grace  will  be the
 consequence.
   One word  as to the exposure  of the child  to  light.   Lio-ht 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 ajamp or  candle.  But after a while 
SLEEP.
63
the eye becomes accustomed to light, and whilst we  still avoid  the  ex-
treme I have mentioned we should equally avoid the opposite.   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 in
appearance, his  blood is  imperfectly oxygenated, and a proneness  to
disease of debility arises.   Of these results we find numerous examples
in  the  narrow lanes and  dark cellars of every large  town, 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  ag-
gravated 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 awakes  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 mother,
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 overlaid.   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
On the Management of Infancy, &c, p. 147. 
64                            SLEEP.
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 altogether
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-
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  advan-
tage 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 which should be encouraged and
prolonged as much as possible ; for during waking  hours children expend
far more vital energy than  adults, and a midday sleep recruits  them,
and prevents them being over-fatigued and fretful in the evening.   For
this  reason, also, children should be put to bed  early;  during the first
year or two, 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 awake 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.
  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 na-
tural for  the child to sleep,  and it will do so if there be  nothing pre-
venting it;, our duty,' therefore, is, to find out the obstacle and remove
it.   The child may be placed  uncomfortably in bed ; there may be un-
due pressure upon some part;  the  bed may be rough and uneven • its 
MEDICINE.
65
feet may be cold;  it may have eaten too much ; or it may be teething.
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 mischievous remedies
which nurses are too ready to employ.   If the child be really restless
and  uneasy, 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
Bhould 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 matter,
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 infant'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 invariable 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  com-
plaint, 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 litttle 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  at- 
66
THE NURSERY AND NURSES.
tendant; nay more,  she should be absolutely  prohibited from  having
any in her possession, for it  is not unusual for her to provide  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.  Dewees remarks :  " Nurses
generally make a point  to have a certain  period of  the  day at their
command; and should  they find this hour  repeatedly interfered with
by the wakefulness of the child, they will  soon have  recourse to such
means as shall prevent its future recurrence.   We have known  a num-
ber of cases where laudanum was administered for this purpose, with so
much  cunning as to elude detection for a long time, even  after the sus-
picion  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 sleeping."1
                     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 few  first 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.   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 ob-
struction 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
1 On Diseases of Children. 
NURSES.
67
should be repeated  occasionally during the day, when they are  ab-
sent.
  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
Bickness, and care should be taken that  the  nurse, for her own  enjoy-
ment, 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 com-
fort and health of children.
   " From pure ignorance on the part of the parents, it is also a common
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.  Wherever one or
two persons sleep the air  is  always considerably contaminated  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 removed from the vitiated air and
impurity of their sleeping apartment into a wholesome and bracing at-
mosphere, 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 morning, 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 en-
 forced 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 impressibility
of early life, it is certainly surprising that  more care is  not bestowed
on the  selection of a  nurse  and nursery maids than we usually find.
1 Combe, p. 61. 
68
NURSES.
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-indulgence, are daily
taught them by example;  and if they be  discouraged 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 children, 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 some-
what 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  irrita-
tion 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 actions
of the nurse  rather than from her precepts, and  the instruction of  a
wise mother will be entirely  thrown away, if counteracted  by the con-
duct of the nurse.   It will also be a great advantage  if she be able to
read and write.  I need not dwell upon the necessity of habits of order,
cleanliness, and personal tidiness;  these  are hardly likely to  be over-
looked by  a careful  mother, although she may not  appreciate their
influence upon the  hajbits 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 the intra-uterine
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, and  other affections which do  not admit of
much classification. 
SECTION   I.
DISEASES OF THE CEREBRO-SPINAL 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  farniliaria solet esse  proli  in utero  quam epilepsia."   And
Sogcrus  relates a case of a pregnant woman who suffered severely from
this disease, and in whom the foetus exhibited  similar convulsive move-
ments.1  Lowenheim held  that it was  not uncommon, and Hoogeveen
and Feilcr 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 con-
sulted 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 excessive, irregu-
lar, 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 lat-
tar instances the child has been  stillborn,  and the period of its death
referred  to the close of  the violent convulsive movements.  In  a case
of this kind, where the death of the child corresponded to the  mother's
perception   of the convulsive movements, Dr. McSweeny found,  on
dissection,  that  the  membranes  of the brain were  greatly  injected.
Whether these are cases of epilepsy may of course admit of a question,
but it  is  of little consequence, as  during intra-uterine  life nothing reme-
dial can  be attempted.

                         HYDROCEPHALUS.

   83.  The occurrence of hydrocephalus in the foetus  is not a discovery
of modern  times.   Thus Blancard relates a case of  a foetus  of seven

                  1 M. N. C. Dec. 1, An. 3, Obs. 160, p. 291.
                  f 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 ;l and Russeus  another, where the head was so distended
with fluid that it weighed more than the rest of the body.2  Lechelius,
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
Rudolphi considers it3 to be  a special disease, arising  from excessive
congestion of the membranes, or from  inflammation.  Another view of
the origin of this disease, which has been put forward by Breschet  and
Behrend, is, that  it consists in an  excess of  the  fluid which exists
naturally in  the cavities of the brain, as was  noticed by Cotunnius,
Morgagni, Magendie, &c, and called by the latter the cerebro-rachidian
fluid.  This  fluid may either  be confined within limits,  or  by its pres-
sure may produce  encephalocele,  hydrencephalocele, or spina bifida.
I  shall  have to notice  this view again when speaking  of  chronic
hydrocephalus, and  therefore  shall only state  that I think it  offers  a
reasonable explanation of a portion of  these cases.   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 considerable,
it has to be destroyed even if alive, in  order  that labor may be com-
pleted ; and in very few cases is the child born alive.  Should  the  dis-
ease 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 Geoffroy St. Hilaire in his learned work on  monsters, and by
other authors who have entered fully into the  many  interesting  ques-
tions 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 por-
tion  only of the brain exists  ; and a third where it is entirely wanting ;
and  in  all the cranial vault is absent, the base of the skull alone re-
maining.
  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

  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.
  4 See the article Anencephalie in Diet, de Med. et de Chir. Prat., vol. ii. p. 377. 
           INTRA-UTERINE  OR  CONGENITAL DISEASES.        73

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 it seldom  lives 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 ; 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, or to the pressure of the cerebro-rachidian fluid in  con-
sequence of which the bones are separated or perhaps absorbed.  It has
been called podencephalie by Geoffroy 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, with-
out 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 anterior fontanelle appear to be the smaller.   Sanson mentions a
case in which  the entire brain escaped by a round opening correspond-
ing to the posterior  fontanelle; the infant  lived  fifteen hours, and its
functions were all naturally fulfilled.1
  86.  If the  sutures be very defective, the cerebellum  may protrude.
"Tn  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 dissec-
tion, 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  pro-

          1 Art Hernie, Diet, de Med. et de Chir. Prat., vol.  ii. p. 496.
          * Cooper's Surgical Dictionary, Art. Hernia Cerebri, p. 754. 
74        INTRA-UTERINE OR CONGENITAL  DISEASES.

truded 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 stillborn.   Richerand  mentions that several such  ex-
amples are  preserved  in  the  museum of the Faculty of Medicine  at
Paris.1
  A curious case of more extensive deficiency, both of bones and inte-
guments, was  published in  1810 by  Dr. Burrows: "The whole of the
forehead, summit, and  a great  part of the occiput, were  deficient, 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 secre-
tions 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, inclosed  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 cephalaematoma  of the scalp and  acci-
dental 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:
cephalsematoma,  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  exter-
num, they will always be found on  the exact part which  presented,
and in no case is any suture more than slightly involved in the  pre-
sentation.   Moreover,  in hernia, the absence  of bone beneath the tu-
mor can be ascertained;  and in cephaleematoma, although the circular
ridge gives at  first a feeling of there being a perforation, yet on  press-
ing the swelling  on one side,  the unbroken surface  of  bone may be
felt.  Lastly,  there is a constant pulsation, synchronous with the  pulse,

                   1 Nosographie Chirurg., vol. ii. p. 316.
                   2 Med. Chir. Trans., vol. ii. p. 52. 
          INTRA-UTERINE OR CONGENITAL DISEASES.         75

in hernia, and the tumor can be depressed to the level of the skull; but
in cephalaematoma there is no pulsation, or an uncertain one  commu-
nicated 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 distin-
guish hernia from any other kind of tumor which is formed upon the
scalp.
  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 loosen-
ing the  cap.   By thus  depressing  the  tumor gradually, and without
injury, an opportunity is  given  for  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 to the  Royal  Academy of  Surgery
of  France, a case which was thus cured.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  in-
Jury-                  .       .        .                   .      .
   When the tumor consists mainly of fluid it may be worth while trying
the effects of  puncture, with or without compression.  Mr. Lyon punc-
tured the tumor on the right side of the nose, and  afterwards on the
left side, but the child  died.  Mr.  Adams  punctured  a tumor seven
times  with  success, ultimately leaving a solid tumor, which was appa-
rently a  protruding  portion  of the brain.   Mr. Earle repeated the
operation nine times, and the child lived  two months.  And Mr. Dendy
operated three times in nine days, allowing nearly twelve ounces of fluid
to escape, but the child died on the tenth day.   These instances, however,
are not very encouraging.
                  SPINA BIFIDA.—HYDRORACHITIS.

  90. In some respects this congenital disease bears a strong analogy
to the one last described, depending either upon an arrest of develop-
ment in some portion of the spinal canal, or upon an excess of the cere-
bro-rachidian fluid, which by its pressure first produces absorption of the
bones, and then protrudes the membranes by  which it is surrounded  in
the form 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
vertebrae,  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
lastlv, in the lower  portion of the sacrum, as in the case published by
M.  Vrolik.

               1 Mem. de l'Acad. de Chir., vol. xiii. p. 103.
               2 Ollivier, Mai. de la Modes Epin., vol. i. p. 184. 
76        INTRA-UTERINE OR CONGENITAL DISEASES.

  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 Fleischmann and others.1
  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
  ill.  Where the arches  are well developed, but without union posteri-
orly : here,  however,  the separation can be but a few lines, resembling
a groove rather  than an  aperture.   Ruysch, Acrell, and Isenflamm2
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 spines of the
vertebra share in the  malformation, and are divided or altogether ab-
sent.   It must be remembered, however, that the absence of  the spi-
nous processess 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 occa-
sionally, as in Mr. Brewerton's case,3 consisting  of  two cysts, is gene-
rally covered by the skin, which, when  it is very small, may be of the
natural color, but which, as the  tumor increases, becomes  thin, trans-
parent, 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 fluid  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, osma-
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.  Olli-
vier states that, when the case is not complicated with  hydrocephalus,
he has generally found the spinal marrow traversing the sac unaltered,
except that in some cases it seems lengthened.4   But if coexistent 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.5  Or, either from  the extreme  distension  or from some morbid

    1 Vitiis congenitis circa Thoracem et Abdomen.  Erlangen.
    2 Arch. Gen. de Med., vol. iv. p. 299.
    8 Edin. Med. and Surg. Journ., vol. xvii.           * Op. cit, vol. i. p. 197.
    5 Duges, Diet, de Med. et de Chir. Prat., vol. x. p. 138, Art. Hydro-rachis. 
          INTRA-UTERINE OR CONGENITAL DISEASES.        77

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  im-
properly 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 supplied
with nerves by the lower part of the spinal marrow varies in  degree,
depending,  most  likely, on the degree of pressure, from within or with-
out, upon the cord.  In almost every case the child has less power than
usual in  its  legs; however, Mr. Cooper  has related a remarkable excep-
tion in a child who had one of the largest spina bifidas 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 swelling 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 con-
trol the  urine nor feces.
   92.  The  tumor may burst before birth with or  without the destruc-
tion of the  child.2  Generally, however, we  find  it unbroken, but  in a
few days or weeks the surface becomes inflamed, small patches of super-
ficial 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 circum-
stance 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 measurement of the swelling  to have
been  thirty inches in  its vertical line.  The urine and feces used to
pass involuntarily.4

   1 Surg.  Diet,, Art. Spina Bifida, p. 1171.    2 Ollivier, dela Moelle Epin., vol. i. p. 200.
   3 Ontleed Heelkund, Verhaudl. Amst, 17G7. 4 Surg. Diet., p. 1171. 
78        INTRA-UTERINE  OR CONGENITAL  DISEASES.

  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
few cases escape that we can indulge but little hope of any one  in par-
ticular.   In addition  to the case of recovery already mentioned, I may
add  that Morgagni,1 Kielmann,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 cha-
racter of the disease, they just afford a reasonable ground  for attempt-
ing 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 per-
haps fetid, after which convulsions set in.  When the opening is larger,
inflammation occurs more rapidly, and  the convulsions follow speedily.
The termination is rapid, in proportion as the inflammation 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. Abernethy
recommended a slight degree of pressure on  the tumor from the com-
mencement, with the double object of limiting the  distension of the dura
mater, and promoting the  absorption of the fluid.  Should the fluid in-
crease, 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 discharge became purulent, and
the  child died.4
   Heister mentions a case of compression under  the care  of  a  surgeon
named Steuber.  Sir Astley Cooper relates a  case  of preservation  of
life,  though not of  radical cure, by  compression,  which I shall ex-
tract.  "James Applebee was 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

     1 De Sed. et Causis, Morb. Epist. xii. Art. 9.   2 Prodrom. Act. Havn, p. 136.
     3 Journal Ge"n. de Med. 1106, vol. xxvii. p. 162.
     4 Cooper's Surgical Diet., Art. Spina Bifida, p. 1172. 
           INTRA-UTERINE  OR CONGENITAL DISEASES.        79

 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
 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 bej;an 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 smallpox in the first
 year,  and the hooping-cough  at three years.  His  head, previously
 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 tumour, but it does not appear that his suggestion 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, pro-
vided the  disease  be  local, and a mere distension by fluid in  consequence
of the imperfection of the bones, and  not a disease of the spinal marrow,
> Med. Chir. Trans., vol. ii. p. 323. 
 80        INTRA-UTERINE OR CONGENITAL DISEASES.

 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. Dessault1 and Mathey2 proposed  the insertion of a seton through
 the  tumor, but this would be to quicken the ordinary chances of menin-
 gitis by admiting 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 suc-
 cess, to  cure the disease radically, by evacuating the fluid, and then
 applying 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 feces were under  the power of the will, &c.   Hav-
 ing  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 oppor-
 tunity of trying  what would be the  effect  of evacuating  the swelling
 by means  of a very fine-pointed instrument, and  by subsequent  pres-
 sure 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  two 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 away,  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 confine 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 ap-
 pearance  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

           1 Traite" de Mai. Chirurg., 1779, vol. ii.
           2 Seance pub. de la Soc. Roy. de Paris,  Dec. 9, 1779, p. 32. 
           INTRA-UTERINE  OR CONGENITAL DISEASES.        81

wrinkled;  a roller was  again had  recourse to;  a card was  put  ovei'
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 coagu-
lable lymph was considerably 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 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.2
   The operation by puncture has  been several times performed since.
Dr. Sherwood tried it and failed.3  Otto punctured  a tumor in a child also
affected with hydrocephalus, and the tumor disappeared, but the child
died three weeks afterwards.4  Pliny-Hayes lost  a patient in two days
after a single puncture.5  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 per-
formed 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.
   I have also tried puncture with direct and lateral  compression  with-
out success.
   Still, small as the chance is, it would appear that,  of all the methods
proposed, the most feasible is compression alone or combined  with acu-
puncturation.
   AIM. Robert, Rosetti, and  Ruggretin have  successfully used punc-
ture with compression.
   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  inflamed,
and  the child became  irritable and restless; but these symptoms 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.
   Dr. Kevins mentioned at the Liverpool Pathological Society, three
cases in which puncture had been tried.  One case was cured,  the gen-
tleman being  now 40 years of age;  the second died,  and the third was
quite well at the end of three  or four months with the sac contracted.6
Dr. liana, of Illinois, has related a case in  which  spontaneous rupture
of the sac took place after measles, and the child recovered (Amer.
Med. Journal, Oct. 1850, p. 551).

  1 Med. Chir. Trans., vol. ii. p. 326.  2 Surg. Diet, p. 1173.
  3 Med. Repository, 1812, vol. i.     4 Ollivier, Mai. de la Moclle Epin., vol. i. p. -06.
  5 Braithwaite's Retrospect, vol. ix.  p. 240.
  6 Loud. Medical Gazette, Jan. ItijO.
       6 
82
CEPHALHEMATOMA.
                       CHAPTER  II.

        CEPHAL^MATOMA—FRACTURES OF THE CRANIUM, ETC.

  99. The  tumors which are observable on the  head of  the  infant
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 discharged,
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 inclosed is observed  to swell, and become more
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 direction 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 posi-
tions 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 posterior
part, including more or less of the  tuberosity.
   In the third position,  I  have found the primary tumor more an-
terior, or nearer to the anterior  angle of the left  parietal  bone, than
the  posterior, but owing  to  the  change from  the  third  to  the se-
cond position, which the head makes in its  transit  through the  cavity,
the  secondary tumor  is  extended posteriorly  over  the  greater  part 
CEPHALHEMATOMA.
83
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
towards the left ilium, "there forms," says NaegeJe,1 "a swelling, first
upon the  upper part of the right half of the face, which in this species
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-colored  mark (the result
of  pressure) than by a defined swelling.
   100. AVe may now turn to the examination of these  tumors them
selves,  their  nature,  pathology,  and  treatment, and  it  will be  seen
that they are by no means so simple  or so uniform as might be sup-
posed.  The simpler ones arc by far the most frequent, in fact  it is
seldom that we  meet with the cephalsematoma, 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 beneatli  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 treatment 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.
  II.  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 bloodvessels,  or to both.   In such  cases we  find
the scalp  unusually vascular, with  small ecchyraoses  on  its surfaces,
especially the inner.  In some cases  I have also observed small ecchy-
moses 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

                1 Mechanism of Parturition, Trans., pp. 77, 78. 
84
CEPHALHEMATOMA.
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.
   in. The third  variety of tumor is the sanguineous, or  cephalaema-
toma, as they are called by Naegele" and others.   The first writer who
distinctly described these tumors was  Michaelis;1 he was followed  by
Naegel^,2 Zeller,3 Hcere,4 Schwarz,5 Golis,6 Osiander,7 Chelius,8 Henke,9
Rau,10 &c, Moscati and Palletta;11  and from the facts published  by
these authors, the  Memoirs  of  MM. Pigne12 and Dubois13 were written.
M. Halmagrand, in his edition of Maygrier,14 and M. Velpeau,l3' 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 " interne" at the
Hopital des Enfans Trouve's, in Paris.16
   The simplest and most general of these  tumors,  which are essentially
of the same nature, is, according as  the blood is effused  immediately
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 CEPHAL^EMATOMATA.

  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 Naegel& nor Zeller allude
to it.   It has been described  by Baudelocque,17 Velpeau, Dubois, &c.
The  blood is effused  immediately underneath the cranial integument.
In most cases it is probably owing to the  violence of  the  labor, and
sometimes to  external  violence.  In  most  cases  it is  promptly dis-
sipated.

  1 Ueber eine eigene Art von Blutgeschwiilsten, &c.—Loder's Journal, vol. ii. cah. 4.
1804.
  2 Erfahrungen und Abhandlungen, &c, p. 247.  1812.
  3 Thesis, Comment, de Cephalsemate.  1822.
  4 De Tumore Cranii rec. nator. sang.  1824.—Siebold's Journal, vol. v.
  5 Siebold's Journal, vol. vii. part 2, p. 440.
  6 Pratische Abhandlungen, &o.             7 Handbuch der Entbindungskunst, &c.
  8 ManueldeChirurg.  (Trans.), vol. ii. p 186.  9 Kinderkrankheiten, p. 148.
  10 Handbuch der Kinderkrankheiten, p. 78.
  11 De Abscessu sang, capit. mediol.  1810.    I2 Journal Hebdom.  Sept. 1838.
  13 Nouv. Diet, de Me"decine, vol. vii. p. 88.    14 Page 551.
  15 Traite" des Accouch., p. 510.  Ed. de Bruxelles.
  16 Mai. des Enfans, p. 495.
  17 Art. des Accouch.,  part i. ch. ii. sect. 11. 
CEPHALHEMATOMA.
85
                 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.1  M. Dubois, during a number of
years at La Maternity (where from 2500 to 3000 children are born an-
nually), has seen but  six cases.  Dr.  Doepp, of St.  Petersburg, 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. Valleix2 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
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.
  I  have, however, seen one  remarkable case in which, after a short and
easy labor, a tumor formed on each tuber parietale, and on being punc-
tured, a small quantity of thick dark blood escaped, and then the scalp
assumed its natural condition.  I am quite at a loss how to explain the
production of the double tumor.   The second stage was  completed in
ten minutes, and it was the patient's seventh child.
  The size of these  tumors varies from  that  of a  small nut to  a
swelling  occupying the  whole parietal  bone.   In the case of double
tumor,  related  by Mr. 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 cedematous;3  and  still more rare is it  to find a pulsation in
the tumor,  although  Naegelt, states that  he did so in  two  or three
instances.

  1 Diet. (L> Med., Art. Cephnlrematonie.         2 Mai. des Enfans, p. 500.
  3 Valleix, Mai. dc- Enfans, p. 5U2. 
86
CEPHALJEMATOMA.
   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 attri-
butes  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.1   Mi-
chaelis states that  the bony circle  may be felt from  the commence-
ment of  the tumor;  but in this  he is not borne out  by the researches
of Naegele, Zeller, Hoere, 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,2 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 commencement of the formation  of  the tumor, but that
it  is  a  subsequent production.   It  is very perceptible to the touch
when found, surrounding 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 fluctu-
ation 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 volume 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.3   And yet the differ-
ential symptoms are sufficiently marked, for in cephalsematomata there
is  always fluctuation, which  is not present in hernia cerebri: in  the
latter there  is always pulsation, but  never  in fully-formed cephalajma-
tomata, and very rarely indeed even at the beginning.  In hernia cerebri
the perforation in the skull may always be felt, whereas in cephalgema-
tomata by a little care we can always (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 cephalffimato-
mata ; and lastly, cephalsematomata almost never form upon the sutures,
whereas  this is  the  most frequent seat  of hernia cerebri.  In a case

  1 Valleix, Gaus>nH.—Presse Med., 1837, No. 54.
  2 C^hul. sous-pericran.—Ibid., No. 39.   3 Mem. de l'Acad. de Chir., vol. v. p. 47. 
                        CEPHALHEMATOMA.                      87

related by Fried, hernia cerebri occupied the occiput, and a sanguineous
tumor each parietal bone.1
  As Dubois observes, there is no danger of confounding cephalsema-
tomata with hydrocephalus externus, and the osseous circle will distin-
guish them from the aqueous cysts mentioned by Zeller.  Hcere 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 con-
siderably ; 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 speedily
dissipated.   The  sub-aponeurotic cephalaimatomata  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 cephalaematomata, the coexistence of which would, of
course, embarrass the diagnosis.
                   SUBCRANIAL CEPHALHEMATOMA.

   103.  This variety is extremely rare.   Hoere was the first to describe
it,2 and since then MM. Moreau and Dubois3 have detailed each a case.
M. Baron states that he has seen several;4 and M. Padieu showed to
M. Valleix  the parietal bone of an infant, which  had been the seat of
one.5  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 cephalsematoma, 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 walnut
originally, but it extended so as nearly to cover the right parietal bone.
On dissection the  tumor was  found filled with coagulated  blood, under-
neath which was " a semicircular layer of dense, reddish, fibrinous exu-
dation,  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 sur-
1 Extract, de Thesis de Haller, vol. i. p. 110.
s Diet, de Med., Art. CephaUcmatouie.
5 Mai. des Enfans, p. 512.
2 De Tumore Cranii, &c.
* Ibid. 
88
CEPHALHEMATOMA.
face 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."  "Between 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."1
   Dr.  West thinks, and I  believe  correctly, that the fracture occurred
during labor, although it was quite natural and  easy.   Such occurrences
have been noticed by D'Outrepont, Carus, Hoere, and Danyau.   They
are still more likely, and more easily explained, when the pelvis is nar-
rowed  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
cephalhematoma, 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 always  unin-
jured.   The pericranium preserves its  transparency, and through it is
perceptible  the deep color of the effused blood.  M. Dieffenbach2 has
noticed a thickening of the pericranium, which is confirmed by M. Val-
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 of  the
bone is necrosed, carious, and destroyed, and  that the injured vessels
of  the diploe  give  rise to the hemorrhage.   Naegele, Zeller, Hcere,
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, accord-
ing as the process of ossification is more  or less  advanced.   Its height

            1 Transactions of Med.-Chir. Soc, vol. xxviii.
            2 Abscessus Capitis Sang. Neonat.—Bust's  Magazin, 1830. 
CEPHALHEMATOMA.
89
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 sur-
face.
  "it. In proportion as the effused blood is absorbed, the ossified  peri-
cranium approaches the cranium, and at length is united to it.
  "ill. After  six months, or even a year, we may still remark an ele-
vation 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 simpler forms
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  cephalhematoma, and will generally suc-
ceed.   Even the sub-pericranial tumors may be dissipated, according
to Golis, Rau, Ilalmagrand, 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  esta-
blishes 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.   Lbwenhardt recommends puncture with  a trocar, and
strapping.   By far the  simplest mode, however, is to make an incision
with a bistoury, sufficiently ample to evacuate  the contents of the tumor;
and by most writers this plan is preferred.   The wound may be 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.  Schbller, 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.
1 Art. des Accouchernens, p. 512, 
90           IRRITATION OF THE NERVOUS  SYSTEM.

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 destruc-
tion  of the  frontal bone was less  considerable, 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.
                 CHAPTER  III.

IRRITATION OF THE  NERVOUS SYSTEM.—TRISMUS NASCENTIUM.
                       NERVOUS IRRITATION.

  108. When we consider the delicate structure of the brain in infants,
the great vascular  action  going on  therein,  the  influence  reflected
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 irri-
tation 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 wakeful-
ness and a keen  sensibility to slight impressions, much restlessness, and
rather more animation  than usual.  In severer cases these  symptoms
are aggravated;  the infant sleeps very little, and  is  awoke  by the

                 1 Mcdicinische Zeitung, September 22, 1841. 
IRRITATION OF THE  NERVOUS  SYSTEM.           91
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 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 together, and  the least
noise disturbs it.  The arms are tossed about, and the lower limbs fre-
quently 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, 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 roll-
ing or turning upward with an occasional wide stare; the child is rest-
less, 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  and 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  spontaneously 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 hea-
viness 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 physi-.

  1  Practical Remarks on disordered States of the cerebral Structures, occurring ia
Infants, p. 10.  1S2J.
  2  Diseases of Woman, p. S57. 
92           IRRITATION OF THE NERVOUS SYSTEM.
cian 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 remarks that it is
colder than natural; in some cases there is at  times a slight and tran-
sient flush; the bowels I have always seen already disturbed by purga-
tives, 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 symptoms.   The cases which I have  seen have been
invariably attributed  to congestion of the brain, and the remedies em-
ployed 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,
however, I have seen, during the last few hours, symptoms of oppressed
brain, as coma, stertorous breathing, and dilated, motionless pupil."  Dr.
Marshall  Hall has also described a similar form of disease, attributing
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  distin-
guished from  the  coma which accompanies diseases of the brain.   It
attacks  them  after some continuance of exhausting diseases,  such as a
tedious  and neglected diarrhoea; and the patients lie in a state of insen-
sibility, the  pupils  dilated, the eyes open and insensible, the face pale,
and  the pulse  feeble.   It may continue  for a day or two, and  terminate
favorably, or it may be fatal."1
   Dr. Whitney, in a valuable paper on  cerebral  auscultation, mentions
that in  such cases he has detected a bellows-sound in the arteries of
the head, with a rasping, chirping  sound occasionally; and he  regards
these sounds, in combination with the anoemic condition of the patient,
as characteristic of the disease.2
   I  have  not been  equally successful in hearing these  sounds, nor  in
deciding  upon the value of cerebral auscultation.   Perhaps  further
investigation may throw some light upon the subject.
   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
 mportance.
   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,

            •  Diseases of the  Brain,  p. 310.
            * American Journ. of Med. Science, Oct. 1843, p. 318. 
IRRITATION  OF THE NERVOUS  SYSTEM.           93
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 nervous
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, projecting 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  proportioned to the
amount we wish to take away; and, in the following pages, when speak-
ing 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, if that  be unnecessary,  sponging the head with
cold  water, or a cold  lotion, and a warm  foot-bath at  bedtime, 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 attempting
to correct the secretions; and I have found for this purpose the follow-
ing simple mixture of great use.  The proportions are, for a child of
twelve or fourteen months old,
               R—.Mucilag. acacise,
                   Syr. zingib., Ha gij.
                   Tinct. opii, gutt. j to iij.
                   Aquas carui vel anisi 5J.—M.

A teaspoonful may be given every three or four hours until the bowels
are quieter, and then at longer intervals; or we may substitute tincture
of hyosciamus for the laudanum.   When the bowels are steady, the mer-
cury  with chalk,  with the  addition,  if necessary, of a little compound
powder of chalk,  may be given; or, instead of the gray powder, minute 
94
TRISMUS NASCENTIUM.
doses of calomel—say one-sixth of a grain.  The diet should consist of
milk, thin  arrowroot,  panada,  &c, without stimulants;  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, nicely
made beef-tea, or beef-gravy, must  be given  frequently, but in small
quantities;  and,  after a time,  a little wine  whey  or  wine  and water.
Ammonia,  ether, bark, or  some other tonic,  will generally be found
useful.  If  the bowels are  irritable, some  soothing 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 irritation,
seems peculiar to hot climates, to certain localities  in  more  temperate
climates, and to vitiated atmospheres.  It is  frequent  in Jamaica and
the West Indies, according to Dr. Evans and James Clarke,1 in Cay-
enne, 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 situated close
to the river,  and very damp;  so  far bearing out the truth of Mr. Sau-
vage's  observation,  " hie  morbus hieme, et cum  aura humida advenit
quam sicca  a3state."3  It only occurred  once in the British Lying-in
Hospital in many years ;4 and Capuron mentions that he once met it in
Paris.5  M. Maturzinski has recorded that, in the  Hospital of Stutt-
gard, from 1828 to 1835, among 848 children, there were  25 cases of
trismus, or about 1  in  34.a   In a letter  to the editors of the New
Orleans Medical and Surgical  Journal for May, 1846, Dr. Wooton
states that it is  of fearful frequency in the cotton  plantations in Ala-
bama.   He  believes that it destroys more negroes  than  any other
disease, always  proving  fatal; but he has never  seen a  white child
attacked.7  In private practice, it is rarely  met with, even amongst the
poor; so that, of the writers who have  noticed  the  disease, very few
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

  1 On the Yellow Fever, 1797.
  2 Edinburgh Medical and Surgical Journal, vol. vii. p. 225.
  3 Nosolog. Method., vol. i. p. 531.
  4 Underwood on Diseases of Children, p. 280.                 6 Vol. iii p 451
  6 Gaz. Med., 1887, p. 338.
  7 Transactions of the College of Physicians of Philadelphia, 1847, p. 115. 
TRISMUS NASCENTIUM.
95
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  ej^es,  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 some-
times 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 convulsive
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 com-
mencement, so as  to prevent the action of sucking and swallowing ; and
any attempts to wet the  mouth or fauces, or to  administer 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 circum-
stance,  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."1
   There is a milder variety, to which the nurses give the name of " white
fits," in which the convulsive  movements of the extremities are less
violent,  the paroxysms  less frequent,  and the power of sucking 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 umbilical
cord fall off; and  both  are distinguished from other varieties of con-
vulsions by the permanent difficulty or impossibility  of swallowing,
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 negroes in Jamaica;

            1 Transactions of the Enyal Irish Academy, vol. iii. p. 92. 
96
TRISMUS NASCENTIUM.
Dr. Underwood to impure air.   Dr. Joseph  Clarke enumerates three
especial exciting causes of the disease: first, impure air; second, neg-
lect 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 remarkable 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 19J.  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 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. Pathology.—It is much easier to determine the predisposing
and exciting  than the proximate causes.   Different  opinions  have been
held by different  practitioners of  high estimation  as  the following sum-
mary will show.  The late Professor Colles attributed trismus to inflam-
mation 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  dissected from
three to six  subjects who have fallen victims to  this disease."2   From
fifteen to thirty post-mortem  examinations constitute evidence very well
worthy  of attention ;  I  shall, therefore, extract  his  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 for-
ceps, 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 new membranes which are formed  by suppurative
inflammation.  In  some few instances, the fundus  of this cavity pre-
sented evident marks of  superficial ulceration, 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 inflammation; 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 umbili-
cal arteries appeared to  be still more inflamed,  an appearance  which
extended often as far as the sides of the bladder.   Besides the appear-
ance of  the  peritoneum along their posterior surface, the cellular sub-

  1 Practical Treatise on Midwifery, p. 514.  * Dublin Hospital Reports, vol. i. p. 286. 
TRISMUS NASCENTIUM.
97
stance 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 inflammation, yet the coats  of the vein altogether were very much
thickened.  The  umbilical arteries exhibited evident marks of inflamma-
tion : first,  on slitting them up, a  thick, yellow fluid, resembling coagu-
lable 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 inflammation; 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  appearance of ulceration on  its
margins; and  all the edges of the  extremity 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 vessels into the soft substance."1
   In the year 1819, Dr. Labatt, then Master of the Lying-in Hospital,
published a paper2 to refute  Mr. Colle's views,  in which he gives memo-
randa 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,3 coin-
cides 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."4
   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.5

  1 Loco citato, p. 280.            2 Edinb. Med and Surg. Journal, vol. xv.  p. 216.
  3 Dublin Journal, vol. viii. p. 548.  4 Practical Midwifery, p. 516.
  5 Gardien, Traite dei Accouch., vol. iv. p. 214. 
98
TRISMUS NASCENTIUM.
   Dr. Wooten made careful investigations on this point, but could come
to no definite conclusions.   The pathological  phenomena he observed
were  general peritonitis, and  the  portion surrounding  the entrance 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.
   119.  M.  Ollivier, in his excellent  work on diseases  of the  spinal
marrow, states that he has no doubt that  trismus is in many cases iden-
tical with tetanus from hemorrhage into the spinal canal; and he refers
to a case of Dr. Abercrombie's, of an infant six days old, 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
   Dr.  Evory Kennedy has contributed another  case,2 and  Professor
Doherty two cases, in which sanguineous  effusion was found  to a con-
siderable  extent in the spinal canal, and especially  into the cellular
tissue surrounding the dura mater.3
   M. Billard, without pronouncing a positive opinion, mentions that
he had  seen but two cases  of this disease, and that in both the only
pathological  condition was an  effusion of blood  into the spinal arach-
noid 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.4
   The results  of post-mortem  examinations made by Maturzinski  are
stated  as  follows: Out  of twenty cases, he found in sixteen a semi-co-
agulated fluid in the spinal canal between the  dura  mater and the ver-
tebrae; 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 places, 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
two exceptions, perfectly healthy.5  He agrees  with Mr. Colles in attri-
buting the disease to the condition of the  umbilicus after the fall of the
funis, aided by the action  of cold.
   Dr. Sims,  of Alabama, has published three  very valuable papers on
this disease, which I am sorry I omitted to notice  in the former edition.
His conclusions differ widely from those of the authors  I have already
quoted.   He considers that trismus nascentium "is the result of mechan-
ical causes;  the predisposing being protracted or tedious labor, but par-
ticularly a too well ossified state of the foetal cranial bones.  The exciting
cause is undue pressure on these bonos, more especially on the occiput;
while the immediate cause  is undue compression of  the medulla oblon-

  1 Traite" des Maladies de la Moder Epincire, vol. ii. pp. 106, 136.
  2 Dublin Journal, vol. vi. p. 467.      3 Dublin Journal, vol. xxv. p. 75.
  * Mai. des Enfans, p. 689.           s Barrin, Mai.  de PEnfance, vol. ii. p. 478. 
TRISMUS NASCENTIUM.
99
gata, and the nerves  originating from it."1  The cases  he divides into
two  great classes,  in one the occiput being displaced  inwardly,  with
its edges overlapped by those of the parietal bones; in  the other the
occiput occupied its natural position on the  outside of these bones, but
pressed upwards by the  mode of decubitus, which in the latter was  on
one  side  or the other;  but in the former on the back,  or in the semi-
lateral  position.
   In Dr. Sims's first paper he considered that this inward displacement
of the occipital bone gave  rise to congestion, and then rupture of ,the
minute spinal veins;  and the post-mortem appearances  in several cases
seemed  to justify  the conclusion ;  but in  the latter paper he has given
up this opinion, and now considers the condition produced  by both kinds
of displacement to be  pressure  of  the pons  and medulla  oblongata
against the cuneiform process of the occipital bone, and that "the  fifth,
seventh, eighth, ninth pair of nerves are compressed, pinched, stretched,
or thrown into folds, near their several points of convergence from the
cranium ;  and he takes  great pains to show how the various  symptoms
would result from such pressure.   The best  argument Dr. Sims adduces
is the success of his  treatment, of  which I shall speak hereafter.
   120.  Thus we find, 1. That in certain cases presenting symptoms of
trismus there is effusion of blood or serum in the spinal canal.
   2. That in  similar cases there  have been found traces of  inflamma-
tion, or its results.
   3. That in some cases, according to Dr. Sims, pressure upon certain
parts of the cerebro-spinal system gives  rise to symptoms of  trismus,
which are relieved by taking off the pressure.
   4. That, in the opinion of many careful observers, the condition of
the umbilicus,  after the fall  of  the  cord,  has an evident connection
with the production of the disease.
   5. That some cases  seem referable to  irritation of the mucous sur-
faces.
   6. That dampness, impurity of the atmosphere, cold,  alterations of
temperature, &c, have  a very direct  agency in  the production of this
disease, as is proved by the situations in  which it prevails, and by the
success of Dr. Joseph Clarke's preventive treatment.
   Professor Busch, of Berlin, and Dr. Levy, of  Copenhagen, attribute
the attack to  inflammation of the umbilical arteries ;  and  the  latter
 gives six cases with dissection, in  confirmation of this  opinion ;  in  all
 there was discoloration  and  suppuration  of the  coats  of the  arteries,
 and  in  some the coats were destroyed, but  the division did not extend
 up to the point where the umbilical unite with the hypogastric arteries.2
   Now, instead of trying to reconcile these differences  of opinion, and
to discover one cause for all cases, it appears  to me  much more philo-
sophical  to admit that there may be  several which may give rise to the
same symptoms.   Those conditions  which  I have first communicated
may be divided into  centric and eccentric causes, and are very intelli-

   1 American Journal  of Med. Science, for April, 1846, July, 1848,  and October, 1848,
p. 302.
  * Brit, and For. Med. Review, vol. x. p. 275. 
100
TRISMUS NASCENTIUM.
gible when  explained by the  discovery of Dr.  Marshall  Hall.   The
irritation from these various sources is  conveyed by the excitor nerves,
and its effects upon the spinal system are reflected by the motor nerves
to the organs  affected in the disease ; but there is nothing  which could
lead us to suppose that these  effects must result from one local cause
only.
   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.
   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 exhi-
bited 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  turpentine,
tincture of soot, assafoetida, and many  of the ordinary purgatives  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, Pro-
fessor Colles advises that our attention should be directed  to the  um-
bilical cord.  He  mentions  that he  had  been informed that  in  Ja-
maica, 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 in-
fant  daily into a cold bath, and daily to dress the umbilical cord  with
spirits of turpentine.  He suggest  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  of 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 hap-
pens after the third dose; then the mixture is given less  frequently.
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 intermediate
doses of castor oil, in the quantity of a large-sized  teaspoonful, some-
times joined with a third part of  spirits  of turpentine, which appears
to me to quicken  the action of the former.  I also occasionally order
three ounces of the  assafoetida clyster of  the Dublin Pharmacopoeia
to be thrown up the rectum."   Under this treatment the  paryoxsms 
TRISMUS NASCENTIUM.
101
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  in-
creased ; 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 inter-
nally, and counter-irritants.
   Dr. Schneider recommends a compound tincture of musk and amber-
gris as having  been of great use.  The following is the formula em-
ployed in the hospital at Bamberg:—
                  R.—Ambr. gris. 3J.
                     nEther. vitr. gss.
                  Stet per hor. xij ssepe agitando, dein adde,
                     Mosch. gj.
                     Liq. anod.  Hoffm. ^iij.—M.'
   Mr. Chalmers mentions that he had succeeded in one  case by a com-
bination of rhubarb and musk.   Barere and  Bajon tried warm douches
and cold baths, embrocations, oil  of  almonds, and syr.  diacod., but  in
almost all cases were unsuccessful.
   Mr. Furlong succeeded in one case by giving at first a drop of lauda-
num three times a day, and a warm bath four times a day, dressing the
navel with turpentine and mercurial ointment, blisters to  the nape of the
neck, and two grains of Dover's powder with five grains  of the sulphate
of  zinc.2   He attaches much value to the zinc, but with such complex
treatment  it is quite  impossible to say to which remedy we are  to
attribute the success.
   My friend Dr. M'Clintock suggests,  and I think with sound reason,
a trial of the tincture of the Indian hemp in this affection.   He has tried
it in a limited number of  cases, and it seemed to lessen  the severity  of
the fits, and retard the progress of the disease.
   In order to remedy the  pressure produced  by the occipital bone when
displaced inwardly, Dr. Sims places the child on its side fully on a pil-
low, and he states that the relief is obvious in  most cases, but when  in-
effectual, he recommends  that  the top of the bone should  be elevated
and placed in its proper position outside the parietal bones.   When the
displacement is outward, the child should be  held erect as much  as pos-
sible, and when laid down placed in the post-parietal  position.   I  have
no  reason to believe that displacement is as frequent  in those countries
as Dr. Sims found it in America, but it is impossible to read his cases
and doubt either that they were trismus, and that they were relieved if
not cured by the relief from pressure afforded by the change of position.
   These, I think, are the principal modes of treatment, and very sad it is
to think how ineffectual they generally are.   The principles we should
ever have in view are to  direct our attention  to  the exciting cause  of

  1 Edin. Med. and Surg. Journ., vol vii. p. 225.         2 Ibid., vol. xxxiii. p. 57. 
102
CHOREA.
the irritation, and remove it if possible, and next to apply all our efforts
to calm the irritation already excited.
   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 an 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 overcrowd it, is also necessary.  In the Western Lying-in Hospital,
to which  I have been many years  attached, the disease  is almost un-
known.
   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.

  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, occurring 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 exam-
ple, 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 observes
in his preface; " its name  is ridiculous, its symptoms singular, its cha-
racter equivocal, its  cause  unknown, and its treatment problematical."
The definition given  by Dr. Copland, in the learned  article in his Dic-
tionary, to which I have  been much indebted, is  the following: " Trem-
ulous, 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. 
CHOREA.
103
  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, llorstius, 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 America.
  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 extremities,
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 stam-
mering1 may in fact  be a local species of chorea, and  also  those  cases
of incessant winking or twitching of the nose or mouth, 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 ordinarly 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 motion,  and closed with unusual force.
  Stiebel has noticed this winking, as a modification of chorea, and he
mentions  also sneezing, rolling of the eyes, and a curious affection of the
organs  of speech, so  that on awaking, the  patient kept continually
uttering a peculiar cry.   Occasionally the hearing is affected, the child
fancying  that it constantly heard certain sounds.  These local affec-
tions may exist singly or  along with the more general affection.
  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  ; control  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 sideways  by the spasm,
he moves  it backwards and  forwards, till at length, the glass  accident-
ally  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

                1 Casper's W'ochenschrift, 1837, No. i.
                2 Sydenham's Works, by Wallis, vol. ii. p. 430. 
104
CHOREA.
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
other shoulder, or  agitated with  a rotatory 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 backAvards  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 perpendicularly  upwards ; as soon  as her
feet gained the perpendicular, all muscular action ceased, and her body
fell as if dead,  her knees first striking the bed, and her buttocks striking
her heels; this was  no sooner  done  than  she instantly mounted up  as
before,  and continued these evolutions,  sometimes for fifteen  hours
successively, at the rate of from twelve to  fifteen times in the minute.3
  In mild cases of chorea, the irregular movements  cease during sleep;
but, when the attack is very severe, they do not  cease entirely.4
  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
occasionally moved  involuntarily during  a  paroxysm.   Dr.  Copland
states that the bowels  are  always constipated, and the abdomen some-
what  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 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.   Out of more  than one  hundred

            1  Rilliet and Barthez, vol. ii. p. 297.
            2  Archives G6n. de MeU, 1834, vol. iv. p. 239.
            3  Condie on Disease of Children,  p. 460,  fourth edition.
            4 Stewart on Diseases of Children, p. 496. 
CHOREA.
105
cases, M. Stiebel did not find one where there was not spinal irritation
evidenced by tenderness in one or more vertebras.
   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 idiotcy; but M.
Rufz has related  two cases in which it did; and certainly  the appear-
ance of some chronic cases gives  one the impression of their being very
little removed from that 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 hemi-
plegia; and Condie mentions that  they  are sometimes carried  off by
tubercular meningitis ;J but this  can only be considered 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 sta-
tionary for a time, and at length  gradually subsiding.  Its duration
varies  from  two or three weeks to several months.   The quickest reco-
very 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. Dufossd 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 became 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,  with a con-
siderable increase  in  stature  generally;  but it may also end in convul-
sions, epilepsy, palsy, anaemia, dropsy, hydrocephalus, or idiotcy;2 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 importance,
and  deserve most  careful  investigation, particularly in the diseases of
children ;  for they are often  masked by the primary disease, and yet
are  occasionally the more fatal.   On this account, I shall endeavor to
lay before my readers these secondary attacks as accurately as I can,
without deciding whether they are mere accidental complications, 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
very much the appearance of the latter; and there will also generally

                1 Diseases of Children, p. 455.
                2 Copland's Dictionary of Medicine, p. 328, 
106
CHOREA.
be found  some irregularity in the menstruation : it is  either scanty,
light-colored, irregular, or altogether absent.   "The following proces-
sion  of morbid phenomena  is  not uncommon," says  Dr.  Copland.
" Chorea, with  defective action  of  the digestive,  assimilating,  and
secreting functions, and torpor of the liver; at a subsequent term,  pro-
tracted catamenia, or scanty and protracted appearance of the secretion,
occasionally with various hysterical affections,  seldom  amounting  to a
complete fit of hysteria; and, lastly, when the catamenia become esta-
blished, the hysterical affection  is sometimes more fully pronounced,
and with the regular establishment of the uterine functions the chorea
disappears."1
  Dr. Copland was the first to demonstrate by post-mortem examination
its complication with  rheumatism, rheumatic pericarditis,  and disease
of the membranes  of  the spine,  and  his observations have since been
confirmed by Drs. Pritchard, Roeser2 and Nairne,3 Trousseau,  Begbie,4
Kirkes,5 &c.
  Congestion  of the brain, inflammation of its membranes,  with serous
effusion, tubercular meningitis, &c, have been detected by Soemmering,
Browne,  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 opinion exists as to their
influence  upon the original affection.   M. Rufz says that  "they exer-
cise no influence upon  either the duration or intensity 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 diminished from the com-
mencement;  in others it increased at first, and afterwards disappeared.
They cite four cases from Legendre, Piet, and Rufz, in which  measles,
scarlatina, and smallpox occurred, and the chorea was cured.0
  130. Pathology.—The post-mortem  appearances  which are recorded
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 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 pancreas ; Drs. Copland,
Pritchard, and Roeser, adhesion of the opposite surfaces of the pericar-
dium,  with  effusion of serum.  In one case  Dr.  Pritchard observed
the surface of the heart covered in  parts with coagulable lymph, its
cavities much  enlarged, and their  parietes thin, pale, and flabby.  Dr.
John Ware  has related a case in which, after the pericarditis had lasted
some little time, symptoms of chorea displayed themselves  forty-eight
hours before death.7
  Soemmering, Brown, Coxe, Willan,  Patterson, Guersent, and others,

              1 Dictionary of Medicine, p. 328.           2 Ibid.
              3 Lond. Journal of Med., January, 1851, p. 91.
              4 Ed. Monthly Journal, Jan.,  1852, p. 363.
              5 Med. Gazette, 1850.
              6 Mai des Enfans, vol. ii. p. 303.
              7Amer. Journ. of Med. Science, April, 1850. 
CHOREA.
107
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 tuber-
cular quadrigemina, and in one a tumor resting on this part of the brain.
MM. Monod  and Hatin observed hypertrophy and  vascularity 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 membranes, 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 subse-
quently to the  membranes of the spinal cord, inflammatory appearances,
with coagulable lymph and  an effusion of  turbid serum,  Avere found
through nearly the whole extent  of  their  membranes ;   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 Gendrin,
&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,8 as in two cases of M. Gendrin,
one of M. Courtois, and three or four of M. Rufz.3   Mr. Coley  has also
recorded the appearance of medullary meningitis, with softening.4  Dr.
Nairne  has recently  stated that he  had   seen  four cases in which
softening  of the  spinal  marrow  had been  found  in conjunction with
 chorea,  but he did not think that the  softening  was the cause of  the
 chorea.
    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 cere-
 bellum, &c.  But we must carefully guard against the error of mistaking
 complicated forms of the disease  for  essential examples 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  dis-
 covered ;  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  normal;

        1 Diet, of Pract. Med., p. 329.       a Mai des Enfans, vol. ii.  p. 314.
        3 Barriere, Mai de l'Enfance, vol. ii. p. 434.
        4 Diseases of Children, p. 447.
        6 Diseases and Derangements of the Nervous System, p. 195. 
108
CHOREA.
the true spinal action is abnormal.   The action is abnormal or irregular,
for want of a precise harmony between the two."   Probably the explana-
tion given by Dr. Copland is as correct as any; he states that "the proxi-
mate  cause of chorea, in its true and  simple form, seems to  consist of
debility, with some degree of irritation of the organic 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 frequently  occur, in
which the disorder evidently commences in the spinal cord or its mem-
branes, 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 attacked to
be about three females to one  male.   In 240 cases M. Dufosse" 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  connected
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 hos-
pital registries, which are  not  proverbial  for their accuracy.   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 puberty
may, and probably does, exert considerable influence.
   What effect climate may have is not very easy to determine ;  the  dis-
ease appears  to occur less frequently in southern countries, and in the
West Indies is  altogether unknown.3   Children of a nervous tempera-
ment, 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  certainly  not
confined to delicate children, for many of those attacked by it have pre-
viously enjoyed excellent health.  It may be doubtful whether we ought
to consider chorea as an  hereditary disease, although Coste, Young, and
Constant, have each met an example, and Stiebel has known families in
which every child was attacked at a certain age.

              'Diet, of Pract, Med., p. 331.
              2 Gardien, Traits des  Accouch., vol. iv. p. 269.
              9 Stewart on Diseases of Children, p. 495. 
CHOREA.
109
  133.  According to some authors, e. g., Mezerai, Cullen, and Hacker,
chorea has occurred epidemically.  Albers, cited by Frank, mentions a
school in which it appeared as an  epidemic, and Rilliet and Barthez a
village in the Tyrol in  which it occurred recently.   Dr. Copland has
given an interesting section on nervous disorders resembling chorea; as
the effect of the bite of the tarantula, the leaping ague of Scotland, and
an affection which spread rapidly among a sect of religious enthusiasts
in Tennessee and Kentucky, described by Dr. Robertson, &c.  &c, which
strikingly resemble chorea, and the extensive  prevalence  of which may
have originated the idea  of an epidemic.  Dr. Wicke1 states, that in a
boarding-school at Eisenach the disease spread by imitation ; and it must
be remembered that no disease is more likely to be imitated, and no class
of persons more likely to become imitators, than those who are the fit-
test subjects for chorea.
   Among the exciting causes  are enumerated worms, dentition, fright,
falls,  or  blows, according to  Reeves, Bedingfield, Hall, Ecker, Rilliet,
and Barthez, &c.    Copland,  Ploucquet, and Pritchard, attribute it to
rheumatic metastasis to the membranes of the spinal cord;  Darwin, Hay-
garth, and Richter,  to mental exercise, emotions, or passions.
   134.  Diagnosis.—The pathognomonic characters of chorea are, per-
manent,  chonic, and, to a certain extent, voluntary movements, irregu-
lar in direction and amount; their cessation during sleep ;  the conscious-
ness and sensibility of the patient;  and the age at which, and the mode
in which, the disease commences.   It is just  possible that choreamay
be  confounded with hysteria, convulsions, paralysis,  and delirium  tre-
mens.
   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 unknown.
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 involuntary, and gene-
rally accompanied with globus hystericus, laughing and crying, and pale
urine.
  n.  In convulsions the movements are spasmodic, entirely involuntary,
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 convul-
sions, the patient is, for the most part, unconscious  and insensible.
   in.  When chorea is confined to one portion of the body—for instance,
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  opinion; and
when more of the body is affected,  the preservation of sensibility, and,
to a considerable  extent,  of motion,  voluntary and involuntary,' will pre-
clude the possibility  of supposing the case  to be paralysis.

              1 Analekten der Kinderkrankheiten, Pt. viii. p. 89. 
110
CHOREA.
  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 favourable, although Rufz and Rilliet and
Barthez have recorded two cases which terminated fatally.
  But when it is complicated with rheumatism, inflammation of the mem-
branes  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.   According 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 Cop-
land's Dictionary.
  The  indications of treatment must be founded  on a careful  study of
each case, its characters, complications, &c.   The  first indication in
simple chorea will be to remove fecal accumulations, and to  correct any
morbid  condition of  the intestinal  canal; the second, to relieve nervous
affections;  and the  third, to subdue the complications, 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
may be  given at first, followed, at intervals, by infusion of gentian and
senna, or by an occasional dose  of castor oil and turpentine.   The fre-
quency 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, narcotics,
and tonics, are recommended.  Valerian was first employed by Bouteille,
and since by Murray, Guersent, and Jadelot, with  success; assafoetida
has  also been found useful.  Oxide of  zinc, gr. iij to gr. v, three times
a day, originally given as a quack  medicine in this disease, has been em-
ployed  by Duncan,  Fouquet, La Roche, Wright, &c.   Should it irritate
the stomach, the addition of gr. ij. of the cuprum ammoniatum will cor-
rect it,  as Dr. Odier, of Geneva, has  observed.   Drs. Copland and Ba-
bington 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 pur-
gatives, with great benefit in obstinate cases.   Camphor has been recom-
mended by Worlhoff, Mahon, &c.   Other practitioners have given, suc-
cessfully,-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 valerian, assafoetida,  oxide or 
CHOREA.
Ill
Bulphate of  zinc, &c, and in combination with some tonic, as in the fol-
lowing formula, given by Dr. Copeland:—

                    R.—Pulv. calumbre gr. x.
                          "  valerians? gr. xij ad ^j.
                        Parb. ferri pp. gr.  x.
                        Pulv. cinnam. gr. vj.—M.

   Ft. pulv. vel  elect, molle cum.  syr. zingib. q. s.   Bis vel ter quotidie
Bumatur.
   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.    Mar-
ley 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 obtained
great success from preparations  of iron ;  Elliotson  and Baudelocque
prefer the subcarbonate, and  Bonneau iron filings, in  combination 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.  arseni-
calis;  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;  Hildbreth, of Ohio; Kirkbride
and Professor Wood,  of Philadelphia, and Bradle, of New York,  in fa-
vor 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 wineglassful of  the de-
coction.4
   Dr. Neumeister, of Arneburg,  has published some  cases successfully
treated  by  a combination of the artemisia vulgaris and assafoetida5 with
a small  quantity of the ol.  animale Dippelii and tinct. castorei.
   138.  When the convulsive  movements are violent, incessant, and pre-
vent sleep, there can be no hesitation in  administering narcotics; it is
in such  cases that opium, stramonium, hyosciamus, and belladonna have
been recommended;  but  it will need  great watchfulness and caution if
the latter be  exhibited, especially with  young  children.  I should my-
self much  prefer opiates, as being more steady  and certain 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
water,  is more likely to  be  beneficial.   Baudelocque substituted sul-
phurous baths for simple water, and with good effects.   They were  easily

      1 Med. Chir. Trans., vol. x.                     2 Underwood, p. 285.
      3 North American Med. Journal, vol. ii.
      4 Condie on Diseases of Children, fourth edition, p.  463.
      6 Journal fur Kinderkrankheiten, Jan. and Feb , 1851, p. 19. 
112
CHOREA.
prepared by adding sulphuret of potash to the ordinary bath, and were
taken every day, the patient remaining in the bath half an 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 strych-
nine, ten of them with  complete success.   He employs the sulphate 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 gene-
rally completed in one month."1
   139.  Opinions differ  very much as  to the propriety of bloodletting;
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 bleed-
ing  and purging, with an  opiate  at  night, and  a sufficient  interval
between  each  evacuation to avoid  all  danger.2  Cullen says that it is
sometimes useful, in other cases  injurious.   Watt found it decidedly
useful,  Armstrong injurious; but  Clutterbuck, Bouteille,  Serres, and
Lisfranc, recommend it.
   Its propriety will depend upon the evidences of congestion or inflam-
mation in the  brain or spinal marrow, indicated by pain, increased vas-
cular action, heat of the head, coldness of the extremities, Lc.;  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 extremi-
ties, will be highly proper.
   Believing the disease to result from pressure upon the spinal nerves,
M. Stiebel rejects all  the specific remedies, and applies leeches to the
sensitive part  of the spine, then mercurial ointment, counter-irritation,
and, at a  later  period, cold  shower baths.   If this treatment do not
relieve the  complaint in two or three weeks, he suspends all remedies,
and  prescribes good diet, fresh air,  &c.
   Marley3 mentions that two of his patients who had resisted the usual

            1  Condie on Diseases of Children, p. 464, fourth edition.
            2  Works, vol. ii. p. 431.
            3  On Diseases of Children, p. 111. 
CHOREA.
113
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 mode-
rate, varying according to the  constitution of the patient and  the com-
plications 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
of air and scene, and by the  use of mineral,  aperient, or chalybeate
waters, according to circumstances.   Sea  bathing, with a free admixture
of amusement, exerts a salutary influence.
  140. The complications will  necessitate a change in the treatment.
When rheumatism occurs, Dr. Copland observes, "it has generally been
promoted by too lowering a treatment, but prevented by tonic and sti-
mulating medicines,  with due attention  to the  alvine evacuations.  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 stimulating  sub-
stances—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 suppression of rheumatic affec-
tions  of the  joints,  by the use  of  embrocations and  liniments,  was
rapidly succeeded by the appearance  of internal disease, the application
of such remedies to  the external seat of the rheumatic disorder should
not be resorted to."1
  When chorea  occurs in girls after the age of puberty, and is com-
plicated with hysteria and menstrual irregularity, it will be necessary,
after  evacuating the bowels, to attempt  the regulation of the uterine
functions by hip baths, emmenagogues, particularly preparations of iron,
and perhaps by leeching the upper part of the thighs.
  When chorea is complicated  with inflammation of the membranes of
the brain, or of the pericardium, as these  are far more dangerous, their
treatment will to a certain extent supersede that for chorea.  Antiphlo-
gistics generally, bleeding, of leeches, calomel, and counter-irritation,
will be indispensably necessary, modified in degree by the  state of the
constitution of the  child, by the  stage of the disease, and by the co-
existence of chorea.    Great  care, great watchfulness, and a nice  tact
in the adaptation of remedies,  will  be necessary.  For the method of
treatment,  I would refer the reader  to the chapters treating  of those
diseases.

                     ' Dictionary of Medicine, p. 335.
8 
114
CONVULSIONS.
                         CHAPTER V.

                            CONVULSIONS.

   141.  There are few diseases of  infants and children which are more
formidable  or  more fatal than convulsions.   They attack children of
all ages, of different natural  constitutions, and under  very various
circumstances,  " sous  toutes les latitudes, sous la  zone brulante des tro-
piques,  comme sous la zone glacee de Spitzberg."x
   The disease has been variously classified, and with different meanings
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 consti-
tute the  idiopathic and symptomatic  convulsions of authors.   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,  deranged
bowels, and which 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."2
   I shall, however, adopt the more recent division into : 1, primary or
essential convulsions, arising from irritation  of  various kinds, mental
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 diseases,
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 appearance  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 between
these convulsions and  lesions of the nervous centres."3
   MM. Rilliet and Barthez refer to twenty-five cases of sympathetic,
and thirty-five cases  of  symptomatic  convulsions ; but this apparent

   1 Brachet sur les Convulsions.  1824.   2 Underwood on Diseases of Children, p. 268.
  3 Manuel Prat,  des Mai.  des Nouv. Nes et des Enfans a ia Mammelle, p. 387. ' 
CONVULSIONS.
115
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.1
    25 Casks of Sympathetic
          Convulsions.
At 18 months old there occurred 1 case.
              '       "4 cases.
              <           7   <<
2 years
3  "
4  "
     35 Cases of Symptomatic
          Convulsions.
At 2 years old there occurred 6 cases.
  3   "
  4   "
 9
10
11
9	"
2	a
5	((
2	ii
3	(<
1	case.
3	cases.
2	"
2	a
   Taken  altogether, primary  convulsions are by far the most frequent
during  early  infancy,  and  symptomatic  convulsions  at  a  more
advanced age.
   143.  Causes.—It has been  stated  that female children are more
obnoxious to these attacks than males ;  but this is  very doubtful.  As
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 temperament
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 ;2
but we find convulsions equally prevalent, I think, in temperate, 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 wdio 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 children,  nine of
whom  had convulsions,  and  six  died.3   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
1 Mai. des Enfans, vol. ii. p. 278.
3 Mai. des Nouveaux Nes, &c, p. 392.
2 North on Convulsions, p. 15. 
116
CONVULSIONS.
many cases to feebleness on 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 affect-
ed by the disease.   I have seen a considerable  number 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  Gualtier  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 transmission from
the soft mass to its regular organization, also imparts  a strong predis-
position to irregular nervous action, when an excess of action  occurs, or
any  circumstance  comes  to interrupt the regular  process of gradual
development."1
   144.  The delicate condition of the brain, its transmission  from  qui-
escence 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, nerv-
ous,  sensitive,  and  irritable  children  are more  liable   to convulsions,
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, wdio have  lost blood  from the  navel-string ;  or weak, pale,
delicate children, and those exhausted from excessive discharges.
   A large-sized head has been regarded as predisposing to convulsions
by Desessart, Gardien,2 and 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 ascertaining
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 maybe established as an axiom, that children  born with
large heads, or whose heads increase in  size disproportionably to  the
other parts of their bodies, will have  convulsions.   In  my own practice
I  have seen convulsions occur very frequently  in  children 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  un-
frequently happens, that when some  children of the same parents  are

                1 Stewart on Diseases of Children, p. 483.
                ' Traite des Accouchemens, &c, vol. iv. p. 250. 
CONVULSIONS.
117
affected with rachitis, others, who are exempt from this disease, are at
a very early age destroyed by convulsions."1
   145.  The exciting or occasional  causes  are very various.   Shame,
anger, and fright have been known to induce an attack.  North relates
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 crying.  It has
been attributed to tight bandaging,  a  pin piercing the child,2  excessive
mental  emotion, a loud noise, sudden exposure to a bright light, hot,
impure air, or  severe cold.  Guersent and Blache mention  their occur-
rence in  children confined in a hot chamber,  or in a  crowded and  hot
theatre, for some hours;  and  Brachet states that  a little girl, being ex-
posed to a severe cold for eight or ten minutes,  was seized with  difficulty
of breathing threatening suffocation, 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. Guersent
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 convulsions, after
which it remained comatose for  thirty-six hours, but ultimately recover-
ed.3   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  during  a time of severe
affliction and distress.
   It  is  said that the exhibition of soothing  medicine by the nurse,
such  as Godfrey's  cordial, syrup of poppies,  &c, may bring on an
attack.
   14(1.  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 escape.   I have
repeatedly observed in these cases a sort of gradation from simple irri-
tation 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 stimu-
lants, &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.  Charles  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.  I have  also
known them result from renal disturbance.

     1  On Convulsions, p. 11.            2 Richard, Mai. des Enfans, p. 541.
     3 On Diseases of Children, p. 258. 
118
CONVULSIONS.
  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 convulsion,
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 excite-
ment and exertion in children  of more advanced age.   The attempt to
press forward the education of  children is, in fact, an excess  of  stimu-
lation 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.  It is remarkable, however, that
in these cases  we have one or two convulsions only, scarcely ever a fre-
quent repetition of them, and this  I think will enable us to distinguish
the convulsions ushering in an eruptive  fever from  others.  Barrier
mentions  three cases of pneumonia, commencing in this manner, and
the fact is noticed by many writers.
  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 he-
patization 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  orthopncea 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
  Dr.  Simpson has suggested  that albuminuria  may  occasionally  give
rise  to convulsions, and he mentions a case of  convulsions in  an infant
on the third day after  birth in  whose urine he detected albumen.3
  From  the mechanical interruption to the regular central circulation,
it is not uncommon to  have convulsions in the course of croup or hoop-
ing-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 cer-
tain to return if the cough continue.
  Convulsions may occur at the termination  of any of the organic dis-
eases, and in such cases the result is generally unfavorable, whether the
sympathetic irritation be of an active kind or result  from exhaustion—
"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

           1 Denis, Recherches sur plusieurs Mai. des Enfans, p. 325.
           2 British and Foreign Review, No. 42, Ap. 1846, p. 392.
           3 Ed. Monthly Journal, Oct., 1852, p. 374. 
CONVULSIONS.
119
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 nerv-
ous system in convulsions, some confusion has arisen from the distinction
between primary or sympathetic and symptomatic convulsions not hav-
ing 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 derangements, or of dis-
turbances, however serious, which result from  irritation only.1  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.
   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  vio-
lence,  are the appearances recorded by some  of the older  physicians.
Effusions of serum, vascular turgescence, tumors attached to the mem-
branes, or imbedded within the substance of the brain, are noticed 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 bloodvessels, ex-
travasation of blood, abscesses, tumors, and inflammation of the menin-
ges of the brain, are the lesions described by others.   Effusion of blood
within  the spinal  canal, engorgement of the vessels of  the brain, and
extreme venous congestion of the  entire substance of the brain, with
serous  effusion, were met with by Horner in one case, and the same
appearances, with extreme mollescence of  the brain, in another.  Tur-
gescence of  the vessels of the brain, its substance of a pink color, with
serous effusion into the ventricles at the base of the cranium and .with-
 in the theca of the spine, are noticed by Kennedy."   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."3
   150. Symptoms.—The mode of invasion varies a good deal in primary

     1 North on Convulsions, p. 41.     2  Condie on Diseases of Children, p. 400. 
120
CONVULSIONS.
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; loss of appetite ;  thirst, and spasmodic turn-
ing 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 attacked
when perfectly well, occasionally in his sleep; or suddenly in the course
of other diseases, with no circumstances which would  lead us to antici-
pate convulsions.
  When first seized, the child  has a bewildered, surprised, frightened
look; its eye expresses terror; the globe is agitated with irregular jerk-
ing movements.  Sometimes  the  pupil  is turned upwards, sometimes
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, and the
child squints horribly; sometimes the pupil is contracted, in other cases
it is dilated; and frequently,  from the turning upward 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 aware  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 and 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 extremi-
ties 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 similarly affected, but more slightly,
and the feet are generally flexed upwards and inwards.
  I have already stated that the respiration  is quick, broken, and sibil-
ant, 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 respiration.
This may be partly owing to disordered innervation, and partly to mus-
cular disturbance.
  The pulse is accelerated, ranging from 110 to 140  or 160, generally
small and  hard,  and often  irregular.   The  action of the heart is dis-
1 North on Convulsions, p. 70. 
CONVULSIONS.
121
turbed,  the rhythm  and force  of  its  contractions being frequently
modified.
  The face  becomes florid, sometimes violet;  the head is hot, the feet
cold, and a clammy moisture soon breaks out over the body, but particu-
larly 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 feces 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.1
  At length the convulsive movements relax, and ultimately cease, 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 conscious and intelli-
gent.
  152.  Variations.—The above is an imperfect sketch of an ordinary
convulsion; it would  be almost impossible to describe the multiplicity
of combinations, 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 symp-
toms ;  this is  the case with primary convulsions, and also with sympa-
thetic;  in the latter there will be present the symptoms of the organic
disease, but the fit may supervene quite unexpectedly, whether at the
beginning 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 convulsions
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 invol-
untary 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  disorder, 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.
1 Rilliet and Barthez, vol. ii. p. 269. 
122
CONVULSIONS.
  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, accord-
ing to MM. Brachet and Bouchut.
  In primary and sympathetic convulsions, the first attack is sometimes,
though not always,  the only one,  but  in  symptomatic convulsions 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 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, however, two  consequences of the  attack, which
remain for a considerable time ; one is an obliquity of vision, not, per-
haps, 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 curvature
of the bones.5
  Bouchut states that he has seen wry neck,  drooping eyelid, squinting,
distortion of the mouth, and contraction  of some of  the limbs ;6 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,7 from which, after  some time, the child may partially
or wholly recover ;  and Dr. Hamilton, chronic epilepsy, chorea, idiocy,
imbecility.8
  Or  an attack of convulsions  may localize itself, as it  were,  and
become partial; thus I have seen spasm of the glottis supersede general
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
notwithstanding.   Hippocrates observes that  convulsions followed  by
fever terminate happily.

     1 Bibliotheq. Med., vol. iii. p. 504.         2 Diseases of Children,  p. 400.
     3 On Nervous Diseases.
     4 Journ. Gen. de Med., vol. xxix.  p. 280.
     5 Traite des Convulsions, p. 46.           6 Mai. des Enfans, p. 400.
     7 Comment, on Diseases of Children, p. 83.
     8 Hamilton  on Diseases of Children, p. 88. 
CONVULSIONS.
123
  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  dispropor-
tionate 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. Johnson ; 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 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 contractions of the
respiratory muscles, is imperfectly performed;  the  lungs become con-
gested,  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."
  So far, these  are modifications of the  ordinary kind  of  convulsion
only.  I shall notice  a very curious variety, which  has been called
Salaam convulsions by  Sir C. Clarke, and Eclampsia mutans by Mr.
Newnham.   It is a very rare disease.  I believe Mr. West was the first
in these countries  to bring it under the notice of the profession.  Sir
C. Clarke had seen but three cases in his practice, up to 1839, and Dr.
Locock only one.  Mr. Newnham has published  four  cases1 (including
Mr. West's);  another has  been related by  Dr. Willshire ;2 two others
have been published in the London Journal of Medicine, translated from
the German,3 and two have been described by Dr. Faber.4  A case very
much resembling this affection is described by Dr. Wright, of Montreal,5
but it appears to have been connected with catamenial disturbance.
  The essential symptom of the disease, is a bowing forward  and down-
ward  of the  head,  so as sometimes  almost to touch the knees;  at first
the movement is slow, but it increases in  frequency until it attains great
rapidity, so much as  to  be repeated fifty or  140 times in succession;
when so rapid it degenerates into a mere  nodding of the head.   The at-
tack, in some cases, is preceded by sleepiness, heaviness about the eyes,
or casting them upwards.   An attack not unfrequently comes on after
awaking from sleep, and in  other cases the  child seems worn for sleep,
which may be disturbed by spasms or screaming.   Sooner or later other

            1 British Record of Obstetric Medicine, No. 6, vol. ii. p. 3.
            2 London Journal of Med., June, 1850.
            s Journal fur Kinderkrankheiten, March, 1850.
            4 Medico-Chir. Review, July,  1851.
            s British American Journal, April,  1850, p. 311. 
124
CONVULSIONS.
automatic movements  occur,  and the  attack  may  ultimately  involve
general or local convulsions, paralysis or idiocy.
  In Dr. Newnham's first case, the child was attacked by paralysis, and
her intellect became weak,  but she  ultimately recovered.   The second
case (Mr. West's) became idiotic, although  the bowing ceased.  In the
third, there  was partial paralysis  of the upper extremities, with intellec-
tual deficiency,  and the fourth ultimately died, the  attack  continuing
with intervals nearly to the end.
  In Dr. Willshire's case there was neither paralysis nor permanent in-
jury to the  intellect, and the patient  recovered  under the treatment
adopted.
  One  of the cases recorded in the Journal der Kinderkrankheiten
became epileptic and semi-idiotic; the  other improved under the use of
iron.   I shall take the liberty of  giving some of Mr. Newnham's conclu-
sions, as he  has  seen more of  the disease than any other  practitioner.
He says : "This affection appears to be spinal in its origin; for although
it will  have  been established by the foregoing  cases  that, previously to
the attack, there had been some peculiar expression of the eyes, and some
degree  of heaviness, or of unwonted irritability,  yet, as all the earlier
phenomena  are spinal, it must be classed as an eccentric affection; and
the little disturbance of the cerebral manifestations may be explained
by  the reflex irritation of  this morbid spinal agency which has  com-
menced, is proceeding,  but  has not reached that culminating point at
which  it interferes with the established harmony of the voluntary or
semi-voluntary muscles.  Though spinal in its origin, it will have been
noticed that in every instance general convulsions will soon  make their
appearance, and cerebral symptoms  will occur.   The  effect upon the
manifestations of mind is most marked, consisting not in a simple arrest of
development and defective nutrition, for then it would remain just as when
the disease supervened, whereas it will have been seen that a desolating
influence is at work; a morbid  action has been established; and although
this shall seem to be at rest for a time, and the mind shall grow during
intervals of  freedom from the attack, yet on a renewal  of  the  distress-
ing symptoms, it will be seen  that the downward action  is progressive,
that the early sparklings of intelligence are obscured, and that the mis-
chievous influence is proceeding surely, to the  extinction of  intellect in
fully formed idiocy.
  "Not only have the manifestations of mind  been blighted, but in
many instances  paralysis has  been a  consequence, either in the form of
paraplegia or hemiplegia; the kind of paralysis therefore has not been
uniform, though in some form or  other, and in a greater or less degree,
it has been invariable.
  "It  is to  be remarked that in each of the recorded cases,  the severe
attacks of the  peculiar bowing  have always been preceded by sleep;
they have been  always noticed to  occur with especial  severity in the
morning after the night's sleep, or after the customary morning nap.
  " There is evidently in this malady a family alliance with epilepsy,
and hence,  as has  been demonstrated by the  foregoing cases, it  often
passes  into epilepsy, or some other form of infantile convulsions.   Te-
tanoid  symptoms do also sometimes occur during its  progress. 
CONVULSIONS.                      125
  "There are some differences in  the phenomena described, which it
would be right to notice: a. During the paroxysm the hands were closed
in Nos. 2 and 3, but they were expanded in No. 4, showing, that in the
former cases, irritation of the flexor muscles, in the latter of the exten-
sors, was predominant,   b.  The throwing the head backward in No. 2,
appears only to have been a consequence of muscular and general feeble-
ness, whence the head, from its own weight, fell backward for the want
of adequate support,  c. In No. 2 the irritation of the decaying teeth
seems to have been the greatest in 1843, when the peculiar bowing  af-
fection was  relieved; but in No. 4 the bowing affection was aggravated
when teething irritation  was greatest.
  "The fondness for music, pictures, or gay colors, has been so marked
in some of the above cases, that it should be noticed, as it shows  that
the injurious impression  has not been made  upon the organs of sense,
and as the judicious employment of these senses would form a most im-
portant part of the future educational treatment, because affording large
inlets of knowledge, and to the development  of sentiment and affec-
tion."1
  Mr. Newnham  inclines to the opinion that the essential  character of
the disease  is inflammatory action  of a weak  and strumous nature, of
the membranes investing the medulla  oblongata, afterwards  extending
to other parts.
  Dr. Willshire considers it probable that the disease is purely  centric
in its  origin, having its first  seat in the sensorium, or in those import-
ant parts placed between the "hemispheric ganglia" and the top of the
spinal cord,  and afterwards in the lower  or non-sensorial portion  of
the spinal  apparatus, as proved by the general  automatic movements
being in some cases of  a decided tetanoid character.  In  others these
movements  were  distinctly  epileptiform, and moreover hemiplegia  has
followed, the former circumstance still further indicating, as the  seat of
mischief, the assemblage of ganglionic centres between the cerebrum
and spinal cord, whilst the latter and the supervening affection or obli-
teration of the intellectual powers appears to prove  the secondary  in-
volvement of the  great hemispheric lobes.   The essential peculiarity of
the disease, Dr. Willshire thinks, may be some change in the circulation
of the minute vessels of  a scrofulous character.
  155.  There is  a species  of convulsive  affection  which has been de-
scribed by Jadelot and Guersent, and which is deserving of notice.   It
is not a general convulsion, but a tonic  contraction of the muscles of the
upper and lower extremities.  It is observed in young infants, and also
in children approaching the  age of puberty.   The wrists and fingers be-
come remarkably  rigid, both being partially flexed, and when the lower
extremities are also affected, they  are stretched out instead  of being
bent.   The muscles are felt  to be rigid and tonic, and their outline may
be distinctly traced underneath the skin.
  The tonic contraction  may continue for  hours or days,  and in some
cases  it has lasted for years, but its  duration is generally shorter.   It
may cease spontaneously, or under  the influence of treatment, and  re-

            1 British Record of Obstetric Med., vol. ii. No. 6. p. 18. 
126
CONVULSIONS.
 turn.  It is seldom accompanied with disturbance  of other muscles, or
 of the intellect, respiration or digestion.  The pulse is sometimes, though
 rarely, contracted.
   It is evidently a disease  of reflex irritation, and  may  in general be
 traced to a gastro-intestinal irritation of some kind, or to dentition, or to a
 vitiated atmosphere.   It rarely terminates fatally, and in cases where an
 autopsy was made, neither Jadelot nor Guersent found any appreciable
 alteration in the brain or spinal marrow.
   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  difference  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   primary,
 sympathetic, or symptomatic, but upon further inquiry we  find that the
 child was perfectly well up to the  moment of the  attack, that the ex-
 citing 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  con-
 clude that the convulsions are primary or essential.
  But if, on examination, we discover evidences of pectoral or abdomi-
 nal  disease, acute or  of long  standing, we  must then infer  that the
 convulsions are sympathetic, and we cannot  be too minute in  our ex-
 amination of all the organs in every case, as the treatment  as well  as
 the diagnosis will  depend upon it.   In these primary and  sympathetic
 attacks the brain and nervous system are only in a state of sympathetic
 irritation, 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  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 at-.
tacked 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 
CONVULSIONS.
127
age.1   Moreover, the absence of adequate exciting causes, the freedom
from organic disease of the chest and abdomen, will  exclude  the pri-
mary 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 depend
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, and
with  recovery of intelligence during the intervals, 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.3
   The convulsions which occur in the course of fever, and which assume,
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 sympa-
 thetic convulsions.
   In  symptomatic convulsions  the  prognosis is  always  serious, and
generally  unfavorable when  they occur  in the course  of  the  disease of
the nervous system;  less so when at the  commencement.3
   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
 Bhould first ascertain to which of the varieties it belongs, whether it is

   1 Rilliet and Barthez, Mai. des Enfans, &c, vol.  ii. pp. 274, 275.
   ' " Inasmuch as convulsions are a frequent attendant on diseases of the brain, it is
 certainly 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 vacillating treatment, and
 much mischief is the result "—Mauthner on Diseases of the Brain, §c, in Children, British
 and Foreign Review, April, 1846, p. 392.
   3 Rilliet and Barthez, Mai. des Enfans, vol. ii. p. 277. 
128
CONVULSIONS.
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 according 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, exposed 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 experience
I have had  only confirms  their opinions, with very few exceptions.   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 bloodletting  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 sympa-
thetic  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 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 child 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 altogether ceased after  the  last application, and the child
recovered. 
CONVULSIONS.
129
  As to'the best situation for applying the leeches, some advise the fore-
head 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 impression, 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 caro-
tids, and, it is  said,  with  success.  Drs.  Bland and Stroehlin  have
published some favorable cases,2 and Mr. North thinks favourably 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  leeching must be
decided by the repetition of  the convulsion, or the occurrence of  slight
convulsive twitchings, or of much starting in sleep.  If these are absent,
and if the infant sleep calmly, no further leeching 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 observation; 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
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 combina-
 tion with as much Dover's powder, and a grain of James's powder.
   Next to intestinal  derivatives,   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
cars, 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:

              1  Commentaries on Diseases of Children, p. 109.
              2  Med. Chir. Journal, April, 1839.
       9 
130                       CONVULSIONS.
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
exhausted 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
(Ettinger 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, assafoetida, musk, bismuth, ammonia, &c.   Drs. Under-
wood1 and Stewart2 speak very highly  of musk  given freely, that is,
from half a  grain  to two grains  every two hours.   Dr. John  Clarke,
however, 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 assa-
foetida,  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 vascular action.   I have used it
in a case of  convulsion  complicating  hooping-cough, with  apparent
benefit.  My friend Dr.  Simpson has also used it with perfect success in
the case of an infant five weeks old, who had had severe convulsions for
nearly a fortnight,  allowing  him to wake for  food ; he was  under its
influence for nearly twenty-four hours, and emerged from the  sleep per-
fectly well with no return of' the fits.   Mr. Williamson, of Manchester, has
recorded the case of an infant six  weeks old, whom he kept constantly
under the influence of chloroform for sixty hours, sixteen ounces having
been used and with complete success.4
  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-

  1 On Diseases of Children, p. 264.              * On Diseases of Children, p. 493.
  * Comment, on Diseases of Children,  p. 108.      * Lancet, June 11, 1853, p. 535. 
CONVULSIONS.
131
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 adminis-
tration  ; perhaps the  best  mode is to combine a little Dover's powder
with calomel or James's powder.   Mr. North recommends Dover's pow-
der 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 would 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, or when  the
nervous irritability is very great, 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 com-
pressed 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 attendant
has reason to believe that no danger is to be apprehended from any of
those circumstances, opium in small doses,  cautiously  repeated, may be
administered with advantage, and it will  sometimes  diminish pain  by
lessening the  sensibility  and irritability  of the patient.   Great care
must, however, be taken,  during  the use of it, to keep the intestinal
canal free.1   Dr. Russell, of Limerick, has  mentioned to me, that he has
derived great benefit from the use of prussic acid, in doses of one-twelfth
of a drop every  hour, and  in a few  cases in which  I have  tried  it,
it seemed to soothe the child  and diminish the convulsion.  It is particu-
larly suited to cases of convulsions complicating hooping-cough.
  Alkaline medicines  will be of  service, when we  are 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-irritation, anti-
spasmodics,  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.
  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
1 Comment, on Diseases of Children, p. 108. 
132
CONVULSIONS.
wine, with great caution, however, and nourishing diet; in other cases a
change of air is highly beneficial, or, if the infant be  suckling, 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 dis-
ease will relieve the convulsions.   In febrile diseases ushered in by fits,
however,  the local treatment may be pretty active.
   The same observations will apply to symptomatic convulsions,  except
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 adjustment of remedies,
but  of these I shall  speak at length when I treat of those diseases.
   The treatment of eclampsia nutans so far has not been satisfactory.
Every species of irritation must be removed, the gums lanced, bad teeth
removed, the bowels freed, the diet regulated, &c.   The food should be
nutritious, but unstimulating, and as far as may be of  a dry character,
according to Mr. Newnham.   Calomel and preparations of steel seem to
have been  beneficial in  some of Mr. Newnham's  cases,  and rather in-
jurious in others.   Prussic acid  seems to have palliated the symptoms,
and opium to have  aggravated them.
   Dr. Willshire's remedies were  blisters behind the ears, keeping the
bowels freed by castor oil, and  the internal exhibition of the iodide of
 potassium and the disulphate of  quinine.
   In one of Dr. Faber's cases, purgations, baths, cold effusions, antispas-
modics, embrocations, &c.; all failed to mitigate the  disease, and in the
 other little or no benefit was derived  from frictions  to the nape of the
 neck with tartar emetic ointment;  quinine  and  antispasmodics, cold
 effusions, and warm douches seemed to do harm,  but the patient improved
 somewhat under the use of iron.
   The treatment for tonic convulsions of the extremities  consists  of
 frictions  and warm or vapor baths, and  gentle  purgatives.   M. Jadelot
 recommends cold  effusions, frictions with ether or  tincture of digitalis,
 and internally camphor or valerian.  M. Guersent advises frictions with
 a liniment containing laudanum, and  if this  fail, laudanum internally.
 Diaphoretics have also  been recommended, and the sesquicarbonate of
 iron in large doses.  With patients of a full  habit, venesection may be
 necessary.
   Contrivances for the  extension of the limbs may be tried  in conjunc-
 tion with warm baths, emollient  frictions, and  in some cases they seem
 to have succeeded.   Section of the contracted muscles has been proposed,
 but it seems to me a very unscientific  proceeding, and I believe has not
been attended with any success. 
CONVULSIONS.
133
  165.  The diet of children attacked by convulsions should in general be
simple and  bland; milk  in  any form, rice, arrowroot, &c,  will  be
suitable and sufficient until the severity of the disease is subdued.   Ani-
mal  food and wine should  in general  be  prohibited, except, as I  have
already said, where there is great exhaustion, or in some cases of  sym-
pathetic  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 beneficial.
I need not dwell upon the necessity of a warm,  loose dress, and the re-
moval of everything which can irritate.
  But perhaps the most important and most neglected hygienic arrange-
ment is perfect quietness; the  nervous system  has been so shattered
that quietness  is essential  to its recovery, and yet if  there be any im-
provement the nurse and parents are so delighted, that they invariably
set  about amusing and exciting the child,  to obtain renewed evidence of
its restoration.  The room should be darkened, and  nothing 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.
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. Jurin  prefers 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  immediately 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 axes 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
1 North on Convulsions, p. 215. 
134                 ACUTE HYDROCEPHALUS.
                      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 hydro-
cephalus ; by Cullen, hydrocephalic  apoplexy;  by Macbride,  hydro-
cephalic fever; by Bricheteau,  hydrocephale aigue; by Gardien, Oapu-
ron, and others, fievre cerebrale ; by Brachet, hydrocephalite; by Rufz,
Piet,  Guersent, Green, Barrier,  Rilliet and Barthez, &c,  meningite
tuberculeuse; by the Germans,  hitzige gehirnhohlenwassersucht.
  By whatsoever name  described, and however various the theories as
to the nature of the disease, it appears to me that both the symptoms
and the post-mortem appearances indicate an affection of the  mem-
branes of the brain  as  the essential character  of the  disease, whether
primary or  secondary;  and as  that affection exhibits  evidences  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 meningitis and tubercular
meningitis; but as the distinction  during  life  is  in many cases impos-
sible, and in  almost all very obscure, 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,
and  by Messrs. St. Clair  and Paisley in 1732-3,  in the Edinburgh
Medical Essays.  In 1768, Dr. Whyte'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 phy-
sician of this city, in which  he attributed 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  em- 
ACUTE  HYDROCEPHALUS.
135
ployment of antiphlogistic  remedies, as venesection  and cold applica-
tions to the head.   In a more advanced stage of the  disease he recom-
mended mercury, on the principle laid down by Dobson, for the purpose
of stimulating the absorbents of the brain.   This essay was afterwards
enlarged into a treatise.  Dr. Withering, in his Account of the Fox-
glove, 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. Perceval,
of Manchester, published a valuable paper  in  the first volume of the
Medical Tracts and Observations, containing a post-mortem examina-
tion of a case in  which death took place before effusion, and recom-
mending 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  inflammation,
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  character 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 inflammation, there
continued to be some dispute as to its exact locality, although Briche-
teau and others regarded  the  effusion  as the  principal  phenomenon.
Golis (1815), Piorry (1822), placed the seat in the arachnoid;  Coindet
in the  cerebral ventricles ;  Brachet in the lymphatics; 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, J. R. Bennett, 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  com-
munications to the different  periodicals  will be found  in Braithwaite or
Ranking's Retrospect, and to which I shall hereafter refer.
   More  recently great light has been  thrown  upon  the pathology of
the disease by the  valuable essays of Guersent,1 Papavoine,2 Fabre
and Constant, Gherard,3 Rufz,4 Piet,4 Green,6 Schweninger,7 &c, who
have demonstrated the existence of tuberculous meningitis.
   Dr.  J. R.  Bennett, in  his  excellent  treatise, gives   the following
statistics:  Of 1,000,000 of each sex, the annual mortality by hydro-

  1 Diet, de MeU. p. 392.                2 Journ. Hebdom., vol. vi. p.  113, 1830.
  ■ American Journal of Medical Science, April, 18o4.
  * Thesis, 1835.                      5 Thesis, 1836.            6  Lancet.
  7 Uber Tuberculose als die gewohnlichste Ursache der Hydrocephalus acutus. 
136
ACUTE  HYDROCEPHALUS.
cepalus, in 1837, was 562 males and 460 females ;  in  1838 it was 574
males, and 450 females;  in  1839 it was  571 males, and 439 females.
In Berlin, in the year 1833, the deaths below 15 were 4,009, of which
196 were from cerebral inflammation and  hydrocephalus.  In 1835, the
deaths below 15 were  3,477,  of  which 257 were from acute hydroce-
phalus.
   Coindet states that on an average 21 children die annually in Geneva
of hydrocephalus, out of a population  of 22,000.
  Bouvier estimates that in  Paris 1,000 children are attacked annually,
of whom 750 die.
  Hasse considers that  from 32,000  to  36,000 children die annually
from  this  disease  in  the  Prussian States,  and 100,000  throughout
Germany.
  Dr. Alison states that  of  201 deaths below the age of  15, at Edin-
burgh Newtown  Dispensary, 40 died of hydrocephalus; of 1862 cases,
under 7 years, at the Marylebone Dispensary,  Dr.  Boyd  says  that 67
were  inflammation of the brain or membranes.   At the Rains Institute
for children, of  56 death 9  were from this disease.   Of 62 deaths at
the Bonn Chirgon, 12 were  from this disease.
  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 con-
ditions.   The first  corresponds  to the acute  hydrocephalus of Golis
and others, and  to the "meningite simple aigue" of Barrier and Rilliet
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 creeping or
chilliness over  the  body.   The  pulse is uncertain—sometimes quick,
perhaps irregular, in other cases but little altered from its natural state.
  In  most  cases, however,  the  development of the disease is sudden,
and marked by high fever, thirst, heat of skin generally,  and  particu-
larly  of  the  head, sometimes, as I have  seen more  than once,  by a
convulsion.1   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 support
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-
quently they are bright  and restless,  moving quickly from one object
to another, and  the conjunctiva more or less injected.   There is a

         1 Dr. John Clarke's Comment, on Diseases of Children, p. 130, 1830. 
ACUTE  HYDROCEPHALUS.
137
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 sleeps 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 respi-
ration precede every other symptom in one of my own children attack-
ed by the disease.   It  was remarkable, too, that the  difficulty was in
expiration, not in  inspiration.
  The stomach almost immediately sympathizes with the cerebral dis-
turbance ;  there is complete loss of appetite, and in almost every case
vomiting, sometimes concurrently,  in others  alternating with the head-
ache.  The tongue is white and loaded, the bowels generally constipated,
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.  By this it  may often be distinguished from
the  convulsions  ushering in the  eruptive fevers.
   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, generally
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 ;  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

  1 Transactions of the Association of the College of Physicians in Ireland, vol. v. p. 438.
  1 On Hydrocephalus, p. 12.                        3 De 1'Arachnitis, p. 207. 
138
ACUTE  HYDROCEPHALUS.
oppressed, and ultimately irregular, a few rapid respirations  being fol-
lowed 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 phy-
sicians,  which I ought  to  mention here,  although I can give no opinion
as to its precise value.   I allude to the information derived from cere-
bral auscultation.   Dr. Fisher, of Boston, was the first to apply auscul-
tation 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 bestowed
upon the subject.   He describes four sounds heard  in the brain  in cer-
tain diseases:  1. The cephalic bellows sound; 2. Cerebral cegophony;
3. Fremissement cataire,  and 4. The cooing sound.
  The  first, or bellows 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 dif-
ferent diseases in which it is heard, and  occasionally by the difficulty of
detecting  it.   Still  it is a subject worthy of minute  attention, and may
ultimately lend important aid to the diagnosis.
  173.  As the disease advances, the symptoms gradually change from
those of excitement to those consequent upon  effusion or pressure, 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 de-
lirium subsides, or occurs  occasionally; the sensibility of the eye is gra-
dually 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 unconscious of sound;  the sense of
touch remains  longer  than any other, and at a period of apparent in-
sensibility 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 prevents our exposing the eyeball.
  When the effusion (or pressure) is moderate, the convulsions increase
in frequency, and sometimes in strength; or perhaps there may be con-
vulsions of one side of the body, and paralysis of the other;  when the
effusion is rapid and excessive, there is often neither convulsion  nor para-
lysis, but  coma and rapid  sinking.   And a new symptom is developed
about this 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-

  1  March,  1838.               2 American Medioal Journal, October, 1843, p. 282.
  8  Dr. John Clarke, Commentaries on Diseases of Children, p. 130. 
ACUTE  HYDROCEPHALUS.
139
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 ap-
pears.  Some, as Stewart and Condie,  place it during the inflammatory
stage, others at a more advanced period, at the commencement or after
the occurrence of effusion.  My own experience confirms the latter view.
   174. During the intervals of the convulsions, consciousness and sensi-
bility 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
Bunken and anxious, as representing the last conscious feeling.   The
vomiting rarely continues; the bowels are sometimes evacuated uncon-
sciously, generally confined;  the urine  may accumulate or be passed  at
long  intervals, and the belly is sunk, concave.  The attack terminates
by a convulsion, 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. II. 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 con-
tracted 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 con-
vulsions, 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."8  Dr. Monro  believes that  the peculiarity of  this case de-
pended 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 ordinary 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.
   176. in. The next phase or 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 the  irregularities are so frequent  that any  arrangement based
upon them has but comparatively little value.
   The child in this case usually exhibits evidences of deranged health

     1 On the Morbid Anatomy of the Brain, p. 70.                 2 Ibid. 
140
ACUTE  HYDROCEPHALUS.
some  time before  the  characteristic symptoms  appear.   The appetite
may have  been lost;  the tongue  is generally whitish, often loaded;
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 atten-
tion 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  tur-
gescence,  or of the first  stage: "Indifference succeeding to increased
sensibility and  irritability; a constipated state after habitual looseness
or diarrhoea; a  scanty, unusually  yellow urine,  with  or without sedi-
ment; dryness of  the skin, which  previously, on the slightest exercise,
even on eating  and drinking,  and particularly during 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."1
  In  the majority  of cases, the  child complains of headache, or, if an
infant, gives signs of it by putting its hands  to  its 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.
  As I have remarked,  the tongue is  white  and  loaded, the bowels
sometimes free, but often  confined ;  the  stools are clay-colored at first,
but afterwards of  a green color, like chopped spinach, and of a gelati-
nous 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 of the exanthemata."  The  child sometimes com-
plains 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.
1 On Water in the Head, p. 15. 
ACUTE  HYDROCEPHALUS.
141
  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 known to  the physician before the
commencement of the  disease, are very different to  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; the bowels are generally torpid, although we see occasionally
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;  some-
times, as Coindet observed, with a white micaceous  sediment.
  The senses, which were 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, throw-
ing 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, squinting, &c.
The conjunctiva frequently  becomes highly injected with an unusual
puriform secretion; and Dr.  Stoben,  of Strasburg,  has  remarked  a
semilunar yellow speck at the lower margin of the cornea without  undue
vascularity, but which became  an ulcer if the case were protracted.
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 variation,
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.
   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.
  181.  IV. Dr. Brockman has described, under the term meningitis en-
cephalica, a species of local meningitis  in which the membranes  of the
On Acute Hydrocephalus, p. 2. 
142
ACUTE  HYDROCEPHALUS.
pons Varolii  and medulla  oblongata are chiefly affected.   I quote the
following description  from Dr. Condie's  excellent work:  "It is some-
times associated with general disease of the brain ; at others it is  uncom-
plicated.  Notwithstanding in its earlier stages it is unattended  by any
serious  symptoms,  it  is an  affection  fully as  dangerous as cerebral
meningitis.   The first stage, or that  of simple  hypersemia, 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 vom-
iting, 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 twitching 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 de-
grees 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 which 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 awak-
ing 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 pre-
ceded by various singular nervous phenomena,  as  sudden pauses in
the respiration, or  equally sudden  syncope.  In  some cases, however,
the paralysis does not follow, but the anomalous symptoms subside, and
the patients  gradually  recover.  Until,  indeed, the paralytic stage ia
fully established,  the recovery of the patient is  still possible.
   "In the uncomplicated cases of  the disease, upon  examination after
death, the cerebrum in general  presents an extremely pallid and  anae-
mic condition, in  striking contrast with  the cerebellum, the vessels of
which are turgid with blood, while  its substance also is often in  a state
of marked  hyperaemia.   The  hyperaemia also increases  in  intensity
towards the central portions of the encephalon; and the  membranes
covering the  pons  Varolii and  medulla  oblongata are found in  a most
decided state of inflammation; the portion of inflamed membrane is per-
fectly 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 effusion of a serous fluid into the
subarachnoid tissue, sometimes  to the extent of several ounces; occa-
sionally a gelatinous matter is effused, and in  some instances the effu-
sion is of a purulent character. 
ACUTE  HYDROCEPHALUS.
143
  "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. Bockman, but  he remarks that  in some
cases the administration of  wine  may be required.  According  to his
experience,  powerful  counter-irritants, as a large blister, or the actual
cautery, prove  also sometimes beneficial."1
  182.  v. 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 disease
corresponds pretty accurately with the three  stages of Dr. Whytt:  the
first characterized by  loss  of appetite, paleness, quick  pulse, vomiting,
and  headache; the second by a slower  but  irregular  pulse, sleep, de-
lirium,  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 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: "From
the 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 tubercular 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 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 writers, as fan-
tastic 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,  nausea, vomiting, &c.  I
saw  one case in which, before cerebral  symptoms 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 common, 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.

  1 Condie on Diseases of Children, p. 423.        ' Diet, de Mel., vol. xix. p. 411. 
144
ACUTE  HYDROCEPHALUS.
  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 increases,
at first of bilious matter or of  the food taken ; the  pulse becomes irre-
gular, 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 oscil-
lating or  turning  upwards, the expression of the face that of  surprise,
or wonder, or indifference, sometimes utterly smooth and without expres-
sion, 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 persist-
ent  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 convulsions 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.   Occasion-
ally 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 convergent;  the pulse is
small, quick  and irregular;  the  respiration irregular;  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
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 appa-
 rent 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,

               1 Lectures in Medical  Gazette, August 16, 1847, p. 92. 
ACUTE  HYDROCEPHALUS.
145
 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.
   Moreover, it must strike every one that between several of the forms
 here described there is comparatively little  difference  of symptoms,
 although their succession and intensity, and duration vary a good deal,
 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
 description,  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. vi.  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,1 but
 omitted by most writers.  It consists  in a sudden, almost instantaneous,
 effusion of fluid within the brain, and  may occur either idiopathically or
 as  the result of obstructed  secretion from  some other organ,  or as a
 secondary affection in the course of  some  other disease, as smallpox,
 measles, or other, febrile eruptions, or on the sudden stoppage of  diar-
 rhoea,  dysentery, or profuse perspiration.
   Though there are evidences of inflammation occasionally found on a
 post-mortem  examination, the suddenness and rapidity of the  disease
 prevent the  development of the usual symptoms.   Those which are to be
 observed rather correspond to the latter stages of hydrocephalus.  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 examination.   Or it may
 suddenly be  attacked by a convulsion, followed by paralysis or apparent
 apoplexy, with insensibility,  stertorous breathing, dilated or contracted
 pupils, and subsultus,  terminating in death  after a few hours.
  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,2 and in some parts  rendered opaque; in other cases

  1 A Treatise  on the Hydrocephalus Acutus, &c, by R. A. Golis, translated by R..
Gooch, M. D., p. 5.
  2 Piorry, de l'lrritation Encephalique, p. 28.  Eberle on Diseases of Children, p. 37^.
       10 
146
ACUTE  HYDROCEPHALUS.
it is smooth and polished, but with the products of inflammation in its
cavity.   Occasionally thick, abundant, and inodorous pus  is found, as
described by Golis, 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 may
be 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 ence-
phalon with blood.  This is not blood, nor serum,  nor purulent matter,
nor fibrin, but a fluid already stated sui generis.,"1
  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.............0.28
              Animal matter, insoluble in alcohol   .  .   .  0.26
              Earthy phosphates.........0.09
              WaAer............988.30

                                                1000.00

That is, the serum of  the  blood, diluted with  about seven  times  its
volume of pure water.2
  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-Duchatelet
and  Martinet state that  in eight cases out of twenty-six  there was
scarcely a trace.   Ford and Underwood make a similar observation.
   In some cases the fluid is present with few if any traces of inflamma-
tion.   These cases, however,  are comparatively rare.
   190. Occasionally the central portions of the brain are  diseased, sof-
tened, and reduced to a mere pulp; when the effusion is  considerable,
the brain has a compressed appearance and the convolutions are flat-
tened.   The vessels of the brain are  considerably congested.
   According to Laennec, Jadelot, Bricheteau, &c, the substance of the

    1 On Hydrocephalus, Preface, p. 10.       * Traite" de Chimie, vol. vii. p. 141. 
ACUTE  HYDROCEPHALUS.
147
brain 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.
Legcndre'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.1
  191.  These post-mortem appearances are more or less common to all
the forms or varieties of hydrocephalus I have noticed, but  ethers are
superadded in tubercular  meningitis; there we  find a  peculiar sticky
condition of the arachnoid, and in the laminae of the pia mater a depo-
sition 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-trans-
parent; 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 thickened
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  deposition 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  bloodvessels of the
brain  and its  membranes less enlarged  and less  turgid than in the
latter," and "from two to four or six  ounces  of  turbid fluid."
  192.  Morbid changes in  other organs are rare in any of the varieties,
except when the  meningeal affection is secondary.  In such cases we
may find inflammation or  ulceration of  the  mucous membrane  of the
stomach and bowels, evidences of follicular enteritis, &c.  Dr.  Cheyne
mentions that he found in  many cases proofs of increased arterial action
on the surface of the liver, that  it  was adherent  to the peritoneum,
enlarged, and studded with tubercles.
  M. Rilliet states  that in general  meningitis and meningitis  of the
convexity tubercles in  the lungs or abdominal organs  are never met with,
but that in meningitis of the base alone they  are : and  we know that in
tubucular meningitis they are uncommon in the lungs, &c.
  From this short statement of the morbid appearances discovered  on a
post-mortem examination, we may  come  to some conclusions as to the
nature of the disease.   With  some exceptions, in which we find merely
a collection of fluid, in each form  we find traces  of  inflammation in the
membranes of the brain, with its results in the form of serum, or pus,  or
lymph.   In a large  class of cases, in addition to evidences of inflamma-
tion of the membranes  and certain  changes  in portions of the brain
itself, we have a deposition of  tubercular matter, but whether the latter
be the consequence of inflammation seems hardly decided as yet.   Mr.
Trousseau  believes it to be so, but Rilliet and Barthez  incline  to the
opposite view.  M.  Bouchut  considers it  a constitutional affection.  I
1 Mai. des Enfans, p. G04. 
148
ACUTE  HYDROCEPHALUS.
cannot resist the temptation to give the conclusion at which  Dr. J. R.
Bennett has arrived in his excellent work on this subject.  " 1. That  in
many instances the disease consists simply in inflammation of the brain
and its membranes ; the symptoms and the post-mortem appearances vary-
ing according as the inflammatory action is seated primarily in the sub-
stances of the brain or in the meninges, and according as it is more acute
or chronic ; and that in some of the more acute forms, rapidly termina-
ting in death, little or no  effusion may be found.   2. That in by far the
largest class of cases, the disease is essentially  the  result of scrofulous
action, and may or may not be attended by the signs of inflammation :
that the most characteristic lesions  in these cases  are the softening of
the central parts of the brain and the effusion of serum ;  but that menin-
gitis,  chiefly of the base, is a very frequent secondary lesion, and  is
usually of a manifestly strumous character, and that therefore in this the
largest and most fatal class, acute hydrocephalus is but a modification
of scrofulous disease.   3. That there are cases,  from these symptoms
hardly to  be distinguished from the last class, in which effusion into the
ventricles is the only morbid  appearance to be met with after death;
and that in these instances, the essence'of the disease appears to consist
in some alteration in the condition of the nervous matter,  probably allied
to irritation and that they may therefore be said  to constitute a purely
nervous variety  of  hydrocephalus.   4.  That there is a  class of  cases
distinct from the above, but closely  allied to them, which may generally
be traced to some source of exhaustion, either direct or indirect, in which
the post-mortem appearances are generally indistinct and of a trifling
kind,  consisting for the most part of some degree  of congestion of the
large  vessels and a little  effusion of serum ; and that in some of these
cases, the effusion has probably resulted from injudicious treatment had
recourse to with  a view to  cure an imaginary inflammation :  these being
the cases  described by Dr. M. Hall, and others, under  the designation
of bydrocephaloid disease."1
  193. Causes.—Age appears to have considerable influence  in predis-
posing to the disease, and this we should expect from the susceptibility
of the brain during its growth.  Certainly in these countries it is much
more frequent during the first six years of life than afterwards.   It is
chiefly during infancy that the first or second forms I have described,
are seen;  tubercular meningitis occurs  both during infancy and  up to
ten or twelve years of age.
  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 is some little difference in the liability of the two sexes ; rather
more males than females  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.
1 On Acute Hydrocephalus, p. 15G. 
ACUTE HYDROCEPHALUS.
149
  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. Steward 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, especially
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 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 p? 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 sci'ofulous 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 twen-
ty-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  thmn 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  movements 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 generally, but
occasionally slow.   From this state  very few recovered.
  I may add that it occurred  as an epidemic in 1840, 1841. and 1842,

            1 Lectures in Medieal Gazette, July 16, 1847, p. 93.
            2 llufeland's Journal  du Prat. Heilkunde, Aug., 1830. 
150
ACUTE HYDROCEPHALUS.
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); attacking
chiefly boys under twelve 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 subse-
quently 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 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 tvacuations.1
  An epidemic  also  occurred in Milbury and Sutton, U. S.,  and has
been  recorded by Dr.  Jos.  Sargent, of  Worcester.2    Of  16  cases,
scarcely one recovered. Death took place from  the 6th  to the 13th day.
It was not, however,  confined to children, and it  is remarkable that in
several cases there occurred petechiae over the body.   The appearances
I have described  presented themselves on  post-mortem  examination,
with the exception of the deposition of  tubercular matter.
  196. Among the exciting causes may be enumerated milk that disa-
grees with the child, mental distress in the  mother or nurse, of  which
I have  seen  several  examples,  prolonged lactation,3 indigestible food,
the sudden suppression of an eruption on the head, retrocession of fe-
brile 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 bombardment
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 in-
fantile remittent fever, towards the  termination of measles, or scarlatina,
or hooping-cough  ; after  a severe bowel complaint  (gastro-enteritis, fol-
licular enteritis, cholera infantum)  or diseases of the liver, as stated by
Harris, Curry, Yates, Thompson, Cheyne, &c.4

  1 Dublin Quarterly Journal of Medical Science, for August,  1846, p. 95.
  2 American Journal of Medical Science, July, 1849,  p. 35.
  3 Observations on the healthy and  diseased Condition of  the Breast, Milk, &c, by
Ed. Morton, M. D., p.  24.
  * Cheyne on Hydrocephalus,  p. 49.  Piorry de 1'IrritationEncephal., p. 52.   Golis, p.
71.  Eberle on Diseases of Children, p. 382. 
ACUTE HYDROCEPHALUS.
151
   It is occasionally, but rarely, connected with bronchitis,1 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 and 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 counte-
nance,  indicative of  oppression, pain,  and  despondency;  frequent
sighing ; a disposition to retirement; a heat, weight, pain, or heaviness
of the head, or all  these combined;  waywardness and fretfulness ; a
low, irregular fever ;  frequent  nausea or retching ;  an  irregular state
of the appetite and bowels,  and the  continuance of the diarrhoea," not-
withstanding  the remedies.   The  second stage  is marked  by  " the
heavy sigh, the deep moan, the  wild scream, the preternatural dilatation
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."2 M. Trousseau has pointed out two
symptoms of importance in the diagnosis of meningitis; one is a pecu-
liar suspicious breathing, and the  other a redness of the skin produced
by the slightest friction.  The former is very remarkable; the  child
takes a  long breath, and then remains without breathing for an  irregular
period of from ten to fifty seconds.   I have repeatedly observed this
occurrence,  although not so constantly as M. Trousseau.  The cutaneous
phenomenon exhibits itself several days before death, and is produced
even by a slight pressure of  the finger: it does not  appear to be con-
nected with febrile action, as it is  absent in many children who  have
high  fever.  There  are not many  diseases likely to be permanently
mistaken for meningitis, nor can we  easily confound a well-marked case
of the latter with another disease; but in  their  commencement some
diseases  do  exhibit somewhat similar symptoms, and some cases of me-
ningitis terminate like other diseases.
   199.  i. In  cerebral  congestion we have a  marked series of head
symptoms not  unlike  the commencement of hydrocephalus; there is
sleep, stupor, even coma,  with agitation of the  limbs, or rigidity, some-
times 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.   In meningitis 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 sunken 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

  1 Mills, Trans, of Association, vol. v. p. 361.
  2 Transactions of Association of College of Physicians in Ireland, vol. v. p. 440. 
152
ACUTE  HYDROCEPHALUS.
there is seldom more than one or two convulsions in such cases,  and in
a short time the occurrence  of eruption will  decide the question :  the
delav is of no consequence, as the treatment, so far as the head symp-
toms are concerned, must be similar.
  III. Infantile remittent or gastric fever seldom  presents  sufficiently
marked head symptoms, at  the  beginning, to be mistaken  for  hydro-
cephalus, but towards its termination, especially when there is follicular
ulceration, the aspect of the case is very similar.  The stupor and in-
sensibility, 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 paralysis, or even  the  twitch-
ings, 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  irregu-
larity 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 confess I do not think this
easy, except in extreme cases.   Certainly  those  cases of  the  former
which commence with high fever, delirium, convulsions, and terminate
fatally in two or three days, do differ widely from the gradual develop-
ment and slower progress of the latter ; but these cases are by no means
the most common, and in the majority of cases the course and symptoms
are so similar, that unless we have some collateral circumstances to guide
us (as, for instance, a  disposition to tuberculosis in other localities, or a
strongly marked scrofulous diathesis), I should not feel  much confidence
in a positive  diagnosis.
  The principal grounds of distinction  laid  down by  Mr. Rilliet, are:
1.  That tubercular meningitis  occurs in delicate, often precocious chil-
dren, and in those subject to glandular enlargements and chronic erup-
tions of  the skin;  whereas in simple meningitis, the subjects are vigor-
ous, well  developed, and healthy.   2.  That the former disease is always
sporadic.   3. That the child previously pines  away, and suffers from
disorder of the stomach and bowels.   4.  That tubercular meningitis
never commences by convulsions, and that the transition from the first
to the second stage is insensible, the advent of  the latter being marked
by  headache, vomiting, and constipation.  5.  That the headache  is more
intense, vomiting not so urgent, constipation obstinate, and fever moderate.
6.  That the progress is slow, and 7. That its duration is more prolonged. 
                     ACUTE HYDROCEPHALUS.                 153

  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 tubercu-
lar  meningitis may be cured  during the first period,  but not  one per
cent, at a more  advanced stage ;l nor is Dr. West's opinion more favor-
able.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 peri-
odicals, such as  those by Thompson,3  Uwins,4 Watson,5 Heinekin,6 in the
older journals, and more recently in the pages of the Edinburgh Jour-
nal, Lancet, Medical Grazette,  &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.
  1 have seen a considerable number of cases, and although when symp-
toms of effusion  are present the case is hopeless, yet at an earlier period
I have  succeeded in curing a much larger proportion than one might
have  expected,  considering the importance of the organ affected, and
the severity of the disease.
  202.  Terminations.—Some German writers have related  cases where
acute hydrocephalus terminated by a  critical discharge.   Meissner men-
tions one case in which epistaxis occurred, and another in which there
was a copious serous discharge from the eyes, with considerable mitiga-
tion of  the symptoms, and a third who  recovered after a similar evacu-
ation.   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 evacu-
ations, such as profuse sweating,  excessive secretion of  urine, eruptions
on  the face, &c.
  203.  The favorable signs which give hope of recovery after judicious
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  respira-
tion; dry, furred tongue; livid face; injected  conjunctiva; glazed eyes ;
increase of the startings and twitchings ; disturbed sleep ; wakefulness,
or coma, all announce a fatal termination.
  In some cases, but very  rarely, the severe  symptoms are mitigated,
and the disease  subsides down into chronic hydrocephalus,  as in a case
1 Diet, de Med., vol. xix. p. 403.
3 Lond. Med. Repos., Jan. 1814.
5 Lond. Med. Repository, Feb. 1816.
2 Lectures. Med. Gazette, July 16, 1847.
4 Med. and Phys. Journal, Aug. 1816.
6 Ibid., Sept. 1819. 
154                 ACUTE HYDROCEPHALUS.
of Dr. Monro's;  and probably this may be favored in young infants by
the distensibility  of the cranium, for certainly symptoms of compression
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, with or with-
out 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 convinced 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 sud-
denly attacked by acute meningitis of the  most severe character.  Six
leeches  were applied immediately  to the  forehead,  and  the bleeding
stopped:  the  convulsions became less  frequent,  and the fever  dimi-
nished ; in about eight hours six leeches  were again applied, and we
found that the convulsions did not return,  but the starting, and crying,
and restlessness continued ; and  consequently after the lapse of six or
eight hours we repeated  the six leeches, i.e., eighteen in twenty-four
hours, stopping 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;
secondly,  the cause and character 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  neces-
sarily modify the  treatment.   You cannot bleed a child of a weak con-
stitution so extensively 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.  Bloodletting.—In all forms of the disease, whatever be the con-
stitution of the child,  whether the disease  be primary or secondary, if
the attack be recent,  I believe bloodletting 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
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,

                 1 Piorry, de 1'Irritation Encephalique, p. 58. 
ACUTE HYDROCEPHALUS.
155
should be  carried  to  actual fainting—" not to faintishness,  but full
fainting."1  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; 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 bloodletting 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  bloodletting,
unless in very robust constitutions, is not always  to be repeated without
danger."   These cases answer to those I have made the second variety
(17r») of  the disease.  In  the first variety,  Dr. Cheyne approves of
ample and repeated bloodletting.
  In  tubercular meningitis, bloodletting 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.
  In  the first stage, Dr. Rilliet advises leeching, mercury, purgatives,
and  counter-irritants ; if it be in the second stage, calomel, mercurial
and iodine ointment, mustard cataplasms, and cold lotions  to the head;
if in the third stage, cold applications to the head, mercurial or iodine
frictions, suspension of the  calomel if there be diarrhoea,  and mustard
cataplasms.  When a child of strumous habit is threatened with menin-
gitis,  or is  seized suddenly with some of its symptoms, he prescribes the
treatment  for tubercularization in general, as iodine and ferruginous
preparations, iodine frictions to the  head, cod-liver oil, exercise in the
open air with the head uncovered, but not exposed to the perpendicular
rays of the sun.
  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-
tight bag 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
On Acute Hydrocephalus, p. 241. 
156
ACUTE  HYDROCEPHALUS.
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 head, and
so by degrees irritate the whole of the scalp.   This appears preferable
to keeping a blister open for any length of time.
  Dr. Cheyne recommends  that  they should be dressed with mercurial
ointment, so as to aid in bringing on mercurial action.
  Frictions to the head with tartar emetic are spoken well of by Golis.
  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, was  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 immediately,
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 inunction with the oint-
ment and liniment of mercury.
  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  re-
membered 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, not-
withstanding 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 internally 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 chil-
dren 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 consti-
tutional and cerebral irritation which it occasions.  And in  those cases
where the bowels are torpid, we must have recourse to purgative medi-
cines, which benefit by emptying the bowels, and act as derivatives 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 di-
arrhoea, that purgatives are  unnecessary;  in many instances there  are
1 Cheyne on Hydrocephalus, p. 41.
2 On Hydrocephalus, p. 111. 
ACUTE  HYDROCEPHALUS.
157
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.
  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 emetic
after bloodletting 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 the effect of  emetics, nor  do  I think  it would  be
wise.   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.
  There may however be another reason for giving small  doses of tartar
emetic.  If it be combined with the calomel, it has been found to quicken
the action of  the latter and so  save time.   I am indebted to my friend
Dr. Aquilla Smith for this suggestion.
  211. Drs. Cheyne and Stoker think very highly of James'spowder in
full doses at the commencement of the disease,  and the former mentions
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  recom-
mended 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 without 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 whether  opium is
at all admissible in this disease.   Cheyne thinks it useful, joined with
an aromatic, in correcting bilious vomiting and  purging. _ Golis is en-
tirely opposed to it.  Mills speaks favourably 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 with-
out any injurious consequences.
   214. Iodine has been used,  and it is said with  benefit.  Dr. Evan-
son is  favorable to its employment, and Rilliet  and others strongly
recommend  it.  Dr. Roser tried the hydriodate of potash and  recom-
mends it when other remedies have failed, and even when paralysis has
occurred.   He dissolves a drachm of the  hydriodate in half an ounce of
water, and gives thirty drops of the solution in  water every hour.2   Mr.
Finder, of Lymiugton, has related three cases of hydrocephalus in the

  1 On the Fatal Diseases of Children, p. 192.   2 llufeland's Journal, April,  1840. 
158
ACUTE  HYDROCEPHALUS.
advanced stage treated successfully by half a grain of the hydriodate of
potash every  two hours.  The only apparent effects of the medicine
were diuresis and salivation.1
   So far as they go, these cases are encouraging.   I have not seen such
good effects from its use, but I certainly think it  deserving  of  a more
extended trial.
   215. Phosphorus has been strongly recommended by M. Coindet, in
combination with three parts of oil of almonds.  It is a very uncertain
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. Cloquet
recommend quinine as having been successful in saving several cases.
During convalescence it is undoubtedly  of great value.
   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  mitigation
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 necessary
attendants  admitted, and absolute silence enjoined as far as possible.
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.
   220. Thus, in the first and second stages of meningitis, our remedies
are: bloodletting in proportion to the  age,  strength, and constitution
1 Med. Gazette, Sept. 30, 1842. 
ACUTE  HYDROCEPHALUS.                 159
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,  hydriodate of pot-
ash, cold  applications, iodine frictions, or repeated blistering of the
head, are  nearly all that we can do with any prospect of benefit.
   221. Lastly, most anxious inquiries  are made of us by parents who
have lost  one child from hydrocephalus  as to the best mode of prevent-
ing the disease in others.  We have  no medicine  which will do this ;
but, nevertheless,  much may be done by good  care and judicious  ma-
nagement.  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 and
in the open air, be encouraged in  running and  jumping, and the ordi-
nary outdoor 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 shower-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  edu-
cation should be carried  on very cautiously;  the attention should  only be
occupied  for a short time together, the memory not overburdened, 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 nutritious, 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 or four threads are
 enough),  from having witnessed the good effects in  several cases. 
160
CHRONIC  HYDROCEPHALUS.
                       CHAPTER  VII.

                      CHRONIC HYDROCEPHALUS.

   222. The chronic form of hydrocephalus is much more rare than the
acute, still we meet with the disease occasionally in children of different
ages,  from  birth up  to  puberty.  I  have already  spoken  of  hydro-
cephalus  as  occurring during intra-uterine  life, and  I  may add that
even of those cases which occur  after birth,  there is  good ground for
believing  that many commenced during intra-uterine life.
   Chronic hydrocephalus may be divided into two species, the congeni-
tal, including those, the causes of which can be traced back to birth or
previously, and acquired.
   223. I. Congenital Hydrocephalus.—This may coexist with  a head
less  than  usual, of the natural size, or of increased  volume.  Bouchut
considers  the second case more frequent than the first, but Dr. Battersby
denies this, and states that the first is always congenital.  " Most fre-
quently children with a head of diminished size have at  their birth the
fontanelles closed, and the sutures ossified.   Most of these children die
as soon as they are born, or perish in  convulsions  a very  short time
after birth.   They are absolutely deprived of intellectual faculties, and
their senses are obliterated.   The head of these little ones is constantly
pointed at its summit, and depressed laterally towards the ears.  The
forehead is also flattened, and the head covered with thick hair. The eyes
are constantly convulsed, they rotate, and are insensible to the light; the
pupil is much dilated, and in some cases the iris has appeared to adhere
to the cornea.   The face, without any expression, is the image  of stu-
pidity. The voracity of these children is great, yet nutrition is badly
performed; liquids are swallowed with great difficulty; they lose their
breath, and excite fears for their  suffocation.  The stools and urine are
discharged involuntarily. The voice is a feeble  and hoarse sound. The
feet  are crossed  immovably;  the thighs are flexed on  the abdomen.
These unfortunates can never stand nor walk.  Their extremities "are
cold.  They appear  to have only  a vegetative existence;  they never
exhibit a  spark of reason, and are one of the saddest pictures of hu-
manity."1  To this  form of  disease, Cruveilhier proposes to apply the
term microcephalus, and he divides it  into three varieties: 1. With
atrophy of the brain.  2.  With serous effusion into  the cavity of the
cranium;  and 3.  Where there is  atonic atrophy and  effusion.2

  1 Battersby's Essay, Ed. Med. and Surg. Journal, Jan. 1851. In rewriting  this chapter,
I have availed myself very freely of my friend, Dr. Battersby's able and learned papers,
in which are collected nearly, if not all the facts on this subject, and in which the differ-
ent points are investigated with great care and acuteness.
  * Anat. Path., Livr. 3, PI. 4. 
CHRONIC HYDROCEPHALUS.
161
  Cases of hydrocephalus with the head of the natural size or unusually
small are related by Mr. Ward1 and Dr. Battersby.
  Hydrocephalus with an enlarged  head is undoubtedly the most fre-
quent ; there may be no evidence of the  disease at birth, or so slight
that it excites no attention, and yet the morbid cause may be, or may
have  been some time at work, and the case strictly one of congenital
hydrocephalus.2
  Barrier remarks that although at birth the head may not be unusually
large, yet as the functions of  innervation are too feebly 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.3
  224.  n. Acquired chronic hydrocephalus, as Barrier observes, is some-
times, though rarely essential, idiopathic, and analogous to other essential
dropsies;  at other times it is symptomatic of another  disease.   The
most common disease giving rise to it is tubercle in the brain, or a can-
cerous or other tumor.   Such  cases  are mentioned in  the  works of
Bonetus, Morgagni, Lieutaud, and Portal.   Lallemand, John Hunter,
Danz, and Constant, mention tumors of the cerebellum with fluid in
the ventricles; but they do not state whether  there was compression
of the straight sinus.  Magendie attributes hydrocephalus, among other
causes, to an obstruction to the flow of the cerebro-spinal fluid through
the ventricles, and has given cases of hydrocephalus with compression of
the fourth ventricle by a tubercle  of the  cerebellum;  by an aqueous
tumor upon the aqueduct of  Sylvius, the valve  of Vieussens, and the
fourth ventricle, and also by compression made  upon the mesocephalon
and the fourth ventricle by an  exostosis of the basilar portion  of the
occipital bone.   He also alludes to cases  of hydrocephalus with com-
pression  of  the  fourth ventricle by a fibrous tumor, developed  in .the
valve of Vieussens, or by tumors of different kinds seated in the annular
protuberance.4
  Barrier gives  three  cases of hydrocephalus from  compression of the
straight sinus, in  children aged 3, 4J, and 5 years.   He  conceives
that  the anatomical conditions  of this form  of hydrocephalus are, 1.
That the tuberculous tumor should occupy the middle lobe of the cere-
bellum.  2.  That  it should make superiorly  a  projection sufficiently
considerable  to  throw up the tentorium cerebelli, and to compress the
straight sinus.5
  Rilliet  and Barthez  agree with M. Barrier that compression  of the
venae galenae, or straight sinus, whether by a tumor in the neighborhood
or by an  obstruction in the cavity of the sinus, or  by its obliteration,
as related by Tonnelle,6 is the most  frequent cause.
  Dr. Whytt  relates a case in which  a scirrhous tumor, occupying the
situation of the pituitary gland, by compressing the neighboring veins,
gave rise  to effusion.
  225.  Hemorrhage into the arachnoid very often resembles hydroce-
phalus, either, as Rilliet and  Barthez suppose,  by a separation  of the

  1  Lond. Med. Gaz., March 27, 1846.     2 Bouchut, Mai. du Nouveaux Nes, p. 450.
  '  Mai. de l'Enfance, vol. ii. p. 585.      4 Sur le Fluide Cephalorachidienne, p. 74.
  &  Mai. de l'Enfance, vol. ii. pp. 594, 603.  6 Mai. des Enfans, vol. ii. p. 32
       11 
162
CHRONIC HYDROCEPHALUS.
serum  and crassamentum, or by  exciting inflammation  and effusion,
according to Breschet and Legendre.1
  226.  Lastly, it would appear  that chronic hydrocephalus may be  a
sequence of the acute meningitis  already described.2   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 mitigated form.
  Dr. West observes that, even where no false membrane is found within
the ventricles, their lining often presents other  evidence, besides mere
thickening, of its having been the  seat of inflammation.  Sometimes it
is very hard and granular, presenting an appearance closely resembling
shagreen, and communicating a  very perceptible sense of roughness to
the finger.  " These and other  similar alterations of the lining of the
ventricles, afford conclusive evidence of the inflammatory origin of most
cases of chronic internal hydrocephalus."
  M. Billard thinks that  chronic  hydrocephalus succeeds almost con-
stantly  to acute meningitis, and I have seen one case at  least which
seems to confirm  this view.
  At the same time  I must  not conceal that many authors—Barrier,
Rilliet and Barthez, Breschet and Battersby—are opposed to this opinion.
  227.  Symptoms.—I have already quoted a description of symptoms
in those cases in which the head is smaller than  usual.
  In other cases of congenital hydrocephalus, the symptoms  at first may
not be very  striking, some want  of muscular power or feebleness  of one
side seems less perfect than usual, rather less intelligence than ordinary,
and no attempt at  articulate speech, will probably be all the phenomena
to be observed.
   The same may be said of most of the cases of acquired chronic hydro-
cephalus in the early period  and at  an early age.   If  the attack come
on  at  a more advanced age, there  will be a sort of retrogression of
development; the  child will lose its muscular power, or the natural exer-
cise of it, the senses and intellect will  be more or less deranged,  &c.
   But if the case be one of chronic meningitis,  the  train of symptoms
are a good  deal  changed in character.   Dr.  Copland thus describes
them:  " Chronic meningitis commonly succeeds to the acute form of the
disease, but it often presents the chronic characters from the commence-
ment.   There is generally continued headache, with slight somnolency,
sluggishness and incapacity or want of desire for  intellectual exertion,
moroseness, irritability of temper,  sometimes confusion  of ideas, embar-
rassment of speech, and  delirium, terminating  in confirmed mania or
idiocy.   The  motions  of the limbs  are slow, difficult, or painful, and
their muscles are subject to  involuntary motions and twitchings,  and
sometimes are not under the control of volition, or are altogether para-
lytic.  Vomiting and convulsions are rarely present, excepting in infants,
where they  are often the chief or  only signs.   In children  the peculiar
knitting of  the -eyebrows, retraction of the angles of the mouth, whin-

        1 Revue MeU, Dec, 1842.    * Copland's Dictionary, part i. p. 230. 
CHRONIC HYDROCEPHALUS.
163
ing or peevish cry, stupor, grinding of the teeth, scanty urine, obstinate
costiveness, and increased  heat of the head, are the chief symptoms."1
   228. At a more advanced stage, the symptoms are common to all the
varieties of chronic hydrocephalus which commence after  birth  with
Borne modification.  The organs of sense are all more or less  affected,
the eyes are turned upwards or downwards, or to one side, and unequally,
bo that the patient squints; the  pupils are dilated,  and the dilatation
generally increases with the amount of compression; the sight is  com-
monly weakened by degrees until it is finally lost, although in some it
is preserved to the end.  The nares become dry and insensible to odors ;
the hearing, which was delicate at first, is lost by degrees ; the taste is
generally preserved longer, and in some cases is perfect to the last; the
touch  is unaltered  longer than any other sense, and may even be more
acute than usual, although in many cases it becomes blunted.
   Dr. Bright  observes that sometimes at birth, and sometimes within
a few weeks after, the sight is lost, though the hearing generally remains
acute, and  as the months pass on, instead of the  intellect gradually
developing itself,  the mind is almost stationary and  the  powers of the
body are  paralyzed.   Patients so  affected generally lie in bed with the
body and  legs much bent and contracted, and lose the power of straight-
ening  themselves, and some have  entirely lost the power of their legs,
and  retain a slight power of their  arms.2
   229. The state  of the intellect varies in different patients.   Perfect
idiocy results from congenital hydrocephalus, as in  the cases related
by Schmitt3 and Battersby; and this is  confirmed by Espinol's experi-
ence.4  But in acquired chronic hydrocephalus, as a general rule, after
effusion has taken place to any extent, we find the intelligence more or
less  affected, excepting perhaps in some of those cases where the  head
rapidly enlarges.   After a time, it is evident that the child has not the
mind of his age; it has become stationary, and then it retrogrades until
he acquires the  look of an idiot,  forgetful, scarce understanding  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 twenty-nine, whose head  began to enlarge three weeks
after birth.  He entirely  lost  the use of  his limbs,  a slight movement
of the arms alone  excepted.  He  was never  able to quit  his cradle
unless assisted by three or  four people.   As he  never made use of his
feet, they remained extremely small, and looked like those of a boy of
twelve years, forming an odd contrast with the rest of his body, which
was  as large as that of a full grown person.  His appetite and hearing
were both good.   His sight was imperfect, and he squinted.  His men-
tal faculties were not contemptible, though he  was generally considered
an idiot on account of his  looking so stupid.   His spirits were always
good, and he was glad  to see people.5

  1 Dictionary of Pract. Med., part 1, p. 230.     2 Reports, vol. ii. part i. p. 424.
  3 Bibliotheq. German., vol. vi. p. 264.         4 Mai. Mentales, vol. ii. p. 335.
  5 Lond. Med. Communications,  vol. i. p.  404. 
164
CHRONIC HYDROCEPHALUS.
   Dr. Monro relates 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.
He states, moreover, " that it is incredible how little the powers of the
mind are  impaired by  this disorder, considering the great enlargement
of the  ventricles of the  brain.   I  have had opportunities of seeing
several examples of this form of hydrocephalus, and  have watched the
progress of the symptoms for years, yet I have never met with  any one
instance in which the powers of the mind could be said to be completely
deranged."1
   Dr. Spurzheim has described several cases in which the mental powers
were not impaired; one in particular, a learned man, " whose  head is
extraordinarily high in 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 results 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."2
   I  have a little child of four or five years old under my care at  present,
who has been the subject of  chronic hydrocephalus, apparently follow-
ing  an  acute attack, and whose head  measures twenty-three inches  in
circumference, whose intellectual  faculties  are apparently in a  state  of
perfect integrity.
   But,  as a general rule, I quite agree with Dr. Watson that "most
commonly the  mental  and voluntary  functions are maimed and per-
verted,  as may be seen in the cases  related by Howship, Solly,  Chatto,
Rett, Craigie, Ecmark, and Ryan, referred to in Dr. Battersby's paper,
as well as those added by himself.
   230.  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 when these are  ossified,
enlargement has taken place.  The amplification is of the vault of the
cranium only, the hair remaining  nearly unchanged;  and it has been
thus described by Dr.  Battersby: "The water of the  cranium  recedes
from its centre, and  the head augments  in  volume according as the
quantity of fluid becomes considerable.  The bones of the face neither
participate in nor contribute  anything  to this enlargement.   They pre-
serve their natural volume and form.   The bones of the  cranium con-
spiring  to its enlargement are the frontal, parietal, the superior part  of
the occipital, and a  small part of the squamous portion of the temporal
bones.  These bones become expanded, thinned, and membranous.   The
frontal  expands, is elevated, and advances forwards over the eyes and
the  face,  which looks  narrower  and  shorter.   The angle which the
superior part of the frontal now enlarged forms with its orbital portion
diminishes, and is effaced almost  entirely, so that the eye is driven
down and  concealed by the lbwer lid, which ascends to the level of the
centre of the pupil.   Camper remarks  that this disposition alone would
suffice to recognize chronic hydrocephalus, even although all the rest  of

   1 On Hydrocephalus, p.  138.     a Monro,  Morbid Anat. of the Brain, p. 138. 
CHRONIC HYDROCEPHALUS.
165
 the head were covered.   The  bones forming the vault of  the cranium
 are  separated, and  the  intervals, more or less large, separating them
 are  occupied by a  fine  membrane, through which fluctuation of the
 water inside ean be felt distinctly.   This  separation  is very great
 between the  parietal  bones, especially at the fontanelles.   The mem-
 brane filling these spaces is sometimes  distended to such a  degree as to
 form a very visible longitudinal  tumor.   On  pressing strongly the
 fingers  upon these  parts of the head, no depression  is left, and the
 intervals of  the  bones  yield  to the compression like a bladder full of
 water.  On gently striking one of these intervals, the liquid can be felt
 at the opposite side.   Resistance is felt everywhere else, that is, in the
 parts naturally ossified."1
   For a considerable time the  face is unaltered, or if anything, it seems
 to shrink, and the aspect of the enormous head with the si-nall face gives a
 very peculiar expression to the child—the fades hydrocephalica, ask has
 been termed : an old,  withered,  semi-idiotic look.  Dr. Monro states
 that in  the end the bones of the face are enlarged, and the angles of
 the eyes more distant from each other.
   When the enlargement of the head is great, its weight is inconvenient,
 so that  the child  has much difficulty in  supporting the head upright, and
 in extreme cases, when the muscles of the neck are weakened, it  is quite
 unable to do so, and either reclines it  on one shoulder  or on some arti-
 ficial support.
   231.  The power of locomotion is enfeebled in all cases, and in many
 absolutely lost.   The limbs are weak and the walk uncertain and trem-
 bling, requiring assistance and support, until, from the  atrophy of the
 muscles or  want of innervation, the child is unable to  walk at all, and
 remains in the recumbent position.
   In other cases  the paralysis is observed earlier, even from the begin-
 ning, and as  Dr. Bright remarks, the patients lie abed with their  legs
 bent under them, or as in  Dr.  Ryan's case, where the child was nearly
 deprived of the functions of vision,  hearing, taste, smell, and touch, and
 entirely of voluntary motion ;  and in  those of Dr. Battersby's cases.
 In some cases one leg only is affected;  in others, the lower half of the
 body, and occasionally the entire extremities.
  Not unfrequently the child  is attacked by general or partial  convul-
 sions, and these may immediately be followed by  paralysis, which may
 extend to the muscles of organic life, giving rise to difficult deglutition,
 retention of urine, or constipation, or involuntary evacuations.
  The respiration, circulation,  and digestion are apparently unaffected
 for a considerable time.   Many  patients have  a  good  appetite, nay,
 even a voracious one, and  digest well, though 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 at length becomes  labored, with an  access  of dyspnoea.
 The  appetite also diminishes ;   there is  little relish for  the  food taken,
and  emaciation advances rapidly.  In  short, as M. Barrier has pithily
On Chronic Hydrocephalus, Edin. Med. & Surg. Journal, Jan. 1850. 
166
CHRONIC HYDROCEPHALUS.
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.
  I am not aware whether the cephalic bruit exists in chronic as well as
in acute hydrocephalus.  Drs. M. Barthe and Roger could not detect it.
Rilliet and Barthez heard it in one  case  resembling  chronic hydroce-
phalus, but on dissection the brain was found to  be healthy.  I tried in
two of Dr. Battersby's cases and one of my own, but failed to discover it.
  232. Pathology.—We have already seen  how much the  head is al-
tered in size and shape, that the bones are widely separated, feeling  as
if loose underneath the skin, and that a species  of secondary tumor is
formed by the protrusion of the water.
  The bones of  the cranium are sometimes of their  natural thickness,
but more frequently they are  thin, weak, semi-transparent, resembling
parchment rather than bone.   They are very porous, and the radiating
fibres around each point of ossification are very visible.   Dr. Battersby
observes " that the first lineaments of the Wormian bones are observed in
hydrocephalic  subjects of a very tender age.   Breschet remarked little
osseous needles in the membranes by which the edges are most generally
united.  These needles are very remarkable  in  the  skull of a  hydro-
cephalic foetus preserved in the Museum of the Rotunda Lying-in Hos-
pital."
  On the other hand, the bones are sometimes found thicker than natu-
ral.   Ecmark, Malaconne, and Kartell have found them  of  a thickness
proportioned to their surface or to the volume of the head.   Riedlin says
he met them twice as thick as natural in a hydrocephalic  head of seven-
teen years.  Joder speaks of a child two years old in  whom all the
bones  of the vertex had a thickness of nine or ten lines.   The cranium
described by Molyneux was so thick  that the  physician took the head of
the patient for that of a giant.  Breschet met with a case  of hydroce-
phalus in which  the bones of the skull had the thickness natural to a
well-formed adult,  and which were united  by solid suture.
  The size of  the head varies widely.  In some  cases it  is  very great.
Meckel states  that he had seen a foetus of seven  months,  the transverse
diameter of whose  head was sixteen inches.   The head of another foetus
come to its full time was, at birth, fifteen  inches in circumference and
five  inches in height.  Another by Willan,  at twenty months, was
twenty-eight inches  in circumference and nineteen  from ear to ear;
one by Freind at two years was  twenty-nine  inches.  A head  in the
Museum of the Rotunda Hospital, Dublin,  is stated to have been twenty-
two  inches in circumference when  the mother  was delivered by the
crotchet.  Wrisberg delivered a Jewess with the crotchet, and the head
was  ten  inches  long and  thirty  and a  half in circumference.  Dr.
Monro's  case, at nine years, was thirty-six  and a half inches  in cir-
cumference.  The head in Bartholin's case was  forty-eight; in  Cruik-
shank's, at sixteen months, fifty-two inches.
  The quantity  of fluid found in the hydrocephalic  heads is often very
considerable.   Willan, in a child aged twenty months, found four quarts;
Ecmark eight  pounds, and Duncan eight  pounds eight  ounces; Wris-
berg, in the Jewess's child, nine pounds ; Brittner, twenty  pounds; Steg- 
CHRONIC HYDROCEPHALUS.
167
man, twenty-four pounds;  Cruikshank, twenty-seven pounds; Sequard,
thirty-six pounds, and Sichel, fifty pounds.1
  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.......0.090

  Other analyses by Marut, Bostock, and Berzelius give nearly  the
same results.   The fluid withdrawn by puncture  by Dr. Battersby, at
eight different times, ranged from 1006.5 to 1014 spec, gravity.  "Al-
bumen  was  always present, but  in  very variable proportions;  the
quantity was sometimes very great, as at the second and  third  punc-
tures, when it nearly equalled that in the fluid of ascites, forming when
heated  a solid mass like  the coagulated white of egg.  It sometimes
amounted to a mere trace, and  the specific gravity was  influenced by
the amount of  it present, so that  the former became a measure of  the
quantity present.   Nearly the same salts were found in  all the  speci-
mens, and generally in  about the  same proportions, viz: a large amount
of the chlorides of potassium  and  sodium, small quantities of the sul-
phate of soda and the phosphate of lime, and a little free alkali, which
always  gave the fluid an alkaline reaction."2
  According to Breschet3  the fluid may be contained (a) between  the
dura mater and  the cranium;  (b) between the dura  mater  and  the
arachnoid; (c)  in the cavity of the arachnoid; (d) in the ventricles, or
(e) in the laminae  of the pia mater.   The cases of ventricular hydro-
cephalus are very much the more  common, and in most cases there will
be some fluid found in the  spinal canal.
  A recollection  of these different localities will in a great measure  en-
able us to  understand  the various conditions in which  the brain  has
been seen 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 naturally result
from compression exercised upon it by fluid on its outer surface; or it
may be, from extreme distension, assume the appearance of a thin, almost
membranous bag,  as in  Dr. Battersby's cases and  many others.   Ac-
cording to the  amount of distension will be the thinness of the walls of
this pouch, and in extreme cases, it will be difficult to distinguish  be-
tween the white and gray matter,  or to  recognize the central  portions
of the  brain at  all.   Generally  we find the corpus  callosum raised
nearly to the skull, the septum lucidum defective or injured, the corpora
striata  flattened,  the nerves  atrophied or softened,4 or  there  may be
no traces of these parts at all.5   The substance of  the brain  may  not
only be unusually diminutive, but  it may be softened and more or less
disorganized.6
  The membranes in all cases of  congenital hydrocephalus exhibit no

  1 Battersby's paper, Ed. Journal, Jan. 1850.  2 Ed. Med. and Surg. Journ., Oct. 1850.
  3 Diet, des Sciences M6d., art. Hydrocephale.  4 Bouchut, Mai. des Nouv. Ne"s, p. 453.
  6 Monro, Morbid Anat. of the Brain, p. 31.   6 Stewart, Dis. of Children, p. 525. 
168
CHRONIC HYDROCEPHALUS.
morbid alterations; and even in acquired hydrocephalus,  these changes
are not very frequent.   The  dura mater is  seldom altered, but  M.
Breschet mentions the absence of the  falx cerebri.   The arachnoid is
sometimes whiter than usual, and infiltrated with serum.   The pia mater
is excessively thin, but not destroyed.
  On the other hand, some  cases occur  in which  there  is evidence  of
inflammation, as in the  case described by Dr. West, which  I have al-
ready quoted, where the membranes were thickened and rough with gran-
ulations, or covered with a layer  of false membrane  both  at the base of
the brain and in the ventricles.
  233.  A question  of  some interest  in pathology still  remains,  viz:
What is  the  proximate or  pathological  cause of congenital hydroce-
phalus?
  After a very careful research  and a minute examination of the con-
dition of the brain in these cases, Dr. Battersby has  come to the con-
clusion  that  chronic hydrocephalus  is  always  congenital,  and  that
congenital  hydrocephalus is due to  an arrest of  development, thus
confirming the opinion of Meckel.1  M.  Breschet observes, "there is a
circumstance to which I  shall direct  the  attention of physicians, and
which appears to explain the frequency of serous  intercranial effusions
in general, and especially of congenital hydrocephalus.   The fine re-
searches of M. Magendie on the cerebro-spinal fluid leave no doubt of
the existence of this"  liquid at all periods of life, intra-uterine and extra-
uterine, and its abundance as well as  its constancy appears to demon-
strate that this liquid -performs important  functions.  Here, then, is a
natural hydrocephalus, or one which is united with the regular perform-
ance  of the  functions of the brain and spinal cord.   The study of
organic evolutions has caused this fluid to be recognized as more abundant
at the first period of the formation of the cerebro-spinal nervous centres
than at any other epoch of life.   From the existence of this  fluid, from
its  more considerable quantity during the first phases  of  life, to the
existence of hydrocephalus,  there is but a degree."2
  Now  if we compare the condition of the different parts of the brain,
as the corpus callosum, fornix,  septum lucidum, &c, in the case of con-
genital hydrocephalus, with  the description by Tiedemann, of the brain
of the foetus at different periods, we shall see sufficient exactness to lead
to the belief  that an arrest  of development did take place at a certain
period,  whether in consequence of the increase  of the  head, or  from
some other cause.
  If, moreover,  Dr.  Todd's  opinion be generally accurate, that " when
an  arrest of development of any portion of the cerebro-spinal axis has
taken place, the space which ought to be occupied by  the organ of im-
perfect growth  is filled with  liquid,"3 we have the  case pretty well
proved, and may  conclude  with Meckel, Breschet,  Duncan, and Bat-
tersby,  that " whatever be  its  remote cause, congenital chronic hydro-
cephalus depends on an arrest of development of the brain, or, according
to Mr. Anderson and Dr. Coste, of the proper brainy material."

            1 Anat. Pathologique,  vol. i. p. 262.
            2 Diet, de Med., art. Hydroceph. Chronique, p. 511.
            3 Cyclop, of Anat. and Phys., part xxv. p. 642. 
CHRONIC HYDROCEPHALUS.
169
  Differing, as I do, in some degree from Dr. Battersby, in not regard-
ing every case  as congenital, I should not, of  course, apply any  such
explanation to those cases  caused by tumors or local pressure of any
kind, or to those still fewer, the result of inflammation.
  234. The  duration of the disease varies so much in  different cases
that no general rule can be laid down.   Some  cases  live for a year  or
two, and then die; others live for twenty or thirty years a sort of vege-
table life.  Those who are attacked by the disease after the  sutures are
ossified, are carried off much more rapidly than others,  because of the
greater pressure upon the brain ; but if the amount is not greater than
the brain can bear, and if its  increase be  arrested,  then life may  be
prolonged.
  Sooner or later, however, almost all the cases terminate fatally,1
either from the pressure, from  an  attack of acute disease, or  from the
absence of due nervous influence upon the organs necessary to life, and
the consequent failure of those functions.
  235.  Causes.—I have already  mentioned the proximate  causes  of
this disease and as to exciting causes, such as blows, falls, cold, worms,
&c,  our  information  upon the subject  is  so  vague that  it  would be
unwise to found any definite opinion upon it.
  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.
  If there be any fever, the case might at first present some resemblance
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
tumors or tubercles  of the brain,  inasmuch as the muscular weakness,
want of equilibrium,  headache,  and in some cases vomiting, are common
to both.   Probably the age and constitution of  the child, and the dura-
tion of the disease, may throw some light upon the matter, as, for instance,
in a child exhibiting  scrofulous tubercles, in other situations we might
suspect that the head symptoms proceeded from a similar cause.
  After enlargement  has taken place, if the sutures be ossified, it might
in some cases be hard to distinguish between chronic hydrocephalus and
hypertrophy of the brain, there being many symptoms in common be-
tween them : if the  sutures be  not ossified, the presence of fluid can
scarcely  be mistaken, and in the  former case, I should think that the
history of the disease would be  a tolerably safe  guide.
  237.  Treatment.—The principal  internal remedies from which we
have any  hope, and but very little  from  them,  are mercury, sudorifics,
diuretics,  and purgatives, with  the  occasional  abstraction of a  small
quantity of blood, if there  be  any  evidence of congestion  or inflam-
mation such as quicker pulse, heat  of scalp, or turgescence.
1 Barrier, Mai. de l'Enfance, vol. ii. p. 612. 
170                CHRONIC HYDROCEPHALUS.
  Dr. Watson  speaks in favorable terms of Dr. Graves' plan in two
instances.  Ten grains of crude mercury,  one scruple of manna, and
five grains of fresh squills are to be rubbed together for one dose, to be
repeated every eight hours.  The first patient, a lad who had  been ill
for  two or three  years, took the  above dose three times  a day for
nearly three  weeks,  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 fort-
night,  when  all the  symptoms  of the disease had  disappeared.   The
boy  was  greatly  emaciated.  He was then ordered an ounce and a
half of Griffith'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, and
the result was a  permanent cure.  The strength of the  dose  must of
course be modified according to the age and  strength of the child.
  I  may  say indeed that mercury  in  some form or other,  from its
control over the inflammation of serous surfaces, and 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 most cases.  Dr.
Reid, Clanny, and others,  recommend it to be given in  large doses, and
state that they have found  it very useful.   I confess from my own
experience I should  prefer moderate or small  doses, as producing less
disturbance.   At  the same time, we  may increase  the  rapidity of the
mercurial action by using  inunction with strong mercurial ointment, or
by dressing the blister with it.  Mr. Wilson  speaks strongly in favor
of mercurial inunction  as a means of reducing the size  of the head.1
   Golis recommends  calomel internally, mercurial frictions to the head,
and  slightly irritating baths, generous but not stimulating diet, and fresh
air when  the weather is suitable ;  by which means he seems to have
been very successful.
   M. Barrier mentions that iodine has  succeeded in a few cases,2 and
from its benefit in scrofulous cases it seems  deserving of a trial.   Drs.
Maunsell and Evanson  speak favorably of it.
   More recently Dr. Guerond3  and Mr.  Hoskyns have published each
a  case  in which  iodide  of  potassium was  given  with great  success.
Half a grain may be  given every four hours  to a child two years old.
   238.  Counter-irritation by blisters  or issues is doubtless of great use,
and  when bleeding is inadmissible it  is the best means of reducing the
chronic inflammation.  Almost all writers are agreed upon the employ-
ment 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.4
   239. Two other external modes of treatment have been proposed, and
to a certain degree have been successful.

  1 Monro, Morbid Anat.  of the Brain, p. 146.     2 Mai. de l'Enfance, vol. ii. p. 614.
  3 American Journal of Med. Science, 1851, Ranking, vol. xiii. p. 330.
  4 Trans, of Association, vol. v. p. 457. 
CHRONIC HYDROCEPHALUS.
171
  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.1   Sir Gilbert
Blane used bandages around the head ;2  Mr. Barnard straps of adhesive
plaster ;3 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 case3,  ten  in number, the fluid  was absorbed,  and the
patient recovered.4
  Other successful cases are on record.5
  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. Trous-
seau 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.6   If symptoms of
compression appear they must be loosened, or if the skin be  irritated
they must be removed.  Drs. Watson and West recommend the trial of
Dr. Arnott's air press, as probably superior for the purpose of  com-
pression  to any other means.
  240. n. Puncture of  the cranium  and  evacuation of the  fluid  was
proposed by some of the  older  surgeons (Severinus and Le Cat,  &c),
and in recent times has been  practised  by Vose, Rossi, Conquest, and
many others.
  In  the former  edition  I mentioned  that a  considerable  amount of
success had  attended the operation, but the careful investigation of Dr.
Battersby has shown that  there is reason for believing this to have been
overestimated.   Of 5Q cases included  by Dr. West in his list, 16  were
said to have recovered, but the list of cases, on strict inquiry, appears by
no means so favorable to  the operation.  Some were merely relieved,
others remained the same ; others had  not been seen for some time, &c,
so that, according to Battersby, "the conclusion we are justified in hold-
ing from an examination of the 16 cases reported by West, is, that not
more than four  of these (Graefe's case  and three of Conquest's, which I
still  look upon  as doubtful) were cured."   Three other cases are re-
ported as cured by Drs. Whitney,7 Edward,8 and Kitsell.9
  On the other hand, besides the 40 unsuccessful  cases  in  Dr. West's

  1 Obs. Commun., 6.
  2 Lectures on the Structure and Physiology of the Bones, p. 269.
  3 Lancet, No. 137, p. 52.                  4 Archives Gen. de MeU, June, 1838.
  5 Lancet, No. 841, p. 82.
  c West's Lectures, Medical Gazette, August 16, 1847, p. 270.
  7 Amer. Journ. of Med. Science, Oct, 1843, p. 303.
  6 Ed. Monthly Journal, p. 398, 1846.         9 Amer. Journal,  Jan. 1850, p. 218. 
172
CHRONIC  HYDROCEPHALUS.
list,  there are many other failures on record.  " Monro states that at
Liverpool, after Vose's case, several cases were operated on which died.
Breschet operated several times without success,2 as did also Dupuytren
three times.   Dr. West has given a fatal case from Fabricius Hildanus.3
A like  unsuccess  attended the  cases  given by Tulpius,4 Schenkius,*
Ferdinandus,6 Panarolius,6  Muraltus,6 Wepfer,7 Forestus,8  Francus,9
Schenkser,10Zang,11 Junker,12 Sorbait,12 Petit,12 Loftie,13 Froriep,14 Lee,15
Vose,16 Jeffrey,17 Dickinson,18 as also the  more recent cases of Wod-
roofe,19 Watson,20 Dendy,21Parkman,22 Whitney,23 Bellingham,24 Taylor,25
Campbell,26 Storks,26 Martin,2 7Gotz,28 Chater,29  Fergusson,30 Physick,31
Taylor,32 Pepper,33 and Battersby.34  We have already seen  that Hol-
brook, Kilgour, and Fergusson punctured the head  without  effect, as
also  did Mr. Dendy, five times, whilst  Monro and Watzer  opened the
dura mater alone.   Spengler and Barruel also appear  to have punctured
the brain, but with what  effect I have been unable  to learn.   An accu-
rate examination of  ancient and modern medical works would very pro-
bably discover other cases, but the above  authorities, along with the
forty cases  in Dr. West's  table, give about 100 unsuccessful, against
seven alleged successful cases, or, in other words, one patient in 14 was
cured by puncturing the head.   But this proportion I do not regard  as
by  any  means  exact, as  I  have  known of the  operation having been
performed in Dublin about ten  times unsuccessfully, and I  have heard
of others in  the  country,  in  which it was undertaken ineffectually.
Unfavorable results  are seldom recorded."3*
  Now,  if we could ascertain that  the  fluid was external to the  brain,
there might  be  some hope that in such cases, relief and even  cure might
be effected by letting out the water,* but as I do not believe  that this is
possible, and as such cases are  extremely rare, I believe we can scarcely
make an exception in their favor.   And with regard to the operation
in ventricular chronic hydrocephalus the above statements  are sufficient
to condemn it altogether.
  Nay more, even if by it we  could evacuate the  water, and that no
more was secreted,  the condition of the brain  is such, as I witnessed
myself in Dr. Battersby's case, that there could  be no hope  of its reco-

  1 On Hydrocephalus, p. 147.         2  Diet, des Sciences Me"d., vol. xv. p. 455-6.
  3 Obs. Chir. Cent., 3. obs. 17.       4  Obs. Med., lib. i. p. 47.
  5 Obs. Varios., p. 10.              6  Monro on the Brain,  &c, p. 70.
  7 Obs. Med. Pract., pp. 40, 53, 60.    8 Schol.  adObserv.,30, lib. viii. Schenck.,p.l0.
  9 Schenk.. Obs. Med., lib. i.         i0 Vallisneri,  Opera, vol. i. sect. 5.
  11 Darstel. blutig. Operat., bd. ii. 3. aufl. p. 68.
  12 Copland's Diet., vol.  i. p. 682.     13  Med. Obs. and Inq., vol. v. p. 121.
  14 Notizen aus dem Geb. der Natur und Heilk.,  vol. v. No.  102, p. 224.
  15 N. Y.  Med. and Phys. Journ., 1828.  16  Med. Chir.  Trans., vol. xiv. p. 354.
  « Lancet, vol. i. p. 617. 1836-7.    18 Ibid., vol. ii. p. 42. 1838-9.
  19 Dub. Med.  Journ., vol. xxiii. p. 37. 2°  Library of  Med.,  vol. v. p. 147.
  21 Winslow's Psycholog. Journal, Monograph, p. 11.
  22 Amer. Journal, vol. xvi. p.  299.    &  Amer. Journal, Oct. 1843, p. 305.
  24 Dub. Med.  Press, vol. iv. p. 148.    & Med. Gazette, Jan. 26th, 1850.
  26 Fergusson's Surgery, p. 491.       &  Mem. de Med. 1835.
  23  CEsterMed. Jahrbuch, June, 1846.  *> Prov. Med. and Surg. Journal, Oct. 1845.
  30 System of Pract. Surgery, p. 491.   S1 Med. and Phys. Journ., vol. lviii. p. 44.
  32 Lond. Med. Gaz., Jan. 1850.       33 Amer. Journ. of Med. Science, Oct.l850,p.552.
  34 Ed. Med. and Surg. Journ., July, 1850.
  35 Essay, Ed.  Med. and Surg. Journ., July, 1850. 
HYDRENCEPHALOID.
173
vering a natural healthy working condition.  The operation is, as Mr.
Fergusson remarks, " attended with considerable danger, not from the
puncture, which is a very simple matter, nor from the sudden escape of
a fluid, nor from the wounding either a vessel or the brain, but from the
inflammation likely to  succeed."   It  is usually performed with a very
fine  trocar,  on one side of  the sagittal suture, so as to avoid the sinus,
and pressure should be made as the fluid escapes.
  241.  [Hydrencephaloid.—There is an affection of the brain incident
to the period of infancy resembling in many of its symptoms the latter
stages of chronic hydrocephalus, so as very often to be mistaken for it.
A more grievous error could not be committed, inasmuch as  the disease
to which I allude  always originates from another cause, and undoubt-
edly demands a very different treatment.  I refer to the affection which
has been so ably described  by Drs. Marshall Hall  and Robert Gooch,
and which has been designated by the  former by the term hydrencepha-
loid, on account of its symptoms very often presenting a striking simi-
larity to those which betoken inflammation of  the brain.
  My experience has led me to believe that this  disease is of frequent
occurrence,  and of so insidious and masked a character as to mislead
the inexperienced members of the  profession, and cause them to resort
to a  treatment calculated  to aggravate the disorder; hence, I have
deemed it proper to insert  a few remarks upon  this  subject.
  " This affection," says Dr. Marshall Hall, in his  admirable essay on
the subject, " may be divided into  two stages;  the  first, that of irrita-
bility; the second, that of torpor.  In  the former,  there seems to be a
feeble attempt at reaction; in the latter, the vital powers appear to be
more prostrate.  These two stages resemble in many of their symptoms
the first and second stages  of hydrocephalus respectively.  In the first
stage, the  infant becomes  irritable,  restless, and peevish, the  face
flushed, the surface hot, and  the pulse frequent; there is an undue sen-
sitiveness of the nerves  of feeling,  and the little patient starts on being
touched, or  from  any sudden noise;  there are sighing, moaning, and
screaming  during sleep; the bowels are generally flatulent and loose,
and the evacuations disordered.   If, through an erroneous notion as to
the nature of the affection, nourishment and cordials be withheld, or if
diarrhoea supervene, either  spontaneously or from the administration of
medicine,  the exhaustion which ensues is apt to lead to a very different
train of symptoms.  The countenance  becomes  pale, and  the  cheeks
cool or cold;  the eyelids  are half closed; the  eyes are unfixed, and
unattracted by any object  placed before them; the pupils unmoved on
the approach of light; the breathing, from being quick, becomes irregu-
lar and effected by sighs; the voice becomes husky, and there is some-
times a teazing cough;  eventually, if  the  strength of the little patient
continue to  decline, there  is a crepitus in  the breathing, the  evacua-
tions are usually green, and the feet cold."
  These symptoms will sometimes supervene in young infants  to early
weaning, especially if they should be subjected  to improper food.   Drs.
Marshall  Hall and West seem to attribute this condition of spurious
hydrocephalus  to either an enfeebled condition resulting from weaning
or to an exhausting treatment applied for some previous complaint.  I 
174
HYDRENCEPHALOID.
have seen many cases, however, in which the children  affected had had
no previous illness, and the exhausting treatment had been applied sub-
sequent to the drowsiness and other characteristic symptoms; and these
are the cases in which  the  practitioner is  most liable to be deceived.
The children thus  affected  have been  laboring under acute chlorosis;
and I have no doubt that the drowsiness, &c, is accompanied in  most
cases by the distressing headache, throbbing in the head, and noises in
the ears,  which generally  accompany  this  enfeebled  condition of the
system, one which in every way resembles  the " pale-faced" amenor-
rhcea of puberty or after life.
   I do  admit the fact that  this disease is very often incident to some
grave illness, which is very exhausting in itself, or for the treatment of
which active measures have  been necessary; hence, it is very frequently
found accompanying the earlier stages of pneumonia, where the sympa-
thetic disturbance  of  the brain has caused a powerful  treatment to be
directed to that organ, which has  been erroneously considered  as  pri-
marily  affected.
   We may have this  disease originating also in cases where there has
been congestion of the  brain, and where, through  over anxiety on the
part of the practitioner, too powerful or too continued a depletory plan
of  treatment  has  been adopted.   Under such  circumstances, the  pri-
mary cerebral  symptoms may be  alleviated by the  remedies; but in a
short time the child apparently relapses into the same  condition; there
is restlessness, jactitation, moaning,  flushed cheek, drowsiness, irritable
stomach,  and tympanitic condition of the abdomen.  To the unwary,
these may all seem positive indications for resorting again to the treat-
ment which was so successful in arresting the same symptoms  in the
commencement.  Should these erroneous views be carried out, the little
patient will sink into a deep coma, and die, not indeed of hydrocepha-
lus, but rather of  pure exhaustion, or from serous effusion, the too fluid
blood leaking out  of  the weakened vessels.
   Under  all circumstances,  therefore, of cerebral irritation, it is essen-
tial for the medical attendant to inquire into the previous history of the
patient.  Discover whether  the food of the child  has been of such a
quantity  and quality  as to  sustain the increasing wants of the growing
child.   Examine  whether it has been subjected to any exhausting dis-
charges calculated to exhaust its nervous system and  interfere with its
nutrition.
   I have met with several cases of pneumonia in which the sympathetic
disorder of the nervous system had induced  so  much  cerebral disturb-
ance as to mask the original disorder, all the remedies had been previ-
ously directed to the brain,  and as soon as the true seat  of the disease was
discovered the local depletion adopted for its treatment, superadded  to
that which under  a  misapprehension  had been  directed to the brain,
were too  much for the little sufferers to endure, and consequent  symp-
toms of cerebral disorder set in which  were still supposed  to be  those
of advancing disease.  Too  much caution cannot be exercised  on this
point, and my own experience leads me to apprehend that many a little
sufferer is hurried to an untimely grave by the fear of acute hydro- 
HYDRENCEPHAL01D.
175
cephalus, on the  part  of the  physician, whilst  in  reality the  opposite
condition of things exists.
  As the diagnosis of this affection is obscure, and mistakes easily com-
mitted which have the most mischievous results, where  a  doubt crosses
the mind as to the nature of the case, an expectant plan of treatment
would be more safe and judicious than  any other, the mere  abstinence
from  remedies, or a species of masterly inactivity in the case and al-
lowing nature to  act, often affording us a valuable hint  as to  the indica-
tions  to be pursued.
  When, however, our diagnosis is positively made out, there is no dis-
ease which admits of more effectual prevention and treatment.
  As soon as the existence  of ar^y of the symptoms described  is ascer-
tained, the child  should be put on good  diet and  all exhausting treat-
ment immediately suspended, and tonics  and  stimulants  should be
given freely.
   The state of restlessness and irritability, so characteristic of this affec-
tion, must be alleviated by means of anodynes.  I have found it a judi-
cious plan, as a general rule, to  be guided by the state  of the pupil; in
all cases where it is dilated, I administer sufficient doses of opium, or some
of its preparations,  to overcome  this condition  of the  pupil;  the  fluid
extract of valerian and assafoetida, administered either  by the mouth or
rectum, have also an excellent effect in calming the nervous irritability.
In administering opiates, a sufficient quantity, proportioned to the age of
the patient, should be  given to calm the excitability and produce sleep;
in smaller doses  it is apt to excite, and by the want of sleep which it
produces it may  maintain, the very condition which we  wish to combat.
   In the stage of coma, we must rouse the system by means of sina-
pisms applied to  the whole cutaneous surface,  and by free administration
of brandy and milk and also enemata of brandy water.   In  some cases
of very great excitement, I have had great success with  inhalations of
small quantities  of ether; in one  case  particularly, where a little girl
four years old, affected with this disease consequent upon a  protracted
pneumonia, screamed day and night incessantly, after  having tried in
vain anodynes, &c,  I had recourse to the inhalation  of thirty drops of
washed ether dropped  on a  pocket handkerchief.  The  result was truly
marvellous; she  fell into a deep  refreshing sleep for three  hours, and
her convalescence progressed rapidly from that moment.
   Where tonics  are required, I  believe that there is no better  combina-
tion than a mixture consisting of the ammonio-citrate  of iron and the
sulphate of quinine.
   There is one point which must never be lost sight  of, viz: that no
kind of depletion must be used  either directly by loss of blood or indi-
rectly by exhausting purges.
   In cases where doubt exists  as  regards  the  affection, I  have found
that the employment of anodyne enemata, consisting either of laudanum
or of the fluid extract of valerian soon produced such effects as to con-
vince us positively of the form of the disease  existing,  and to justify us
in pursuing a supporting and calming plan  of treatment.] 
176              INFLAMMATION OF THE  BRAIN.
                     CHAPTER  VIII.

INFLAMMATION OF THE BRAIN.—ENCEPHALITIS.—INDURATION AND  HY-
                 PERTROPHY.—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, oc-
casional headache;  or it  may attack a  child suddenly  awaking  out of
sleep, trembling  and frightened;  or in  the daytime by headache, vom-
iting, confusion, and more or less of stupor;  or it may  commence by a
violent  convulsion;  or lastly, some  defect of movement,  or difficulty
of speech, increasing to  absolute  loss of  the power of articulation, 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 commencement,
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 hemi-
sphere,  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, twitchings,
or convulsions  of other  limbs.  In  some  cases  the limbs become pow-
erless, 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.
177
  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 remarked :
" When cerebritis is  general,  these symptoms affect all the limbs simul-
taneously ; when local, only some of them, according to the seat of the
inflammation."1
  Occasionally, but much more rarely, the limbs,  or some of them, be-
come 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, indura-
tion 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 advanced  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 pro-
ducing 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.
   Other cases are on  record, in which inflammation of the brain has
followed disease   of  the ear.   Dr. Abercrombie mentions a case of in-
flammation  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-
stance of the brain alone is affected by simple inflammation.  The more
               1 Diet, of Med., Parti, p. 231.
12 
178     HYPERTROPHY AND INDURATION OF THE  BRAIN.

rapid loss of voluntary power, the earlier occurrence of paralysis and
stupor, and the  inferior amount of excitement, mark certainly a differ-
ence  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 between
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.   Cseteris 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  iodine frictions  or  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 continued  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 consi-
derable doubt in the minds of pathologists as to whether  hypertrophy
and induration are the result  of inflammation:  the disease  is rare, and
generally  obscure, and it is not easy to trace  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 hypertrophy; and
Laennec, who was one of the first to describe the disease, remarks : " It
has happened to me to see several cases, which I  considered internal
hydrocephalus, but which,  on  a post-mortem examination, presented but
a small quantity of water in the ventricles, although the flattened con-
volutions of the brain proved  that this viscus  had undergone a degree
of compression  which could only  be attributed  to excessive size and
consequently to too active  nutrition of the cerebral substance."1
  The disease has not been long known, and we are indebted  for our

             1 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 654. 
        HYPERTROPHY AND INDURATION  OF THE BRAIN.    179

information chiefly to the researches of Scouttetten, Jadelot, Laennec,
Bouillaud, Andral, Miinchmayer, Papavoine, Sims, Green, Lees, Mauth-
ner, &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 thir-
teen 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 twenty 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 consid-
erable, but that its growth is slower  after the  fourth year.  In  conclu-
sion, it may be observed, as a remarkable fact, that the minimum weight
usually occurs in cases of atrophy or  phthisis, and the maximum in pneu-
monia, 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 dul-
ness, drowsiness, or apathy, with an  apparently excessive  size  of the
head.   There is 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 prominent 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 vomiting 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 the crarlial
bones corresponding  to  the prominences of the convolutions, are dis-
tinctly perceptible, especially at the occiput.  The functions of the brain

            1  British and  Foreign Review, No. 42, p. 387.
            2  Condie, Diseases of Children, p. 383. 
180     HYPERTROPHY AND INDURATION OF THE  BRAIN.

become now much disturbed ; headache, giddiness, impairment of muscu-
lar 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 usu-
ally 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 excitement of the vascular system, and to excite dis-
eased action in other parts, which render still  more obvious the  influ-
ence of hypertrophy on the nervous system generally.   If the  child
happen to catch a  slight cold,  attacks of convulsions, cough,  or of
asthma, occur in consequence, 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 hypertrophy 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  unu-
sually  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, and Dr. Condie 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.
  The size of the head will vary a good deal, the younger the child the
more distensible the cranium.  Dr. Mtinchmayer3 has noticed a peculiar
prominence of the parietal protuberances, and this observation has been
confirmed by Dr. Lee, who regards the symptom as a valuable distinc-
tion between hypertrophy and  chronic hydrocephalus.4  The   other
symptoms especially noted by Dr. Lee in his cases were obtuseness of
intellect, apathy, great irritability and excessive appetite.
  254. Drs.  Sims and Green have noticed a sensation of firmness com-
municated to the finger when the pressure is made upon the fontanelles,
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
martiy die  during childhood from the consequences of the hypertrophy,

         1 Mauthner, p. 174.  British and Foreign Review, No. 42, p. 388.
         2 Diseases of Children, p. 383.
         3 Schmidt's Jahrbucher, vol. xxv., 1840.
         4 Dublin Journal, vol. xxii. p. 24. 
        HYPERTROPHY  AND INDURATION OF THE  BRAIN.    181

such as convulsions, &c, or  from states of the brain  superinduced by
other diseases.
  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 pres-
sure 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, 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.2
   Dr. Lee regards  the disease as  " dependent upon or connected with
struma."
   257.  Diagnosis.—It is not very difficult in most cases to distinguish
hypertrophy from  acute hydrocephalus; not  because the symptoms of
the former are so very  clear,  but because  those of the latter are gene-
rally sufficiently marked.  Their acute inflammatory character, the high
fever, quick pulse, and  the  sequence of symptoms,  are  very unlike
hypertrophy.
   Chronic hydrocephalus has more resemblance to it, and especially in

          1 West's Lectures, Medical Gazette, August 27, 1847, p. 354.
          2 Mai. des Eufans, vol. i. p. 665. 
1S2     HYPERTROPHY AND INDURATION OF THE  BRAIN.

the most  obvious  characteristic, enlargement of the head.  Mauthner
has thus marked the points of difference :  " In hypertrophy, the poste-
rior part of the skull first presents an unnatural prominence.  In chronic
hvdrocephalus, the forehead  is the  first part to present unnatural pro-
minence.  The altered  direction of the eyes, and  the very great width
of the sutures and fontanelles, are  likewise  characteristic.  In hyper-
trophy, 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 expres-
sion  of premature old  age.   In  hypertrophy, functional disturbance
comes on  very gradually, not before the period of dentition or weaning,
and consists at first in an affection of the respiratory apparatus, difficulty
of breathing, and  attacks  of apncea.   In  chronic hydrocephalus, func-
tional 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
   Add  to these, the projection of the parietal protuberance, observed
by Drs. Munchmayer and  Lee, which is not observed in chronic hydro-
cephalus.
   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.
   At the  same time, as Dr. Lee has observed, in the majority of cases,
the post-mortem appearances do not throw much light upon the cause
of death.
   259.  Treatment.—When the disease is fully confirmed, there appears
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  con-
gestion or inflammation, by means of leeches, cold lotions, purgatives,
and counter-irritants.
   But, when the disease is  commencing, we ought to prohibit everything
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.
   I do  not know that iodine, either internally or externally, has  been
administered;  but it appears to  me well worth a trial,  in  connection
with other counter-irritants;  or the  scalp might be painted with tincture
of iodine  at the same time  that hydriodate of potash is given internally.
   The  appetite, which  is  generally too good,  should be restrained as
to the quantity of food, and that not  too nutritious in  quality.   The

             1 British and Foreign Medical Review, No. 42, p. 389. 
RAMOLLISSEMENT OF THE BRAIN.
183
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 stimu-
late  the  intellect  too highly; and  it may be necessary to suspend it
entirely at times.
  When  the affection results  from saturnine poisons, we  are  recom-
mended to employ bloodletting, opium in large doses,  cold applications,
and evacuants, &c.
                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 independently
of the former, as in some cases of hydrocephalus  already noticed, and
in other cases of old  standing  disease  of the brain  (tubercles,  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 con-
vulsions, 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 symp-
tom succeeding the evidences of encephalitis just noticed; sometimes the
rigid contraction already mentioned, followed by relaxation and paraly-
sis.   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 begin-
ning, and ultimately rendered impossible—a fact which Dr. Abercrombie
has noticed in adults.   In some cases, there is squinting and 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.
  I have seen a  case of  ramollissement of the cerebellum, the effect of
inflammation caused by a fall, and which gave rise  to very few symp-
1 Abercrombie on Diseases of the Brain, p. 128. 
184
ABSCESS  OF THE BRAIN.
toms, and those not characteristic.   Frequent paroxysms of headache,
vomiting, and loss of appetite; but  neither impaired intellect nor mus-
cular power, and no affection of  the bladder or genital organs.  The
pulse was quiet, the tongue clean, and there was no convulsion.1
   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,
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 semi-fluid, like cream.   So  we may find it of small extent,
limited to a portion of the brain, or occupying  the  greater  portion of
an hemisphere.  Mauthner  has  observed that the white substance 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 inflam-
mation 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  convulsion, the
loss of the power of articulation, or the complete resolution of muscular
force, appear to be more characteristic than any other symptoms.
   264. The fact that we cannot  recognize  with any certainty the dis-
ease during life, that all the  cases on record died, will  at once explain
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 ter-
mination.  If  the  leeching, counter-irritation, and  mercury  have  not
secured the patient against this consequence of  inflammation, 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."3
  So few cases are on  record that it  is  impossible to give a general
description of the disease without calling in the aid of the imagination.
I think  it better, therefore, to quote two  cases from Dr. Abercrombie's
excellent work than to attempt any more formal statement.
1 Dublin Journal, July, 1853.
2 Diseases of the Brain, p. 72.
3 Ibid. 
ABSCESS  OF THE BRAIN.
185
  The first occurred in  a girl set. 5, and the case is described by Dr.
Bateman.1   "An abscess was found in the  posterior part of the right
hemisphere, inclosed 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 motion ; and
when  the attack subsided the left side remained paralytic.   She then
had  headache,  squinting, blindness,  and repeated  convulsions; and
died after  an illness of eleven  weeks, having been comatose  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."2
  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 twelfth,  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 reco-
vered 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  3viij, the
convulsion  ceased  instantly, and  the  headache was  relieved, but the
right arm  continued in a state of complete  paralysis.   19th and 20th,
the arm had recovered a little motion ;  some headache  continued, with
occasional  vomiting ; pulse  60.   On the three following days the con-
vulsive 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 permanent 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  remedies  were again employed with activity,
without  any effect in arresting the progress of the disease.  The thigh
and leg now wen,t through a course precisely similar to that described
in regard to the arm, and on the  29th remained in a  state of perma-
nent  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.—Com-
1 Edinburgh Medical and Surgical JourDal, vol. i. p. 150.
2 Abercrombie on Diseases of the Brain, p. 111. 
186
TUMORS OR TUBERCLES OF THE
plete  paralysis of  the whole  right side ; no return of convulsion ;  she
continued quite sensible, 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.
   " 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 hemisphere,
very near the  surface, and the other immediately behind  it.  They  had
no communication  with each  other, or with the ventricle.   In the pos-
terior 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 occurred be-
tween 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.
1 Abercrombie on Diseases of the Brain, p. 93. 
BRAIN  AND SPINAL  MARROW.
187
  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 fe-
males ;  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
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  was 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  disturb-
ance ; 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 headache
is severe;  or perhaps the  child may lose its natural vivacity,  and be-
come apathetic and dull, weary of play, and wishing to be alone.
   At a more advanced  period of the disease, even when  uncomplicated,

  '  On Diseases of the Brain and Spinal Marrow, p. 167.
  2 Mai. de l'Enfance, vol. ii. p. GoO.
  3 Dr. Green,  Med. Chir. Trans., vol. xxv. p. 193. Abercrombie  on Diseases of the
Brain, &c, p. 171. 
188
TUMORS OR TUBERCLES OF  THE
so far as we can ascertain, there gradually steals over the countenance
an expression of mental feebleness and vacuity;  the child is indisposed
to intellectual exertion, even if not actually incapacitated.   In propor-
tion  as morbid  actions (meningitis,  encephalitis)  are excited by the
tumors, we find the mind exhibit the same  disturbance as is usual in
these disorders.
  271.  Convulsions are by no means  uncommon, though not universal;
they pretty constantly occur in those cases where the tubercles occupy
the central portion of the brain, or are disseminated extensively through-
out.   Rigidity or contraction of one or more of the extremities is more
common; it generally affects the leg and  arm of the same side, some-
times only one limb, and very rarely both upper or both the lower limbs.
It is not easy to determine whether it be referable directly to the pres-
sure  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 convulsively 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, or
affecting generally the sensation and motion of one side.  It is remark-
able  that although the child may recover partially  and for a time from
the affection of the eyes and ears, from the rigidity and deficient sensi-
bility ; 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 cerebral
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 un-
equal.   My friend Dr. Chas. Johnson attaches great value, as a pathog-
nomonic 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 cha-
racteristics 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 circulation.  Nine of Dr.
Green's cases died with symptoms of acute hydrocephalus, 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. 
BRAIN  AND SPINAL  MARROW.
189
  273.  The duration of the disease is very difficult to be determined ;
the tumors may be 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 diseases 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 cases for several years.

  And the termination is uncertain, generally occasioned by a secondary
complication, and  more quickly than would have  happened  from the
Bimple 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.  Inflamma-
tion of the substance of the brain, with (probably), first, some degree of
induration, and then ramollissement.  2. Effusion of fluid into the ventri-
cles, 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 different
kinds.  Dr.  Monro  mentions  a hard tumor of a dirty yellow  color
growing from the innersurf ace  of  the  dura mater,1 and occasionally
imbedded in the  brain ; scrofulous,  adipose, scirrhous, and  encysted
tumors, but they are  very  rare in children,  with  the exception  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.2
  Dr. Abercrombie described a tumor compressing the brain, which was
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 imme-
diately opaque and coagulated."3
  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.4  The  character
of these masses is  that of the ordinary tubercular matter ; we often find

  1 On the Morbid Anatomy  of the Brain, p. 45.
  2 Gazette Medicale, 1836, p. 487.           s Diseases of the Brain, &c, p. 178.
  * Dr. Green, Med. Chir. Trans., vol. xxv. p. 199. 
190              TUMORS OR TUBERCLES  OF THE
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; oc-
casionally, however,  the shape is modified by pressure, or by the junc-
tion 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  mater,
or irregular unconnected shreds of cellular membrane.  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 cerebellum, 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.
   276.  So much for the tumors themselves;  but as a careful analysis
shows that the more marked symptoms, especially in the more advanced
stage of the  disease, arise rather  from  morbid conditions  of the sur-
rounding brain or membranes than  from  the mechanical  pressure and
irritation of the tumor, it is of great consequence to notice these  condi-
tions.   In some rare cases no change  could  be detected in the  mem-
branes of the brain, but in the majority there are decisive evidences 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 soft-
ened, but superficially, or the softening may be extensive and deep, with
evidences of inflammation2 or without.  In some rare cases the surround-
ing substance is fuller and more firm than usual, as if slightly indurated;
in others it appears hypertrophied.   Lastly, the ventricles are  some-
times largely distended with fluid, as in chronic hydrocephalus, the con-
sequence, most probably, of mechanical obstruction to the  circulation,
occasioned by the pressure of the tubercles.
   277.  Causes.—No doubt the deposit of tubercle in  the brain depends
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

         1 Monro, Morbid Anatomy of the Brain, p. 51.
         2  Moncrieff's case in Monro on Morbid Anatomy of Brain, p. 51. 
BRAIN  AND SPINAL MARROW.
191
Abercrombie afford testimony to its rarity in adults, Dr. Green found it
once in every fifty-one cases out of 1324 admitted into the Children's
Hospital; and the testimony of Barrier, Constant, Rilliet and Barthez,
&c, confirms this fact.   Scrofulous diathesis, 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 know-
ledge 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 character-
istic symptom, but from  the irregularity and distance of the symptoms
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.   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, to-
gether with emaciation, without apparent organic disease.   But  it may
be months before any other decided evidence of cerebral disease is de-
veloped.   Dr. Adams mentions scrofulous habit, paroxysmal headaches,
vomiting, convulsions, muscular tremors and weakness of the limbs, with
variations in the pulse, as the principal diagnostic symptoms.  "When,
however, a child has suffered for some  time from severe headache, when
the headache is followed by convulsive movements, some paralytic affec-
tion,  amaurosis, contraction of muscles, occasional vomiting, accesses of
fever, and  the  train of symptoms already mentioned, and when these
symptoms succeed each other at various intervals of weeks  or months,
we have  very great reason to believe that  the child has tubercle  of the
brain."1
  M. Rilliet founds his diagnosis of cerebral tubercle upon  the  follow-
ing general considerations:   1. The age of the child, the disease being
much more frequent after than before the  age  of three years.  2. The
circumstances which preceded the attack, and particularly  the causes
under the influence of which the disease was developed.   3.  The  state
of health at the period of invasion.   4.  The primary symptoms,  as con-
vulsions, lancinating headache (continued or  intermitting), paralysis,
amaurosis, and much more rarely, rigidity.   5. Lesions of  the  cranial
parietes, exophthalmia, nasal or auricular discharge coinciding with cere-
bral symptoms, or having been preceded by continued vomiting.  6.
The chronic progress of the symptoms, for time alone will sometimes
discover  the nature of the disease.   Chronic symptoms with reference
to motility are more to be depended on than disorders  of  the intellect.
7. It is necessary to keep in remembrance the great frequency of tuber-
cular disease in childhood and the infrequency of other kinds of chronic
cerebral  disease.
  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,

               1 Dr. Green, Med. Chir. Trans , vol. xxv. p 207. 
192
TUMORS OR TUBERCLES OF  THE
at the occiput when the tumor is in the cerebellum, and in some cases it
has suffered 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  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 M. Barrier, the  child showed  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
record where the tumor occupied the lower portions of  the spinal mar-

               1 Translation of Abercrombie, p. 202.
               2 Traite" de la Moelle Epiniere, &c, vol. ii. p. 272. 
BRAIN  AND SPINAL  MARROW.
193
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, epilepsy,
feebleness of limbs, loss of sensibility, retention of urine, constipation,
&c. &c.
  A certain amount of disturbance is due, doubtless, to the mechanical
pressure of the tubercle, but still more to the congestion, inflammation,
and softening  of  the surrounding tissues, which are observed in the
spinal  cord, just as we found them in the brain.
  284. My friend, Dr. Geoghegan, of this city,  has recently published1
a very interesting case of a scrofulous tumor in the lower portion of the
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, set. 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 :  Com-
plete paralysis of sensation of the lower part of the body,  commencing
at a point a little above the upper margin of the pelvis ;  severe pinch-
ing, or the introduction of a needle, not eliciting the slightest 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 con-
tractions 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 mo-
tion, chiefly in the  flexion of  the leg.   These effects are most intense
when the stimulus is applied 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 somewhat flexed
and rigid, conditions which increased as the case progressed.  There is
incontinence of urine and feces, 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 detection
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 vertebrae, tenderness is evinced on  percussion,
13
1 Med. Press, March 8, 1848. 
194    TUBERCLES OF  THE BRAIN  AND SPINAL MARROW.

but not on firm pressure.    The functions of the brain are perfectly
natural; the  child, however, seeming more lively than  is usual at his
age."
   " It appeared that  since last April this patient had suffered from un-
easiness in the back,  in the situation of  the tenderness, although, from
his silent habit, he did not complain of pain ; he used frequently, how-
ever, 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 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 reintroduced, 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 them-
selves; 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 intervention
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 perceptible
enlargement of the spinal cord was discovered."   " On  dissection of
the diseased portion, it  was observed to be of a light, sulphur-yellow
color, having  much  the aspect  of  matter often found in  scrofulous
glands, containing a few minute cavities, and having embedded 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 quan-
 tity of crude tubercles.  The rectum was natural, and the urinary blad-
 der  contracted and empty  ;  its  mucous surface not  thickened  or ulcer-
 ated,  and presenting livid  patches of venous submucous  congestion.
 The total thickness of its eoats, a quarter of an inch."
   285. It is more than  probable that any treatment will fail in relieving
 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 AND APOPLEXY OF THE BRAIN.
195
                       CHAPTER  X.

              CONGESTION AND APOPLEXY OF THE BRAIN.

  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 cephalDematoma" (103), and the effects of which
are manifested shortly after birth, and  which  generally terminates fa-
tally.   Of eight  cases  collected  by Dr. West, two were  stillborn, 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.  Evans Kennedy and Dr. Doherty have related  several cases in
which  it occurred a few days after birth.1
  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.2
   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.
   It occurs both in  children apparently  healthy, and in those of de-
 ilitated constitutions.3
   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 ex-
cessive 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

   1 Dublin Journal, vol. x. p. 421; vol. xxv. p. 49.    * Diseases of Children, p.  3S8,
  * Cases by Quain, Lond. Journ. of Med., No. 1, p. 27. 
196       CONGESTION AND APOPLEXY OF THE BRAIN.

brain are subjected to  great  pressure  by the accumulation  of blood,
their tunics may give way, and the blood escapes into the substance 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 diffi-
culty 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  mentions
its occurrence in  a  case of general oedema.
   The symptoms are, more or less complete stupor, lividity of the face,
which appears tumid, contraction and insensibility  of the  pupils, labo-
rious respiration, hemiplegia, or occasionally rigidity of the  neck and
lower extremities, and sometimes convulsions.
  If not relieved, those 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, apparantly from hemorrhage into the brain.
There  was loss of  power in all the limbs, insensibility,  loss of intelli-
gence, and stertorous breathing.  On dissection, nothing  but extreme
congestion of the brain  was discovered.1
  289. When the congestion is confined to the spinal marrow, the symp-
toms 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 stillborn infants, according to Cruveilhier,2 occurs  also after
birth, during the first few hours or days of life, as well as subsequently.
It is not easy to  explain why it should occur previous to birth in many
cases, for in them there has been neither undue  pressure 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.  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 mis-
taken  for them.    M.  Legendre,  who has  carefully investigated that
subject,  remarks :  "After two or three  vomitings, or even without
1 Gaa. Med., 1835, p. 572.
2 Anat. Path., livr. xv. p. 1. 
CONGESTION  AND APOPLEXY  OF THE BRAIN.
197
previous vomiting, the infants were attacked with fever and some  con-
vulsive movement, 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 permanent
contraction of the feet and  hands, followed  by tonic or clonic convul-
sions.  During the  convulsions,  sense and  sensibility were abolished,
and the face, ordinarily congested, became of a deeper color.   During
the intervals there  was drowsiness  and stupor, which, slight  at first,
increased  as the disease  made progress; the fever continued, and
became more intense as they approached the fatal termination.   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 follow rapidly.  The difference of symptoms and
their intensity will depend very much upon the amount of effusion.   In
some cases convulsions are almost the only  symptom observed,  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  distension may take
 place, and the brain,  relieved of some of the pressure, 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 (226),  except that the head is more  unequally
 enlarged, running the  same course, and ultimately 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, m  1833,
 has  collected eight cases, one by a physician  at Breslau, and one by
  M. Guibert (set. 14); one by M. Pay en (set. 12); one, of a child  ex-
  posed to  the sun, by M. Andral (*t. 12); another of  a child  who after
  beincr exposed to the sun, died suddenly (in a fit of anger) from hemor-
  rhage into the  cerebellum;  one by Tonnelte (set.  2);  one  by Burnet
  (aet. 1);  and one by M.  Serres (set. three months).  Since then,  Lalle-
» Bouchut, Mai. des Nouv. Nes, p. 4C8. 
198       CONGESTION AND APOPLEXY OF  THE BRAIN.

mand has related the history of one case (set. 3) in his third letter, and
M. Constant of another (set. II).1   MM. Sestie'2 and Cazalis have  re-
corded three, M. Valleix three cases,3 M. Billard one, and  Dr. West
one case.4
  But hemorrhage into the brain may be 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 may be 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 power 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 an  addi-
tion  to them.
  295. Pathology.—When a child  dies of apoplexy from excessive con-
gestion merely, we find, on  examining the  head, that  the  scalp is un-
usually vascular, the sinuses of the  dura mater filled with blood, and the
vessels on the superficies of the brain engorged.   Very commonly the
meningeal vessels participate in the general congestion.  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 cavi/ty 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, Cruveilhier met with  three
examples of it;  M.  Valleix with one ;  and M. Walther has recorded
another.5  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 the latter;
and  I may add that in very young infants who die  of apoplexy, it is by
no means uncommon to find cephalsematoma, or even patches of blood
effused  under the scalp  or pericranium,  quite  independent of  local
pressure.
               1 Gaz. des Hopit. des Enfans, Ap. 1842.
               2 Bull, de la Soc. Anat., 1832.  Bull., xlii.  p. 331.
               3 Clinique des Mai. des Enfans, p. 575.
               4 Lectures.  Med. Gaz.. June ]8, 1847, p. 1002.
               5 Banking's Abstract, vol. iii. p. 159. 
CONGESTION AND APOPLEXY OF THE  BRAIN.
199
  297. The blood effused into the serous cavity presents different as-
pects, 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 gra-
dually disappears, and the clot becomes adherent to  the parietal  serous
membrane, and undergoes an important transformation.   A  new mem-
brane is formed, and covers both its surfaces, but the layer on the upper
surface gradually becomes thinner, until  it is closely adherent  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 jnembrane can be traced behind the clot.
   The clot  increases in firmness and diminishes  in  volume by the gra-
dual absorption of its serum.   At first of the  usual  red color, it  be-
comes 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  constituting
 a kind of chronic hydrocephalus.2                         _ t
   Notwithstanding the large amount of  blood  thus effused, it is gene-
 rally quite impossible to detect any opening in the vessels  from which
 it could have escaped ; we merely find unusual congestion of the arach-
 noid, pia mater, and brain in most cases.
    M. Piedagnel mentions three sources:  1. Fracture and rupture ot
 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, intes-
 tines &c.  We do not find  the brain either hypertrophied  or the con-
 volutions 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 condi-
  tions, 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 white, yellow, or
  red color.   The apoplexy may be limited, or it may be diffused through-
  out the hemisphere, giving to it a peculiar spotted appearance.3   Rdliet
  and Barthez found this capillary apoplexy limited in  five cases  and  dif-
  fused in three.

                  ' Bouchut, Mai. des Nouveaux Ne'e, 4GG.
                  2 Rilliet and Barthez, Mai. des Enfans, vi. ii. p. 39.
                  » Valleix, Clinique des Mai. des Enfans, p. 594. 
200       CONGESTION AND APOPLEXY OF  THE BRAIN.

  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  apoplectic
foci are found in various parts of the brain, as in the optic thalami, cor-
pora 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 imbedded in, but distinct
from the cerebral substance.  When it is connected with ramollissement,
however, it has the appearance of being mixed  with the softened brain,
and does not, generally, form a distinct clot.  Rillet and Barthez relate
a case of  very extensive effusion, which, in some degree, illustrates the
observation;  and Billard another, of  a child who died on the third day
after its birth, of hemorrhage into  the  left hemisphere.  He found  a
certain  degree of softening around the clot, but it would seem to have
been rather the consequence of the  effusion.1
  299.  Causes.—Rilliet and Barthez thus enumerate the causes of apo-
plexy:  "1. The untimely cure of diseases of the scalp;  2. Diseases of
the sinus of the dura mater ; 3. Compression of the vena cava superior
by the bronchial glands; 4. Vascular compression, owing to  hypertro-
phy of the abdominal organs; 5. Cachexia, or  general debility, origin-
ally connected with tubercularization;  6. Sometimes the hemorrhage
is primitive, and unconnected with any anterior disease.2
  Iv, 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 injury
connected with labor, although we are not able  to appreciate  it at  the
time, and at a later period to diseases which obstruct the return of the
blood from the head, as hooping-cough and perhaps disease of the valves
of the heart.
  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 cere-
bral diseases, that the differential diagnosis is, in many cases,  extremely
difficult.  For example:—
  I. Congestive apoplexy may very closely resemble primary convulsions,
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 re-
stored 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 effu-
sion is moderate, or chronic hydrocephalus when considerable, and espe-
cially when the cyst of serum is formed, as I have mentioned.   In acute
meningitis, the symptoms exhibit more  of the  character of  inflamma-
tion ;  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.
1 Mai. des Enfans, p. 600.
* Mai. des Enfans, vol. ii. p. 63. 
          CONGESTION  AND APOPLEXY  OF THE BRAIN.       201

  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 effusion
generally precede all  others, although some time may elapse before  the
head is perceptibly enlarged.
  III.  Cerebral apoplexy, if slight, may be mistaken for  an attack of
convulsions, or of epilepsy, but it will generally be  found that the con-
vulsion is less violent, shorter, and that the patient does not recover
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 me-
ningeal  and  cerebral apoplexy almost  always prove fatal.  There is
scarcely a case of cure on record,  either of  primary, secondary,  or
chronic apoplexy, in which any reliance can be placed; not from defi-
cient veracity on the  part of the writers, but from doubtful diagnosis.
  302. Treatment.—When the case is recent, and,  above all, if we have
reason to believe it one of congestive apoplexy, we should have recourse
to bloodletting immediately, either from the arm or  jugular vein, or by
leeches.   The effect of this proceeding will probably determine the cor-
rectness  of our diagnosis, for if the symptoms have been the effect of
congestion merely, they will at once be mitigated, and the more alarm-
ing ones disappear.   Judging from the result, we may find it advisable
to repeat the leeches, and to have recourse to cold applications to  the
head, purgative enemata, small doses of calomel and James's powder, if
the patient can swallow,  and, after a short  time, to 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 repetition of these remedies, it will
be  necessary to establish some permanent counter-irritation, either  a
seton or issue, or a perpetual blister on 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  pur- 
202
PARALYSIS.
pose we have four remedies of great value, calomel, cold  lotions, coun-
ter-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 evidenced 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 ul-
ceration.  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, i4 e.  where
a large quantity of blood  has  been effused and separated into its com-
ponent parts, without an  immediately fatal  result, Rilliet and Barthez
recommended 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 deposits,  but in
meningeal apoplexy they  conceive that " nothing but  good can result
from it."1
                      CHAPTER  XI.

                            PARALYSIS.

  305.  1.  Paralytic affections, general, partial  or local, particularly
the latter, though not very frequent, are by no means  rare in children.
That  they have not  been more distinctly noticed  by writers may have
arisen from their classing them under  their various causes, instead of
regarding them as examples of a special disease.
  The attack presents  great varieties  as to extent and the  accompa-
nying symptoms :  In some cases the upper and  lower extremities of
one side are affected, constituting hemiplegia;  in others both the lower
extremities, paraplegia:  but I  am not aware that both the upper ex-
tremities alone are ever paralyzed.   Again, the seizure may be partial,
1 Mai. des Enfans, vol. ii. p. 66. 
PARALYSIS.
203
loss of power to a great extent, with perhaps a diminution of sensation,
but not absolute paralysis : or it may be local, affecting a portion of one
extremity, certain muscles of the face, of the eyeballs, eyelids, or of the
organs of deglutition, &c.
  Lastly, in  any of these cases, the  sensibility may be  impaired or
destroyed, or, as we occasionally find, unaltered or even increased.  In
seven out of  eighteen cases given by Dr. West, " the leg only was af-
fected, and in two  of these the power over both legs was  lost;  in five
both the leg and the arm were palsied, while in six instances facial para-
lysis existed.  In four of these six cases the paralysis of the portio dura
was not associated  with impaired power over any of the limbs ; once it
was combined with  palsy  of the leg and once with general  impairment
of the power of  walking."1
  2.  There does not appear to be any age exempt from these attacks;
infants at the breast or children of fourteen or fifteen years of age may
be the subjects of  them,  but  they are perhaps more common from the
period of the first dentition up to the tenth year.   There is some reason
to believe that in some cases the paralysis is congenital, whether from
disease in utero, or  from pressure  during  the transit of the infant
through the pelvis,  it is difficult to determine.  Professor Robert Smith,
of this city, brought before the  Surgical  Society  several  cases where
one extremity was not fully  developed, and in which there was a de-
ficiency of cerebral substance in  the opposite  hemisphere of the brain,
but whether they ought to be considered as  fair examples of paralysis,
or merely of arrest of development, may be a question.
   Dr. Evory Kennedy, whose experience in the Lying-in Hospital was
very  great, states that " paralysis in  the new-born infant is sot a very
unfrequent disease ;  it may occur  as the effect of injury to the nerve
in the part paralyzed, or  in its course after its transmission  through the
cranial or spinal aperture.  Examples of this we have in injuries to the
portio dura, as in face presentations,  or when the  head  has been long
pressed  against  the  projecting ischiatic spines.   Several cases of this
kind  have occurred  to me, in which  the  disease  was quite local, the
paralysis being removed on the subsidence of  tumefaction produced by
the protracted pressure."2  Inmost cases, however, Dr. Kennedy men-
tions that the paralysis  is  connected with  cerebral or spinal derange-
ment ; in some  preceded by apoplexy,  in  others  by convulsions,  or
convulsions of the  opposite side may co-exist with  paralysis.   Some-
times the affected limb was  convulsed; in other cases, there Avas a more
or  less complete paralysis  of one  side, with a partial paralysis of the
other.   Cases  illustrating  these varieties  are related by  the  author.
Leeches, stimulating  frictions  to the spine, and calomel, appear to have
been very successfully employed.
   More recently, Dr. Landowzy  has published a  paper showing that
facial paralysis  may be  the  result of pressure by the  forceps during
delivery, even though the instrument  may have left no marks upon the
infant;  and  he  considers that  the same result  may follow when the

  1 Diseases of Infancy and Childhood, p. 137.
  2 On Apoplexy and Paralysis in ISew-born Infants, Dublin Journal, vol. x. p. 430. 
204
PARALYSIS.
pressure is from pelvic tumors or deformity ; and he states that during
quiescence the face is  quite  natural, but that when the child cries the
paralysis becomes evident.  He found the disease to cease spontaneously
after an interval of from a few hours to two months.1
  Dr.  Doherty, in an excellent paper,2 gives two cases  which were
delivered by the forceps,  and in which facial paralysis  was observed
immediately afterwards; and two other cases, in  one of which paralysis
of the arm and in the other of the muscles of the neck occurred shortly
after birth.  The former was cured by the use of mercurial alteratives,
continued purges, the douche, and chalybeate tonics.
  There can be no doubt, then, that facial paralysis may be congenital,
and as little, I think,  that more extensive paralytic  affections are so
occasionally.
  Dr. Henry Kennedy has given two cases which  he  thinks were con-
genital.   One of them he relates  as follows:  " A child, set.  six, was
brought to me on account of his walking lame.   The mother said that
from the time the child began to walk it had limped; several medical
men had seen  it, but that  it was no better.   On examination, the right
lower extremity was wasted, and its temperature  was evidently lower
than the other.   Nothing could be detected wrong  with any of the
joints except that they could literally be twisted  in every direction."3
  Dr.  West also mentions cases, which one can  scarcely doubt were
congenital.
  In all these cases, the growth has evidently been checked and retarded;
the affected limb has not  kept pace in volume or length with the sound
one, and its power is much inferior.  I have  a  case under my care at
present somewhat  resembling these, but with less loss of power.  The
child, set. eight, had an attack of endocarditis about  five or six years
ago, from which he recovered, but with injured valor.  About two years
ago, he showed symptoms of lameness, and since that time his leg has
evidently been checked in its growth, and is now  less in volume than
the other; but he manages to use it pretty well.
  306.  3. Causes and Symptoms.—Paralysis in infants and children may
arise either from organic disease of the nervous system ; from pressure
upon  some part of the nervous centres or upon individual  nerves; or,
lastly, it may be a reflex  irritation from  some  distant part.   Let us
examine the principal  varieties shortly.
  (1). No doubt that paralysis in children, as in adults, may result from
a partial effusion of blood  pressing upon certain parts of the nervous
centres, less in amount than in  cases  of  apoplexy,  but  sufficient to
occasion loss of motive power and  sensibility in one-half  of the body.
Morgagni, for example, mentions a case of spinal  apoplexy which was
attended with  pain and paralysis,4 and other cases might be adduced.
They are,  however, rare in children.
  (2).  When  speaking of tumors of the brain and spinal marrow, I
mentioned that paralysis generally occurs at some period of the disease;
at its  commencement in a few cases, but generally at  a more advanced

  1 British and Foreign Med. Review, vol. x. p. 269.
  2 Dublin Journal, vol. xxv. pp. 82-87.              s Med. Press,  vol. vi. p. 202.
  * Epistola 10, Sect. 13. 
PARALYSIS.
205
stage.   It may be partial, the effect of local pressure, or affecting gene-
rally  the  motion  and sensibility of one  side.  It is remarkable  that
although the child may recover to  a certain  extent  from the other
accidents of this disease, the paralysis is in almost every case permanent
and without  mitigation.1  In Dr. Geoghegan's case there was complete
paraplegia;  but  in  Dr.  Green's case,  certain  muscles of the eyeballs
alone were affected.
  (3).  Encephalitis is  not unfrequently accompanied with partial  or
general hemiplegia, and this paralysis may be combined with involuntary
movements of these limbs,  or with rigidity.
  When the inflammation  ends in softening, we also  find  hemiplegia
among its effects, alone or  with convulsive movements  of the other half
of the body.   In these cases,  however, the concomitant symptoms  are
pretty plain, and we shall generally be  able to trace the palsy to its true
proximate cause.
  (4).  In abscess of the brain we almost always find paralysis, as in the
cases I  have related in a former chapter from Drs. Bateman and Aber-
crombie.  Such cases, however, are both rare and  obscure.
  (5).  Chronic softening of the spinal marrow is characterized by par-
tial or  general  hemiplegia.   There is great general weakness  of the
lower limbs, which the patient can scarcely move.  " Sometimes one limb,"
McCalsy  observes,  " or a  portion of it only,  is  paralyzed.   In  this
case, the extremity, or the diseased portion of the spinal medulla, when
it is only partially affected, is in a state of atrophy, the muscles being
much softer and smaller  than  those  of the  opposite extremity.   In
some cases, when the muscles have continued long in a state of paralysis,
the  antagonist muscles, acting with uncontrolled force, produce a per-
manent contraction."   " On  examining the  spinal marrow after death,
we  find it in different states of softening, from that almost resembling a
fluid  to that which  permits the finger  to be  pressed upon it, and  only
presents a kind of indentation.1'2
  (6). Acute tubercular meningitis, which often  commences by a convul-
sion, not unfrequently exhibits paralysis towards its termination.  The
arm or leg, or both of them, lose power and sensibility, and occasionally
we  see  convulsive  movements of the  opposite extremity.   From this
disease, and  especially from the stage at which paralysis takes place,
patients rarely recover, and therefore the  paralysis possesses less prac-
tical interest for us.
   In some cases of meningitis, when recovery does take place, we find
remaining a kind of partial paralysis ; for example,  one leg will be more
feeble than the other; the  child rather drags it, and complains  perhaps
of its being weak.   I have repeatedly observed that children recovering
from this disease are less able to walk, less sure footed, and more apt to
trip and stumble over slight obstacles than previous to their illness,  indi-
cations probably of both loss of power and sensibility.
   Squinting, also,  which so often remains after this disease, is clearly a
partial  paralysis of the muscles of the eyeball.
   I have also known paralysis of the  portio dura remain after an attack
of  meningitis, presenting all its peculiarities, the face natural in repose,

  1 See Dr. J. McCormac's paper. May 27, 1843.   2 On Diseases of Children, p. 430. 
206
PARALYSIS.
but distorted when  speaking or excited, mastication natural, &c.   This
case has now remained in the same condition for several years.
  (7).  I have already mentioned the paralysis of chronic hydrocephalus.
In  slighter  cases we find  a diminution  of power, but rarely of sensi-
bility of the lower limbs;  the child may be able  to move  them, but can
with difficulty,  if at all,  stand or walk.  In other cases the paralysis is
observed at an early period, or even  from the beginning, and as Dr.
Bright remarks, the patients lie in  bed with their legs bent under them,
or,  as in Dr. Ryan's and Battersby's cases, the child may be nearly de-
prived of the functions of vision, hearing, taste, smell, and touch, and
entirely of voluntary motion.  In some cases, one leg only is affected; in
others, the lower half of the body,  and occasionally, but rarely, the ex-
tremities.
  The same thing is observed in spina bifida, which  is  an  analogous
disease ; the limbs may be of the natural size, but they are deficient in
power.  Generally speaking, the sensibility is preserved, and occasionally
increased, but I have seen cases in which it was decidedly diminished.
  (8).  After convulsions we not unfrequently find  a partial weakening
of the motor power  of certain muscles of the limbs or eyeball; but if the
child recover promptly from the principal disease, this  symptom  gra-
dually disappears.
  (9).  When treating of chorea,  I  observed that in some cases it ter-
minates in palsy, either in consequence of inflammation or from pressure
upon some portion of the brain, spinal cord or nerves, which is not un-
common in that disease.   Dr. H. Kennedy has noticed some  symptoms
of  chorea in two of the  cases of paralysis which be has reported.
  (10). So far the paralysis may be distinctly traced to some pathological
condition of the brain and its membranes, or of  the spinal marrow,  of
which it appears to be the direct result. In most of these  cases the intel-
lect of the child is weakened or totally obscured, and  the expression  of
the face corresponds very accurately; we  see  either  compression, stu-
pidity, or a fatuous semi-idiotic expression.
  But by far the most numerous  class of cases of paralysis in children
are of quite another kind; originating in causes which act through the
excito-motory system of nerves, they present admirable examples  of
reflex irritation.  They generally occur in children between the ages of
one and six years, though sometimes earlier.2  Of Dr. West's eighteen
cases,  thirteen occurred  between  eight months and three  years of age.
  (11). From the age alone at which the attack occurs, we might at once
conclude that dentition must be one main cause,  and we  have evidence
to prove that it is so in the fact that in many cases the most careful in-
quiry shows us no other exciting  cause, that the gums are much swollen
and irritated, and that scarifying the gums is often  followed  by a  case
of  the palsy.   The attack may arise during either the first  or second
dentition, but is much more frequent with the second, or perhaps it may
be,  as Dr. Heiss has suggested, that the origin is overlooked in youDg
infants from their not using their lower limbs3

  1  Dublin Journal, vol. ix. p. 91, N. S.     2 Underwood, Diseases of Children, p. 2G9.
  5  London Journal of Medicine, Jan. 1850. 
PARALYSIS.
207
   One great peculiarity of these attacks is their suddenness.  The child
may go to bed perfectly well, and during sleep  perhaps become uneasy,
restless, grinding its  teeth, or groaning and screaming out suddenly.
Towards morning, it may be rather feverish, and its head hotter than
usual.   The  next  day, we  find it unable to  raise its arm or leg, or
perhaps an arm and leg, or more rarely both arms or an arm and both
legs.   The affected arm  hangs down helplessly, and, from the gravita-
tion of the blood, the hand and fingers become bluish and swollen, but
the temperature of the  limb  is  not diminished.   The  sensibility is
generally more obtuse  than  usual, and sometimes entirely lost.  No
pain is felt, but occasionally a sensation of dragging about the shoulder-
joint.   The leg when affected  is equally powerless and insensible, and
now and then the palsy seems  to  extend itself from the  upper to the
lower extremity.
   Some variation as  to the mode of  invasion is observed; the prelimi-
nary symptoms  may be more  prolonged, and occasionally the attack is
ushered in by a convulsion.
   The  duration of this form  of paralysis  is  very uncertain.   Some
cases recover after a few days or a week or  two, others continue for
months or years; some  appear easily cured, others resist all treatment,
and in the course of time exhibit symptoms of more serious disease of
the spinal cord or brain, as dyspnoea, twitching of  the muscles, squint-
ing, perhaps convulsions, or the child falls into a comatose state  and
dies.
   But there is another class of cases, where the disease  is not cured,
or only partially, but the patient does not die.   The limb remains par-
tially  or  wholly paralyzed, its  growth  is retarded, and  its muscles
become atrophied,1 while the  rest of the body is fully developed.   In
cases of the  upper extremity,  the shoulder-joint may be injured.   Dr.
West  saw two  cases of dislocation,  evidently  from relaxation of the
ligaments and the constant  weight of the paralyzed arm.
   Dr. Underwood mentions  that he has known the sound side to become
paralyzed, the  side  previously affected  recovering  its  power.  As a
general rule, the intellect is not enfeebled unless organic disease of the
brain should be  superinduced;  but in some  few cases the expression of
the face would rather denote a feeble state of the  mind.
   It is not easy to pronounce upon  the  exact  pathological cause of all
these attacks.   In the majority of cases, no lesion of the nervous  sys-
tem is discoverable, the attack being a reflex  irritation simply.   And
even  when we find some disease of the brain or spinal marrow, it is not
always easy to say whether that may be the primary lesion or one that
has supervened.  Dr. Heiss  is disposed to attribute the paralysis to
pressure upon the roots of the brachial nerves from excessive congestion;
and he has given a case in which this state of  the nerves was found in
a child who suffered from paralysis and was killed by an accident.2
   Dr. West states that of  his eighteen cases  there were  but  two in
which the paralysis appeared to be  connected with permanent disease
' Simpson, Ed. Monthly Journal, Jan. 1851.
8 London Journal of Med., Jan. 1850. 
2C8
PARALYSIS.
of the brain;  and in eight out of eighteen cases no indications of  cere-
bral disturbance occurred before  the paralysis, or  came on afterwards.
  Dr. Coley, whilst regarding the disease as a reflex irritation, observes
that  he  has  always  found  " organic mischief  either near  the  pons
Varolii or in the intestinal or laryngeal mucous  membrane as the pri-
mary cause of the morbid action of the motor nerves."'
  In  two cases mentioned by Rilliet  and Barthez, where death was oc-
casioned by an  attack of pneumonia, there  was no alteration whatever
in the brain or spinal marrow.2
  5.  Another more limited and local form of paralysis to which I have
already alluded, also  occurs during dentition.   I  mean the facial para-
lysis, or paralysis of the portio dura, and  which  has also been termed
Bell's paralysis in consequence of  that celebrated physiologist being
one of the first, if  not the very first, to give the true explanation  of it.
  It may arise during dentition,  with or without any other symptom of
nervous  disturbance, and its peculiarities are so  marked that we can
have no difficulty in recognizing it at once.
  During repose, the countenance has its natural calm and equal aspect,
both  sides being alike and natural;  but if any emotion be  excited, or
the child  attempt to speak, the  face becomes instantly distorted;  the
muscles of the  affected side are  passive, whilst those of the unaffected
side draw the mouth, cheek, and sometimes  the eyelid outwards.  The
child  can masticate its food as well as other children, but if  it should
get into the pouch of the cheek, he will generally be obliged to remove
it with his finger, because the buccinator muscle  is paralyzed, although
the temporal and masseter muscles  are not.   The tongue is  not para-
lyzed, although  if the  child be desired to put out his tongue, it is pro-
truded crookedly,  yet this is on account of  the distortion of  the mouth.
If the angle of  the mouth on the paralyzed side  be drawn a little out-
wards by the finger, then the tongue  will project straight.
  The eyelids appear weakened and  unable to close promptly  and com-
pletely, so that  in some cases they seem permanently half open.
  Dr. Watson has drawn the  following graphic picture of  a patient
affected  with  this  disease.  " The appearance presented  by  patients
affected by  facial palsy is peculiar and very striking.   From one-half
of the countenance all expression  is gone, the features are  blank, still,
and unmeaning.   The other half retains its natural cast, except that in
some cases,  the  angle of the mouth  on that  side  seems drawn a little
awry.  This is apt to be mistaken for proof of  a spasmodic  condition
of that part; but it is owing  simply, as I stated  before, to  the want of
the usual balance or counterpoise from the corresponding muscular fibres
of the palsied side.  The patient  cannot laugh, or weep, or  frown, or
express  any feeling or  emotion with one  side of his  face, while the
features of the other may be in full play.   One-half of the aspect is that
of a  sleeping or of a  dead person; or  stares at you  solemnly; the
other  half is  alive and merry.   The incongruity would be  ludicrously
droll, were it  not also  so pitiable and distressing."3

            1  British Record of Obstetric Med., June 1, 1848, p. 189.
            2 Mai  des Enfans, vol. ii. p. 336.
            3 Practice of Physic, vol. i. p. 548. 
PARALYSIS.                         209
  This power of paralysis often proves but temporary, the child gradu-
ally  recovering the use of the affected muscles, but in other cases  the
paralysis remains permanently, and it is important to bear in mind that
it may result from more serious organic mischief.  Dr. Graves mentions
that  he has seen it  the result of  an apoplectic seizure, and he relates a
case  in which  it was  caused by an  abscess  of the  internal ear,  with
destruction  of  the  tympanum, ossicula, the  portio dura, and a  part of
the petrous portion of the temporal bone.1
  It may occur alone or in combination with palsy of the limbs.   During
dentition, also, we find not unfrequently a partial paralysis of the muscles
of the eyeball, giving  rise to squinting, and in some cases a peculiar
drooping of the eyelid, so that the child cannot expose  the  entire eye,
as in ptosis.  As to the curability of paralysis connected with dentition,
Dr.  West informs us  that in  six only of his  eighteen cases was a cure
effected ;  in  two of them  the portio dura alone was affected ; in  two
others the paralysis of both leg and arm was  incomplete and associated
with a state of general  debility, and  in two the loss of power in one
leg had come on after  the child  had been sitting for some hours  on a
stone door-step.  The facial paralysis, when it exists alone, is by far the
most easily cured, and it is a disease involving no danger.
  (12). Cold may directly cause  paralysis.   I have just mentioned that
in two of Dr. West's cases it resulted from sitting on a cold stone step,
and  such cases are by no means uncommon.   Paralysis of one arm has
come on  from lying too long  in the grass, and  of the portio dura from
driving in an open  vehicle in the teeth  of a cold wind.
  (13). From  the  delicacy of the mucous membranes and the  suscep-
tibility of the nervous system in young  children, we cannot be surprised
that paralysis, as well as convulsions, may be caused by a disordered
state of  the alimentary canal, proceeding from indigestible food, worms,
constipation, fyc.  Drs.  Underwood,2 H.  Kennedy,3  Doherty,4  Graves
and  others  attribute it to this  cause,  and  Dr. H. Kennedy especially
where it  complicates remittent fever.
  (14). Remittent fever is occasionally followed by paralysis, most fre-
quently of one of the extremities, of which  Dr. Doherty has  given a
case.  Whether it is a pure reflex irritation,  or  proceeds  from some or-
ganic mischief,  it is very difficult to decide.  Dr. H. Kennedy has given
three cases, and remarks, that he found  them  very uncertain as to re-
covery, some requiring  months and  others remaining  incurable.   Sir
Walter Scott is an illustrous  example of the power of the disease.
  (15). In like manner, paralysis  may  follow scarlatina; when  the
patient  becomes convalescent, he is found to have  lost the use of an
arm  or a leg.   Dr.  Kennedy has published a case of this kind, in which
there existed a bruit de soufflet and  slight  symptoms of chorea.   He
has also kindly furnished me with another which occurred in the practice
of Dr. Jabuteau of Portarlington.   The child on recovering from scar-
latina  was exposed to  cold,  and was attacked  by anasarca, for which
diuretics  and calomel were exhibited.  Very unexpectedly salivation oc-

     1 Chir. Med., vol. i. p. 569.            2 Diseases of Children, p. 2G9.
     3 Dublin Journal, vol. ix. p. 88, N. S.    * Dublin Journal, vol. xxv. p. 78.
       14 
210
PARALYSIS.
curred, and it was whilst thus relieved from the anasarca, but under the
ptyalism,  that paralysis of  the right side occurred.  Dr. Simpson also
mentions similar cases.1
  (16).  But other and some apparently unlikely causes  may bring  on
an attack.   Sir Charles Bell knew facial paralysis to accompany mumps.
Dr. Watson mentioned a case in which it arose  from a scrofulous tumor
behind the ear, which was followed by caries of the bone.2   My friend
Dr. Stokes  informs  me that he has seen it  connected with  a  carious
tooth, with a mild attack of tonsillitis, and Dr.  Graves from an abscess of
the internal ear.
  6.  Pathology.—I have incidentally stated nearly all that is to  be
said upon the pathology of this affection.  Certain  cases,  although by
no means frequent, evidently result from disease of the brain and spinal
marrow, and the appearances after death will exhibit either hemorrhage,
inflammation and  its consequences,  or tumors,  as  I have described in
their respective chapters.
  Dr. McCormac  attributes it in  some cases  to  spinal concussion  or
temporary injury of  the sciatic nerves ; but he does not give any evi-
dence in support of  this opinion.
  In  other cases,  where an opportunity of making an examination has
been afforded, no morbid change whatever has  been detected, or perhaps,
as in Dr.  Heiss's case, some congestion about the roots  of the nerves.
But our information  about the disease is  very scanty, as it very rarely
proves fatal.
  7. Diagnosis.—As a  general  rule,  there will be little  difficulty  in
forming a correct  diagnosis if we make a careful examination.  But a
superficial inquiry may mislead, and we may attribute the loss of power
to the injury of a joint, to a blow, or to pressure, instead of  regarding it
as a serious disease.  But the absence of pain on moving  the limb, or
examining it, the loss of voluntary power, and the diminished  sensibility
generally, are sufficiently characteristic.
  Another very important  question is how to distinguish  those cases
where the palsy results from organic disease of the nervous system from
those which are reflex irritation merely ?  As  a general rule, those cases
where an evident exciting cause exists, such as dentition, cold, &c, may
be set down as reflex irritation, and this will include a large class ; but
of the doubtful cases which  remain, what are we to say ?   I should
place great value as a  guide upon the  presence or absence of other
symptoms,  such  as  startings, wakefulness, partial convulsions,  stupor,
heat of head, quick  pulse, &c, provided that  no other irritation  existed
which might give rise to them.
  Facial paralysis is almost always a reflex irritation, but I  have men-
tioned an exception  which occurred  in my own practice.
   Upon the whole, I am inclined to agree with  Dr. West, who observes
that " in many cases the history of the patient will of itself be sufficient
to guard you from error; for if paralysis occur suddenly, affecting both
limbs on one side, and be neither preceded nor attended by any cerebral
symptom, it is almost certain that it does not  depend on serious organic

     1 Ed. Monthly Journ., Jan. 1851.        2 Pract. of Phys., vol. i. p. 555. 
PARALYSIS.
211
disease of the brain.   Our decision will be more  difficult if the loss of
power have  been gradual, especially if only one limb be affected; but
if  the brain be diseased, you will rarely find a mere weakening of the
motor power; for connected with it there will usually be occasional in-
voluntary tremor or twitchings of the limbs, or contraction of the fingers
or toes.  When the paralysis succeeds to convulsions, the case will be
still more obscure.  In most cases of simple paralysis, however, the palsy
comes on after a single fit; while if it depend on some local mischief in
the brain, it is  generally preceded by several convulsive seizures, during
each of which the limb that  afterwards becomes palsied is in a state of
perpetual movement, or is sometimes the  only part where convulsive
movements occur."1
   8. Prognosis.—When  the attack  originates in  organic diseases  of
the brain, the prognosis will depend upon  the nature of that  disease,
and  upon  the general  condition  of the  patient, the  paralysis being
rather an aggravation of the prognosis.  Upon these subjects  I have
entered fully in the respective chapters.
   This paralysis, which is the result of reflex irritation, is rarely fatal,
but  it  may impair the usefulness  of the  limb for a  long time, and
entail its comparative  inferiority to its fellow for life.
   Facial paralysis involves no danger of itself, though it often proves
tedious and sometimes incurable.
   Dr.  West thus sums up the results in his eighteen cases : " in  only six
of the eighteen did a cure of the palsy take place;" "in four of these cases
the treatment was commenced within two or three  days after the occur-
rence of the paralysis, and continued uninterruptedly until the patient's
recovery.  In  one the treatment was begun after the  lapse of  three
weeks; and in another, though begun immediately, it was discontinued
for  some weeks.  In  four instances partial  improvement took place,
and  there seems reason for anticipating that in one, this improvement
will  go  on  to  complete recovery.   In two the  improvement was but
slight; in both these  cases,  however, there was more serious cerebral
disease than  in  any others.   The treatment of another was continued
out for a week, and  though  the child gradually recovered power over
the arm, yet the  leg remained quite useless.   In the other three cases,
treatment was begun within a few days, and was continued  without
interruption.  In eight  cases, in which  no treatment was adopted, or
not till after the  lapse of a period of six months, no improvement took
place in  the patients' condition."
   9.  Treatment.—I shall not now allude to the treatment of those
cases which depend upon  organic  disease  of the  brain, but refer my
readers to the different chapters upon these diseases.
   The facial  paralysis which results from  the use of instruments, or
from pressure,  requires but little treatment; it subsides spontaneously
in many cases ;  and in  others  its disappearance  may be  assisted  by
fomentations to the part upon which pressure has been made.
   In facial  paralysis at a later  period, after  removing every possible
cause,  scarifying the  gums  thoroughly,  clearing  out  the bowels, &c,
1 Diseases of Infancy and Childhood, p. 140. 
212
PARALYSIS.
it is advisable in many cases to apply a leech or two to  the neighbor-
hood of the portio dura, near where it emerges from the  skull.
  Small blisters are also of use, and I think benefit will be derived from
painting the  part with  tincture of iodine, or  rubbing in  the  ointment
of the hydriodate of potash.
  Dr.  Watson advises that mercury should be given so as just  to touch
the gums, and for a valid reason:  "I always take the latter  precaution,
lest any effusion of lymph should  cause abiding pressure on the nerve."
He, however, is rather speaking of adults, and we must not forget that
this effect is not so  easily produced in children, and we may, I think, rest
satisfied with giving a certain amount of mercury, especially if mercu-
rial diarrhoea be produced, even though  the gums be unaffected.
  The constitution  must also be carefully attended to, the bowels regu-
lated, a purgative given occasionally and tonics if necessary.  I  agree
with Dr. West, that preparations of iron  answer better than other tonics.
  When the paralysis affects the limbs, the treatment should be directed
to the  spine, or near to the place whence the nerves affected issue from
the spinal canal.   Frictions to the limbs, stimulating applications, &c,
which  are so commonly employed, are of little use, as they do not go
near to the root of  the evil;  they may quicken the circulation and pre-
serve the heat of the limb, and when the disease is subsiding,  may per-
haps assist in restoring muscular tone, but no more.   Cupping or leeches
near the spine, especially if we have reason to believe that there is any
congestion ;l or where the disease is more chronic, blisters or  irritating
liniments seem to afford the best chance of relief, but they not unfre-
quently  fail.  Purgatives,  not severe ones, and tonics  seem  to  be of
more use than anything else.  Dr. H. Kennedy speaks favorably of
turpentine in doses of a few drops three or four times a day.
  Electricity has been tried, but the results have not been equal.  Dr.
West has found it rather uncertain.  Dr. Simpson has known  it to fail.
Dr. Stokes is strongly impressed with the value of electro-galvanism, and
he  has found electro-puncturation very successful, but the latter could
hardly be used with young children.
  In chronic cases, strychnine may be cautiously tried  in very minute
doses, say from ^ to ^ part of a grain three times a day to a child of
three years old, very gradually increasing the dose,  but  it will require
great  watchfulness, and an immediate suspension of the  medicine if
twitching and starting of the muscles be produced.  In one case in which
Dr. West gave it and at the same time applied a blister, the child seemed
much benefited.  Dr. Coley quotes two cases in which it was remarkably
useful; he recommends the thirtieth part of a grain every eight  hours
to an infant six or  eight months old, and about the twentieth part of a
grain  to a child two or three years of age; the dose to be gradually in-
creased if convulsive twitchings are not observed after a few days.  He
recommends a purgative in most cases before commencing the strychnine.
   The list of remedies we see is  not extensive, nor is their successful
action at all certain, but the chances of success are greater when we
see the child shortly after the attack.
1 Heiss, Lond. Journ. of Med., Jan. 1850. 
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 inflamma-
tion ; and the latter mentions a case of death immediately after birth,
in which the  bronchi were filled with a thick mucus, apparently the
result of chronic catarrh.
  Examples of lobular pneumonia are recorded by Cruveilhier ; of san-
guineous 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,  Cruveil-
hier, Lobstein, and Billard; of scirrhus, by  Wrisberg; of  oedema of
the lungs, by Zierhold; and of hydro-pneumonia.1

                             II.  CORYZA.

  308. 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  a 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  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 expressed by
1 Graetzer Die Krankheiten des Fcitus, pp. 163, 169. 
214
CORYZA.
" 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 exter-
nally.   After the  symptoms had  continued for some  days, the infant
became feeble and languid, and upon looking into the throat " the ton-
sils 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 dis-
ease."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 dis-
covered ;  and the affection seems to have been an intense inflammation
of the entire Schneiderian membrane, with great constitutional 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.
   I shall notice the syphilitic coryza by and  by ;  it seldom constitutes
the sole symptom, and its true character will  be  determined  generally
by the concomitant symptoms.
   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 of
extra-uterine existence rendering the infant peculiarly susceptible.   It
also accompanies  certain other diseases, as  the exanthemata, and in
' Underwood on Diseases of Children, p. 175. 
EPISTAXIS.
215
these countries  prevails epidemically during winter and spring, but
affecting chiefly infants of more advanced age.
  311.  Treatment.—When it exists simply, and is not a symptom  of
a 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  head-
ache ;  and  a  gentle  diaphoretic  mixture  may be 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 popular
remedy of  greasing the nose  externally, which I know by  experience to
be very useful, although I am quite unable to explain why.   [Dr.  Chas.
D. Meigs recommends  the application of a flannel  cap  to the infant's
head, and to be worn until the affection yields.   In children subject to
this annoying disease,  I have succeeded in  obviating a constant recur-
rence of attacks by adopting Dr. Meigs's mode of treatment.]
  These measures will apply equally to infants and children :  but with
the former, if the nose  be  quite  obstructed, it will be better to sub-
stitute 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 advisa-
ble.
  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 children
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 pri-
mary nasal  hemorrhage to this  extent, and  the researches  of MM.
Rilliet and Barthez confirm his conclusion.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
1 Mai. des Enfans, vol. ii. p. 28. 
216
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 hemorrhage is oc-
casionally sufficient to destroy life.
  313.  In general there can be no difficulty in the diagnosis of the dis-
ease.   The escape of the blood externally marks its source ; but it some-
times 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 supposed  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.—When the amount of this discharge is neither too
great nor too often repeated, the effort may be salutary rather  than in-
jurious, 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 extremi-
ties, 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 morbid
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 re-
lief,  be proper to have recourse to some of the local applications just
named.
                        CHAPTER II.

SPASM  OF THE GLOTTIS.—THYMIC ASTHMA.—LARYNGISMUS STRIDULUS.

  315.  Much confusion  has arisen  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,  occur-
ring at  intervals, and repeated irregularly but frequently, appears, at
first sight,  to be a simply local affection, but upon  close investigation
will be found to have a deeper origin and a more important character.
It is not unfrequent in Great  Britain and Germany, but very rare in
France, as Barrier, Rilliet and Barthez, are  mainly  indebted for  their 
SPASM  OF THE GLOTTIS.
217
descriptions to British or German physicians.  Drs. Stewart and Con-
die speak of it as common in America.
  It occurs in infants of from a few months or even days  to three  or
four  years old.   Dr. Copland limits it to between three and four years
of age.   Dr. James Reid to the period of dentition.  However, Dr. H.
Ley  saw one case at four or five years old, and another between six and
seven, and Mr. Porter one at nearly six years of age.  Dr. Jas. Reid saw
a case of this disease in an infant two days old, and heard of another in
an infant a few hours after birth;  Sir H. Marsh mentions one three
days, and Dr. Underwood  one  fourteen days after birth.   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.
Most of the German writers state that it is  most common  between  the
age  of  three weeks  and eighteen months, but especially  between  the
fourth and tenth month.
   316.  The first record we have of the disease, I believe, was in 1761,
by Dr. Simpson, who termed it " the spasmodic asthma of infants."   A
few years afterwards Dr. John  Millar described it (in  1769), and from
him  it was called Millar's asthma.   Dr.  Rush, of Philadelphia, followed
him  in 1770 (in the  Philadelphia Gazette), and both he  and Dr. War-
burton, in 1809, and Dr. Hamilton in 1813, give a fair account of it.
But  by  far the  most complete  description of it is given by Dr. John
Clarke, in 1815, under the title, " A peculiar species  of convulsion 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 ex-
tremities, if the paroxysm continue long, become purple;  the head is
thrown  backward, and the spine is often bent  as in  opisthotonos; at
length  a strong expiration takes place, a  fit  of crying generally suc-
ceeds, and the child, evidently  much exhausted, generally falls asleep."1
   There appears to be a considerable resemblance between this  disease
and  the very rapid form  of hydrocephalus described by  Dr. Munro,
which I have formerly noticed.
   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, sometimes
even for minutes, threatens suffocation.   The whole body becomes stiff;
the  face, hands, feet, and particularly the fingers and toe nails, black or
blue ; and the little  patients lose their breath and consciousness ; at
length,  however, with a cry of  alarm, they again recover both.''
   Dr. Underwood evidently embraces spasm of the glottis  in that mys-
terious  term, "inward fits," which,  he says,  is occasionally  accompanied
"with a peculiar sound of  the  voice, somewhat like  the croup," with a
quick breathing at intervals.2

              1 Commentaries on the Diseases of Children, p. 87.
              2 Diseases of Children, p. 181. 
218
SPASM  OF THE GLOTTIS.
  Dr. Cheyne thus describes the disease in his work on hydrocephalus:
"It begins with crowing inspiration, like that which takes place at the
commencement of a paroxysm of pertussis.   At first there are long in-
tervals between  the spasmodic inspirations  (several days, perhaps), as
they appear to be connected with a disordered stomach and the absence
of bile in the bowels—to arise from sudden exertion or fits of passion ;
and as the child  often continues to thrive notwithstanding, the disease
is not much attended to."
  Very valuable  monographs on this  affection have since appeared by
Dr. H.  Davies, Mr. Pretty (cerebral croup), M.  Roberton, Dr. Mont-
gomery (thymic  asthma), Mr. Hood,  Sir Henry Marsh (spasm of the
glottis),  Dr. Jas.  Reid,  Dr.  Ley  (laryngismus stridulus), (infantile
laryngismus),  MM. Blache, Guersent, Kopp, Hirsch, Kyll,  Caspar,
Fricke,  Oppenheim, &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, sometimes
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, becomes red or
even purple in the face, the eyes are injected and suffused, the eyeballs
protruding, the hands  clinched, 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 ex-
pressive 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 feces are often discharged involuntarily during a paroxysm.
  I have  mentioned that the hands are clinched during the paroxysm,
as a portion of the general muscular effort;  but if we observe carefully,
we shall find that the remarkable spasm of  the thumbs and great toes,
described  by Dr.  Kellie, is present; the thumbs are spasmodically con- 
SPASM  OF THE GLOTTIS.
219
tracted, 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 continue in a slighter
degree after  the spasm of the glottis has  subsided, 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
  Dr. Jas. Reid  has  described  four  forms of the  disease which differ
merely in intensity, from the slight catching  of  the breath, the decided
spasmodic breathlessness with carpo-pedal spasm of the second up  to
the general convulsions of the third,  and the complete asphyxia  of the
fourth form.
  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 II. Marsh has observed.2
  During the  intervals the child appears pretty well, but pale, exhaust-
ed, 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 exam-
ined, 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 complicated
with this affection.   He mentions also that in one case there was obsti-
nate constipation, with dysuria, and that every  attempt to evacuate the
bladder brought on the spasm.3
  To another  symptom which has been occasionally observed consider-
able importance  has  been attached,  from  its  correspondence  with  a
pathological condition to which the disease has been  attributed.   I  al-

    1 Diseases of Children, p. 317.        2  Dublin Hosp. Reports, vol. v. p. 618.
    3 Underwood on Diseases of Children, p. 187. 
220
SPASM  OF THE GLOTTIS.
lude to a swelling of the thyroid and thymus glands.  Dr. Montgomery
mentions a case in which he observed this enlargement, and by direct-
ing his treatment to this point the child was cured.1  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.
  This enlargement, which would be a most important symptom if gen-
eral, has not been very  commonly  observed.   One cannot doubt the
accuracy of those who have mentioned it; but, to have the significance
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 spontaneously,
or in consequence of suitable treatment;  or it  may persist  longer, and
subside after the cutting  of some teeth,  or from long-continued treat-
ment.   A considerable number of cases run either of these courses, and
terminate favorably.
  Others, however, prove more serious and end fatally, either suddenly,
during the first attack, or during a fit  subsequently; or  they die after
a longer 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, Jas. Reid, 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 at-
tributed 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, according
to the other diseases with which it may happen to be complicated.
   For instance, in many cases, no appearance  of disease whatever, in
any organ, could be detected.2  In others,  the cranium is large  and
imperfectly ossified, the  mass  of the  brain  large  and rather  soft,3 or
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 intes-
tines, 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 ex-
ample, it is thus proved not to be  of the nature of croup, as supposed
by  Underwood,  Ferrier, Hecker, Albers, &c, or of asthma, as stated by

            1  Dublin Journal, vol. ix. p. 439.
            2 Sir H. Marsh, Dublin Hospital Rep., vol. v. p. 616.
            3 Dr. Shoepf-Merci, Edin Journal, Nov. 1850. 
SPASM  OF THE GLOTTIS.
221
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 ventricles,
and mesenteric disease.1
  Dr. Cheyne has no doubt that the brain is really the  seat of  the dis-
ease, although the precise morbid condition has not been ascertained.
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 convolutions 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 thymus
gland by Richa, and in  1726 by Verduis.   This view 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  suffocation; 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 extended 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, adhe-
sions 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 de-
generation ;  on pressure being applied, there came away an abundant
milky humor,  like the spermatic liquor in consistence."2
   Dr. Hirsch  published five cases; three proved fatal, and in two there
was a post-mortem examination : " The thymus of the first of these occu-
pied all the  anterior mediastinum,  and was  composed of two large lobes
besides several smaller ones.   An  appendix of the gland arose about its

                1 Commentaries on  Diseases of Children, p.  90.
                2 Dublin Journal, vol.  ix., p. 514. 
222
SPASM  OF THE GLOTTIS.
middle, and surrounded the common jugular vein ;  the glandular paren-
chyma  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 ex-
tended from the thyroid gland beyond the pericardium, which it covered ;
it had contracted adhesions with the arteria innominata and right caro-
tid, 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 extends
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 two 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 description
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 accompa-
nying symptoms were not those of spasm of the  glottis, but  of pneu-
monia.
  Sir H. Marsh 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 mem-
brane of the stomach ;  but in neither is  any enlargement  of the thymus
mentioned, and the author is far too acute and careful an observer to
have overlooked  it  had it been present.3
  M. Trousseau refers the disease to a spasmodic condition, with a want
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 hospital, he has
never met with a single case of thymus sufficiently  enlarged 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,

   1 Dublin Jom-nal, vol. ix. p. 517.         2 Ibid., p. 433.
   3 Dublin Hosp. Rep., vol. v. p. 515.      * On Laryngismus Stridulus, p. 113. 
SPASM  OF THE GLOTTIS.
223
those which adduce  the evidence  of irritation in the central nervous
system ;  2, those which attribute the affection  to pressure upon  some
particular nerves; and 3, those which look to the  enlargement of the
thymus gland as  the ufons et origo inali."  Let us  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 ces-
sation  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 producing 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 distension,  a number
of circumstances will occur which  combine in rendering 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 dis-
tension.   The combined result of this  is  great  and dangerous  pres-
sure 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.'n
   No  doubt these views are stamped with  high authority, and with a
considerable array of learning and research; but there  are two important
facts which meet one at the outset, and which h,ave very great  weight,
so far  as the mechanical production of the  disease is concerned:—
   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 dis-
covered after death.   It is impossible to suppose that such observers  as
Clarke, Cheyne, Hall,  Ley, Marsh, Schoepf-Merei, &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  affec-
1 Dublin Med. Journal, vol. ix. p. 437. 
224
SPASM  OF THE GLOTTIS.
tion of  the glottis or trachea was observed, although at the same time
the lungs were seriously affected.
   Dr.  Condie remarks:  " There has not been adduced a single well-
established fact to show that an 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 consider
the structure of the trachea, and that the peculiarity of the disease 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 caus-
ing this disease, whether exercised by enlarged thymus or absorbent
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 rne, 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 pheno-
nema 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
icornage,' or roaring.   Secondly, it would induce paralysis of the infe-
rior portion of the pneumogastric, with congestion in the lung or lungs,
and the well-known 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, stra-
bismus, contraction of the thumbs  to  the  palms of the hands;  of the
wrists, feet and toes; general convulsions !  sudden dissolution! a series
of phenomena totally unallied to paralysis.
   "4.  Indeed, the larynx is sometimes absolutely closed, an effect which
paralysis of the recurrent nerve and of its dilator muscles cannot effect.

    1 Diseases of Children, p. 318.           2 Ranking's Abstract, vol. i. p. 246. 
SPASM  OF THE  GLOTTIS.
225
   " 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 pro-
duced 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 occur 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  supposi-
tion 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 efforts of  mechanical pressure upon the trachea by the hyper-
trophied 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, {. 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  nervous  system,
already  perhaps  more  irritable than usual,2 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 overfed or improperly fed infants.
      c. The spinal nerves in constipation, intestinal  disorder, or ca-
           tharsis.   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  aitercostals  and  diaphragmatic,  the motors of respira-
           tion."3

          1 Underwood on Diseases of  Children, p. 184.
          2 Riid on Infantile Laryngismus, p. 71.
          3 Diseases and  Derangements of the Nervous Svstem, p. 71.
      15 
226
SPASM  OF THE  GLOTTIS.
  327.  Causes.—Among the predisposing causes  has been mentioned
the peculiar condition of  the larynx  in infants, scrofulous constitution,
hereditary peculiarities, and climate.  It certainly is often observed 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 ex-
cessive action.   Dentition is, perhaps, the most common of such causes;
next, indigestible food,  or overfeeding, constipation, or  disorder of the
bowels, suppressed eruptions.   Mr. Coley mentions  a curious kind of
constipation giving rise to it, in which  there was an accumulation of
feces 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 com-
plexion, 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  tra-
chea, or of much constitutional suffering, are sufficiently characteristic,
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  the same degree,  and, notwithstand-
ing, respiration is steadily performed; but in spasm  of  the glottis, it is
the inspiratory effort  which is arrested, and for  the time, inspiration 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 generally little or no
disturbance of the circulation, and no fever; but,  as  the disease in-
creases, there is a disposition to  general convulsions; whilst in  croup
we  have high fever, quick pulse, thirst, heat of skin, and no convulsions,
except at the termination.
  2. The milder forms of the disease are  distinguished from convulsions
by  the purely local nature of the  spasm, and the absence of constitu-
tional 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  hoop and the  crowing
1 Ley on Laryngismus Stridulus, p. 53.
2 Diseases of children, p. 290. 
SPASM  OF THE GLOTTIS.
227
inspiration, owing to both resulting from the same mechanical condition
of the larynx, viz : more or less perfect closure, terminating in a forci-
ble 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 case 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 ;  Dr. Gooch states, that it  proves fatal  to  one
third of those attacked.   Of Sir H. Marsh's cases, five recovered and two
died.   In Dr. Hirsch's cases, three out of five died.   And it appears to
be more fatal with males than females.   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 symp-
toms will, in many cases, yield to the remedies employed.
   The change which indicates a favorable termination is a diminution 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 processes
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 overfeeding, 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 should be placed in an upright
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 application of ammonia to
the nostrils is useful, or tickling the fauces with a feather, so as to  induce
vomiting.2
   If these means fail, an attempt must be made at artificial respiration.
   In  extreme cases, it has  been a question whether tracheotomy ought
1 Lancet, July 12, 1847.
2 Diseases of Children, p. 358. 
228
SPASM  OF THE GLOTTIS.
not to be performed; and certainly, in prospect of instant death, it may
be right to try some extreme measures; but the advantage to be derived
from this operation is by no means certain, and as yet we want facts to
warrant our recommending it.
   Mr. W. J. Cox has used  chloroform during a paroxysm with  great
success.  " In a few seconds, the muscles  will be relaxed, the spasms
will be over, and  the  little patient will breathe freely."1   A few  drops
of the fluid should be sprinkled on a  handkerchief, or poured into the
hand  and held before the mouth.
   Generally speaking, the paroxysm terminates too quickly to allow  of
much interference.
   332. During the intervals, our  object should be to diminish the fre-
quency of the spasm, and to improve the general health.
   In very few cases is bleeding either  necessary or useful;  in  many, it
would do mischief by weakening the vital  powers.   When the child is
robust, florid, and plethoric, a few leeches  may, perhaps, be beneficial;
but when there is any threatening of general convulsions, or any other
evidence  that the brain is more  than  usually involved, then  prompt
bloodletting 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 recommends
the antacid aperients.
   Antispasmodics have been found  useful.   Millar gave assafoetida 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.  Underwood
assafoetida, oleum succini, tinct.  fuliginis, of the  old pharmacopoeia,
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  £vj) 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 ;v and Dr. Chas. D. Meigs recom-
mends the application of ice to the epigastrium.
   In  cases where dysuria was  present, Dr. Davis derived great benefit
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 of 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 when-
ever it was left out they returned.
   334.  With almost all children  who  have the  disease for some time,
but especially with those of a delicate  constitution,  tonics will  be found
1 Lancet, Sept. 1, 1849. 
PERTUSSIS.
229
beneficial.   Sulphate of quinine,  infusion of cascarilla, or 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 recommends the
vinum  ferri, combined with the carbonate of ammonia and hyoscyamus,
if the  child  be languid  and  irritable;  Mr.  Cox the citrate of iron,
with small doses of hydrocyanic acid to allay irritation (a quarter of a
minim  three times a day  to a child three years old).
   Dr.  Schoepf-Merei states that no remedy is equal to the cod-liver oil,
in doses of two to four teaspoonfuls a day  to a child of three or four
months old, increasing according to the age.
   Attention to the diet of  the child is of great importance.  We  may
succeed in removing the disease, and improper food will instantly repro-
duce 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  fix
upon one kind of food to the exclusion of all  other.   Dr. Montgomery
very wisely cautions us against laying infants on their back when feed-
ing, 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 atmosphere
within the room in which the child lives. I must add  that the tempera-
ture 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 II. Marsh  and Mr. Roberton have 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 imme-
diate 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.

  335.  I have placed  hooping-cough next  in order  to spasm of the
glottis because of the similarity between them, the former constituting
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  inspiratione
sonora, iterata, srepe vomitus."   Dr.  Copland's definition is an expan- 
230
PERTUSSIS.
sion  of  this,  with more details.  He  says  that it is " a convulsive and
suffocative cough,  accompanied with a reiterated hoop, or consisting of
many successive short expirations, followed by one deep and loud inspi-
ration, and these alternating for several times; occurring in paroxysms,
ending  with  the  expectoration of tough phlegm,  and frequently with
vomiting;  infectious,  and often epidemic, appearing but  once during
life."
  It has obtained various popular and learned names: chin-cough, kink-
cough, and hooping-cough, in England;  kinkhoast, in Scotland; coque-
luche, in France;  and, in Germany, keichhusten, stickhusten, eselshus-
ten,  &c.  By Willis, it was called  tussis convulsiva ; by Hoffman, tussis
ferina ;  and by Sydenham, pertussis.
  336.  It is very doubtful whether it was  known to  the ancients.  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,3
Sydenham,3  Alberti,4  Brendel,5 Butler,6 Danz,7  Paldam,8 Perrada,9
Watt,10 Marcus,11 &c.;  and more  recently by  Guibert,12 Desruelles,13
Blaud de Beaucaire,14 Blache," 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, Bar-
thez and Rilliet, Bouchut, &c.
  337.  Hooping-cough has this peculiarity in common with some erup-
tive  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  thirty years:—

  1 Opera Omnia,  Amst. 1682, vol. ii. p. 169.  De Morbus Convulsiva Puerorum, &c.
  2 Obs. on Asthma and Hooping-cough, 1769.
  3 Opera Universa, 1726, p. 311.            «De Tussi Infant. Epidemica, 1728.
  5 Prog, de Tussi Convuls , 1747.            6 A Treatise on Kink-Cough, 1773.
  7 Versuch einer Allgem. Gesch. des Keichhustens, 1791.
  8 Der Stickhusten, 1805.                  9 Memoria, &c.  Verona, 1815.
  10 Treatise on the History and Treatment of Chin-Cough, 1813.
  11 De Keichhusten, 1816.
  12 Recherches sur la Croup, et la Coqueluche, 1824.
  13 Traite de la Coqueluche, 1824.          14 Revue Med.,  1831.
  13 Archives Ge"n., vol. Hi. 1833.
  16 Treatise on the Nature and Treatment of Hooping-cough, 1838.
  17 Cyclopaedia of Practical Med., vol. ii.  p. 428.
  18 Diet, de Med. et de Chir. Pratiques, vol. v. p. 487.
  19 Diet, of Medicine, part. v. p. 236. 
PERTUSSIS.
231
in 135 cases.	
" 357	"
" 596	a
" 333	a
" 186	a
" 109	a
» 37	a
" 34	"
" 12	"
" 10	a
" 5	u
. 3	n
1817	
  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
twelve years old.1  Dr. Hood mentions having seen a child  of a fort-
night 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  Heberden
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 termina-
tion 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  is  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  suffering
much more,  the fever intense, great thirst,  the pulse quick, the oppres-
sion  and general distress considerable, the cough very frequent  and

  1 Mai. des Enfans, vol. v. ii. p. 230.    2 On the Fatal Diseases of Childreu, p. 103.
  * Barrier, Mai. de l'Enfance, vol. i. p. 370.
Under 6 months,
Above 6   "   and under 1 year,
  "   1 year      "    2 years,
  '*   2 years     "    3  "
  "   3   "      "4  "
  «   4   "      "5  "
  «   5   "      "6  "
  "   6   <•      "7  "
  "   7   "      "8  "
  »   8   "      "9  "
  a   9   a      «<   jo  "
  "  10 years,...... 
232
PERTUSSIS.
painful, drv 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 gene-
rally 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, without
any  irritation of the mucous membrane.   M. Blache mentions that the
child of his colleague, Dr. Tavernier, set. 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 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 com-
mon  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  nature of
the disease.
  339. These catarrhal symptoms continue for twelve 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 suc-
cessions, we find it prolonged by a succession of expiratory efforts, and
at its termination we occasionally hear a forcible  inspiration, accompa-
nied by a loud ringing sound.  The prolonged paroxysm of  coughing,
or kink, and the hoop, mark the  commencement 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 suc-
cession, 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 hooping sound is  produced ; a little rest pro-
bably follows, and is succeeded by another fit of coughing, and another
hoop; until, after a succession of these actions, the paroxysm is ter-
minated 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  suppress, 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

  1 Diet. G6n. des Sciences Me"d., art. Coqueluche, p. 24.
  2 On the Chin-cough, p. 37.      3 First Lines of the Practice of Phytic, sect. 1406.
  4 Dr. C. Johnson, Cyclop, of Pract. Med., vol. ii. p. 128. 
PERTUSSIS.
233
breathlcssness 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 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 to food.   If the attack be severe,
it will be pale, thin, and languid.
  340. The length  of the intervals, and  the frequency of the paroxysms
vary a great deal.  At first, and for some time, they are very frequent
when the disease  is severe.   I have known them occur every half-hour
during the day and night; but in other cases they return every five or
ten minutes  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 imme-
diately, or it will occur in double paroxysms.
  A full meal, a fit of anger, crying, fright, or laughter, will generally
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 paroxysms
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,

  1 MarU y on Diseases of Children, p. 157.     *  Study of Medicine, vol. ii. p. 393. 
234
PERTUSSIS.
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 short intervals
between  the  successions.   The  hooping inspiration, so characteristic,
seems  limited  to  the  larynx and  trachea.   Neither pulmonary  nor
bronchial respiration is heard, even in those parts where puerile respi-
ration  had been audible a few minutes before."1
   Similar testimony is borne by Dr.  Williams; he says: "On applying
the ear to the chest during a fit of hooping-cough, one is surprised, 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, pre-
venting 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 disease
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 examined 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 resembling a loud 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 accumulate,
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 percussion
throughout this stage in  simple cases.
   The explanation given of  the cough and the hoop by Dr. Roe is,
I think, satisfactory:  "Any one 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 paroxj'sm of hoop-
ing 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 spas-
modically, 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 ex-
tremely  probable that  the spasmodic action involves the smaller bron-
chial tubes as well as the larger.   " The hoop takes place in the larynx

            1 Del'Auscultation Mediate, vol. i. p. 188,  2d ed.
            2 Pathology  and Diagnosis of Diseases of the Chest, p. 89. 
PERTUSSIS.
235
and trachea, and appears to be caused by a rush of air through a con-
tracted  passage, for no sudden or violent  inspiration 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 glot-
tidis is contracted, and the air passing quickly through a very narrow
opening, causes the hoop."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 delicacy
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 underneath the eyes ; the
spirits are unequal, often depressed.
  As the disease  declines, the paroxysms  become less frequent, though,
perhaps, equal in violence.   They  now  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 in-
tervals  only, and with much less violence, until they cease altogether.
Meanwhile, if not too much  exhausted, the constitution  begins to re-
cover its healthy  condition ;  tranquil  sleep restores the nervous system ;
the absence of vomiting  allows the food to be digested, and the child
recovers flesh and  spirits ;  the circulation returns to  its normal condi-
tion, and the surface assumes  its natural aspect.
  343. Thus we may 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  prolongation
of the cough in inspiration, i. e. the kink and the forcible  inspiration or
hoop.   In some very rare cases  the kink is but little  remarked, but it
is always present in a greater or less degree,  and is, so far, more cha-
racteristic  than the hoop, 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 power of diagnosis.
  The entire duration of  the disease is from two to  four months.   Ac-
cording to popular belief it is six weeks  coming to its height, and six
weeks going off; but  it  maybe  almost indefinitely prolonged, as, for
some  time afterwards, the hoop  returns  when the child  catches cold.
Marley  mentions  a  case in which  the symptoms did not  disappear for
' On Hooping-cough, p. 44. 
236                         PERTUSSIS.

two years i1 and Dewees and others mention its continuance for twelve
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, ophthalmia, &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 morbid  ac-
tion, and from the circumstance that in three out of  the four most fre-
quent complications the  hooping-cough causes and reproduces them.   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 foregoing.
   345.  i.  Pertussis complicated  with Bronchitis and  Pneumonia.—
This  will be found  in these countries the  most frequent, and one of 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.  West'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 pre-
disposition, 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 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
1 Diseases of Children, p. 159.
8 Diseases of Infants, p.  169.
6 31edical Gazette, Feb.  25, 1848, p. 311.
2 Mai. de l'Enfance, vol. i. p. 378.
4 On the Chin-Cough, p. 75. 
PERTUSSIS.
237
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,
with a diminution or  cessation of the hoop, and we  may  certainly as-
certain the fact by  percussion and auscultation.
  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
few 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 alse nasi expand, and the  muscles of
the chest and abdomen are in vigorous action, even during the intervals
of coughing.   We  may sometimes count thirty, fifty, eighty, or a hun-
dred respirations per minute, and the pulse will be, in  proportion, fre-
quent, 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 character,
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  may be 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  have  more
frequently seen both lungs affected than one  alone, and it will be ob-
served that these rhonchi are as audible immediately after a fit of cough-
ing,  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. 
238
PERTUSSIS.
  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 solidi-
fied, absolutely dull,  without respiration  or rhonchus,  but  in which
bronchophony will be audible.
  If the child  live  until  suppuration  be established, which  is very sel-
dom the case,  there may be  heard a  large  mucous bubble, or a large
crepitus, with,  perhaps, cavernous respiration, and  the dulness, on per-
cussion, may diminish.
  So,  in the progress of recovery,  the lung which was solified, and im-
permeable 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  amelioration, we
shall have a diminution of the dyspnoea and rapid breathing, 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 comparatively slight,
but in  the second stage, when the constitution is  somewhat shaken, it
may prove more serious, and require great  attention and  prompt treat-
ment  to  prevent it running on into infantile remittent and  its con-
sequences.  This disordered  condition of the bowels will  be marked by
a foul, loaded  tongue, loss of appetite, tympanitic abdomen, and un-
healthy 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  commencement.   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 inflamma-
tion are absent.  The frequency 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;

            1 Dr. C. JohnsoD, Cyclop, of Tract. Med., vol. ii. p. 430. 
PERTUSSIS.
239
in the present it is quick, hurried, and somewhat unequal, but not diffi-
cult.
   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. in.  Pertussis complicated with Congestion of  the Brain, Con-
vulsions, 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 conges-
tion, convulsions, or  hydrocephalus ; and  all who have had much ex-
perience will admit the rarity of cure, and the rapidity with which 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  termination  of the
case.    Or, lastly,  no symptoms referable to the nervous system call for
our solicitude until after the  hooping-cough has continued many weeks;
but then the long  continuance of the disease  seems to excite  mischief
in the brain, and  death  overtakes  the patient when  we  had already
begun to  hope that nothing more than  time was needed to perfect his
cure."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 occurrence of nerv-
ous affections, any hereditary taint, or the  occurrence of convulsions  or
hydrocephalus in other members of the family.

             1 Lectures in Medical Gazette, Feb. 25, 1848, p. 312. 
240
PERTUSSIS.
   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 repeated, does
,not return with every fit of coughing, but generally as the result of a
very severe paroxysm.   This constitutes our great difficulty in the treat-
ment; we may relieve the  head temporarily, but just as we  fancy our-
selves 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 treatment.
   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 exercise
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 con-
sequence  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 hydrocepha-
lus, occurring as secondary  affections, it  does  not appear easy, nor do I
deem it very important, and therefore I have grouped  them together.
It is almost certain that if  the convulsions continue for  any length of
time without proving fatal,  they will terminate in hydrocephalus.  My
experienced friend, Dr. Johnson,  observes, in  his excellent  essay, "It
is said that in hydrocephalus one side of the body is more affected than
the other ; but in  convulsions, which are independent 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 peculi-
arity  in the convulsion itself."1
1 Cyclop, of Pract. Med., vol. ii. p. 431. 
PERTUSSIS.
241
  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 convul-
sions, 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 way, and effusion of blood
takes place between the membranes, or into the cerebral substance.
  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 Marley1  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, aet. 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 hoop, and followed by vomiting of glairy
matters, more frequent during  the night than the day, free from com-
plications,  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 diminished,
when,  in the  night  of the 31st May, the patient died suddenly, after a
severe  fit of coughing.   On making a post-mortem examination, the lungs
were healthy, the bronchial mucous membrane inflamed.  The bronchial
and  thymus glands, the"head, and abdominal viscera,  were healthy; but
on opening the cranium, a great effusion 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."2
  The symptoms, then, which  ought to excite alarm, are a  continuance
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 complication, it is in
all cases a  most serious one.
  353. Pathology.—We have very rarely any opportunity of examining
the condition of the organs  engaged in simple hooping-cough, on account

    1 Diseases of Children p. 159*.            2 Mai. de l'Enfance, vol. i. p. 381.
       16 
242
PERTUSSIS.
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 vascularity
of the mucous membrane of the glottis and larynx, and sometimes sub-
mucous 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  have been
mentioned  by Astruc, Mackintosh,  and Alcock.
  The bronchial  tubes are found  more or less filled by mucus, and
occasionally by muco-purulent fluid.
  My  friend  Dr.  Hess informs me, that in several cases of hooping-
cough, which  proved fatal from lobular pneumonia, and which he ex-
amined with Mr. Friedleben, they found an enlargement of the bronchial
glands, so that pressure on the nervus vagus and the recurrens seemed
not unlikely.
   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, 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,
congestion of the vessels of the cerebrum and cerebellum,  effusion  of
serum, tubercular  deposition, &c.
   And in cases  complicated  by apoplexy, extreme congestion and vas-
cularity of the substance of the brain,  or sanguineous effusion, as in M.
Barrier's case.
   Thus the rarity of opportunities  for  examining cases of  simple hoop-
ing cough after death, and the fact  that, in  those which have been exa-
mined, some of the  appearances I have enumerated have  been found,
has misled  many observers as to the essential nature of the disease, and
given rise to very  various and contradictory views on the subjects.
   355. Linnaeus maintained that it  arose  from inhaling, in respiration,
the minute eggs of a peculiar species of insect ;l  and his view, somewhat
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  conse-
quence of suppressed transpiration.  Huxham thought it was owing to
a morbid condition  of the intestinal canal ;  Butter that it depended
upon derangement  of the liver ; Waldschmidt and Stoll that it was
caused by crude and bilious matter  in the stomach.

            1 Diss. Exanth. viva in Amoenit. Acad., vol. v. p. 82. 
PERTUSSIS.
243
  Dr. Watt,  judging from the results of his post-mortem examinations,
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.
  Air. Dawson limits the inflammation to the mucous membrane of the
glottis and larynx.   Dr. E. Watson  considers the pharynx and larynx
to be involved with peculiar irritability of the glottis.1   MM. Marcus,2
Broussais, Boisseau, Guersent,  Rostan  and  DugSs, regard it as a spe-
cific inflammation  of the bronchi.
  M. Danz places the seat of the disease in the lungs, and Strong, Cul-
len, 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
  M. 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 trachsea and bronchi we're 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 spasmodic,
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  by Kilian ; but not-
withstanding  the  most  careful  dissection,  MM.  Jadelot, Guersent,
Baron, and Billard,  could discover none.   M. Albers, of Bonn, out  of
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.5
  The  late Dr. Sanders, of Edinburgh, considered congestion at the
origin of the pneumogastric and other respiratory nerves to be the essen-
tial pathology of hooping-cough, and Dr. S. Piddock adopts this  opinion
and bases his treatment of this disease upon it.6
  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 bronchise  are affected.
  Dr. Alderson makes  the disease  to consist in inflammation of the
lungs.7
  Dillon, Hufeland,  Lbbel, Breschet, Albers, and Eberle,8 regard it as
a nervous disease,  perhaps of the brain, or perhaps of the pneumogas-
tric nerve.
  Dcsruelles says  that "hooping-cough is nothing more than bronchitis

        1 Dub. Med. Press, Feb. 1850.
        2 Traite de la Coqueluche, 1816; trad. par. M. Jacques, p. 67.
        3 London Med. and Phys. Journal, vol. xlviii.
        4 Lectures on Surgery, p. 132.
        6 Roe on Hooping-cough, p. 57.          6 Lancet, June  16, 1849.
        7 Med. Chir. Trans., vol. xvi. part 1.      s Diseases of Children, p.  479. 
244
PERTUSSIS.
complicated with irritation of the brain ; and that the inflammation  of
the bronchiae is always primitive, the irritation of the brain consecutive.
So long as the bronchitis is  simple, the cough is without  any peculi-
arity ;  but when the  diaphragm,  muscles  of  expiration,  and of the
glottis, larynx, and  posterior membrane  of the bronchiae and the air
cells of the lungs,  come into action, and  are  simultaneously affected
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 returns, and appears
in paroxysms."1
  M. Blache is of opinion " that hooping-cough is a nervous affection,
having its seat both in the mucous membrane of the bronchise, and in
the pneumogastric  nerves:  an  affection very frequently complicated
with bronchitis and  pneumonia, but which may exist without them ; and,
like all other diseases of the same kind, having no appreciable anatomi-
cal character."2  In this opinion Dr. Roe, MM. Barrier,3 Rilliet  and
Barthez,4 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 irritation
of these parts  having been very  generally observed  in the post-mortem
inspections I have made.  I conceive that the morbid impression or irri-
tation occasioned by the exciting cause in the upper parts of the respi-
ratory surfaces, particularly the  glottis and  its vicinity, affects  the  res-
piratory nerves, especially the pneumogastric; and  that the irritation
is extended to  the origin  of the nerves, when it aggravates and  perpetu-
ates the primary affection."5
  Dr. James Duncan has recently proposed to class hooping-cough with
exanthematous  diseases, a view which was  formerly broached by Yolz,
the resemblance having been  already noticed by Jos. Frank.  The es-
sence of the disease, according to Dr. Duncan, consists  in  turgescence
of the bronchial glands, coinciding with or arising from a peculiar fever,
and the result of a specific poison;  and acting upon the pneumogastric
nerve, in the way Dr. Ley supposed in the case  of spasm of the glottis.6
   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 can-
not co-exist.7
   356.  It would have been very  easy to  have  multiplied  conflicting
opinions;  for  most writers, having pre-conceived 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 pathology of the affection,
and both  were undoubtedly in error.
   The different views of the nature  of the disease may be thus summed
up: —

    1 Traite de la Coqueluche, p. 77.
    2 De la Coqueluche. Archiv. Gen. de Med., 1S33. vol. iii., second series.
    3 Mai.  de l'Enfance, vol. i. p. 39.            < Mai. des Enfans, vol. ii. p. 228.
    5 Diet,  of Med., Part v. p. 242.
    6 Dublin Quarterly Journal of Medical Science, &c, Aug., 1847.
    7 Prov. Med. and Surg. Journ., June 16, 1847. 
PERTUSSIS.
245
  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 inflammation
of the air-tubes, and subsequently a  spasmodic or nervous affection.
  5. That it is a nervous affection, having its seat in the bronchial mu-
cous membrane, and in the pneumogastric or other nerves.
  357.  Now, ir 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 disease, 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, symp-
toms, 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 complication of  each.   This
is so evident that the best modern authorities have based their  descrip-
tion of the disease upon it.
  On this ground we must reject those post-mortem evidences of exten-
sive 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  proceed  to
the consideration of  the question  of  the nature  of the  disease,  we  find
very little assistance to be  obtained  from morbid  anatomy, 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 bron-
chitis; 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 succussions  during
expiration, with an impossibility for  a time of making a complete inspi-
ration.   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  pre-
sence of mucus, and has for its object its removal, yet its character is
peculiarly spasmodic and unlike any ordinary cough. 
246                         PERTUSSIS.
  Now, without attributing it to organic  disease of the brain or spinal
marrow, we cannot but refer the peculiarity of this  cough and hoop 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 transfer-
ence 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, followed
by the reflected nervous  irritation which  gives rise to the peculiar phe-
nomena 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 with-
out being  so much exposed to the contagion as  to bring  on the disease,"
yet there  does appear to be something in the constitution 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 endued 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-
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. 
PERTUSSIS.                        247
  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 great part of Europe.
  According to  M. Desruelles,1 Pasquier mentions an epidemic of this
kind in  1411, in Paris, which attacked more than one hundred thousand
people.   De Thou  and  Sennert mention  another in the  same city in
1510 ;  Riverius  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 sometimes
the patients were attacked  by epistaxis, sometimes by  convulsions; in
other cases  by eruptive  fever, or by some visceral inflammation,  as is
recorded by Ozanam.4
   360.  It must always be  extremely difficult, if not impossible, abso-
lutely to prove the contagiousness of an epidemic  disease, inasmuch as
proximity or contact involves also exposure to the same atmospheric
influence.   Nevertheless,  there are diseases which  prevail epidemically
(smallpox 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 the
disorder at  a day-school, and, being  confined at home by it, communi-
cated it to their father and mother,4  and those related by Duges.6
   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, Dug&s, &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 posi-
tive and negative evidence in  forming  our judgment.  The most  strik-
ing  characteristics of the  disease are the subsidence of the catarrhal

   1 Traite" de la Coqueluche, p.  100.         2 American Med. Repos., vol. x. p. 95.
  3 Med.  and Phys. Journ., vol. xxiii. p. 100.
  4 Barrier, Mai. de l'Enfance, vol. i. p. 372. 5 Ibid., vol. i. p. 373.
  6 Diet,  de Med. et de Chir. Prat,, vol. v. p. 488. 
248                         PERTUSSIS.

and setting in of the spasmodic stage, with the remarkable kink and hoop.
It is not very easy to mistake either;  but I must recall to my readers
what I have mentioned before, that the hoop is not always present, and
also that in very young infants  a common cough is often  accompanied
by an occasional hoop, 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 inspiration,
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 charac-
ter 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 coinci-
dent with the  commencement of the disease.   In pertussis we have the
hoop, the glairy tenacious  expectoration  and almost always vomiting;
in bronchitis the kinks are shorter  and less intense, no hoop, but little
expectoration, and  no vomiting.   In  simple pertussis  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 mucous, afterwards sub-
crepitant.   In pertussis the kinks  continue  for a time, then decrease
until the cough becomes simple, and the child convalescent; in bron-
chitis 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 set-
ting  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 oc-
curred 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  Brandenburg, as 1 to 29 J; in
Sweden and Finland,  1 to 13|;  in  Strasburg, 1 to 94 ;  in Boston, 1 to

         1  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. 
PERTUSSIS.
249
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 63.1.1
  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 there 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 af-
fections,  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 was  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  Connaught, 1 in 9.1."2
  363. With  such evidence  of the fatal  results  of the  disease, it will
become us to inform ourselves most carefully as to the age, constitution,
previous  health, and  the actual state, not merely  of the  lungs, but of
every organ of the body, before giving our prognosis; and even 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 paroxysms
being distant, with intervals of complete relief and quiet respiration, the
rest  at night not  much  disturbed, the appetite good, no local  complica-
tions, and  the absence  of  fever.  The unfavorable symptoms are, fre-
quent 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 hoopingJcough 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, followed
by an expectorant every four or six hours, with a  dose of aperient medi-
cine, and a repetition of the emetic occasionally, a warm  bath  at bed-
time, and confinement to a warm, equable temperature.   I would also
remark that in different epidemics  different  remedies  seem to succeed.
Siome formerly successful, seeming to lose their power, and when  this is
the case it is right to  suspend their use and have recourse to others.
  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  oppression, 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.   Dr. Pidduck, in accordance with his views of the pa-
thology of  the disease, advises leeches directly over the junction of the
occiput and the atlas  vertebra, followed by a  blister between the shoul-
ders, and he speaks most strongly of their good effects if the disease be
uncomplicated.

                 1 Condie on Diseases of Children,  p. 367.
                 2 Report upon the Tables of  Deaths, p. 15. 
250
PERTUSSIS.
  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 authori-
ties.  They may be  given, as I  have said, at the commencement, 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 recom-
mended 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 ac-
cording 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, magnesia
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
hoop, the tenacious  mucus, and the absence of fever, we  shall find it
beneficial to continue the emetics occasionally, and also the expectorant
medicine ; but in addition it will be necessary to employ some antispas-
modic 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's3  plan, who, after an emetic, prescribed one drop of lauda-
num,  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 testi-
mony, 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.4  The formula he employed was this :—
                     R.—Extr. cicutae gr. x.
                         Aq. purse,
                         Aq. menth. pip., a a 3iv.
                         Sacch.  alb. ad grat. sapor, q. s.—M.
1 On the Diseases most incident to Children, p. 50.
2 On Diseases of Children, 437.
3 Med. Chir. Trans., vol. i. p. 25.         4  On Diseases of Children, p. 142. 
PERTUSSIS.
251
  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 laetuca
virosa in the second  stage.  He advises half a grain, with sugar, three
times a day, for children of two years of age.1
  Acetate  of lead has  been highly praised by Dr. Reece.2  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 extract, 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 to a child of four
years, a  grain and a half in each dose.3  Jackson, Guersent, and Blache
recommended its continuance until the effect  upon the pupil is evident;
it may then be discontinued.4
  Kahleiss gave it in combination with Dover's powder, 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. Caron du Villard  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  the
latter 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 in-
creased to  a  minim, which may be given  every  fourth hour ; for a child
of three years  of age, about one  minim, gradually increased, if  neces-

    1 Med.-Chir. Trans., vol. vi. p. 608.       2 Med.-Chir. Rev., vol. xv.  p. 37.
    3 American Journal of Med Science, Aug.  1834.
    4 Barrier, Mai. de l'Enfance, vol. i. p. 392. 
252
PERTUSSIS.
sary, 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 gen-
erally 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 medicine 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
symptoms are generally present, a few drops of ipecacuanha or antimo-
nial wine may be advantageously combined with the hydrocyanic  acid;
but the latter alone possesses the power of curing this formidable  com-
plaint."1
  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 te-
nacity of the mucus of the second stage will be increased, and its expec-
toration rendered more difficult;  secondly, that (with the exception  of
the prussic  acid) narcotics  are  of less  efficacy  in  proportion  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 pur-
gative.
  Among the antispasmodic remedies we  find  also assafoetida, castor,
musk, valerian, sal ammoniac, &c, highly recommended, and  which may,
perhaps, in some  cases be useful, but which are evidently inferior  to the
narcotics.
  366.  Variations in the mode  of administering narcotics and  anti-
spasmodics have been adopted.  Mr. Warren recommends liquid lauda-
num to be rubbed on the abdomen and pit of the stomach daily.   Mor-
phia, 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.  Embrocations
consisting in part of laudanum,  have been  very long employed with
benefit.
  Another mode is by inhalation.   Marley mentions that he has known
1 On Hooping-Cough, p. 89. 
PERTUSSIS.
253
"inhaling the steam of a decoction of the fresh leaves of hemlock, alone
or with ether, to be  of use."1  Dr. Stewart 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 successful.
   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 commencement
of a fit of coughing.  I preferred  this simple mode of administration
(and do still) because of the  impossibility of thereby 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 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 mitiga-
tion 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 reme-
dies.   In no instance was insensibility  or the least inconvenience occa-
sioned.
   There are  two obstacles to its  fair administration to young children;
1, they do not give notice of the approach of the cough, so that by the
time the  chloroform is ready the paroxysm has  commenced, and, as that
consists  of expirations  mainly,  the chloroform will have evaporated
before  its full effect is produced;  2, young children resist  any apparent
impediment to free respiration, as a  hand placed before their mouth.   I
have, however, had an opportunity  of trying it  in  four cases of young
persons above sixteen years of age.   In two (girls), in whom the  hoop
was  fully developed, it arrested it at once;  and, after using  it for  two
days, the hoop  entirely disappeared, a trifling cough only continuing
for some time.   In a third (girl), it was  used from the commencement.
It immediately  stopped or  prevented  the  hoop, and always relieved
the  tickling  preceding the  cough; and, after  using it three or four
times a day for three weeks, the  disease disappeared.  She  never  lost
appetite  or sleep, vomited only once or twice, and was never distressed
by the cough.   Her brother, who  had  the  disease  most  severely,
also took chloroform, and it reduced the paroxysms more  than one-half
in number  during the twenty-four hours,  without  diminishing their
intensity;  but, as it seemed to make him stupid, it was suspended, and
prussic acid given, under which treatment  the  disease was cured in a
month.

    1 Diseases of Children, p.  163.              2 Diseases of Children, p. 109.
     Lancet, June 21, 1815. 
254
PERTUSSIS.
  In 1797, Mr. W. Simmonds, of Manchester, recorded his experience
of the great value of arsenic in the form of Fowler's solution—in small
doses even with infants.   He says that it seldom failed to put a  stop to
the disease in about a fortnight, and that with proper precautions no ill
effects were  produced.
  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, cin-
chona has the most advocates.
  Dr. Burton, Mr. Sutliff, Dr. Lettsom, and Dr. Armstrong recommend
it very highly in combination with tincture of cantharides and paregoric,
as in the following formula for a child of three years old:—
               R.—Decoct, cort. Peruv. ^vj.
                   Elixir sudorif. (paregoric) giij.
                   Tinct. cantharid. gj.—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. Sutliffs
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 tena-
cious 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.
                   Extr. conii gr. xij.
                   Syr. rhoeados gij.
                   Aquse anethi ^iij.—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."
  Tannin, in doses of from half a grain to gr. iij, every second, third,
or fourth  hour, has been  recommended by some high  German  autho-
rities.
  Dr. Durr speaks highly of tannin and benzoin  in the  latter stages of
hooping-cough.   He gives from two  to five centigrammes of each with
fifty centigrammes of sugar every two hours.2
  Dr. E.  Watson applied  Dr. Horace  Green's plan  of cauterizing  the
glottis  and  larynx with a solution of  nitrate of  silver,  and in several
cases with apparent success. The  strength of the solution was gr. xv
to the ounce, and applied by whalebone tipped with sponge, at  first to
the pharynx only.
  Oxide of zinc  has  been  praised  by  Guersent and  Lombard;  the

                1 Graves's Clinical Med., p. 762.
                2 Prov. Med. and Surg. Journ., Ap. 3, 1850. 
PERTUSSIS.
255
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 and Lom-
bard, &c.;  liquor ammonise by Dr. Peyroton,  &c.   In fact, there is no
end to the  list of remedies which have  been  recommended in hooping-
cough ; and probably my readers may thank me for not extending 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
when combined  with a  narcotic,  as  already mentioned;  but  that they
will cure or cut short the disease I do not believe.  Roche's embrocation
is a popular liniment, or we may order  one of compound camphor lini-
ment 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 oint-
wnent, which is most strongly  recommended by many writers  of high
authority.
   Vaccination has been recommended as a remedy.  I am  not aware
of its having been tried in  this country; but  Dr.  Hess informs  me that
some continental experience is rather favorable to it.
   [I have  employed vaccination in several cases, and have every reason
to  be satisfied with the  result,  having found it to modify both the
severity and length of the affection.]
   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 usefulness in short-
ening 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 be 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.
   Dr. Beatty made it a rule  to confine his patients to their bedroom
 until the cure was completed ;  and Dr.  Graves seems to approve of  his
 plan.   Of the two extremes, doubtless it is the best.

              1 Underwood on Diseases of Children, p. 428.  Note. 
256
PERTUSSIS.
  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 taken 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
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 necessary when
either of  the  complications I have  described, exist.  It will not, how*
ever,  be necessary to enter at length into the subject at present, as th"
reader will 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 inflam-
mation, 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  bloodletting, 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 after-
wards.  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 expectorant mixture
or its alternation with it, will be advisable.   I have also seen great 
PERTUSSIS.
257
benefit from spirits of turpentine given alternately with the ipecacuanha
or tartar emetic.
  The bowels  must  be carefully regulated.   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 confec-
tion 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 prevented.
At each visit an accurate account of the state of the stomach and bowels
should be obtained, and the  treatment judiciously adapted  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
accompanied 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 colour or smell, which is by no means  uncommon, mild laxatives,
with small doses of hydr. c. creta or calomel, will probably excite bene-
ficial action  upon the  mucous membrane, and restore the natural secre-
tions.
  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 following simple
mixture for  a child of a year old :—

                  R.—Mist, cretae ^j.
                     Confect. arom. gr. v.
                     Syr. zingib. ^ij.
                     Tincturae opii gtt. ij.—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 discharge after other measures  have failed.  I have  also derived
great benefit from hydrocyanic acid in this complication;  it decidedly
diminished the irritability of the bowels at the same time that it acted
beneficially upon the cough.
   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 con-
stantly recur, and in these cases there are  two plans strongly recom-
mended by Dr. Johnson:  " One is a total alteration of the child's diet,
       17 
258
PERTUSSIS.
and the other is change of air.  When the child affected is at the breast, de-
fectiveness 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 accession 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 sus-
picion, to have a young  and healthy one procured.   Change of air often
in the  most remarkable manner puts a stop to the recurrence of convul-
sions, and will be  found  particularly 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 convulsion.
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 chlo-
roform or ether, but as yet I have had no opportunity of trying either,
lam not prepared to say whether the convulsion 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 recovery from
the  complication,  it has  still a long and exhausting disorder to encounter.
   In addition to the leeching, cold applications, blisters, and  purgatives,
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 affec-
tion, a more liberal use  of tonics, and a more generous diet,  will be  ne-
 cessary 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 bloodletting will guide us as to
the necessity for  its repetition.  If the stupor diminishes,  the  intelli-
gence 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
 con:a, 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 reme-
 dies I have recommended for apoplexy, but it is most  likely that they
 will altogether fail. 
CROUP.
259
                        CHAPTER IV.

                  CROUP.—CYNANCHE TRACHEALIS.

   374.  The disease which is the subject of the present chapter consists,
essentially, in  inflammation  of the larynx and  trachea  primarily, but
"which may occupy a greater  extent of  the respiratory organs; accom-
panied by a peculiar pellicular secretion, with a certain amount of spas-
modic action, modifying the respiratory and vocal functions.
   By the ancients it seems to have been confounded with other diseases
of the air-passages.   According to  Cheyne, Michaelis, &c, Baillou, of
Paris, in 1576, was the first  to indicate the anatomical characters of
croup.  Etmiiller described a disease  strongly resembling it, and after
him  Molloi, 1743; Malouin, 1746;  Ghisi  of Cremona,  in  1747,  who
Called  it angina  strepitosa;  Starz,  in  1749 (morbus 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 observations.  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 sys-
tematic works on  diseases of children, besides being  more or less  de-
scribed by writers on diseases of the respiratory organs.
   It has  been described under various names, but I prefer the ordinary
name "croup,"  as being generally intelligible, and as  involving no  pa-
thological opinion.
   375. It is one of the most  alarming and fatal diseases to which chil-
dren are liable; sudden  in its  attack, alarming in  its symptoms, and
rapid in its results, it  sweeps  over a famrly, leaving  behind it distresa
and desolation.
   Generally speaking, it attacks children between the ages of one and
twelve years, and  most frequently those  under five years.   Marley men-
tions having seen  it in an infant at the breast;1  Hamilton in one of six
or eight months;8 Cheyne in  one of three months;3  Bouchut in one of

       ' Diseases of Children, p. 130.       * Disc ies of Infanta, p. 142.
       ■ Pathology  of the Larynx and Bronchia, p. 15. 
260
CROUP.
eight days old.1   M. Andral gives the following table of ages in 332
cases.   It occurred
ir	ng the 1st month			in	1	case.
	"	3d	a	(<	1	"
	(<	5th	tt	i<	1	!<
ro	m 5 to 12 months			(<	18 cases.	
tt	1 to	2 years		n	61	if
n	2 to	3	it	<<	45	"
a	3 to	4	tt	tt	54	it
tt	4 to	5	it	tt	42	It
tc	5 to	6	it	tt	29	tt
f <	6 to	7	it	it	29	"
ii	7 to	8	it	it	3	li
It	8 to	11	tt	n	6	it
"	11 to	15	tt	a	7	It
"	15 to	30	■ <	tt	13	"
a	30 to	50	ii	tt	10	it
tt	50 to	70	u	a	12	it
  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 twenty-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 two years;  319 in those under  one year; 112
in those between five and ten years; 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 se-
condary 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 two years of age.*
  Mr. Wilde observes, in his Report upon the  Irish Census of 1841:
"This fourth most fatal epidemic affection carried off 42,705, in the pro-
portion 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 dis-
eases,  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 occasionally
attacked, upon  which M. Louis has published a valuable paper.7
   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.

   1 Mai. des Nouv. Ne"s, p. 265.         2 Barrier, Mai. de l'Enfance, vol. i. p. 414-5.
  3 Condie, Diseases of Children, p. 332. 4 Mai.  des Eufans, vol. i. p. 351.
  « Arch. Gen. de MeU, May, 1848, p..l.0.  6 Wilde's Report, p. 1G.
  7 Recherches Anat. Path., p. 203.  Sur le Croup cousidere chez l'Adulte. 
CROUP.
261
  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 functions.   The com-
mencement 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 complica-
tion with other diseases.3
  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 primary
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 threatened suffo-
cation.
  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 importance.  It is not,
however, like the  subsequent hoarseness, but  rather an unusual huski-
ness, 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

  1 Surgical Pathology of the Larynx and Trachea, p. 29.
  2 Diseases of the Chest, p. 2U5.
  *  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. 
262
CROUP.
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 rapid-
ity 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  premonitory catarrh nor
hoarseness, but  where the disease first appears fully formed.
   The duration of the precursory stage is very uncertain, varying from
a few hours to a day or two ; as a general rule, it does not extend beyond
eighteen or twenty-four hours.
   378. II.  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,1 Cheyne,2 and indeed most writers, have noticed, as a pecu-
liarity, the first  occurrence of the croupy cough at night, without giving
any explanation of it.  It seems probable that it may be another exam-
ple of the disposition there is in nervous or convulsive attacks to occur
in the night.  After mentioning the setting in of this stage with "in-
crease of fever,  anxiety, and distress, and by indications of  mechanical
obstruction in the larynx itself" Dr. Stokes remarks: "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 inflamma-
tory spasm of the part."3  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, they are peculiarly apt  to occur in
the night.
   " 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 crow-
ing 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 remission."4
   The cough, then,  with the rough breathing (bruit serratique) and the

                1 Med. Histories and Reflexions, vol. iii. p.  134.
                * Pathology of the Larynx and Bronchia, p. 16.
                3 Diseases of the Chest, p. 208.
                * Pathology of the Larynx and Bronchia, p. 15. 
CROUP.
263
hoarse voice, are the distinctive characteristics of this stage.  The sound
of the cough is  so peculiar that, once  heard, it is never forgotten.  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 hoarse-
ness even when  quiet, but very marked when the child is cryipg.
  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 clinched,
the arms  thrown about, all  covering rejected, and whatever might im-
pede the access  of air is hastily removed.  The body is sometimes erect,
sometimes recumbent, and occasionally with the head rigidly bent back-
wards.1  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  frequently 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 respi-
ratory 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  physical  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, 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 frottement 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."2  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 well
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  applied to the  throat or upper part
of the chest before it  can be heard by the ear unapplied."3  In addition,

  1 This  peculiar symptom is observed in several different diseases, and, among others,
spinal arachnitis, pleuritis, pericarditis, &c; and I have in vain striven 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.
  * Diseases of the  Chest,  p. 214.                  3 Diseases of the Chest, p. 84. 
264
CROUP.
M. Barthez remarks that  at  a certain period of the disease, when  the
stethoscope is applied to  the larynx, we may perceive a peculiar vibra-
tion, as of something flapping, 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 vibration be prolonged into  the trachea and bronchial
tubes, it is unfavorable, from the evidence it affords of the great extent
of the disease.1
  Thus, the physical examination of the chest may yield either positive
or negative results of great practical value in the treatment  of the dis-
ease, 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 characteristic,
and the inspiration less labored.   This intermission may continue during
the greater part of the  day;  but the exacerbation reappears towards
evening, probably after a sleep, with greater  severity than  before.   The
cough, dyspnoea, anxiety, and fever are  increased;  the hand is  con-
stantly  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.
  381.  Arrived at this  period, the progress of the disease becomes very
rapid, and its advance is marked at every step by an aggravation of the
symptoms.   The remissions are  less perceptible, the cough  more diffi-
cult, suppressed, and strangulating; suffocation more imminent; and the
paroxysms are occasionally followed  by vomiting, and  the expulsion of
a glairy mucus,  sometimes,  but rarely, mixed with flocculent or  mem-
branous shreds, which affords temporary relief.   The  croupal  respira-
tion is permanent and increases,  and if the lungs be unaffected, the ribs
are drawn somewhat inwards, and towards the mesial line  (as in atelec-
tasis) instead of being protruded by the distended lungs ; the voice  be-
comes broken, whispering, and  suppressed, partly from the  pain it ex-
cites, and partly from its bringing  on the cough.   Deglutition is occa-
sionally 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.2

    1 Archives Ge"n. de MeU, July, 1838.       2 Valentin, sur le Croup, p. 219. 
CROUP.
265
  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 always
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 moment
we  examine, due to inflammatory spasm, to the mechanical obstruction
of the  false  membranes, or  to  both  combined.  M. Trousseau  states
that when the cough, having  been clear, loud, and ringing, becomes less
frequent, and at length  almost without sound and suffocating,  we may
be certain that exudation has taken place.1
  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. Hegewisch2 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 impor-
tance, 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  occurred 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
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.  III.  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 accel-
erated, and with diminished  power.   The pulse is not  only quick  and
weak, but often unequal and  intermitting ; the  cough is less  frequent,
less sonorous, suppressed, and  suffocative.  The voice is  low, whisper-
ing, or perhaps entirely abolished; the speech quick, imperfect, or lost.
The respiration is extremely difficult, and accompanied with a loud hiss-
ing noise.   All the muscles of  inspiration are called into powerful ac-
tion ; thus the aloe 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  gene-

  1 Journal de Connois.  Med. Chir.,  1834, p. 3.    2 Rust's Magazine, vol. xxxii. p. 2. 
266
CROUP.
rally is pallid, and the veins  are very visible,  especially 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 gratified at the risk of suffoca-
tion.   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  may be  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 extends 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 be-
comes  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 havu
the disease  terminate by convulsions.
  Occasionally,  the disease terminates more  suddenly than I have de-
scribed ; 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 different
and  less fatal  course.  The  fever may be slight, and  the laryngeal
affection much  milder.  Still there will be the sibilant and impeded
respiration, the  croupy  cough,  and  the hoarseness, never to  be mis-
taken  when once they have  been  heard.   These will be troublesome
during  the  night, and perhaps  there may be  more or  less complete
remission during the day.  No matter how slight the attack may be,
the most vigilant  care is  requisite, as the  disease very  often acquires
great intensity in  a very sudden manner, and a very 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 
CROUP.
267
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 my 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 character, as  in a case at pre-
sent 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 membranes of the  larynx and  trachea, in the majority
of cases, show evidences of inflammation ;  they are of a bright red, vas-
cular, and thickened, so that they can be peeled off easily. Occasionally
the redness is partial, with patches of  ecchymosis around the follicular
orifices;  and in some rare  cases, as has been noticed by Albers and Ju-
rine, Rilliet, and Barthez, the mucous membrane is  pale, and apparently
perfectly healthy, underneath the false membrane.   This Albers  ex-
plains 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 give  the  mucous membranes a dotted ap-
pearance, 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.  II. 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 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 
268
CROUP.
trachea; in others it forms  demi-cylinders,  or  more rarely,  entire
cylinders, or tubes of different length—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-puriform 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 attempt to
remove the false membrane brings away  the  mucous coat.  When the
secretion is extensive and general, it is  generally less adherent; and
when  removed, the surface, which  had been in contact  with the  mucous
membrane  is  generally smooth,  and of a whitish yellow color,  with
longitudinal strise, owing, probably, to  the impression of the muscular
fibres of the trachea.
  In  this  adherent surface,  also, we  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 possibility,
and have discovered vascular striae which penetrate  the  substance.
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 extremely rare on
account of the  rapidity of the disease.
  As  to the chemical  properties  of the  false membrane, I cannot do
better than quote the following passages from M. Bretonneau's valuable
work: "I  have endeavored," he observes,  "by  means of different
chemical reagents, 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 hydro-
chloric acids coagulate all; acetic acid,  liquid ammonia, and alkaline
solutions, dissolve all, and convert them into a diffluent and transparent
mucus, exactly at  the same temperature, and in the same vessel."2
  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 inflammation
corpuscles, and a species of cell double the size of the  pus globule, but
otherwise similar to it.3
  Instead of this plastic lymph, we occasionally find the air-passages in-

  1  Mai. des Enfans, vol. i. p. 319.              2 Traite" de la Diphtherite, p 293.
  8 Ranking's Abstract, vol. iv. p. 334. 
croup.                          269
flamed, and to a greater or less extent lined with a layer of viscid puri-
form or muco-puriform matter, offering, of course, an  impediment  to
respiration, but more easily expectorated.1
  388. It may be as well to notice here  certain other morbid conditions,
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
extending  into  the larynx.  In  almost all  cases the  oesophagus  is
healthy ; in two cases related by Bretonneau, however, the false mem-
brane 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
commencement 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 membrane
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 vas-
cular ; in others red and softened.   Moreover, they contain a  quantity
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
and extensive ;  nor does it depend upon the extension of false membranes
to the bronchi, for it is present in many  instances when they are absent.
  An emphysematous condition of the lungs exists in a large proportion
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.
  o!i{). Now, from the morbid appearances  I have mentioned, there
cannot be much doubt of the pathology  of  the disease :  that it consists
of inflammation of the mucous membrane, giving rise  to a  peculiar
secretion, and exciting spasmodic  action ;,  and the result is a great im-
pediment to the ingress of air, to its access to the minute bloodvessels,
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 inflammation
of croup ;  and that its vessels exude the albuminous or characteristic
discharge,  which,  from its plasticity, and  the effects of temperature,
1 Dr. Francis, New York Med. and Phys. Journal, vol. iii. p. 56. 
270
CROUP.
and the continued passage of air over it, becomes concreted into a false
membrane.
  " 2. That the occasional appearance of bloodvessels 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 globules
generally attracting each other, and  appearing like bloodvessels, 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 follicles
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 cryptre
becomes more and more copious, the albuminous membrane is  the more
fully separated, and ultimately excreted, if the vital  powers of the res-
piratory organs and of the system are sufficient to accomplish  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 productions in  the
air-passages; but that  these are not  the only morbid conditions  consti-
tuting the disease.
   " 5.  That, in conjunction with the foregoing—sometimes  only with
the former of them in  a slight degree—there is always 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  ex-
udation of albuminous matter may be going on for a considerable time
before they are suspected,  the  accession of the spasmodic symptoms
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 varying
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 treatment of  the  pa-
tient, &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 bene-
ficially 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 uninterrupted respiration  and  cir-
culation through the lungs.
   " 10. That the partial detachment of  fragments  of membrane, par- 
CROUP.
271
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 exudation, 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 exudations
in the pharynx, or in the vicinity of the larynx or epiglottis, may pro-
duce croupal symptoms in weak, exhausted, and nervous children, with-
out the larynx or trachea being materially  diseased; and that even the
sympathetic irritation of teething may occasion the spasmodic form  of
croup, without much inflammatory irritation  of the air-passages,  parti-
cularly  when the  prima via is disordered, and the membranes about the
base of the brain  are in an excited state.
  " 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 inflammatory
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 spas-
modic 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 inflamed
and coated with  lymph, but also  because the larynx and trachea are
spasmodically affected, and it is most important to bear this in mind.'
Dr. Stewart remarks,  that " the  cough, or the peculiar sound  so re-
markable  in expiration in croup, is  observed to exhibit 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 enlargement of the glottis,  by
1 Desruelles, Traite" du Croup, p. 170. 
272
CROUP.
the shock of the same column of air overcoming the contraction of the
muscles."1  Dr. Stokes considers the "cause of obstruction in this dis-
ease to be more spasm than effusion of lymph," and adduces  in  proof
the temporary suppression of  the sibilant breathing which follows vom-
iting.
   390.  It is not very easy to  explain satisfactorily why children are so
much more liable to the disease than adults.   Dr. Cheyne considers 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."  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 relation
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 which deter-
mines the progressive development of  the larynx  up to the period of
puberty, may also predispose the  mucous surface to  the plastic or forma-
tive irritations."2   I confess I do not think the explanation 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, accord-
ing  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.3
   391.  Causes.—The principal causes appear to be constitutional apti-
tude, exposure  to  a cold,  damp,  changeable  atmosphere,  insufficient
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, and dif-
ferent children in the  same family  sometimes share the liability.   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, northwest
of Europe generally, the middle and south of France, the north of Italy,
&c, are countries in which it is very prevalent.   In  towns, 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

    1 Diseases of Children, p. 75.          2 Diseases of the Chest, p. 211, note.
   8 Valentin, Sur le Croup, p. 464. 
CROUP.
273
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."1
  The suppression of cutaneous eruptions,  the  breathing  of  noxious
gases,  swallowing boiling water, &c., are all  occasional causes of the
disease.
  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  consid-
erable  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, in 1762 (Rosenstein);
Frankfort, in 1764 (Van Bergen);  Sweden, in 1768-72 (Wahlbom and
Baeck);  Wertheim, in 1772 (Zobel); in  Gallicia, in 1778 (Hirschfeld);
Clausthal, in 1783 (Boehmer); United States, in  1805 (Barker); Stutt-
gard, in 1807 (Autenrieth); Saxony, in 1807-8 (Albers); and in 1811
(Schundtmann) ;2  at Vienna, in 1807-8 (Golis); and in Maryland, in
1807 (Chatard).
  Several partial  or local  epidemics have since  occurred, but  none so
general as the above, that I am aware of.  Dr. Vauthier has published
an account of the epidemic which prevailed in the  Hopital  des Enfans
at Paris in 1846-7.3
  Several authors, as Wichman,  Boehmer, Field, and others, maintain
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  spread
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 con-
sider 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 con-

         ' Diseases of Children, p. 347.
        2 Albers, de Trachseitide, p. 70.  Valentin, Sur le Croup, p. 4C2.
        3 Archiv. Ge"n. de M6d., May and June, 1848.
       18 
274
CROUP.
tinuous and unremitting severity of symptoms, by strength and rapidity
of pulse, heat  of skin,  diflScult  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 occasionally
occur.  The attack  may  terminate fatally in twelve hours, or be pro-
longed to four or five days, but rarely longer.
  On the other hand, the disease may be confined to the trachea, con-
stituting the tracheal  croup of continental writers, and having a less
rapid and  less fatal progress, with some variation  in the symptoms.
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 terminated in
bronchitis.
  II.  Croup, with a Predominance of Nervous or Spasmodic Symptoms.
—The attack may come on like ordinary croup, with feverishness, 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  two  may awake with
perfectly formed  croup,  hoarse  voice, ringing cough,  dyspnoea, 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 neg-
lected, 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 spasmodic
irritation may be relieved before  there  has been time for false mem-
branes 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  com-
plicated, 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 generally.
1 Blaud, Recherches sur le Croup, p. 312. 
CROUP.
275
We find the croup, dyspnoea, and hoarseness much as in an  ordinary
case;  but there is 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 expecto-
ration increased.   If the croupy sound  be not very loud, we shall  be
able to 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 bron-
chitis, 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, with
some bronchitic 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, according
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 diffi-
cult.   We ought to examine the chest daily, to seize upon a moment of
comparative quiet;  and, if we can avail ourselves of the temporary sus-
pension 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 universally fatal
course, without remission or mitigation.
  395. in. Other complications have  been noticed, but they occur much
less frequently; thus, Cheyne, Condie,  and others, mention the occur-
rence of  pleuritis;  several authors  speak  of  emphysema ;  others  of
partial rupture of the trachea; and Martin1 of a case in which vomit-
ing 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 tonsillaris,
or cynanche pharyngea, the inflammation,  which, in those parts, gives

          1 Rec. Period, de la Soc. de Med. de Paris, April, 1810.
          2 Albers, Comment, de Trachseatide, p. 69. 
276
CROUP.
rise  to  the ash-colored or whitish  membranous exudation, may extend
itself to the larynx and trachea, giving rise to croup, and adding a for-
midable 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.1
   It also occurs in  the course of several of the exanthemata; during the
first or  eruptive stage of measles, miliary eruption, scarlatina, as I have
mentioned, smallpox, &c, according to the testimony of many authors.
In the latter case it comes  on most frequently during the  suppurative
stage of confluent smallpox, 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, Ste-
venson, 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 mem-
brane is  less extensive;  the false membranes are yellowish,  and  of
smaller extent,  thinner, less adherent, and softer than  in the disease
just  described.  They seldom occupy the entire larynx, but often the
interior portion of the epiglottis, and the superior part of  the  larynx,
as far as  the chordae vocales, or the ventricles of the larynx.   In one
case out of eleven only did Rilliet and Barthez detect  them at the infe-
rior  portion of the trachea, and  in another in  the bronchial tubes.
   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 two others it was nasal, embarrassed,  but not
extinguished ; in three it was muffled,  and in  one  it was extinct; with-
out 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  is  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 ulcera-
tion) of the tonsils,  uvula,  and palate, with a  gray or  yellowish exuda-
tion of lymph ; the parts are swollen, and of a dark red color, and there
is considerable difficulty in swallowing.

  1 Med. Obs. and Inq.  by Dr. Rush, vol.  ii. p. 376.   Ferrier, Med. Hist, and Reflec-
tions, vol. iii. p. 205. 
CROUP.
277
  Dr. Stokes has given a comparative view of the symptoms of primary
and secondary croup, which I shall take the liberty of extracting:—
  " 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.
  " 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 upwards ; 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, without
the pre-existence of catarrh.
  "11.  In the former, the complication with acute pulmonary inflam-
mation 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 catarrhal
stage, by the hoarse voice, by the sibilant respiration, and by the ring-
ing cough; in spasm of the glottis there is no catarrh, inspiration only
is difficult; the crowing sound is quite different from the expiratory noise
in croup; there is no cough,  and the voice is unaltered.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 is fever, expecto-
ration, and no such paroxysms of suffocation as in croup.
  ill.  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

                1  Diseases of the Chest, p. 206.
                2  Albers, Comment,  de Trachteatide, &c, p. 50. 
278
CROUP.
symptoms, fever, dyspnoea,  and cough.1  I  have  already given Dr.
Stokes's parallel between the two affections.
  iv. In pertussis there is hurry of respiration, but  neither the diffi-
culty nor  the sibilant sound; the cough, though loud, has not the pecu-
liar metallic sound, and in the intervals there is complete relief, neither
hoarseness nor dyspnoea.
  v. If the previous history were obscure, it might be possible  to mis-
take the symptoms resulting from foreign bodies in the  trachea 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 paroxysm id
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 laryn-
gitis ; the  respiration gradually becomes easier, and expectoration takes
place.   "Most commonly,"  says Dr.  Cheyne,  "after the  disease has
arrived  at its height, the decline  is,  as it were, a retrogression 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."
Sometimes the crisis is marked by the expectoration of false membrane,
but this is not always a proof that the disease will subside.
  n.  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.
  III. In  the majority of cases, croup ends fatally with the symptoms I
have already detailed.  Marley says that  two-thirds die.  Vieussieux,
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 as-
phyxia.
  401.  The prognosis, therefore, in all cases of croup, is very serious;
the probabilities are against recovery,  but in estimating those probabili-
ties we  must take into careful consideration the period of the disease at
which the child comes under treatment, the intensity of  the symptoms,
1 Pathology of Larynx and Bronchia, p. 16. 
CROUP.
279
the degree of fever, the  complications, and the extent  of the  disease,
and the strength of the constitution.
   If the  disease be attacked at the very commencement, it is by no
means an unmanageable  or fatal disease, but will in most cases  yield to
appropriate treatment; nay, if it be further advanced before we see it,
yet if  it be a mild case, the symptoms marked but not  violent, the in-
flammation limited, the fever moderate, and no  complication, the child
may recover under proper care.
   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,  and
time has been lost, there will be but little hope from treatment at  any
period; none if the case have been overlooked for 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 owing 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 accumu-
lation  in the air-passages; 2.  When the time for doing this has passed,
to procure the discharge of these  matters; 3. To mitigate the spas-
modic  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 almost always cut short the disease.   My own children, for exam-
ple 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 neces-
sary 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 secre-
tion  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
   M. Valleix states that of 31 cases in which  emetics formed the basis
of treatment, 15 recovered, while of 22 in which they were rarely given,
but one recovered.
   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 vomit-
ing is excited, and  then continued in doses of an eighth or  a  twelfth
' Pathology of the Larynx and Bronchia, p. 51. 
280
CROUP.
 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.  Dr. Meigs uses
 the  alum, and speaks most  highly of it in doses of a teaspoonful  of
 the powder in honey or syrup, and repeated in a quarter  of an hour,
 if it do not excite full vomiting.1
    Dr.  Hubbard prefers the  turbith mineral (subsulphate  of mercury)
.. for this purpose.
    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
 bloodletting.    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.
 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 calcu-
 lated to produce more beneficial effects than in croup.  The  practitioner
 who, in violent cases, neglects this important measures, 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  management  of
 the disease."2
    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 re-
 cently in his  Clinical Medicine,  my friend Dr. Graves has called atten-
 tion 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  followed 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, however, 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

              1  American Journ.  of Med. Sciences, Ap. 1847, p. 290.
              2 Diseases of children,  p. 305. 
CROUP.
281
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 ad-
vanced."1
  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.
  Dr. Horace Green, of  New  York, has proposed the local application
of nitrate  of silver  in croup, as  well  as  in  other laryngeal affections.
Ordinarily he uses a solution of  from two  scruples to a drachm of the
crystals of nitrate of silver in an ounce of water, and he  applies it at
first to  the fauces  and  glottis, and  afterwards  within  the larynx, by
means of a small  piece of sponge fastened on a curved rod of whale-
bone.   " The instrument being  prepared  by suitably  saturating  the
sponge  with the solution to be  applied, and the head of the child being
firmly held by an assistant, and  the  base of the tongue depressed  by
a spoon or any other suitable instrument, the operator  carries the wet
sponge  quickly over the top of the epiglottis, and on the laryngeal sur-
face of  this cartilage;  then pressing it suddenly downwards and for-
wards, passes it through the opening  of the glottis into  the laryngeal
cavity."2   This Dr. Green says  does  not produce the amount of irrita-
tion we  should expect, and he considers it suitable to every stage either
of simple or complicated croup.   He  has given several  cases, in which
this treatment succeded.   Dr. Blakeman of New York has recorded two
cases in which it succeeded ; the first requiring  three, and the second
two applications of the solution.3  Dr. Clarke has related six cases thus
treated, of which four recovered, and two died.4
  Dr. Latour has used the solid  nitrate of silver  to all the parts within
reach, and  afterwards contrived to squeeze some of the solution into the
larynx.  The child recovered.5
  Dr. J. F. Meigs, of Philadelphia, used a solution of nitrate of silver
(gr.  x to Jj) to the fauces, applied with a camel's-hair brush.  He does
not, however, seem to attribute much of his success to this  application.6
Dr.  Townsend proved it of great use in one case.7
  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
cases I  have only succeeded once.  The proper time for administering

           1 Clinical Med., Lecture xxxix., vol. ii. p. 4. Second edition.
           2 Observations on the Pathology of Croup, p. 83.
           3 New York Med. and Surg. Reporter, &c, Oct. 1847.
           4 American Journ. of Med. Sciences, Ap. 1850, p. 360.
           5 Gazette Med., Aug and Oct. 1846.
           6 American Journ. of the Med. Sciences, Ap. 1847, p. 290.
           7 Ibid., July, 1851, p. 85. 
282
CROUP.
relief is when the cough, dyspnoea, and palpitation increase towards 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 practised 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 dessertspoonful " 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 doses.
   On the other hand, we must not forget that with some children tartar
emetic  produces  a very depressing effect.  Dr. Stewart  mentions  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 calo-
mel, 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 succeeded 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 thickened and changed in structure."4
I have  generally given it  in  combination 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 combination  of calomel with tartar emetic, in  the
proportion of four or six grains of the former with a fourth of a grain

             1 Med. Hist, and Reflections, vol. iii. p. 139,
             2 Diseases of the Chest, p. 217.
             3 Diseases of the  Chest, p. 218.
            4 Surgical Pathology of the Larynx and Trachea, p. 45. 
CROUP.
283
of the latter, every fifteen minutes, until vomiting is excited, in the case
of children from two  to five years old.   He  further states  that  he
" 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.  Dewees recommends turpentine, hartshorn, or
the mustard and vinegar poultice.   Others, as Drs. Ferrier, Underwood,
&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 immediate neighborhood
of inflammation, but he admits their value when the lungs are congest-
ed.2  Rilliet and Barthez, and Bouchut, disapprove 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 neglected ;
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 diar-
rhoea 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, ammo-
nia, and small doses of ipecacuanha, &c, with an occasional 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 the  calomel
and the expectorants I have already mentioned.
   If the fits of coughing be severe and suffocative, an occasional emetic
will be of service in loosening and  perhaps expelling the lymphy exuda-
tion.  The continued use of tartar emetic must depend upon the circum-

             1 Diseases of Children, p. 359.
            2 Surgical Pathology of Larynx and Trachea, p. 45.
            » Mai. de l'Enfance, p. 269. 
284                           croup.

stances 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  afterwards slightly stimulant.
It may be useful, also, in the  spasmodic  form of the disease, but must
not impede the employment of antispasmodics by the mouth or in ene-
mata.
   Dr. Budd, of Bristol, recommends converting the bed of the patient
into a vapor bath, and giving an emetic every four hours.1
   A warm bath will  also be found useful occasionally, but in some cases
it seems to aggravate the dyspnoea.
   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 powder may be combined with the calomel or with
camphor,  or camphor with James's powder and hyoscyamus ; or a drop
or two 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 bloodletting,  emetics, and
blisters.   He  gave one grain, combined with a grain of hyd.  c. creta,
every two hours.2
   Mr. Hird speaks  highly of the effects of  alkalis in allaying spasm,
and promoting the absorption  of the exudation;  he gives ten or fifteen
minims of the liq. potassse every four hours.3
   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 antiino-
nials, or ipecacuanha, or squills, as in the following formula:—

              R.—Decoct, senegae 3 ij.
                  Oxymel scillse 31J.
                  Vini ipecac, sjj, or Liq antimon. jiij.—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

      1 Med. Times and Gazette. June 19, 18-52, p. 611.
     * Dublin Journal, May, 1810.             3 Lancet, December 5, 1846. 
croup.                          285
early part of the second stage, but it would, I think, be unwise to depend
upon it to the exclusion  of other remedies.
  Should the active measures hitherto recommended cause much depres-
sion, 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 combine
them with antispasmodics or stimulants, such, for instance, as camphor,
musk, assafoetida, &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  collapse,
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
recommended 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 rube-
facients 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 convulsions.
   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 character
of the symptoms and the strength of the patient.   If  the bowels be not
too  much  affected,  the calomel may be continued,  and an occasional
emetic exhibited; but in general we  have to act  more indirectly, and
through  the medium of  the constitution, aided by counter-irritants.
  414.  Thus we see the means at  our disposal which offer a probability
of success are  not very numerous.  Early vomiting, continued nausea,
bloodletting, warm baths, counter-irritants, expectorants, tartar emetic,
calomel,  some few antispasmodics and  stimulants, compose the  whole
list; but these, used judiciously, promptly, and vigorously 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 cathartics
will afford the greatest relief.
   Dr. Copland recommends the administration of  bark, and, no doubt,
in the more advanced stage, when there is much  sinking, it is calculated
to be of  use.
   416.  When croup is complicated with bronchitis, pneumonia, or pleu-
risy, the same principles of treatment will apply;  but in addition, local 
286                           croup.

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 constitution.
  417.  Secondary croup  requires a more skilful modification of treat-
ment ;  it is seldom that very active means can be employed.   In addi-
tion  to the remedies for the primary disease (to be hereafter mentioned),
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 diphtherite, &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 conse-
quence.   Now, it is a very natural and plausible question whether this
difficulty might not be  avoided  by an operation; in other words, whe-
ther the operation of tracheotomy, by admitting air freely to the lungs,
might not, even in the third stage, prolong life and increase 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 practised in Spain, Denmark,
Germany, America, and in Geneva, Brest, Lyons, Paris, London, Dub-
lin, &c.
  T shall mention the opinions of some of the principal authorities. Dr.
Cheyne is opposed to it because he thinks it would be useless unless the
membrane could be removed, which, in most cases, would be impossible,
and  in  others  superfluous, on account of its  rapid  reproduction.   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
  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 himself, he
has arrived at the conclusion that " the operation does not afford suffi-
cient prospect of benefit to admit of  our having recourse to it."4

  1 Pathology of Larynx and Bronchia, p. 41.       2 Diseases of Children, p. 480.
  3 Underwood on Diseases of Children, p. 451.
  4 Surgical Pathology of Larynx and Trachea, p. 57, el seq. 
CROUP.
287
  Mr. Carmichael has recorded a case in which he performed the opera-
tion with success, and a second  which was unsuccessful.1
  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 present
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.3  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.4
  Dr. J. F. Meigs has seen the operation performed three  times, and
in two of the cases  the children recovered.'  But  he mentions that it
had been performed in Philadelphia in eight cases prior to 1848, and in
four cases during that year (exclusive of  his three cases), and in all un-
successfully.
  Dr. Bigger has recently recorded a  successful case in the Dublin
Medical Press.6
  Dr. Coley relates a case in which he  performed the operation,  and
the patient died.7
  Mr. W. Craig has published a case in which he operated successfully.8
The child was set. 7, and the false membrane had extended below the
incision, but was removed through it.
  419. On  the Continent, however, the  operation has found some ad-
vocates,  and  apparently  met with  somewhat greater success.  Caron
Marigault, Senn, Maslhieurat, Berard, Petit, Rilliet  and Barthez, Bar-
rier,  Guersent, Bouchut, Thore, R.  Latour, &c, are  in favor of it; but
it has also  powerful opponents  in Vieussieux, Double, Albers, Jurine,
Royer Collard, Bricheteau, Becquerel, Bondet, &c.
  In  the cases in which tracheotomy was  performed by Guersent and
the "internes," in the Hopital des Enfans at Paris, in 1841,  the opera-
tion,  while it was of no advantage whatever when the pseudo-membra-
nous  exudation  extended to  the bronchi,  appeared  in many cases to
accelerate the fatal termination by inducing severe bronchitis, or an exces-
sive secretion of mucus in the  bronchi, pneumonia, or convulsions; while
in many cases the patient died immediately after the operation, without
any local lesion existing to which the fatal termination could be referred.9
  M. Guersent states that he has performed the operation one hundred
and fifty times since 1834 ;  the  later operations having been much more
successful than the earlier ones. In 1850  he operated upon forty chil-
dren  in  private practice, and  eleven recovered ; of twenty operated
upon  in the hospital, seven recovered. During 1851, of thirty-one ope-
rations at the hospital,  thirteen were successful.10

  1 Transactions of Association of Physicians of Ireland, vol. iii. p. 170.
  2 Diseases of the Chest, p. 219.       3  Diseases of Children, p. 85.
  4 Diseases of Children, p. 309.
  s American Journal of Med. Sciences, April, 1849, p. 307.
  • Jan. 6, 1847.              7 Brit. Record  of Obst. Science, Feb. 1, 1848, p. 60.
  8 Med. Times and Gazette, May 21, 1858, p. 522.
  » Condie, Diseases of Children, p. 309.
  10 Mem.  de la Societd, de Chir. de Paris, vol. iii. 1852-8.  Brit, and For. Rev., Ap.
1854, p. 466. 
288
CROUP.
  The researches of M. Bretonneau  revived  the  operation  in France,
and gave hopes of its being more successful.  Out of  fifty-five cases of
different ages, he found the exudation reaching  to the bronchial ramifi-
cations 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 terminated  at dif-
ferent parts of the  trachea, so that it was inferred that it was possible
to perform  the  operation  below the  seat  of  the  disease, 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 operation.   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.
  M. Valleix found that out  of a number of cases treated by medicine,
about one-third  recovered, and as many when the operation had been
performed, and  certainly,  as he remarks, even  one recovery is  a life
saved,  inasmuch as  the operation is generally performed under most dis-
couraging circumstances, and as a dernier ressort.
  Dr. Karl Weber  has recently recorded two cases, one  of which suc-
ceeded.1
  More recently, M. Trousseau has reported the result of the operation
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 below
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 mis-
chance as far as the operation was concerned.   He gives the following
summary of the  success of croup treated by tracheotomy.  M. Bre-
tonneau saved six out  of twenty ; M. Trousseau  saved  twenty-seven out
of 112 ; M.  Leclerc, of Tours, succeeded in two  cases ; M. Velpeau suc-
ceeded 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,  Guersent, Jun.,  Boni-
face, Depres, Blandin; &c,  but he is unable to communicate particu-
lars.2
  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 regard 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

              1  Henle's Zeitschrift, vol. iii. pt. 2, p. 8.
              2  Rilliet and Barthez, Mai. des Enfans, vol. i. p.  379. 
CROUP.
289
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.
   II. 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
operation, being purely mechanical,  can afford no  relief,  but may  seri-
ously add to the clanger.
   IV.  Bronchitis or pneumonia may exist at the time of the operation,
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 hemor-
rhage 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.
   VII. 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 argument
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 how to  recognize them with sufficient ac-
curacy.   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  symptoms
present, then,  the dyspnoea being relieved, and the threatened asphyxia
postponed, we might hope to  gain time for the  operation of other reme-
dies ; for,  as Trousseau remarks, tracheotomy is not a cure, but a means
of gaining time for a cure.   Mr.  Porter has himself 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 possible  delay, endeavor to inflate the
lungs and restore animation by whatever means shall appear  to  be the
speediest, and of these,  perhaps the most  preferable will be laryngo-
tomy."
  422. This being the case, I shall mention a few of the peculiarities in
the mode  of performing the operation suggested  by AIM. 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,

             1 Surgical Pathology of the Larynx and Trachea, p. 64.
       19 
290
CROUP.
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; or a portion  of  one or two of the rings of the trachea
may be removed which will render a canula unnecessary according to Mr.
Lawrence's suggestion, or we may use the instrument recently invented,
which saves time and the  necessity for cutting the cartilages.  If the
child is in a state of asphyxia or syncope, cold water should be dashed
in its face, and a feather introduced into the trachea, so as to excite in-
spiratory action.   In case  of  orthopnoea, a  few drops of water may be
thrown into the trachea, and that tube cleared of blood and false mem-
brane by means of a small sponge fixed upon a slender stem  of whale-
bone.  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 ged  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 with the disease, to
apply a stronger  solution to it by means of the sponge.
   M. Trousseau prefers the large curved canula of M. Bretonneau, or
the bivalve canula of M. Gendrin.  It is necessary to have it sufficiently
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, afterwards  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 at-
tempt to breathe through the  larynx, as  " an essential principle of  tra-
cheotomy is to  withdraw the  canula as soon  as possible ;"  and when
the patient has been gradually accustomed  to natural respiration,  and
it is performed with facility, the  canula  may be altogether withdrawn,
and the wound 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.  Trousseau
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, 
                              croup.                           291

 at the moment of the operation, that the false membranes do not extend
 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 opera-
 tion.
   " 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.  Caeteris 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 noiseless,
 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 despair-
 ing 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 reopens  freely;  we may conclude that  the child  is ill
 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, smallpox,
 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 be-
 comes mucous and catarrhal, the infant will recover ; if, on the contrary,
 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 symp-
 toms 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. 
292
ATELECTASIS PULMONUIVf.
  "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
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 the false membranes."1
  424.  During the attack of croup the diet should be strictly antiphlo-
gistic, 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  bedclothes light
yet warm.
  In  favorable cases, when the child is convalescent, the  clothing must
be carefully arranged, to secure against cold.  I should recommend 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.—When croup appears among the chil-
dren of a family, our attention should be directed to those not attacked,
in order to anticipate and prevent such a seizure ; and a patient recover-
ing 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 im-
possible, other suitable  precautions must be taken.  Flannel should be
worn  to guard against vicissitudes of temperature  or cold winds.   The
cold or shower bath 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.

                      ATELECTASIS  PULMONUM.

  1. This term has been given to a condition of the lungs, or a portion
of them, which is of comparatively recent observation, and the precise
pathological value of which is far from being settled as yet.

              1 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 380. 
ATELECTASIS PULMONUM.
293
  We may take as the type of this condition, the lungs of a foetus who
has not breathed,  although the extent varies very much, and according
to the extent so do the symptoms.
  This state, to which the names atelectasis, atelectasia, apneumatosis,
etat foetal,  &c, have been given, may be  observed  immediately after
birth, or at  a later period; the former is evidently congenital, the latter
acquired.  I feel no doubt as to the occurrence of such an acquired dis-
ease, any more than of its being  also congenital, although  I may not
quite agree  with the interpretation that has been given of it.
  2. Let us first examine into the form  of  the disease as  we see it  in
infants  of  a few days  old, as it  has been described by MM. Joerg,1
Hasse,2 &c, and thus we shall be better prepared to appreciate it  in
older children.
  I. 3.  Symptoms.—We find  the atelectasis of new-born infants charac-
terized by a feeble and incomplete respiration,  which  is occasionally in-
termitting.  Instead of the loud hearty cry, the child wails weakly and
complainingly from want of breath.   It seems to have great difficulty
in sucking, and if the chest be stripped so as to  be  observed naked, it
has scarcely the  usual rounded  appearance,  and its movements are
limited, or  apparently inverted, the sides of the chest being flattened
rather than expanded.
  The surface is cold and more or less livid from the  imperfect aeration
of the blood; the pulse is weak and languid.  If the amount of  imper-
meable lung be not so great as to  be inconsistent with a  prolongation
of life, it is sure to influence  and  impair the  nutrition, the  infant be-
comes weak, delicate and emaciated.
  Dr. Rees mentions  that such patients are obnoxious to  attacks  of
laryngismus stridulus, by one of which the infant is frequently carried off.
  When the atelectasis is of moderate extent,  it may terminate in par-
tial or  complete recovery, but when  at all extensive it  usually ends
fatally.   In some cases when  great efforts are  required for respiration,
Joerg states that congestion or inflammation of the lungs  may be pro-
duced:  in this, however, Hasse differs from  him, and  considers that in-
flammation is neither  necessary nor even frequently the consequence  of
atelectasis,  for that the part of the lung in this condition  is  passive  to
other morbid processes, especially to inflammation, as he has seen these
parts remain unaltered in the  midst of surrounding hepatization.
  From recent researches,  we have reason to believe  that this state  of
the  lungs has an important relation to oedema of the  cellular tissue,  of
which I shall speak hereafter.
  4. Now the state of the lungs which gives rise to these symptoms  is
simply that  a portion  of them remains in the condition in which  it was
before birth, undilated and impervious to air.   Medico-legal  researches
have shown  long ago,  that the entire foetal lung is not at once inflated,
but the small portion thus temporarily impervious gradually diminishes,
and does not interfere with the well-being of the infant.   If, however,
a larger portion be undilated and remain permanently so, then we have
the  disease  in question produced.

              1 Die Foetuslunge in neubornen kinder.
              2 Pathological Anatomy, p. 2-18. Sydenham Society. 
294                 ATELECTASIS PULMONUM.
  That portion of the lung in a state of atelectasia, seldom so much as
an entire lobe, appears condensed; it is depressed below the level of the
neighboring or surrounding parts, of a dark red or violet color, without
crepitation, and  when divided  by the knife, no  air can be  expressed.
The cut surface is red and smooth, from which, when squeezed, a slightly
sanguineous serum without air bubbles exudes, and the affected  part
sinks absolutely  in water.   The tissue  feels rather harder than  other
parts, but less tenacious.   " The diseased patches," says Hasse, " display
a brown red, or  rather a bluish red color, which is more intense if the
whole lobule is uniformly unexpanded, in which case it  is marked off by
a sharp contour from the surrounding pale-red healthy substance. When,
on the other hand, scattered cells  within such a lobule  become inflated,
the violet color is interrupted here and there, and  passes by a  gradual
transition,  and without any distinct boundary,  into the  natural shade.1
The inferior and posterior portions of either  or both lungs  may be
affected, but most frequently those of the right  lung.   When atelectatic
infants die  a day or two  after birth, it is generally possible to dilate
artificially  the undeveloped part.   The depressed lobule is then seen to
rise gradually to the level of the rest,  and to assume the color, permea-
bility, and  the characters of sound lung, but this does  not appear to be
always possible when it has remained for weeks or months in a  state of
atelectasis.  In  infants dying from this disease, both  Joerg and Hasse
found the foramen ovale invariably open.
  So far then as our investigations  have as yet  gone,  it would appear
that this state of the lung in new-born infants, is not  the result of in-
flammation ; that it is not necessarily connected in any  way with inflam-
matory action in the lungs; nay, that it is  not, properly speaking, a dis-
ease at all, but  merely an  arrest  of physiological development;  there
is nothing  new or morbid in this  part of the lung, but  merely the per-
sistence of the old intra-uterine condition.
  5.  Causes.—There is great obscurity about the causes of this affection;
in many cases we cannot account for it all; in others, it may perhaps be
owing to defective nervous energy, in consequence  of compression of
the head during its passage through the pelvis, inducing a degree of
asphyxia.
  6.  Treatment.—It is not improbable that this condition may be pre-
vented if we are careful to induce full inspiration when the  child is
born, so as to establish respiration completely before the funis is  divided.
The impression  of cold,  and the unceremonious handling, washing, &c,
generally achieve this, but we ought to see that  it is  secured; and if
we  find the respiration feeble,  and the cry unusually weak, the mouth
being clear of mucous, the infant should  be stimulated by slight taps,
sprinkling  of cold water, frictions to  the  back, warm  baths, &c,  until
we  are satisfied  with the  action of the lungs, or that these remedies have
failed altogether.
  Joerg recommends repeated  enemata and emetics ; the former can do
no  harm, and may do good, but I should  fear  a frequent repetition of
the former.
  A warm equable temperature is necessary, and the infant should not
1 Pathological Anatomy, p. 249. 
ATELECTASIS PULMONUM.
295
be clothed less  warmly than  usual, and  at  the time of dressing  and
undressing, the  back and  chest  should be well rubbed with the warm
hand.
  II.  7.  The acquired form of atelectasis is characterized by a dry bark-
ing cough, very  distressing, which may continue for a considerable time,
and recur after  an uncertain interval of rest;  it is generally worse at
night than in the daytime.  There is also a certain amount of dyspnoea
varying according to the extent of the solidified portions of the lungs,
and it possesses  this peculiarity according to Dr. Rees, that it is shown
" first in the rapidity,  and secondly, in  the unequal lengths of the in-
spiratory  and  expiratory efforts,  the  former being  much  the  longer ;
moreover, owing to the persistence of the difficulty, it becomes  habitual
to the child, so that you find it cheerful,  and taking notice, when  the
quickness of breathing is to the observer  really distressing, and would
be taken by any one unconversant with the nature of the case to denote
active inflammation."1
  The action of the heart is naturally much increased both in frequency
and force, so as  after some time to indicate that enlargement has taken
place, and this  violent action  is  occasionally  accompanied by hemor-
rhage from the nose, rectum, &c,  which appears to afford temporary re-
lief.
  But the most  striking symptom of all is the altered movement of the
ribs  in  respiration, which  resembles  the peculiar motion which  every
one must have observed in  an infant at birth before respiration  is com-
pletely established, viz: during inspiration the  ribs laterally are drawn
rather inwards and backwards  towards the mesial  line, protruding  the
sternum slightly instead of distending outwards, as in ordinary inspira-
tion, the result of which is rather a diminution  than an increase in  the
cavity of  the chest.   This, which can only be detected when  the  chest
is uncovered, will serve to impress upon my junior readers the necessity
of a thorough and minute examination of  the chest of  infants and chil-
dren whenever the lungs appear to be affected.
  If the atelectasis be  extensive, of course there will be dulness on per-
cussion over the  diseased portion,  and a deficiency of respiratory mur-
mur, with perhaps bronchial respiration.
  As in new-born  infants in whom this state continues long,  we find
the power of nutrition greatly impaired, the child becomes  emaciated,
but not  so much so as in the former class of cases according to Dr.
Rees, and it is seen chiefly in the limbs, the abdomen always becoming
tumefied.  The skin acquires a dusky color, owing probably to  the  im-
pediment offered to the return  of  the blood and its imperfect oxygena-
tion.  The general symptoms of inflammation of the lungs  are  entirely
absent.
  Lastly,  Dr. Rees has stated a  result of long continued atelectasis,
which appears to me to require somewhat more evidence than we have
at present.  He believes that in adaptation to  the  state of the lungs
the form of the chest becomes gradually changed.   " The direction of
the deformity will  depend upon the original constitution of  the  patient.
1 Atelectasis Pulmonum, p. 8. 
296
ATELECTASIS PULMONUM.
If a strumous diathesis  be present, strumous or rickety malformation
of the chest will result.   The bones themselves will yield beneath the
arms, where a hollow will occur, narrowing the cavity in that direction,
while the front  projects unnaturally forwards.  The  common  form of
rickety chest is, I believe, usually the consequence  of  atelectasis of the
lung, and this explains a difference not readily accounted for ;  namely,
why in one case, with considerable rickety deformity of the extremities,
there is a fully expanded and well-formed chest,  while  in another, with
the limbs straight, the altered shape of the chest is so  considerable; it
is because in the latter case the lungs have previously become shrunken,
owing to a vitiated atmosphere or other depressing cause, atelectasis of
the lungs has taken  place, and the walls of  the  chest  are  forced in-
wards to adapt them to the state of the respiratory organs."1
  Now, without denying that this may be the  case in some instances, I
cannot think that it is the  ordinary way in which pigeon breast is pro-
duced;   If a collapsed state of the lung alone  involved such an adapta-
tion of the ribs, we should  surely see  it, as  Dr.  Corrigan suggested to
me, in pleuritis, in which the chest contracts but the deformity  in ques-
tion is not produced.    We can understand, however, that if a rickety dis-
position  of  the bones of the ribs exists, together with atelectasis, that
the atmospheric pressure externally not being counteracted  by expan-
sion of the lung, the result of these two conditions may be the flatten-
ing of the ribs, and protrusion of the sternum; or, the pressure of the
atmosphere alone with the ribs in this condition may, and often does,
produce  this deformity, as  Dr. Corrigan has shown.2
   8. Pathology.—The condition of the affected portion of the lung does
not differ materially from  that which I have  already  described.   It is
of denser texture, of a darker color, and depressed somewhat below the
level of  the neighboring parts.  The pleura, according to Friedleben,
is somewhat thickened, and can be peeled off the affected parts.
   But the most important  fact is that by inflation  those parts can be
raised to the level and made to assume the  appearance of the  healthy
lung.
   The deformity of the chest will be apparent, if it exist, as well as the
tumid abdomen, with the  enlarged venous trunks both external  and
internal.
   The heart is generally hypertrophied, but chiefly the cavities of the
right side, if the disease has existed for some  time.
   9.  So much for the post-mortem  appearances.   There are, however,
two important pathological questions, about one of which a good deal
has  been written latterly, but which  can  hardly be answered  satisfac-
torily at present, upon which I must say a few words.
   1. Is  atelectasis ever an acquired disease, or is it merely  that the
foetal  condition of the lung has remained unchanged from birth until
the age at which it is discovered ?
   Friedleben takes  the latter view, and whatever he  writes is entitled
to respect.   He founds his opinion upon the  anatomical  characters,

       1 Atelectasis Pulmonum, p. 11.
       2 See Dr. Corrigan's Lecture, Dublin Hosp. Gazette, Ap. 1,  1815, p. 47. 
ATELECTASIS PULMONUM.
297
which undoubtedly resemble as closely as possible the foetal lung,1 and
upon the physiological impossibility that the lung could lose its power
of expansion  without mechanical  cause;  " but this appears to me a
petitio principii,^ the supposition being that it does so;  and, surely, if
probabilities are to have any weight, it is at least as unlikely that a
portion  of  the lung not affected  by disease or mechanical impediment,
should remain for years after birth unchanged.
   The great authority of Dr. West is decidedly in favor of atelectasis
occurring at a period subsequent to birth, "so that lungs once perme-
able to air may cease to admit it, and  death  at length  occur from
apncea, without any serious  structural change having taken place in the
organs of respiration."
   Dr. G. A. Rees, in his pamphlet, has given seven cases in which he
detected it in  children from two months to two years old, and he enter-
tains  no doubt of its  being an acquired disease.
   If I had any doubt in my own mind, the experience and observations
of Drs.  Baly and Gairdner2 would have  removed  it, as  they have
recorded a precisely similar  condition, the effect of disease, in adults
of various ages.
   2.  Is atelectasis identical with that disease which has been described
as lobular  pneumonia, or with the  carnification which we meet with in
lungs affected by pneumonia ?
   In  the chapter on  pneumonia, I  have shown that this is pretty much
the view taken by both Legendre and Bailey, founded mainly upon the
fact that in some, but by no means in  all  cases,  they succeeded in
inflating the lobules.   This opinion has been still further carried out by
M. Fuchs.
   Dr. West conceives that most if  not all the cases of so called lobular
pneumonia, and  especially of that stage which has been termed carni-
fication, were, in truth, examples of atelectasis produced by an occlu-
sion of the pulmonary vesicles.   "Nothing," he says,  " can  show more
forcibly the influence of a name than the fact that this condition of the
lungs should have been described by all writers as lobular pneumonia,
and that its symptoms should have been  attributed to  inflammation,
while yet it was  evident from the   concurrent  testimony of every one
that neither in its progress nor in its results was it similar to inflamma-
tion in the adult, much less identical with it."3
   An attentive consideration  of  the arguments  and evidence adduced,
whilst it has satisfied me  that atelectasis has  frequently been mistaken
for lobular  pneumonia, has not, I must confess, convinced me that the
two diseases are identical.   As yet, I. am not prepared to deny  the dis-
tinct  existence of lobular pneumonia any more than that of  atelectasis,
unless more extended observation  shall afford a greater  mass of evi-
dence than we at present  possess.   This seems to be as nearly as possi-
ble the opinion of M. Hasse,  who  thus draws the  distinction between
the post-mortem appearances of atelectasis and pneumonia.   "In atelec-
tasis,  the coloring of  the  diseased  portions of lung  always approaches

                1 Arcliiv. fur Physiolog. Heilkunde, 1847.
                2 Edinburgh Monthly Journal, Nov. 1850.
                3 Diseases of Infancy and Childhood, p. 159. 
298
ATELECTASIS PULMONUM.
more to a violet, their exterior appearing smooth and glistening, so as
to contrast with the dull  brown  red surface of inflammation.  In in-
flammation, again, the diseased portions  are preternaturally distended,
whilst in atelectasis they are collapsed, and inferior even to the healthy
texture  in volume, but susceptible, provided  the disease has not lasted
too long, of artificial inflammation, and capable through  its  means of
acquiring a perfectly natural appearance.   In inflammation the pulmo-
nary texture is softened;  in atelectasis it is hard, and the cut surface
is not granular, but smooth. Where no complication exists, the  anatomi-
cal characters of a first or  third stage of pneumonia are  not  discover-
able in or near the diseased patch : in short, we have nothing like pneu-
monia except the solid non-crepitant mass which has  been confounded
with the second stage of that disease, viz: with red hepatization."1
   He adds, that "unequivocal cases of infantile pneumonia, whether lo-
bar or lobular, such as I have myself examined, and such as Kewisch has
published, afford, on the other hand, the strongest negative grounds for
establishing atelectasis as a distinct form."
   From the evidence adduced, I think I may draw the following  con-
clusions :—
   1. That in certain new-born infants a portion or portions of the lung
remain undilated or impermeable to air, and that these give rise to cer-
tain symptoms  and signs,  and involve certain consequences already  enu-
merated.   That the anatomical characteristics of these portions of the
lungs are their  being solid, free from air, of less proportionate bulk,
capable of being inflated, and after inflation of assuming  their natural
character.
   2. That a similar disease may be acquired during childhood present-
ing analogous signs and similar anatomical characters.
   3. That this condition  may be, and probably has  often  been,  mis-
taken for lobular pneumonia, especially in young infants.  That patho-
logical condition which  has been termed " carnification,"  has  certainly
a very close resemblance to the condition of the lung in atelectasis, and
I should not be prepared to  deny that such cases may really  be exam-
ples of  the latter disease.
   4. But I cannot at present agree with  the opinion that  all which has
been regarded  as lobular  pneumonia,  is  really but  atelectasis superin-
duced by a vascular congestion, closing the  air-cells, or by an obstruc-
tion in the air-tubes.
   5. It does not seem  impossible that  this disease, although distinct
from pneumonia, may result from it, or  from  an attack of bronchitis,
as Dr. Rees believes, and as Dr.  Gairdner's  researches have proved, in
the case of adults.
   10. Diagnosis.—The most important diagnostic sign of atelectasis is
the altered movements of the ribs, which only occurs in one other disease,
viz: occasionally in croup.   In the latter disease it has been noted by
Dr.  Rees and Sibson, but the accompanying symptoms are too marked
for any one to confound the two diseases.
   Dulness on percussion,  with the absence of either respiratory murmur
1 Pathological Anatomy, p. 252. 
ATELECTASIS PULMONUM.
299
or crepitation, may perhaps enable us to distinguish it from pneumonia,
but there may be doubtful cases.
   The progressive emaciation accompanied by the pulmonary symptoms
may excite suspicions of phthisis, but a  careful examination will gene-
rally lead us to a correct  conclusion.
   11.  Prognosis.—If timely measures be adopted,  this disease is cura-
ble, and even when they are neglected or fail, if the child survive for
a time, the constitution becomes familiarized to the state  of  the lungs,
and  certain  adaptations  occur which allow  of the child growing  and
thriving.
   In other cases, however, the secondary effects are  more serious, the
child becomes more and more emaciated  and reduced in strength, the
cough  is very distressing, and he dies at length of exhaustion.
   12.  Treatment.—Very active treatment is evidently quite  unsuitable
to these cases, and so far as we yet know, the number of remedial agents
is but  small.
   The first object should  be to place the child in suitable hygienic cir-
cumstances—to secure a plentiful supply of pure air, warm clothing and
suitable food, as to a deficiency in these requisites we may  frequently
trace the origin of the disease.
   The diet should be good, but not excessive in quantity; meat once a
day, with milk or very weak tea, but neither vegetables, fruit, nor pastry,
on account of the  disordered state of the digestive organs, as evidenced
by the tumid belly.
   Emetics occasionally seem to be of use as well as stimulating expec-
torants, such as the decoction of senega with ammonia.
   A very principal part of the treatment must be directed to the skin
and kidneys.  Dr. Rees prefers a combination of ipecacuanha with nitre,
hyoscyamus, and sulphate of magnesia, so as to act as a gentle purgative,
as well as a diuretic.
   A mild mercurial,  the hyd. c. creta, for instance, may be given occa-
sionally alone, or  in  combination with  a purgative, as the bowels are
generally confined.
   External  irritation, by rubefacients or  blisters, may be tried, and  it
appears to me probable, that electro-galvanism might  be of use, but I
am not aware of its having been tried.
   In accordance with his views, as to the production  of deformity, Dr.
G. A. Rees  insists upon the patient observing a  recumbent position,
lying on its back on a firm unyielding surface:  "The position seems to
antagonize, to the  small extent  we are able, the altered movement, and
by keeping  the spine supported and extended, renders more tardy the
projection of the column, thus giving the best chance for the extended
lung again to expand." 
300
BRONCHITIS.
                       CHAPTER  VI.

                            BRONCHITIS.

  426.  Bronchitis, or bronchial catarrh, is the term applied to inflam-
mation of the mucous membrane  of the bronchial tubes, accompanied
with increased secretion; and those two elements, the inflammation 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 a catarrh, according to  the predominance of either, and occa-
sioned their estimating the disease as  more simple than  it is  in fact.
Following  the  example of M.  Barrier, I shall use either  term to ex-
press the disease, without limiting my meaning to the  strict pathologi-
cal definition of either.
  In one form or other, it is undoubtedly one of the most frequent dis-
eases of infancy and childhood.  From the moment of birth, indeed, to
extreme 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 complicated,
general or  partial, acute or chronic, and these circumstances will require
serious consideration  in  our estimate of the disease, and in determin-
ing the treatment.   Let us  first  speak of  primary bronchitis,  which
I shall divide into acute and chronic ; and afterwards of secondary pul-
monary catarrh.
  i. Acute Bronchitis.—The ordinary form of acute bronchitis com-
mences generally with a chilliness over  the whole body;  the child com-
plains 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, espe-
cially with young infants.
   The breathing is generally accelerated,  but the amount varies ac-
cording to  the  intensity of the disease.  So long as the attack is con-
fined 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 impeded, requiring rapid 
BRONCHITIS.
301
and  energetic muscular  effort.  When the mucous secretion  is estab-
lished, 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 respi-
ration  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 impedi-
ment to respiration, it acquires a bluish tinge, as the consequence of
the imperfect aeration of the  blood.
  42S. The  physical signs are simple and  easily recognized.   On per-
cussion, the chest yields  a clear sound, if the  disease be uncomplicated;
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 rades pretty general, the former espe-
cially before  the mucus is freely secreted, the  latter afterwards.  Some-
times 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 rale audible.
   When the attack is slight, the appetite will be  but little impaired,
digestion will take place satisfactorily, and the bowels continue regular;
but  when the fever is considerable, the appetite is  lost, there is occa-
sionally 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 dyspnoea, mucous secretion, and fever ; and these
symptoms generally continue  stationary for  a few days ; then, in favora-
ble  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 catarrh,
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 as-
sumed, 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 gene-
rally recover, but when  thus  aggravated, if the child is much reduced
 alreadv, and the attack very severe, the case may terminate  unfavora-
bly.
   430. The other modification of acute  bronchitis to which I have
 alluded, and which has been  called suffocative  catarrh, capillary bron- 
302
BRONCHITIS.
chitis, catarrhal fever, is a more severe and more  dangerous form  of
disease.   It is not so common as the other forms of bronchitis ; Rilliet
and  Barthez met with but six  cases  of it as a primary affection, and
three as  a secondary.  However, in certain  epidemics of bronchitis it
is much more frequent, as I have observed latterly in this city.
  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 pre-
cede the  local, or at least their greater severity occasions them  to oc-
cupy most of our attention.
  The fever is intense;  the pulse rapid and full; the skin is hot and
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 yellowish
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  ordi-
nary 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 mu-
cous rales, which are heard over the whole lung, mixed, in some  parts,
with a moist crepitus.   The wheezing is audible at some  distance from
the patient.
  432. These symptoms may all be observed very soon after the com-
mencement of the disease, and every hour they seem to increase.  The
respiration becomes more hurried and embarrassed, and at  length un-
equal, irregular, and panting,  with great oppression, and  strong muscu-
lar  efforts, great heaving of the chest, and  rapid action of the alse 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  abundance
of the mucus secreted, which is occasionally  so excessive as to threaten
suffocation.
  The pulse becomes quicker, but smaller, weaker, and unequal, some-
times, towards the end, irregular.
  If the disease be not quickly  terminated, we may sometimes observe
occasional remissions, followed by a  return of all the symptoms.
  In unfavorable cases, the disease rapidly gains ground, the symptoms
become aggravated, the cough most distressing and painful, the respira-
tion amazingly rapid and difficult,  the pulse very quick,  irregular, and 
BRONCHITIS.
303
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.
  I have remarked that in  children  of three years old and upwards,
the disease  may terminate  in pneumonia, but  in young infants  more
frequently in  profuse fluid effusions into the bronchial tubes and  cells,
producing asphyxia.
  "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 termi-
nate in the extinction of life.   This is  attributed to the permanent ob-
struction or plugging up of one of the bronchi.  The slightest attack
of bronchitis  may, in this way, be suddenly transformed 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  dura-
tion 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 dyspnoea  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  coun-
tenance 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 stomach 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 perspiration breaks out on the face and
neck.   The cough is at  first dry, attended with a wheezing sound in the
chest, but towards the  termination of the complaint it frequently be-
comes 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.  Occasionally considerable remissions occur for a short period,
during which  the pulse  will become fuller and slower, and the counte-
nance brighter and more calm.  When  the disease is tending to a fatal
termination, the patient becomes drowsy, insensible, and comatose, and
death takes  place by suffocation in  a paroxysm of convulsions."2

               1 North Amer. Med. and Surg. Journ., vol. i. p. 24.
               2 Eberle on Diseases of Children, p. 322. 
304
BRONCHITIS.
  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 began with a slight feeling of distress, and with a dis-
tinctly formed chill.   The hands and feet became cold, the whole surface
of the body pale and  contracted, and the  patient appears  languid and
drowsy.   This state of depression frequently continues for  a whole day
before the febrile action is fully developed.  In many instances, how-
ever, 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, somewhat tense, and generally
full, the cheeks flushed, the eyes suffused with tears, and a thin, trans-
parent fluid usually issues from the  nose, attended, at the commence-
ment, 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 secre-
tion, 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 disease 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 expec-
toration becomes very abundant  after the  fever has continued for three
or four  days;  and as  the copious secretion  of  mucus keeps up a con-
stant irritation of the bronchia, the  cough usually becomes  very fre-
quent as the disease advances."1
  436.  The most marked distinction  between the symptoms of ordinary
bronchitis and the suffocative catarrh or capillary bronchitis, consists in
the greater amount of fever in the latter cases, the occurrence of  de-
pression,  almost amounting to collapse, the hurried, wheezing, and diffi-
cult respiration, the cough being  more frequent, and occurring in par-
oxysms 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 ordinary
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 seldom 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 occa-
sional paroxysms of dyspnoea.   On applying the  stethoscope, we find
1 Diseases of Children, p. 318. 
BRONCHITIS.
305
raucous 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 hollow; 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.
  The strength is  very much  diminished, the appetite deteriorated or
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, simulating
phthisis, may present itself under a  still more unusual form, and  last
longer.  The disease is then accompanied with fits of suffocation, fol-
lowed 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 con-
siderable  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 cavern-
ous 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  examination that the  child had suffered from chronic
bronchitis, with considerable dilatation of the bronchial tubes."1
   The disease ordinarily lasts from  thirty to  forty days, and  may then
terminate  fatally;  or, under the  influence 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
raucous 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,  generally
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 propor-
tion 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 considerable
dilatation which takes place in a few days.  Not  unfrequently, in this
20
1 Mai. des Enfans, vol. i. p. 43. 
306
BRONCHITIS.
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 secretion, the hy-
pertrophy of the mucous  crypts whose orifices are enlarged,  hypertro-
phy of the longitudinal fibrous tissue, and of the muscular fibres of the
trachea and bronchi,  and  marked dilatation of the middle and terminal
bronchial tubes.
  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 generally dif-
fused, 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 infants,
without causing dilatation of the  bronchial  tubes, as the direct conse-
quence  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
bronchite, but it is not difficult to ascertain it.  It is easy to understand
how much  this dilatation, if extensive, must  increase 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 dura-
tion 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 puri-
form, 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, 
BRONCHITIS.
307
discoverable upon dissection, as redness, swelling, softening, and  some-
times suppuration of the lymphatic glands, near the primary division 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  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 bronchial tubes in seventy-
four ; in sixteen dilatation of the "vacuoles;" in seventeen  there was
vesicular bronchitis;  and  in ten, false membranes 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 erup-
tive fevers.   We find  it very troublesome in hooping-cough,  measles,
scarlatina,  smallpox, 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 may be 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  may possibly  detect
dulness on  percussing some portions  of the chest, and there is a mixture
of subcrepitus 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  con-
sequence 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 reso-
nance on percussion, if the tubes be  not filled with muco-puriform secre-
tion.  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, giv-
ing 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 how far bronchitis may  be  the fore-
runner of tubercles.   M. Fauvel says it is rare to find tubercles in these
cases, and Rillet and  Barthez confirm his statement, so far as the  rapid,
acute form is  concerned, but they are  not so clear  that they may not
                       r
      1 Mai. de l'Enfance, vol. i. p. 341.        2 Mai. des Enfans, vol. i. p. 27. 
308
BRONCHITIS.
complicate chronic bronchitis—whether as primary or secondary affec-
tion 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 affec-
tion.   Thus,  of  115  cases of  simple  bronchitis,  Rilliet and Barthez
found that but twenty-one were primary.   It may also result  from the
suppression of an eruption to which the constitution is accustomed.
  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 dis-
eases  in boys, in the  course of which bronchitis occurs as a  complica-
tion.
  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 northeast winds, smoke or noxious gases, disordered
liver,  stomach, and bowels, or dentition.
  445.  Lastly, either primary or secondary bronchitis may occur as an
epidemic, and generally with considerable fever,  dependent,  probably,
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, de-
scribed by Valleriola; of 1580, by Sporisch ;  of 1733, by Storch;  and
of 1743, by Huxham, in which great 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 Padua, and at Leipsic.  At Lyons,  out of three hundred intern stu-
dents of the  College, about two hundred were  attacked, and  of these
eighty were under fifteen years  of age.  During the height of the  epi-

              1  Diseases of Children, p. 88.
              2  Diseases of Children, by Dr. Meigs, Jun., p. 106.
              3  Mai. de l'Enfance, vol. i. p. 317.    * 
BRONCHITIS.
309
demic, 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, according
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 peo-
ple, 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 oc-
casionally each child  took sick  successively, allowing  the  one first at-
tacked to recover previously.
   " The characteristic features of the complaint, as in previous epidemics
of influenza, have been affections of the  chest, invariably accompanied
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, perhaps,  rathsi'
less thirst than one would  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;  sometimes, 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.
   " 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 
310
BRONCHITIS.
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 describe
it as scraping the  chest.  After a day or  two the  fever is developed
and the cough not less troublesome, and for some days the child suffers
great distress ; until the fever subsides, the cough  diminishes, 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 per-
fectly 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 organ.  In these cases respiration was much
more rapid, and performed  with some difficulty, a wheezing being au-
dible 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 abun-
dant ; 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 ac-
cording to the  extent and intensity of the  attack.  Mixed with  these is
frequently heard  a  crepitus ; not  the small, distinct crepitus of pneu-
monia,  but larger and  more moist.  Percussion yielded a  pretty clear
sound generally,  with  a diminution  of tone occasionally  in  different
parts ;  mainly, I think, in those where the crepitus occurred.
   "In the progress towards convalescence the crepitus first disappeared;
then the movements of the  chest became  less labored, and the  respira-
tions less  frequent;  the distress diminished, and  the  fever subsided
gradually.   The bronchitic rales continued in  a  minor degree for  a
considerable time ; and, what was very remarkable, in a great  number
of cases, as the general bronchitis  diminished, I  found the primary
tubes, and even the larynx  became 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 
BRONCHITIS.
311
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 two  cases  I believed  at  the first  moment it was so, and examined
the chest as a matter of  duty, to make sure, rather than writh any ex-
pectation of detecting serious disease.  In these cases double pneumo-
nia existed.   The  respiration  in  all  was,  as  I  have  said, extremely
rapid, with great action of the alae nasi, but without the labored move-
ments 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 pre-
sent, mixed in a few cases with mucous or sibilant ntles.   The part of
the chest affected was dull on percussion.  Under the treatment adopted,
the signs of pneumonia  gradually disappeared, and, in proportion, the
fever subsided, the cough generally increasing  for a time, the chest be-
came 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 two first, 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 mix-
ture, was advised  by Dr. Stokes in some of the cases, and with imme-
diate 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,
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 linseed-
meal, and  should be applied  directly to  the  surface, warm, and very
moist, changing them every  two hours, or oftener.  If irritation be de-
sired, a dessertspoonful of the flour of mustard may be mixed with the
meal.
   " Warm  baths  are exceedingly useful, and may be used every night, 
312
BRONCHITIS.
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 sonorous on
percussion, and there are abundant mucous and sibilant rades to be heard.
  I. The absence of crepitating rale and of dulness will ordinarily dis-
tinguish the case from lobular pneumonia; but as the two diseases  may
be co-existent, of course we cannot come  to so decided a  conclusion in
every case.
  n.  The cough in capillary bronchitis occurs  in paroxysms, like  the
kink in  pertussis, and for some little time the absence of the hoop  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 exacerbations,
and night-sweats, 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 dyspnoea, 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 dyspnoea, a firmer, slower pulse,
&c, are favorable.
  449.  Treatment.—There is an important  distinction between catarrh
in the adult and in infants.   When  the first  stage  is passed  with  the
former,  and  profuse secretion takes place, the disease is essentially over-
come, 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 occupy the smaller
tubes, there  is considerable  danger  of lobular  pneumonia,  unless  the
treatment be continued.
  The indications we  should  have in  view are:  1. To diminish the in-
flammation ;  2. To remove or lessen the secretion ;  3.  To support  the
strength; and 4. To relieve certain symptoms when it is impossible 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 stim-
ulating  liniment  to  the chest.   Almond milk, with ipecacuanha wine
and syrup of squills, answers 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 re-
lieve the cough, and, to a certain extent,  control the secretion. 
BRONCHITIS.
313
   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 com-
mence 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 bloodletting, 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  at-
tack.   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 warm 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  Avish 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 intervening, and should be
warm and  moist.   When it cools, it should be exchanged for a fresh one.
  452. In suffocative catarrh we 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-
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 tur-
pentine.   The formulae I generally employ are the following:—
               R.—Mist, amygdal. gij.
                   Vini ipecacuan. gj vel antim. tart. gr. j.
                   Carbon, ammonire gr. vj  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 diminished
according to the age.   Or,
                   Mucil. acacise,
                   Syr. simpl., aa ^ij.
                   Spts. tereb. rectif. gtt. xx to gtt. xxx.
                   Aqu*e carui gij.—M.
           A teaspoonful to be given every two, three, or four hours. 
314                        BRONCHITIS.

  From  these  medicines, I  have found  great benefit, after bleeding,
warm baths, &c.   In many  cases, I have found the  tartar emetic mix-
ture act  quite magically in relieving the  chest;  but it is necessary to
watch, lest it produce too much depression, in which case the ammonia
may be  increased or the tartar  emetic  omitted, or a  little weak wine
and water given.  I quite agree with M. Barrier and others that active
bloodletting is essential in severe cases of capillary bronchitis, and that
it should be  followed by other evacuants, as emetics,  purgatives, &c;
but in cases not so severe,  and in weak  delicate children, the tartar
emetic supersedes the necessity for bleeding.
  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.   A
large poultice to  the chest, without blistering, or over the dressing of
the blister, has a most soothing effect.  It should be changed every half
hour, and continued for two or three hours.
  453. In  that form of the disease described by Dr. Parrish, he ordered
" a warm bath, sinapisms to the feet, a large blister over the breast,
and  laxative injections, containing  assafoetida.  But  the remedy  on
which I  chiefly relied was assafoetida, rubbed up with mint water,  given
frequently and in large doses."   However, as other remedies were em-
ployed, they may have  had  as much influence as  the assafoetida.   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 eva-
cuated the bowels, and  then, if the pulse were full  and quick, leeches
or the lancet were freely used;  after which,  antimonials, calomel, 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  occa-
sional  emetic very  useful,  and  an expectorant mixture, composed of
equal parts of paregoric, syrup  of  squills, and sweet  spirits of  nitre,
with water.
  454.   Chronic bronchitis will require a somewhat modified treatment.
We cannot here use bloodletting very freely, nor in every 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 mixtures,  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;  and of these, perhaps, some
of the vegetable bitters, as quinine, infusion of cascarilla, gentian, &c, 
         INFLAMMATION OP THE LUNGS. — PNEUMONIA.      315

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 overfeeding.   As  convalescence  proceeds, we
must  gradually increase the quantity of the food, taking care  to keep
up the strength without overloading the stomach.
                        CHAPTER  VII.

             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 and Guersent2
were  the  first to investigate the  subject, and they were followed by
Leger,3 Denis,4 Brunet,5 Gerhard,6 dimming,7 Valleix,8 Billard,9 &c.;
but probably the  most valuable contribution to the history of the disease
is to be found in  the works of Rilliet and Barthez,10 Barrier,11 and Dr.
West,12 of London.

  1 Recherches sur les Mai. les plus import, et les moins connues des Enf. nouveaux-nes.
  2 Dictionnaire  de Medecine.               3 Essai sur la Pneumonie des Enfans.
  4 Recherches Anat. et Phys. sur quelques Mai. des Enfans.
  5 Me'm. sur la  Pneumonie lobulaire.
  8 American Journal of Med. Sciences, vols. xiii. xiv.
  7 Trans, of Assoc.  oT College of Physicians in Ireland, vol. v. p. 28.
  s ("Unique des  Mai. des Enfans nouveaux-nes.
  9 Traite de Mai des Enfans.
  10 Trait e Clinique et Pratique des Mai. des Enfans, vol. i. p. 60.
  " Traite pratique des Mai. de l*Enfancc, vol. i. p. 45.
  12 Lectures on the Diseases of Infancy and Childhood, p. 175. 
316     INFLAMMATION OF THE  LUNGS. — PNEUMONIA.

  Notwithstanding that the disease has been so often  slightly treated,
it is sufficiently frequent in children of all ages and in  different circum-
stances.   For example, the registered deaths in Great  Britain for 1830
show  that 18,151 children—10,000 males, and 8151  females died of
pneumonia; and in Philadelphia, during the ten years  preceding 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 since  have established a  distinction  between
pneumonia affecting an entire lobe of the lung,  and  pneumonia affecting
the lobules.   The former,  lobar pneumonia, resembles the disease in the
adult; the latter, lobular pneumonia, is  peculiar to children, but some
eminent authorities, Legendre, Fuchs, and I believe Dr. West, consider
that the latter is not pneumonia, but atelectasis.  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.   We should bear in mind, however,
that the proportion  may  differ,  according  as our  observations include
the children of the rich or those of the poor; those  cases which we  meet
in private practice or in hospitals.
  Mr. Friedleben conceives that true lobar pneumonia is very frequent
in early life, and that lobular pneumonia is for the most  part  confined
to the first year.
  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 exhibits
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 strong and
frequent than in adults, dry at first, and  with little or no effort at expec-
toration.  This cough continues, and increases in frequency in most cases,
but we have not the  advantage of the peculiar  expectoration of adults,
for very young infants swallow the expectoration,  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 ob- 
         INFLAMMATION OF  THE LUNGS. — PNEUMONIA.      317

scure, sometimes at  the  epigastrium and  radiating to the  abdomen;
sometimes near the base of the lung.  Dr. Gerhard observed it  most
frequently at the anterior edge of the axilla.
  The dyspnoea, Barrier remarks, is greater than 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 it
amounted to  118 ; but although the frequency may in part be owing to
the amount of disease, it appears to be partly  an involuntary precaution
to avoid the irritation and cough consequent on a full inspiration.  Some-
times this hurried  respiration intermits, and for a short time the respi-
ration seems  natural; but very speedily the rapid movement 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 pro-
gress favorably, the  pulse diminishes in frequency,  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 alee
nasi dilate,  and even the momentary interruption  caused by speaking
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 in-
effectual ; the congestion is so great that it impedes  both the circulation
in the lungs  and the respiration.
   Rilliet and Barthez have remarked that the irregular, abrupt respi-
ration occurred almost  exclusively when  the  summit of the lung was
principally affected.   When the disease  proves rapidly fatal, the fre-
quency of respiration goes on increasing until death ; but when  the dis-
ease is prolonged,  we may observe a diminution during the last few days,
not from any amelioration, but probably from a degree of organic in-
sensibility.
   The pulse  is very quick from the beginning, seldom under  120, even
in  cases where  the distress does not  appear  very great;  but it  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 frequency, it becomes ex-
tremely small, irregular, and at length insensible.   The heat  of skin
bears a relation to the rapidity of the circulation;  during the first part
of  the  attack, the skin is dry  and very hot;  towards the end,  in unfa-
vorable 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.
1 Mai. de l'Enfance, vol. i. p. 193.
2 Trans, of Association, vol. v. 
318      INFLAMMATION OF THE LUNGS. — PNEUMONIA.

  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  alee 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 physical signs  of lobar  pneumonia are of great  impor-
tance, 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  dwell at length upon them.   Percussion
yields a  distinct dulness of sound in  the affected part, compared with
those portions of the lungs which are free; but we must be on our guard
against making the opposite  side a standard  of comparison,  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 respiration
is very quick  and  short, it is less characteristic, and will require that
we make the child cough, or take a deep inspiration.   With infants 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  un-
frequently, when one lung only  is affected, we shall find puerile respira-
tion  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  bronchophony,
with extreme dulness.
  In the third stage, the stethoscopic  signs are  pretty nearly  the same
as in the second, except that  the bronchial  respiration is more distinct
and also more  extensive, occupying situations where  crepitation had  not
previously been heard.   It becomes  audible in front as well as posteri-
orly, and is  perceived, along with dulness on percussion, in the infra-
mammary, as well as in the infra-scapular region.  It is generally more
extensive  on  one side  than   the  other, and occasionally it is audible
throughout the entire back part of  one side of  the  chest.   It is never
confined to the upper part of the lung, unless there have  existed pre-
viously tubercular disease.
  Dr. West observes that bronchial  respiration  must always be con-
sidered of serious import;  in  eleven out of  twenty cases of pneumonia,
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, probably
from the endeavor to  breathe through the mouth ; and the thirst  is con-
siderable.  In very young children Dr. West has noticed a peculiarity
of sucking.
  Vomiting occurs  occasionally at the commencement  of  the disease, 
         INFLAMMATION OF THE LUNGS. — PNEUMONIA.     319

and more frequently than with adults; subsequently it is generally the
consequence of medicine.   Diarrhoea, on the other hand, is rare, except
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 ; never-
theless, jaundice does sometimes,  though rarely,  occur,   and in such
cases, MM. Chomel and Bouillaud1 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.2  Others  have asserted  that the
jaundice  is not the  result of  the peculiar condition of the  liver,  but of
the incomplete haematosis caused by the pneumonia,  and that it is  analo-
gous 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 is
headache, and a degree of stupor ;  in a few cases delirium or convul-
sions.
   In some cases, as M. Tonnelier has remarked, these nervous symp-
toms may be the result of sympathetic irritation,  but in  others they
appear to depend upon  coincident meningitis.
   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, dyspnoea, 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 dis-
appears,  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
alee nasi  moving incessantly ; the cough short,  frequent,  and distressing  ;
the pulse small, weak, quick, and  at length irregular  or intermitting;
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 in  one; thirteen in
one; fourteen in three;  and sixteen, eighteen, twenty,  and twenty-five
in one case each.
   463. Lobular  Pneumonia.—We will  now  enumerate the symptoms
1 Clinique, vol. ii. p. 138.
2 Traite" de la Pneumonie, p. 384. 
320     INFLAMMATION OF THE LUNGS. — PNEUMONIA.

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 instance),
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 circum-
scribed, but diffused, and principally in the region of the diaphragm,
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 de'ath.
   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 in-
fants and young children it is  always swallowed;,but, from some obser-
vations 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 extent
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 pneu-
monia 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 bron-
chitis slight, the respiration will be found very rapid and  short, with
free motion of the alse nasi, and ultimately of the chest and abdomen.
   " Moreover," M. Barrier observes, "it is not merely by the  number
of respirations per minute that we must judge  of the extent and gravity
of the lesions of the lungs.  We must also observe whether the respira-
tion be superficial or profound, if it be  easy  or painful  and anxious,
costal or abdominal, regular or irregular.   In general, the  more  fre-
quent, deep, and  anxious it is, the more serious is  the attack.   But we
must not forget that occasionally we find the respiration increased in
infants for  a few minutes, without apparent cause,  and that it soon sub-
sides again."
   161. The physical signs are  of great importance, even  though they
may not  be quite  so  definite  and certain  as  in adults.   Dr. Gerhard 
         INFLAMMATION OF  THE LUNGS. — PNEUMONIA.      321

lays great stress upon the dulness on percussion;  he conceives it in
many cases of more use than auscultation.  M. Vernois found the dul-
ness very  marked  in  twenty out of  twenty-two cases, and  slight in
the remaining two.   M. Valleix  found dulness in twelve out of sixteen
cases, seven times on the  right side, and five times on both sides.   Ril-
liet and  Barthez found but little  deviation from the normal sound in
partial or  mammelonated  pneumonia, but decided dulness in the gene-
ralized 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."1
  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,
and the impression  communicated to the finger is that of greater solidity
below than above the scapulae.   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."
  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, sometimes in
front, and at different points, according  as the lobules affected may be
distant or near.
  The true crepitant  rade is much rarer in infants than in adults, al-
though it is occasionally audible for a  few moments.2  If one lung only
be  affected, we shall find  the subcrepitant 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 contrast, unless
the disease of one lung be so far advanced as to  give rise to bronchial
breathing,  whilst in others nothing  but the subcrepitus can be de-
tected.
  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 broncho-
phony.   The subcrepitant 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.

         1 Mai. de l'Enfance,  vol. i. p. 105-7.
         2 Trousseau and Lasegue, Arch  Gen. de Med., vol. xxvi. p. 130.
       21 
322      INFLAMMATION OF  THE LUNGS. — PNEUMONIA.

  Occasionally these more defined phenomena of pneumonia are masked
by the great amount of moist rades, but even  these have a sort of me-
tallic sound in this disease, which, taken  along  with the vocal  reso-
nance  and the dulness on percussion, may prevent an error in our
diagnosis.
  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  different keys,
yield, even when the child is  old  enough to talk well, results far too
uncertain to be trustworthy."1
  465.  The external appearance of the infant is not  characteristic ; it
will  show that the  chest  is affected, but  not the  peculiar form of dis-
ease.   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 alse nasi will be found in ac-
tion 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 pneumonia
is frequently double.
  The pulse varies very much, of course, but it is generally in propor-
tion  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
1 to 2  or 3.
  The digestive system is mor.?* or  less deranged ; vomiting is frequent
at the  commencement of thfi disease, but rare subsequently.  Intestinal
catarrh, according to M. ^Barrier's experience, precedes the attack of
pneumonia in  many cwses,  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, how-
ever, we have no symptoms of intestinal inflammation; there is neither
pain, tenderness, nor tympanitis.
  As in lobar pneumonia,  we  may have a certain degree of sleepiness,
indifference or  cloudiness of  intellect; nay, even some more marked
nervous affections, as  anxiety, agitation,  contractions  or convulsions,
and delirium.
  466. i. Termination and Duration.—As I have described it, lobular
pneumonia may continue steadily advancing, the  symptoms increasing
in gravity, and the constitution suffering more severely, until death.
Or, the disease having  arrived at its maximum of intensity, the symp-
Lectures on Diseases of Infancy and Childhood, p. 195. 
         INFLAMMATION OF THE LUNGS. — PNEUMONIA.      323

toms may gradually diminish; and, if the  termination is to be favor-
able, 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 pneumo-
nia, 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 long-
est 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.
  M. Friedleben states that in the great majority of children, the first
stage lasted for twelve hours, the second for three days, the third from
five to seven  days, after which  convalescence commenced, but that it
sometimes proves fatal in from twelve to twenty  hours.
  467. ii. 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, ap-
proaching 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 abscesses tend to
the  surface, and occasionally open into the pleura,  the  very sudden
occurrence of pleurisy may lead us to suspect a perforation.
  468. in. 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 gan-
grene mentioned by  Rilliet  and Barthez,  three  had gangrene 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 probability, that the gangrene
is due rather to some peculiar morbid alteration 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 crepitating
rfile, and the quicker termination  of the former; the insidious approach,
the greater obscurity of the  physical  signs, the  slight dulness on per-
cussion in the first  stage, the diffused subcrepitant rale, the  different 
324      INFLAMMATION OF THE LUNGS. — PNEUMONIA.

points at which it is heard, and the changes which  it undergoes subse-
quently, the greater duration and greater fatality, of the latter.
  470.  Now let us examine the different  characters of primary and
secondary pneumonia, whether 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
is anxiety, agitation, and  sighing.   As the disease advances,  some of
these symptoms disappear,  and new ones  appear.    The fever rather
increases, as does the dyspnoea and hurry of respiration ;  the alas nasi
are observed to move extensively, and more effort is required to breathe;
the cough is very troublesome, short, and painful; expectoration makes
its appearance, except  in young subjects ; the pulse is very quick; the
crepitating or subcrepitating rale gives place in  some portions to bron-
chial 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 alse
nasi are quiescent, the heat of the 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 dis-
appears, and the patient becomes convalescent.
   471. When pneumonia supervenes upon another disease,  or is second-
ary, 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 expectoration.   If
no cough existed previously,  we shall be  induced, probably, 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 respira-
tion 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 subcrepi-
tant  rales, we may also hear bronchial respiration  and bronchophony,
 increasing in intensity and extent.   The primary disease will generally
be found  to  have  undergone 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  dyspnoea,  coldness of
 extremities, &c, which denote the approach of death.
   We  can readily understand that the  secondary  must be more fatal 
         INFLAMMATION OF  THE LUNGS. — PNEUMONIA.     325

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, by pul-
monary catarrh, and that it is,-probably, an extension of this latter affec-
tion.  Rilliet and Barthez have drawn the  following  conclusions 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,  mammelonated, partial, and  generalized
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 sur-
rounding 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 con-
clusion.
  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 emphysema,
which is in general in proportion to  the extent of  the pneumonia and
bronchitis, to the acuteness of  the disease, and to the amount of dys-
pnoea which is present.
  475.  iv.  I have already mentioned that lobular  pneumonia is occa-
sionally complicated  with  convulsions  and other cerebral  affections of
minor decree.   Six of M. Barrier's cases were thus attacked and died.
In three there were proofs of meningitis.
1 Mai. des Enfans, vol. i. p. 75. 
326     INFLAMMATION OF THE  LUNGS.—PNEUMONIA.

   476. But in many cases the pneumonia, whether lobar or lobular, but
far more frequently the latter, is secondary, and occurs as a complica-
tion in the course of other diseases.
   It occurs most frequently in the course of measles, but we find it com-
plicating 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 pneumonia, 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  infants evidences
of congestion,  red and gray hepatization, extending  from the base of
the  lung  towards the summit, but very rarely terminating  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 ;l and this, as  he  observes, agrees very
closely with the results obtained by M. Grisolle 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.  Of M. Barrier's
twenty cases, ten were of the right lung ; six of the left; and four were
double.  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 supe-
rior  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 posteriorly.
  478. II. Lobular Pneumonia.—Considerable difference  of  opinion
exists as to the true  nature of lobular pneumonia, and the  exact  cha-
racter  of its pathology.  It appears to me  that its existence as an in-
flammatory disease is fairly established, and without pronouncing upon
the opposite views of Legendre and Bailly, Fuchs, &c, I shall first lay

            1 Lectures on Diseases of Infancy and Childhood, p. 176.
            2 Traite" de la Pneumonie, p. 18. 
         INFLAMMATION OF THE LUNGS. — PNEUMONIA.      327

before the reader  the  ordinary appearances, and  by and  by refer to
the  different  pathological views  held by  these  ingenious  observers.
Anatomically speaking, lobular pneumonia is so called from its occupy-
ing one or more lobules;  and it has been divided into several varieties,
mammelonated,  disseminated, partial, generalized, 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 finger, and
not collapsing when the chest is opened, as  the surrounding pulmonary
tissue does.  These patches, ordinarily circular, but sometimes elongated
from above downwards, are most frequent at the  posterior edge of the
lung, but are to be found  on  other portions.  Occasionally 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 granu-
lar 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 a sanious frothy fluid escapes: from the central portion,
if pressed, we obtain a red serous fluid, without air, as in  lobar pneu-
monia.
   The three degrees of pneumonia may be  observed :  the first with the
tissue marbled, of a rose  and gray color; the red portions, irregularly
limited, somewhat less resisting than the neighboring  parts, floating in
water ; when pressed giving forth a frothy fluid, and crepitating under
the finger.  This  is  the  first degree;  the second has  just been de-
scribed.
   The third degree is characterized by a gray, yellow, or yellowish gray
color, owing to the infiltration  of  pus in the  pulmonary parenchyma.
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 sur-
rounding healthy tissue.
   The same  authors have entered  into more special detail, however,
and have described three  varieties, the mammelonated, the  partial, and
the generalized.
   479. I. The mammelonated 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 sur-
rounding parts when cut  through.
   The  volume of these nodules varies from that of  a hempseed to  a 
328      INFLAMMATION  OF THE LUNGS.—PNEUMONIA.

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 limit-
ed 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-
ease attain the third  degree, and form an  abcess.  The pus primarily
deposited in the pulmonary tissue is collected  in the  centre of the in-
flamed lobule,  surrounded by  two concentric  zones, the inner  one of
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 may  be 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  pleurae  at  this point.   If this adhesion do
not take place, the abscess may open there, and a pneumo-thorax  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  diaphragm,
and  through  this  adhesion the  abscess  opened  into  the peritoneal
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 conclusion: " Lobular pneumonia may terminate by sup-
puration in three  ways:  1. Gray hepatization, when the  pus is com-
bined 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 (vacuole).   This  is far
from being rare, and is intimately connected with  capillary bronchitis.
3. Abscess, properly so called, or  collections of pus, primitively iso-
lated, and closed  completely; communicating at  a later period with
the bronchial tubes,  by  rupture of its walls.  This form  is really very
rare. l
  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  occur-
red 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.
1 Mai. de l'Enfance, vol.  i. p. 60. 
         INFLAMMATION OF  THE LUNGS. — PNEUMONIA.      329

  482. ii.  The partial lobular pneumonia is less defined than the mam-
melonated;  its circumference  is confounded insensibly with the  sur-
rounding 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 hepatized, or
the outer portion congested and the  centre hepatized ;  and by the  exten-
sion 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 difference.   The three degrees of
inflammation are evident in both, but they are disposed differently; in
the latter, commencing  most generally  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 por-
tions will be  those  of longest standing;  and  as the disease begins at
different  points, we  may find gray hepatization in any part, and conges-
tion or red hepatization occupying the spaces between.
  Abscess  may be the result of  this species of pneumonia, but less fre-
quently 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 mammelonated, 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 genera-
lized, into lobar pneumonia; but is far  from  being a necessary transi-
tion.
  483.  Carnification.—There is another morbid condition which de-
mands our  attention.   It has not been  described by authors genej»lly,
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 ordinarily
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 thickness.  In these
parts,  the  pulmonary  tissue is collapsed, of a violet  color, but with
whitish patches, which circumscribe the lobules.   There is  no crepita-
tion ;  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
  AVhen 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 hepati-
zation ;  but it differs in that insufflation restores it to its natural  condi-
1 Journ. des Connois. Med. Chir., 1835, 404. 
330      INFLAMMATION OF THE LUNGS. — PNEUMONIA.

tion just as we find in atelectasis pulmonum,  which it resembles much,
although produced  by different causes.1   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.
  Rilliet and Barthez observed forty-two cases of carnification ;  sixteen
double; seventeen on the right side only ;  and nine on the left.2
  484.  Cfrangene 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  appear-
ances, as being as concise and accurate,  and more vivid, than any I could
give :   " The  right lung, which consisted only of two lobes, was univer-
sally 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  bronchitis.  The upper part of  the
upper lobe, and a small portion near the diaphragmatic surface of  the
lower lobe, felt soft  and boggy to the touch.   On cutting into the upper
lobe,  a cavity was opened  as large as a  hen's egg, very irregular in
form, intersected  in various  directions by the  tubes and vessels that
crossed it,  from which, as well as from  the walls of the  cavity, portions
of 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  ad-
vanc^i stage of purulent infiltration, and  other  parts of  the lobe were
in arr earlier stage of the same condition ; besides  which, small collec-
tions of puriform fluid, not bigger  than a  split pea, were found in vari-
ous 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."3
   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  pneumonia,  and
especially  of  lobular pneumonia, from the  earliest slight  congestion,
with  increased  secretion, up to entire  vascularity,  thickening and soft-
ening  of the mucous membrane,  and dilatation of  the tubes with puru-

            1 Archiv. fur Physiologische Heilkunde, 6th par. vol. iv.
            2 Mai. des Enfans, vol. i. p. 74.
            3 Lectures on Diseases of Infancy and Childhood, p. 209. 
         INFLAMMATION OF  THE  LUNGS. — PNEUMONIA.     331

lent 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 inflammation 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 recent
inflammation, more frequently the latter.  Adhesions, false membranes,
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
one hundred and twenty-three.
  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 complicated
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 irritation;
but although diarrhoea is a very common complication of  secondary
lobular pneumonia, it rarely, if ever, appears to be owing to  inflamma-
tion 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  con-
fined 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 capil-
lary 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 extension of inflam-
mation 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 period of from  one to six
years.  Before and after  that age, the disease  is rare.  2.  The  ana-
tomical  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 development, 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

               1 Valleix, Clinique des Mai.  des Enfans, p. 70. 
332      INFLAMMATION OF THE LUNGS. — PNEUMONIA.

from one to six years, because this catarrh of the small tubes is most
frequent during the same period, and  because it calls into action those
anatomical and physiological peculiarities which diminish after that ago.
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 engorgement, as by a species of partial asphyxia.
7. MM. Rilliet and Barthez have not understood all the importance of
the bronchitic affection; 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  precedes pneumonia,  and  not the contrary, is to put  forth a
slightly founded  objection, and one easily refuted.   9. If lobar pneu-
monia 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 ?  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 pneumonia
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.
   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 entirely new view
of the disease  termed lobular pneumonia.4
   This condition of the lung they believe is not the result of inflamma-

     1 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.
     * Archives Gen. de M6d., Jan., Feb., and March, 1844. 
         INFLAMMATION OF THE LUNGS.—PNEUMONIA.      333

tion, but that the lung or portions of it collapse, owing to the congested
or distended state of the  capillaries, and assume this " Hat foetal," or
" dtat foetal congestionnel."   These portions they say differ from hepa-
tized lung, inasmuch as they  may be easily distended by air, and so re-
stored to their primary state, whereas the hepatized lung is impermeable
to air ;  but in this they are opposed to the experience of M.  Bouchut.
According to these authors, therefore,  lobular pneumonia is truly a pul-
monary catarrh, answering pretty much to  capillary  bronchitis, with
these collapsed portions of the lung reduced  to  a condition analogous
to the foetal lung, or to that  state which has been termed atelectasis.
   M. Friedleben differs from this  view, and  considers that the pneu-
monia of  children runs through the same course  as that of adults, but
that the lobar pneumonia is more frequent than has been supposed.1
   Dr. Fuchs has carried further  the theory of Lcgendre and  Bailly.
He states that he has never found a condition of the  pulmonary paren-
chyma at all  analogous to that observed in the  pneumonia of adults,
and that the changes are  not due to inflammation, but to the cells  be-
coming  void of air and atrophied.  To this  condition he  applies the
term apneumatosis, and he thus describes  the condition  of the  lung :
"The apneumatic lung  is in its first stage of a dark color, contains air,
swims and crepitates ;  its compass  is less than that of a collapsed lung,
and hence single lobules in the apneumatic condition appear as if sunk
in the normal tissue.   Inflation can be performed.  In the second stage,
the tissue becomes firm, compact, and  void of air; it assumes a uniform
character, a  small  compass, has an even  surface on division, and no
longer permits of inflation.   In  the third, it  appears  as a blue-gray
colored tissue with white streaks."  Dr. Fuchs  distinguishes  between
this morbid condition established after respiration ; and the foetal con-
dition of the  lungs before respiration, and whilst he admits that the first
stage may come on as a pulmonary catarrh in very young  children, in
older ones it will have more the character of a determinate inflammation.
   Now  let me observe that in this question there are two points involved
—first,  what is the true nature of that state of the lung which has been
called carnification—is it the  result of inflammation ?  is it a modifica-
tion of hepatization, or  is it really a collapse or  atrophy of the paren-
chyma,  the result of changes in the neighboring parts ?  and secondly, if
it be non-inflammatory and only a passive apneumatosis and atrophy, is
it the principal or the only change observed in lobular pneumonia, and
are we to infer that that disease is truly a  capillary bronchitis with the
addition of (or producing) this collapsed condition of the lung ?   I do
not feel competent to decide these questions, but it appears to me that
additional observations are required before we can agree with the origi-
nal views of MM. Legendre and Bailly, West and Fuchs.
   I am, however, inclined to  believe that bronchitis may result in either
lobular  pneumonia or atelectasis, but that probably atelectasis is often
mistaken  for lobular pneumonia, and  further,  the  condition which has
been termed carnification has greater resemblance to the latter than to
the former disease.

           1 Arch, fur Physiologische Heilkunde, Part 2, 1847.
           2 Der Bronchitis, der Kinder, 1819. 
334      INFLAMMATION OF THE LUNGS.—PNEUMONIA.

  For further details on this subject I would  refer my readers to Dr.
Willshire's valuable and  elaborate essay, Historic Data  on Infantile
Pneumonia, in which he has traced the  succession of opinions and
analyzed the views of the different authors with no small learning and
ability.1
  488.  Causes.—Among the predisposing causes,  age appears to exer-
cise a considerable influence.  It has been said that primary pneumonia
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, i. e., 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 age of his  patients  were, of simple
pneumonia, from seven to twelve days; of pneumonia with oedema, from
two 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 Barthez,
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 asserts 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
of an enfeebled and broken-down constitution being peculiarly liable to

  i British and Foreign  Med.-Chir. Rev., Oct. 1853, p. 514.
  2 Clinique des Mai. des Enfans, p. 173.           3 Mai. des Enfans, p. 478.
  * Mai. de l'Enfance, vol. i. p. 187.              5 Diseases of Children, p. 312. 
         INFLAMMATION  OF THE LUNGS. — PNEUMONIA.     335

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 pneu-
monia; 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 frequent
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 pneumonia 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. Barrier,
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 gene-
rally met with 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 3326 cases of pneumonia; in
spring,  2454 ; in summer,  1827; and in autumn, 3600.
  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 HSpital 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 prevail-
ing, as  I noticed in the last chapter.
  Dr.  Cheyne mentions that  it prevailed epidemically every  winter,
about Leith—in the years 1802, 3, 4, and 8,  he  had seldom less than
from 15 to 30 cases under his care.2
  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 sev-
enty-eight cases which came under Dr. West's care for  inflammation of
the lungs, " thirty-one were stated to have had previous attacks of the
disease ; twenty-one, once; four, twice ; two, four times; and four were
said to have had it several times, though the exact number  of seizures

    1 Diseases of Children, p. 50.    2 Pathology of Larynx and Bronchia, p. 187. 
336      INFLAMMATION OF THE LUNGS. — PNEUMONIA.

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 pneu-
monia, 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  conges-
tion, 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 dis-
ease of the vertebrae, one; fungus haematodes  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  charac-
ters of collapsed lung in so marked a degree as to preclude the possi-
bility of error.   The causes  of  death in these fourteen cases were :—
congenital atelectasis, one;  induration of the cellular  tissue, one;  con-
vulsions, one ;  meningitis of the convexity of the  brain, one ;  conges-
tion of the brain occurring in the course of hooping-cough, one;  tubercle
of the  brain, one ;  atrophy of one  hemisphere of the  cerebellum, one;
atrophy, five;  laryngismus stridulus, one;  fungus hsematodes of the
kidney,  one.
  " In forty-seven of the above  seventy-nine cases, the pulmonary tis-
sue was quite free from tubercle.  In twenty-two, the lungs contained
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 inflammation.
  " The pleura was mainly affected in twelve of these cases, its inflam-
mation 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 was chiefly or  entirely  confined
to the  bronchi, and in six of these the inflammation was idiopathic.
  " In fifty-six cases pneumonia prevailed,  which was  idiopathic in sev-
enteen, 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 diseases:
Hooping-cough, sixteen; phthisis, seven; acute pleurisy, six;   measles,
five; croup, three; scarlatina, three; diarrhoea, three;  acute hydro-
cephalus, three; croup,  consequent  on  measles, two; remittent fever,
two ; acute meningitis, two ; chronic bronchitis, one ; coryza, one ;  ana-
sarca  after scarlatina, one ;  cancrum oris  after remittent fever, one;
acute rheumatism,  one ;  convulsions, one.

                  1 Lectures on Diseases of Children, p. 180, note. 
         INFLAMMATION  OF THE LUNGS. — PNEUMONIA.      337

   " 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 which  it occurs
as  a secondary attack.   However, as Dr.  West observes, it would re-
quire a large number of cases to enable us to draw any stringent con-
clusions.  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 with chronic catarrh, occurring in
the course of  measles; in two, with scarlatina; in three, but obscurely,
with smallpox; 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, hur-
ried breathing, dulness  on  percussion,  crepitant rale, and fever.  In
lobular pneumonia, the cough, dyspnoea, and fever, are much the same,
the pain  is less, and the dulness  on percussion not so perceptible in the
mammelonated form of the disease.   In  the generalized form we shall
have less difficulty, as the dulness is marked, and the crepitant or sub-
crepitant 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-crepi-
tating  rades.  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  situation.   The
distinguishing  characteristic rales of  pneumonia  are, of  course, alto-
gether absent, and the vocal sound may  be  different.
   in.  There may be great difficulty in distinguishing  pneumonia 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 previous  his-
tory.   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

           1 Lectures on Diseases of Infancy and Childhood, p. 181.
       00 
338      INFLAMMATION OF THE  LUNGS. — PNEUMONIA.

proved that these symptoms  depended upon a tubercular infiltration of
the lung.   "In  such cases," they remark, "we  must observe the in-
tensity 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 persistence is the conse-
quence of the tubercles.   I am completely of the  opinion, but this
does not prove that the fever and bronchial respiration  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 (per-
haps because  more  frequently primary) is  less fatal than lobular, and
uncomplicated much less fatal than  when complicated.   Secondary
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  inroads 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 pneumonia,
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 judgment in their ap-
plication.  The principal remedies are  bleeding, tartar 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  exa-
mined, 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 pow-
erful means for arresting  inflammation of the lungs.  Some of the con-
tinental writers object to it, as weakening the patient, but, as Dr. West
observes, this opinion, being formed from the cases of secondary pneu-
monia 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 dis-
1 Traite de la Pneumonie, p. 513. 
         INFLAMMATION OF THE LUNGS. — PNEUMONIA.      339

ease, 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 ap-
plied 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 may be removed when counter-irri-
tants are to be applied, and then replaced.  It soothes  the sensations,
relieves the aching  pain, quickens the action of the counter-irritants,
and promotes expectoration.
   498. n. 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 watch-
fulness and caution, as it sometimes produces very alarming 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 vomiting, and then
diminish the dose, so as to occasion nausea merely.   Dr. West recom-
mends  " one-eighth of  a grain  every ten minutes, till vomiting is pro-
duced,  in the case of a child two years old, and  continued every hour
or two  afterwards, for twenty-four or  thirty-six hours."
   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 palata-
ble, will probably check the tendency of  the tartar emetic to act on
the bowels:—
                 R.—Mist, amygdal.  51J.
                    Antim.  tartarizati, gr. j. vel ij.
                    Syr. papav. alb. gij.—M.
             A teaspoonful to be given every three or four hours.
1 Trans, of Association, vol. v. p. 49. 
340      INFLAMMATION OF THE LUNGS. — PNEUMONIA.

  But in secondary pneumonia, when the patient is much reduced espe-
cially, or when the stomach and intestinal canal have been affected, 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 weakness,
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 calo-
mel  so  long  as we are employing tartar emetic ; but when a change
becomes desirable, or 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  pos-
sesses 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 or 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  excite-
ment, even though the pulse  still  remains quicker than natural, a mode-
rate-sized blister, applied for  a few hours only over the seat of the dis-
ease, 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 eover the chest with one at once.
   In cases where more active  measures are inadmissible, a succession of
blisters must be substituted, care being taken that they are not applied
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.
   When 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  com-
posed of equal parts of decoction of senega and water, with syrup of 
PLEURISY.—PLEURITIS.
341
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, senegae,  §ij.
                         Carb. ammon. Qj. to 3J.
                         Vini ipecac, gss.
                         Syr. smilac. asp. £iv.—M.
                         Aquae, gij.
                  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 termination 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 benefi-
cial.
   The diet in primary  pneumonia  must  be low and spare, but towards
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 treat-
 ment, and in some cases (as  intestinal  irritation) exclude  some of the
 most valuable remedies for pneumonia.
                     CHAPTER  VIII.

                      PLEURISY.—PLEURITIS.

  503. Inflammation of the pleura, or pleuritis, may attack children
of all ases, although its comparative frequency varies a good deal.   Of
4012 patients treated at the London Infirmary for Children during the
year 1816, only three cases of pleurisy1 were noted;  but out of 4158
1 Report of the Royal Infirmary for the year 1846. 
342
PLEURISY. — PLEURITIS.
admitted in 1845 to the Royal Institution  for Diseases of Children in
the district of Wiefden, Vienna, there were seventy-six cases of the dis-
ease.1   "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 ;2 and of  twenty-five deaths at
all ages,  from  pleurisy,  registered  in the month  of January, 1847,3
eleven occurred under the age of fifteen years."4
   M. Billard5 states that he has found it more common than one would
have expected;  and, on the other hand, M. Valleix considers it rather
rare.6
   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
2 to 15, the pleura of 158, or eighty-seven  per cent, was affected.7
   Dr.  Eberld 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.8   Dr. Battersby has recorded six cases
of simple or  complicated  pleurisy.9
   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 supposition
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 pleurisy in
children.  We are  indebted  to  Meissner,  Henke,  and  Heyfelder,10 in
Germany; to Billard, Constant,11  Baron,12 Berton,13 Rilliet and Barthez,
and Barrier,  in France;  to  Crisp,14 West, and Battersby,15  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 modified
somewhat in early  infancy.   Rilliet and Barthez have  also described
the disease occurring in children of a broken down constitution  under
the name cachectic pleurisy.
   505. Primary Acute Pleurisy commences  generally with depression
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

  1 Jahrbericht iiber die Leistungen des  Unentzeldlischen Kinderkranken Instituts, &c.
  2 Sixth Annual Report of Registrar-General.
  3 Weekly Tables of Births, &c, January, 1847.
  « Dr.  Battersby, Dublin Journal, Nov. 1847, p. 349.
  5 Mai. des Enfans Nouveaux-ces, p. 529.    6 Clinique des Mai. des  Enfans, p. 198.
  7 De la Pleuresie  dans  l'Enfance.          8 London Med. Gaz., Dec. 25, 1846.
  9 Dublin Journal, November,  1847.       I0 Archives, third series, vol. v. p. 59.
 »'  Gazette Med., 1836,  p. 265.  Lancette, 1837, p. 146.
 12 Thesis, 1841.                       13 Traite des Mai. des Enfans.
 11 London Med. Gazette, Dec.  25, 1846.     15 Dublin Journal, Nov. 1847, p. 348. 
PLEURISY. — PLEURITIS.
343
 the symptoms which usher in the disease are more alarming, 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 what-
 ever in its chest, while the short cough and  hurried  breathing  may be
 thought  to be merely the result of the cerebral disturbance."1
   Early in the complaint, the child complains of pain in the side (gene-
 rally the left) 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."2
   In the majority of cases there is no expectoration, and when present,
 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.3
   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.
 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,  while  in the latter  the  infant is not so restless, nor
 crying so  constantly, especially  when  moved or held erect, as in pleu-
 ritis."4
   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 alae 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 gene-
rally lie  as they are placed in bed.  In  older children,  one side or the

   1 Dr. West's Lectures, p. 213.              * Diseases of Children, p. 290.
   3 London .Mod. Gazette,  Dec. 25, 1846, p. 1104.
   4 Dublin Journal, Nov.,  1S17, p. 371. 
314
PLEURISY. — PLEURITIS.
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  enfeebled,
and  gradually retreating upwards as the effusion  increases.  Then we
may detect  bronchial respiration, generally constant, but occasionally
disappearing and  returning at intervals,  owing, M. Bouchut  thinks,
either to the short inspirations  or the interruption to  the passage 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 inferior angle of  the scapula or the
interscapular 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  inspiration 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 respiratory mur-
mur,  more rarely by frottement, and sometimes by pure respiration.  In
some few cases, this peculiar characteristic is absent.
  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 begin-
ning, 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 reso-
nance 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
1 Mai. des Enfans, vol. i. p. 149. 
PLEURISY. — PLEURITIS.
345
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 per-
sistence.  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 percus-
sion  as  well as of auscultation.
  Taupin,1 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 inflamma-
tions.   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 respi-
ration  or the voice; and this is exactly the opposite of what we find 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 natural
feebleness of the vocal  vibrations.2  Dr. Battersby thinks it impossible
to detect this vibration before the eighth year.
  On inspection of the  chest, the affected side appears immovable dur-
ing 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  com-
plaint, nor when it runs its course rapidly.   When the attack  is pro-
longed several weeks, there is a notable difference in  the two sides of
the chest, in  proportion to the effusion.   The affected side is  enlarged,
the intercostal spaces are raised to the level of the ribs,  or even pro-
truded 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.  My very intelligent friend, Dr. Battersby, has re-
lated four such cases,3 and I have seen  several.
  Thus, although  the rational signs of pleurisy are not very clear, we
can hardly mistake the physical signs.   In the earlier stage, feebleness
of respiration, succeeded by the bronchial souffle, with marked and in-
creasing dulness on percussion, absence of vibration in the side affected,
perhaps egophony or vocal resonance, and at a later period, if the effu-
sion  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 ascer-
tained; there  is fever, quick breathing, and  cough, but whether pain or

        1 Recherches sur le Diagnostique des Mai. de Poitrine chez les Enfans.
        2 Diseases of the Chest, p. 498.
        3 Dublin Journal, November, 1847, p. 353. 
346
PLEURISY. — PLEURITIS.
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 disease  advances it
loses its appetite; is sometimes attacked by diarrhoea ; the fever is occa-
sionally  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 progress  of
pneumonia, either from contiguity of structure or in consequence 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 orthopnoea.
More frequently it commences with  sudden  and  severe pain, with  in-
creased 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 pleurisy
supervening on pneumonia have been thus stated by Rilliet and Bar-
thez : "When  effusion is superadded to pneumonia, it happens  occa-
sionally, but very rarely,  that there  is a complete  absence  of the respi-
ratory murmur instead of bronchial respiration.   Ordinarily the souffle
is considerably increased in intensity ; sometimes  it has even a cavern-
ous 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 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 dul-
ness is absolute, whereas, a short time before, it was but relatively dull.
We lay it down, then, as  a principle, that when a pleuritic effusion su-
pervenes in a child laboring under hepatization of the posterior part  of
the lung, all the abnormal sounds which were perceptible in the diseased
part are considerably exaggerated, and the resonance 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 respi-
ratory 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 dulness,
are suddenly exaggerated, it is an  evidence  that the  pneumonia 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  extremities,
paleness of  face, and general sinking of the powers of  life, warn us  of
the final result.
1 Mai. des Eufans, vol. i. p. 152. 
PLEURISY. — PLEURITIS.
347
  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 symptoms 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 respiration ;
the  effusion, however,  increases,  the respiratory murmur is  feeble or
absent; there is occasionally the bronchial soufflet, 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.
  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 pleu-
risy.  Rilliet and Barthez mention a case of meningitis which  occurred
in the progress of pleurisy, which itself was developed during the ex-
istence  of  Bright's  disease, but upon which of the two the meningitis
depended it would 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 beneath
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-absorption
of the  fluid ; 5. By its vicarious expectoration;  and 6. By a sponta-
neous opening through the parietes of the chest, as in the case related
by  Dr.  Battersby.
   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, espe- 
348
PLEURISY. — PLEURITIS.
cialby underneath the false membranes.   In one case, Rilliet and  Bar-
thez found the pleura beneath the false membrane  ver}' 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 re-
garded 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 adhesions
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  laminae may be super-imposed, forming 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.
  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 carnification.
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 resembles
the lung in  a state of hepatization, but is firmer and less penetrable  by
the  finger, and on pressure less sanguinolent  fluid  escapes.   In  such
cases it is pretty certain that  the  hepatization preceded 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  pres-
sure than it would otherwise have  been.   Rilliet and Barthez have  at-
tempted to point out the  anatomical  characters when the pneumonia
succeeds to  the effusion, but without much success.   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 
PLEURISY. — PLEURITIS.
349
side than the left; and that when complicated with pneumonia it is still
more  frequently unilateral, but that the left side is more  commonly af-
fected.
  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;"  and this is  in conformity
with my own observations.
  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,
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  re-
moved by operation.   Dr. Battersby has related several cases in which
the effusion was sufficient to dislocate the heart from its usual situation,
and I have seen three or four.
  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 com-
mon 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 pleurisy,
ebdit 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 com- 
350
PLEURISY.—PLEURITIS.
mon 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 per cent. ;
that pulmonary complications existed in two-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 dis-
ease.  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, dis-
covered pleuritis in  six ; in one, simple;  in five, combined with pneu-
monia.  M. Barrier observed no case of pleuritis independent of pneu-
monia before the  sixth  year ; very few between the 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 winter; Rilliet and
Barthez in the month of April.
   Impure air, insufficient food, inadequate clothing, a prolonged sojourn
in a hospital, lying too long on the back, seem  to exercise as much in-
fluence on the production of pleurisy as upon pneumonia.
   Exposure to cold is, perhaps, the principal exciting cause, but Rilliet
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, per-
haps, 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 pneumonia in nine, 
PLEURISY. — PLEURITIS.
351
with tubercular pneumonia  in  six, with entero-colitis in five, and with
other different 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 or  egophony, 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 inten-
sity, 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 diffi-
culties,  remarks: "But even then, and in spite of  all the circumstances
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, N
symptoms  like those of pneumonia having set in  suddenly and  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.2
   There is also something peculiar in  the aspect  of the child, breathing
shortly and quickly, holding the chest fixed,  and moving cautiously as
if fearing pain, which  has led me to suspect pleurisy even before asking
a question.
   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 Bar-
thez 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,3  Baudelocque,4  Barrier,  and  Battersby,5   concur  in  this
opinion.
   Of seventy-six cases treated at the Institution for  Diseases of  Chil-
dren at Vienna,  but two 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 uncomplicated
empyema, after  the occurrence of deformity of  the  chest, and even
after the evacuation of the fluid by a natural  or artificial opening.   Dr.

    i Mai. des Nouv. Nes, p. 345.
    2 Lectures on Diseases of Infancy and Childhood, p. 214.
    3 Gazette Med.  de  Paris, 1837, p. 265.     4 Lancette  Francaise, 1837, p. 146.
    5 Dublin Journal, November, 1847, p. 363. 
352
PLEURISY. — PLEURITIS.
Hughes performed paracentesis in four children between seven and nine
years of age, and all recovered ;J and Ileyfelder in three cases, between
six and seven years old,  with perfect success.2
  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  bloodletting, 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 dis-
ease,  as it is possible that this  may preclude very active remedies for
the secondary  affection.   After the  proper treatment for acute pneu-
monia,  for instance, and the exhaustion and weakness produced by that
affection,  it is  evident that,  should pleuritis suddenly arise, our treat-
ment of the latter must  be very much modified.
  As  a general rule, in chronic pleurisy  bloodletting  is rarely called
for; certainly, if we detect 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 employment
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
nitre  given in the following form :—
                        R.—Nitr. potassse, gj.
                            Antim. tartar, gr. ij.
                            Sacch. alb. ^ij.
                            Aquae, §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 powder,  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. cretse cum opio, or Dover's powder,  we may substitute the hydr.
cum creta.  I have before remarked that mercurial diarrhoea in children
is nearly  as good a sign  of the constitution being under the influence 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

                1 Guy's Hospital Reports, Nos. 3 and 4, 1844.
                2 Arch. Gen. de Med., third Series, vol. v. p. 59. 
PLEURISY. — PLEURITIS.
353
are counter-indicated, and in chronic pleurisy, where they are unneces-
sary 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 occasion
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 aro-
matic 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 alternately
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
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 water, 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 sanguinariae 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  necessary
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  per-
formed the operation several times, but without success; that Dupuy-
tren 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. Davics, and several by Dr. Hamilton Roe.   Herpin succeeded
in one case, and Ileyfelder in three.  Dr.  Hughes mentions that within

                       1 Lancet, December 30, 1843.
     23 
354
PLEURISY. — PLEURITIS.
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.   When 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 depending opening
can readily be obtained, as  I shall presently show, by  adapting the
position of the patient to our purpose."1
   Previous to  the operation, Mr. Cocks always employs Dr. Babington's
exploring needle, of which he speaks most highly, and deservedly.  The
instruments he employs for evacuating the fluid are, of course, the tro-
car 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 required.
   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 trocar,  may be inserted.  This  preliminary step is
not absolutely necessary; but, as the  skin is by far the  most impene-
trable and resisting of the tissues to be traversed, its previous division
will render the introduction and withdrawal 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  ascertained, the trocar and canula may then be car-
ried into  the  chest  through the same track, giving the  instrument a
slight  obliquity upwards, which will  enable it to clear the edge of the
rib.   The  depth  to  which the trocar 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
1 Guy's Hospital Reports, 1844, No. 3, p. 67. 
PLEURISY. — PLEURITIS.
355
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
trocar, 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  in-
spiration,  and then the body of  the patient should be gently lowered
into  a horizontal posture, and turned slightly over to the  affected 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 recom-
mence 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 continu-
ous 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  ob-
tained, when the canula should be immediately withdrawn.  The greatest
care should be taken to remove  the tube, and thus close the opening,
while the  chest of the patient is yet 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 inspi-
ration.  The admission of the slightest  quantity of air is immediately
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  per-
formed, thirteen may be fairly stated to have recovered, so far as regards
the effusion into the pleural  cavity.    Two may be justly mentioned  as
bavino- 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 profes-
sion.  Ten have ultimately died  of other diseases, generally connected
with that  for which the operation  was  performed, but  entirely inde-
pendent of its  performance.   Of these  ten  cases ultimately fatal, six
have died of phthisis ; one of gangrenous pulmonary abscess of  the  op-
posite side :  one, after three months, of chronic pneumonia;  one rather
i Guy's Hospital Reports, 1844, No. 3, p. 74. 
356
PULMONARY PHTHISIS.
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 temporary  relief), of pneumonia and
pericarditis."1
                      CHAPTER  IX.

                       PULMONARY PHTHISIS.

  1. This fearful malady, though less frequent than in adults, is by no
means uncommon among the children of the poor, and such as are seen
in foundling or children's hospitals, poor-houses, &c.; in private practice,
among more wealthy families, I do not  think it is very common, except
where  it forms a part of a  more general development of tubercles in
scrofulous children.  The characters, symptoms, course  and  termina-
tion, very much resemble the same disease in the adult, so that it will
be unnecessary for  me to  enter minutely into the different  parts of its
history.   There exist, however, differences  sufficiently  marked  to be
worthy of notice, and which have a practical bearing upon our treat-
ment.  These deviations from the ordinary course of phthisis, I shall
point out as we proceed, as briefly as I can.
  2. Experience has shown us that tubercular deposition is  exceedingly
common  in  infancy and childhood:  thus M. Lombard found  that  one-
eighth of the infants who died from one to two years old in  the Hopital
des Enfans  Malades, at Paris, were tuberculous;  two-sevenths of those
from two to three years; four-sevenths from  three to four  years;  and
three-fourths  of those who die from four to five  years old.   M. Papa-
voine makes a very similar report.
  M. Guersent calculates that tubercles are found in two-thirds or  five-
sixths of all the children from one to fifteen years of age, whose bodies
are examined  after death.   M. Barrier states that he found tubercles
in thirty-eight per cent, of those who died from two to  five years of age ;
seventy-two per cent, in those from five to eight years ; 100 per cent, in
those from  eight to eleven years; and seventy per cent, in those from
eleven to fifteen years.   In 130 autopsies, he found  that tubercles ex-
isted in  seventy-five.3
   Thus we see that the frequency of tubercular deposition is very great
 in the earlier years  of  life, and we further  find  that the organs  most
 commonly affected  are the lungs and bronchial glands ; but yet the lungs
 are not so invariably the seat of the  morbid product in children as in
 the adult, for whereas M. Louis found in 125 adult  cases, but one ex-
 ception  to the law, that wherever tubercles were deposited in any organ,
 they were also found  in the lungs, MM. Rilliet and  Barthez met  with
 forty-seven cases out of  312 tuberculous patients, in which  the lungs

                1 Guy's Hospital Reports, 1844, No. 4, p. 366.
                2 Mai. de l'Enfance, vol. i. p. 329. 
PULMONARY PHTHISIS.
357
were  entirely unaffected.   This is the first deviation I have to bring
before the reader.   Dr. West has constructed a table, showing the com-
parative frequency of the occurrence of tubercle in different organs in
adults and children, which I shall take the liberty of extracting.
Of 100 cases in which tubercle was deposited
  in some of the viscera, it was present
In the lungs
  "  bronchial glands
  "  mesenteric  "
  "  small intestines
  "  spleen
  "  pleura
  "  peritoneum
  "  liver
  "  large intestines
  "  membranes of the brain
  "  kidneys  .
  "  brain
  "  stomach .
  "  heart and pericardium
  Children from
  1 to 1j years.
_____________A^____________.
  According to
Rilliet and Barthez.
      84
      79'
      46
      42
      40
      34
      27
      22
      19
      16
      15
      11
       6
       3
Adults from 20 years and upwards.
According to
  Louis.
  100
   28
   33
   33
   13
    2
    0
    0
   10
    0
    2
    0.8
    0
    0
According to
 Lombard.
   100
     9
    19
     0
     6
     1
     0
     1
     0
     2
     1
     2
     0
     0
  3. Symptoms.—The disease may set in during the course, or towards
the termination of some other affection, especially if tubercular, and, of
course, the symptoms will be modified more  or less by the concurrent
disease, or by the condition in which  a preceding one may have left the
patient.   Or it may commence quite independently, and then the symp-
toms resemble  very much those in the adult, differing rather in degree
than in kind.1
   The child, at the  commencement,  seems  unwell,  loses its appetite,
acquires a delicate semi-transparent look, complains of  erratic pains in
the chest, &c, even before alarm is excited by a  cough.  At first the
cough is slight, dry, and more distressing by its frequency than its se-
verity;  as the  disease advances, it becomes more troublesome, sometimes
almost incessant, in other cases occurring in paroxysms.   In a few cases,
the cough is  comparatively  rare, attracting but little  attention, but,
nevertheless, it is present  in almost  every case.   Rilliet and Barthez
thus speak of this symptom: " The cough, once present, persists through
the entire duration of the disease.  It presents, it is  true, great_varia-
tions in its characters  and its  intensity,  but it is rare  to find it sus-
pended either  completely or for a time.   In one  infant alone have we
seen the cough commence after haemoptysis, ceaseafter a time, and not
reappear  until after a recurrence of the accident."2       ...
   The respiratory movement is rarely natural, in general it is hurried,
and sometimes extremely rapid, even up to 40, 60, or 80 in the minute,
accompanied by an amount of dyspnoea, in some  degree in  proportion
to the amount of tubercular  deposit,  whether the tubercles be softened
or in a crude state ;  or it may depend upon  an accession of  pneumonia
or bronchitis,  but if  neither of these exist, it is stated to be  a tolerably
accurate  measure of  the extent of the disease.  With some children we

               ' Barrier, Mai. de l'Enfance, vol. i. p. 649.
               2 Rilliet and Barthez, Mai.  des Enfans, vol. iii. p. 277. 
358
PULMONARY PHTHISIS.
see the entire chest dilate, in others respiration is mainly accomplished
by the movements of the diaphragm, and in a third class it  is entirely
costal.
  In infants, there  is no expectoration, and very rarely in children
under six years of age; whether it be that none is thrown off, or that it
is swallowed, is not easy to decide;  from six to fifteen years, it is more
abundant, and presents much the same character as in the adult, but it is
not so easy to infer from  them the presence of a cavity.   Nor is haemo-
ptysis at all common;  it is extremely rare at the beginning,  and in the
course of the disease it occasionally just tinges the sputa.   Towards the
end it may occur more abundantly,  and may even terminate  life  some-
what abruptly.  MM.  Rilliet  and Barthez never saw it either at the
commencement or in the course of phthisis, but in five cases the parents
reported that it had  occurred.  Pain and uneasiness in the thorax is of
uncertain occurrence; many patients are too  young to complain  of it;
many have it not.   When it does occur, it is sometimes behind the ster-
num, sometimes between the shoulders or in either side.
  Night perspirations, although they do occur, are much less common
than in adults.
  4. Thus affected, the child rapidly loses flesh and  strength, and the
color of  the skin is altered, but the symptoms which  especially charac-
terize the hectic fever  of  consumption in adults, such as  the quick hard
pulse, heat of skin, hectic flush, perspirations and general irritability,
are generally less intense.  This M. Barrier is disposed to attribute to
the less frequent occurrence of suppuration and cavities.
  Dr.  West  thus sums up the peculiarities of the symptoms as  they
occur in  children:  " 1. The frequent latency of the  thoracic symptoms
during its early stages.   2. The almost invariable absence  of haemo-
ptysis at the commencement of the  disease, and its comparatively rare
occurrence during its subsequent progress.   3.  The partial or complete
absence  of expectoration.  4.  The  rarity of profuse general sweats,
and  the ill-marked  character  of the  hectic symptoms.  5. The fre-
quency with which death takes place  from  intercurrent bronchitis  or
pneumonia."1
  5. It  is evident  that  the  symptoms already enumerated, although
sufficient to excite our  fears as  to the disease, are by no means so cha-
racteristic as those in the adult, and are inadequate  alone to assure  us
of its true nature.  But  by adding to them the information afforded by
percussion and auscultation, even though that be not always  so certain
as we should wish, we shall generally be able to remove all doubt.  There
are some peculiarities in the results of auscultation and percussion, which
deserve our attention, and which  have  been  succinctly pointed out by
M. Barrier.  " On account of the great resonance of the chest in chil-
dren, it would require, in order to produce much dulness on percussion,
that the  tubercles should  be both numerous  and agglomerated; there-
fore, a very dull sound in children indicates a greater amount of tuber-
cularization than an  equally dull sound in adults.  Moreover, in adults,
the tubercles are generally concentrated at the top of the lung, produc-
1 Diseases of Infancy and Childhood, p. 301. 
PULMONARY PHTHISIS.
359
ing a  circumscribed dulness rarely appreciable, whereas in  children,
this concentration at the summit being less frequent, and the dissemina-
tion  of the tubercles more general, the  dulness is less  circumscribed,
less intense, and consequently less evident.  But  on the other  hand,
where  dulness exists in adults, it corresponds generally to the advanced
stage of phthisis, that is, to the presence  of cavities ; but with children,
phthisis remains most frequently in the first stage up to the time of death,
and the dulness corresponds  to the crude  condition of the tubercles."1
   The increase of sonoriety which we may occasionally observe in adults
where  cavities are formed, is necessarily  less frequent in children  be-
cause cavities are so.   In  some cases where the tubercles  are thinly
scattered  through the lungs,  the results of  auscultation  may be almost
negative ; but where  they are  collected in certain numbers, although both
attention  and an educated  ear may be necessary, we shall generally be
able to ascertain the true state of the case..
   One of the earliest auscultatory phenomena, in the stage of  crude
tubercles, is the  prolonged expiratory murmur, first noticed I believe by
the late Dr. Jackson,  of Boston, U. S., and confirmed since by the re-
searches of Andral,  Fournet,  &c.  M. Ilirtz, of Strasburg, has noticed
a  variation in  the  expiratory murmur in this stage,  which he  terms
the bruit expiratoire rapeux ; the sound is  at once rougher  and clearer
than the normal murmur.
   According to M.  Fournet,2 it is  not  only modified  by a degree of
roughness and dryness, but  its  intensity  and duration are increased in
comparison with the  inspiratory murmur, which is diminished, although it
also requires a degree of roughness, dryness, and difficulty.  Occasional
changes in the tone  of  the respiratory sounds may, however, modify or
obscure the foregoing peculiarities.   These changes consist at first of a
clearer murmur  than  natural, which may gradually increase  to what
M. Fournet  calls a timbre  soufflant et  bronchique, which  may exist
from the  first  to the  last stage of  tubercles.  The same  author  has
ascertained that all these changes commence with  expiration, but that
by degrees at a  later period they involve inspiration also.
   Another sound, which has been  termed a bruit de froissement, or
craquement sec,  has   been  mentioned as peculiar  to  the  stage   of
crudity; but not only are these  sounds obscure and observed with diffi-
culty, but  it would seem that their precise value and significance are  not
yet ascertained.
   MM. Rilliet and Barthez regard the hardness (durete)  of respiration,
the prolongation  of expiration with the sonoriety, as the most character-
istic symptoms, but which are liable to be  changed or masked by various
circumstances.   They  attempt  further to distinguish between  miliary
tubercles  and the yellow or gray infiltration; in the former, they state
that the respiration  is rough, expiration prolonged, and  the  sonoriety
unaltered; in the two latter cases, by the  feebleness or  absence of  the
respiratory murmur, and the  diminution of loss of sonoriety.3
   There do not  appear to be any special signs which correspond to  the

    1 Mai.  de l'Enfance, &c, vol. i. p.  651.
    2 Recherches (Tin. sur 1'Auscultation et sur la Premiere Periode de la Phthisie.
    3 Mai. des Enfans, vol. iii. p. 247. 
360
PULMONARY PHTHISIS.
softening of the tubercles until these are in process of  elimination, and
cavities commence to form.  If the cavities  are  situated in the upper
part of  the  lung, and are sufficiently large, we shall  have  the mucous
rale, cavernous respiration, gurgling, perhaps pectoriloquy, and dulness,
just as in the adult.   Whilst  the  cavities  are small, the  value  of the
mucous rale will depend upon its being limited to the  situation  of the
tubercles, as it may also arise from bronchitic irritation, and when it is
general, the probability would be that it does so.
   However, it must not be forgotten, as Rilliet and Barthez observe,
that cavities do not  always give rise to these  peculiar signs, but rather
to bronchial symptoms, as bronchial  respiration, mucous rale, broncho-
phony and  dulness, and also that  symptoms of cavities may be present
without  any cavity at all.
   The vocal resonance is changed  in phthisis, during the  earlier stage,
especially in those parts where the tubercles are numerous or agglome-
rated; the voice becomes more resonant, and  occasionally  we find bron-
chophony ;  at a later period, when cavities  are  formed,  we may have
pectoriloquy.  In  children  as well as in  adults, the  vibration  of the
parietes of the thorax is diminished during the crude stage, and increased
over large cavities, if any  such form.
   These phenomena  are  generally present  in children  as well as in
adults, nor  are  they much more difficult  to ascertain generally; the
chief obstacle arises from  the restlessness and unwillingness of the child
to submit to  examination, but with  gentleness,  patience, and  a little
coaxing, we may always attain our object.
   Externally, the two sides of the thorax may present different degrees
of mobility, according as  one side  is  more affected than the  other.  Oc-
 casionally, when cavities  exist on  one side, we may perceive a depres-
sion of  the subclavicular region, and  this part is less dilated during in-
 spiration.  According to  M. Hirtz, the thorax becomes more cylindri-
 cal, i. e. the  transverse diameter, which in the normal state is greater
 than the antero-posterior, gradually diminishes.  Lastly, we may proba-
 bly perceive a difference of volume between  the two sides of the chest;
 but M. Barrier has given a case which shows that this is not always a
 proof of a greater  amount of disease in the  smaller.
    Dr. West thus  enumerates the more important peculiarities in the
 phenomena observed by auscultation in the child :  " 1, the smaller value
 of coarse respiration, prolonged expiration,  and  interrupted breathing,
 owing  to their general  diffusion over the chest, and to their occasional
 existence independent of  phthisis; 2, the  apparent and to some extent
 the real exaggeration of the signs, both of the early and of far advanced
 disease  of the lungs, in some cases of  bronchial phthisis; 3, the loss of
 that information which the phenomena of the voice furnish in the case of
 the adult;  4, the  small  value of inequality of  breathing  in the  two
 lungs;  5, the difficulty of detecting minute variations in the sonoriety
 of the chest; and 6, the existence of dulness in the interscapular region,
 together with moderate resonance of the upper parts  of  the chest, and
 tolerably good respiration there,  which are characteristic of the pre-
 sence of enlarged bronchial glands."1
1 Diseases of Infancy and Childhood, p. 302. 
PULMONARY  PHTHISIS.
361
   <i.  I have  already mentioned that in many cases the symptoms  are
but slight, for some time after the commencement of phthisis ;  but as
the disease advances they assume a much more serious character, though
not steadily progressive.   We may observe great fluctuation; some days
the child seems  better, with  less cough and dyspnoea, and better appe-
tite and  spirits;  then  an attack of bronchitis, or perhaps pneumonia,
throws the child into a very distressing  and alarming state; or the con-
currence of bronchial phthisis presents a more aggravated condition than
usual.  As the  disease  advances, we  find the  cough  generally more
troublesome, the respiration more hurried and  attended by  wheezing,
with little or  no expectoration; if the child be young, it becomes rapidly
emaciated  and very feeble.   Some degree  of hectic may ensue, with par-
tial night-sweats, but not at all as well marked as in adults.   The mouth
frequently becomes aphthous, and the stomach  and bowels deranged;
and though diarrhoea  is  not  uncommon, it does not alternate with the
night-sweats  as in the  adult.  "In a very large proportion of cases of
phthisis, the  functions  of all the organs  of the body become at length so
much disturbed, and  nutrition  generally so  much impaired,  that  the
patient dies,  because the whole machine is worn out.   But though this
is the case in  many instances, yet it often happens, even where the powers
had  long seemed  nearly exhausted, and  the body wasted  almost  to a
skeleton, that death is far  from tranquil, but is preceded  by hours of
severe agony, for which it is not easy to account.   In many cases, and
especially in  those where the disease runs a rapid course, the fatal termi-
nation is due to an attack of intercurrent bronchitis or pneumonia, which
is sometimes supposed to have been the  patient's only disease, until a
post-mortem  examination reveals  the  tubercular  degeneration of  the
lungs, to which  the inflammatory affection was  but secondary.   Death
from  haemoptysis is rare, and still rarer is the  perforation of the lung
by the walls  of the cavity giving way at some point, and thus producing
pneumothorax.   The abdominal symptoms sometimes mask the thoracic,
and the patient  dies of tubercular peritonitis, who, had life  been  pro-
longed, would have sunk eventually under pulmonary phthisis.   Many
children in whom  the signs of incipient phthisis have  appeared, die of
acute hydrocephalus,  excited by the  membranes  of the brain having
become the seat of tubercular deposit;  and some, in  whom the disease
has attained  a more advanced stage, are  suddenly carried  off by head
symptoms, the cause of  which is  explained by  the discovery of large
masses of  tubercle in  the cerebral substance.   Convulsions, however,
sometimes precede death for several hours, or head symptoms of greater
or less  intensity constitute  the  most striking feature  in the patient's
history for some days before death takes place, and yet an examination
of the body throws no light upon the cause of their occurrence.   Some-
times, too, the symptoms that precede  death  are those of fever of a
typhoid character, rather than of serious  mischief in  the chest."1
   Such is the graphic  picture of the  termination  of phthisis from the
pen of no  ordinary observer.   From  the  beginning to the conclusion,
1 Diseases of Infancy and Childhood, p. 309. 
362
PULMONARY PHTHISIS.
the melancholy cases advance from bad to worse, with but rare intervals
of comfort to the bystanders, fewer still of hope for the little patients.
   The entire duration of the disease varies a good deal.  According to
Rilliet and Barthez, it averages from three to seven months.   M. Bar-
rier states that the non-acute cases are not so prolonged as in the adult,
and that the course is shorter in  proportion  as the child  is younger.
Dr. West mentions that he has known cases persist two, three, four, or
nearly five years before  terminating fatally.   I should be inclined  to
think Rilliet and Barthez's estimate within the mark,  at least for  pa-
tients in private practice.
   7. Modifications and Complications.—1. Now and then we meet with
unusually rapid cases of the disease; and, in such cases, we are liable
to  fall  into an error of diagnosis, inasmuch as the symptoms  present
all the characters of an acute disease, and there is not time  for  the
peculiar symptoms to manifest themselves.  M. Barrier  states that such
are more common than in adult life.  Dr. West has given the following
case in  illustration:  "A remarkable instance of this came under  my
notice some years ago, in the case of a little boy, nine months old, who
was fat and ruddy, and had always had perfectly good health until the
10th of  April.  On that day, he was taken  with symptoms which his
mother supposed to be  those of a bad cold.  On account of this  he
was kept in the house, and various domestic  remedies  were employed,
though without any improvement, and,  on April 24, he  came under my
notice.  There did not then appear to be any urgent symptom, though
the child seemed much  oppressed at the chest.  The case appeared to
be one of rather severe  catarrh, occurring during the  period of denti-
tion.   The gums were lanced, and a mixture containing the vinum ipe-
cacuanhas was  ordered, to which, finding the symptoms did not abate,
small  doses of antimonial  were added  on the 27th.   On the 30th, I
was informed  that the  child was  much worse, that' his dyspnoea was
greatly increased, and that his hands and feet had been swollen for the
last forty-eight hours.   I found  the little boy breathing fifty times in
the minute, with great oppression at the chest, the face much flushed,
the skin dry,  the trunk hot, the limbs cool, and  the  hands and feet
much swollen.   Auscultation detected generally diffused small crepita-
tion  through both lungs, with indistinct bronchial breathing  at  the
upper and back part of  the  left side.   Three hours after this visit, the
child died without a struggle, on being  lifted out of bed for his mother
to apply some leeches  to  his chest.   On examining  the body after
death, a very  thick  layer  of- fat  was  found everywhere  beneath the
integuments.   The lungs  presented an extreme  degree of  tubercular
degeneration, and many of the  bronchial glands were  enlarged by the
morbid deposit to the size of a  pigeon's egg.  None of the tubercle in
the lungs was  softened; but it existed  both in the form of yellow mili-
ary tubercle of tubercular infiltration and of masses of crude  tubercle
formed  by the agglomeration of many separate deposits.  The pulmo-
nary substance in the  intervals between the tubercular deposits was of
a bright red color in the  first stage of pneumonia, and in many parts
bordering upon  the second stage;  and there was very  considerable 
PULMONARY PHTHISIS.
363
injection of the  bronchial  tubes.  The various abdominal viscera con-
tained tubercle, but it was not far advanced in the mesenteric glands."1
  2. On the other hand, the disease may assume an unusually chronic
form, and, instead of terminating  in two or three months, may run on
to a year, or even more.  In  such  cases, however, we are not  exposed
to the same liability to error in our diagnosis.  The patient, or the pa-
rents, however, suffer more from the  fluctuations of  hopes  and  fears.
I shall again trespass upon  Dr. West for an illustration.  " In March,
1842, I saw a little girl, six years old, whose father had died of phthisis,
and who had had a cough ever since she suffered from measles, two and
a half years before.   Her mother's anxiety  had been  excited by the
increase of  this  cough, and by the  child's losing flesh during  the few
weeks  previous  to her  coming to me.  Auscultation at this time dis-
covered  that air entered the lung in the left infra-clavicular region
more scantily than in the right, and that the respiration was coarse and
attended with much creaking at the upper part of both lungs.   In  May,
the general symptoms were much improved, and the creaking sounds
were  no longer  heard.   For many months,  the  child continued to ap-
pear tolerably well, though her cough never ceased entirely; but in the
early part of the winter of 1844 her health completely failed.   Exami-
nation of the chest in the beginning of December elicited  great defi-
ciency of resonance  at  the upper part of the left lung, both  in  front
and  behind.  Bronchial  breathing, intermixed with large mucous rale,
was heard in the left suprascapular region, and abundant moist sounds
pervaded the lung posteriorly.  In  the left infra-clavicular  and  mam-
mary regions, the respiration was very deficient, and accompanied with
distant  moist sounds.   Extreme  coarseness of the respiration was the
only morbid sound heard at the  upper part of the right lung, and the
breathing on that side was puerile in  other parts.  In January,  1845,
the child had slight haemoptysis, which recurred occasionally at intervals
of a few weeks or months until her  death, but was not profuse at any
time.  In September, 1845, resonance was slightly impaired under the
right clavicle, and also in a  greater  degree posteriorly as far as the
angle of the scapula.  There was absolute dulness of the left side  as far
as the nipple in front and the angle of the scapula behind.   There was
no natural breathing in the left lung, but the  respiration was bronchial,
and accompanied with large  raucous rale as low as the nipple,  the rale
being smaller and the admission of air  scanty below that point.  About
the  left  scapula, there were cavernous sounds and  distinct  gurgling,
smaller moist sounds lower  down.   In  the right lung,  respiration was
puerile in front,  except quite at the upper part, where the breathing was
coarse, and  attended with mucous  rale;  and  posteriorly the characters
were still more marked.   It cannot be necessary to detail the results
of the subsequent examination of the chest, which showed that disease
advanced slowly in the right lung,  though there was at no time proof of
the  existence of a cavity there.  The child's condition fluctuated;  some-
times she seemed  almost  dying under an aggravation of all the symp-
toms, and then  again  she rallied,  and  was  able to walk about, and
1 Diseases of Infancy and Childhood, p. 302. 
364
PULMONARY PHTHISIS.
seemed tolerably comfortable.  Life was prolonged until June, 1847,
and she had seemed almost as well as usual until a very few days before
her death."1  This case, we see, lasted five  years at least.   I  have
under my care at this moment  a little girl who has been similarly
affected for two years, and as yet only the upper third of the left lung
is involved, the remainder of that lung and the whole of the right being
free.  She is delicate, but quite able to go about, with  but little cough,
no night-sweats,  little expectoration,  no haemoptysis,  some degree of
emaciation, and  a feeble appetite.  Dr. West mentions  another  case,
which has lasted still  longer; and I doubt  not  that similar cases are
occasionally met with by other medical men.
  3. Bronchitis.—I have already mentioned that the course of phthisis
is often much modified by attacks of bronchitis, which are sometimes at-
tributable to cold, and at other times occur without any assignable cause.
They are marked by increase of fever, more rapid breathing, more dis-
tressing cough, &c, and by the presence  of bronchitic rales in one or
both lungs.   The extent varies ; sometimes it is  very considerable, and
accompanied with great exhaustion ; in other cases it is much  slighter.
By degrees the attack may subside under appropriate treatment, and
the patient gradually recover a certain amount of health  and  comfort,
but if not, it will, of course, hasten the progress of the primary disease,
and shorten the  patient's life.
  4. Pneumonia.—Another frequent complication of pulmonary phthisis
in early life is pneumonia, which, according to Rilliet and Barthez, occurs
more frequently before than after the tenth year.   If it occur at an early
stage before attention has been drawn  to the tuberculous  deposit, a  su-
perficial examination may easily lead to  an erroneous diagnosis.  Seve-
ral causes for the attack have been enumerated by Rilliet and Barthez.
"1.  It may result from the local irritation  of the pulmonary tubercle,
and then it surrounds the latter, and we find the tissue of the lung hepa-
tized and mixed with a variable quantity of miliary tubercles.  It may
either be lobar or lobular, but the latter form is more frequent.   2. The
lung being very  tuberculous, the pneumonia may be situated at the part
most free, i. e. at the base, like the terminal pneumonia of adults; it is
always lobar, and can hardly be attributed to the irritation of the  tu-
bercles, but most likely to the susceptibility acquired by that part of the
lung  upon which its functions depend.  3.  When the  lungs are but
slightly tubercular and other organs very much  so, pneumonia  may be
developed which is not under the local influence  of the tubercle.  It is
a secondary inflammation, analogous to  that which complicates chronic
catarrhs, and which  exhibits  the characters of cachectic  phlegmasia.
4. In cases where the tubercles are few, the pneumonia may be alto-
gether independent of this cause, and  is due to  some  other disease, as
measles, hooping-cough,  &c."2   Both lungs may be attacked, but  when
one  only is  affected by  lobular pneumonia, it is more frequently  the
right, and when by lobar pneumonia, the left lung is more liable than
the right.

                  1 Diseases of Infancy and Childhood,  p. 306.
                  2 Mai. des Enfans, vol. iii.  p. 243. 
PULMONARY PHTHISIS.
365
  I have already mentioned the difficulty of diagnosis, unless sufficient
care and attention be paid.   It is of great consequence that we should
ascertain the presence of tubercles, and not hastily assume that the case
is one of ordinary pneumonia.  " The existence of a considerable  amount
of tubercular deposit  in the lungs may be imputed in those  cases  in
which the degree of oppression of the chest has, from the very com-
mencement of the illness, been altogether out of  proportion to  the se-
verity of the catarrhal or bronchial  symptoms with which the disease
set  in.  A further evidence of its nature  is  afforded if the skin, though
very dry, present a less  considerable  or less pungent heat than  attends
simple pneumonia, while the pulse from  the  very outset is  less devel-
oped.   Suspicion would  be strengthened if the frequency of respiration
very greatly exceeded the amount of mischief disclosed by auscultation,
and especially if the rapidity of the  breathing, though so great that it
would excite the most serious alarm if the case were one of pneumonia,
should yet continue the same for days together, without marked deteri-
oration  in the patient's condition.   Auscultation also would throw much
light on the  nature  of the  case, for  the  sounds  detected in the chest
would be the subcrepitant and mucous rales rather than the small crepi-
tation of pneumonia, while, though the smaller  sounds would be disco-
vered at the  lower part of the chest,  the  greatest dulness on percussion
would generally be detected at the upper part, and bronchial breathing
would very likely be perceived more or less  distinctly in the same situa-
tion."1
  We must also take into account the constitution of the child and  of
his immediate relations, the presence  of scrofulous disease in any  of
them will naturally confirm our suspicion of the existence of tubercles,
and we must carefully  observe  the  accordance or  discordance of the
signs and symptoms of each disease.
   The  danger of this complication is very great, not merely as to the
immediate shortening of the patient's  life,  but  as destroying whatever
little hope there may have been of a favorable issue, so that our prog-
nosis should in  all cases be  very guarded.
   5.  Bronchial Phthisis.—But pulmonary phthisis  in children differs
from the same disease in adults by the more frequent occurrence of  tu-
bercular deposition into  the bronchial glands, or bronchial phthisis as it
is termed.  In  the adult, this occurs about once in four cases of phthisis,
but it is subsidiary to the pulmonary affection; in children, it constitutes
a very important disease, often more considerable and nearly as frequent
as the deposition in  the  lungs.  Dr.  West  states that tubercle existed
in the bronchial glands in fifty-four  out of fifty-five  cases that came
under his notice in which it  was present in some  organ or other;  in
eleven  of these cases it was in an incipient  state; in  twenty-five, all the
glands  were affected by it; in twelve,  the tubercle  was both generally
diffused and was more or less softened;  in  two,  the tubercle was in a
firm, friable, cheesy state, and  in four  it had begun to undergo the
cretaceous change.2

                 1 Diseases of Infancy and Childhood, p. 303.
                 2 Ibid., p. 290. 
366
PULMONARY PHTHISIS.
  This form of disease generally occurs between  the ages of two  and
six years, though it is by no means limited to that period.   The symp-
toms differ a good deal from those in  the  adult;  the attention may be
first attracted by a severe attack of bronchitis, either after measles or
independent of it.  The cough and dyspnoea  are the most  prominent
symptoms, the former is  frequent and severe, recurring in paroxysms
somewhat resembling those of hooping-cough, or those we observe in
vesicular bronchitis.  The respiration is hurried and  oppressed  with
considerable wheezing, the veins of the neck are  swollen and those of
the surface of the thorax become dilated.   "The great fluctuations which
take place in the condition of the  patient constitute one  of the most
striking characteristics of this form of phthisis.   Attacks of bronchitis
sometimes come on, during which the  respiration  becomes painfully ac-
celerated and oppressed, and the paroxysmal cough is merged, for a time,
in a constant hacking or suppressed attempts at coughing.  These bron-
chitic symptoms, which often seem to threaten life, and which sometimes
actually destroy it, clear up by  degrees, in the  majority of cases, but
leave  the child  with a severer cough and more hurried respiration  than
before, while it loses flesh rapidly, and not infrequently sweats a good
deal about the head and upper part of the trunk.  Accommodation of
posture, too, in many instances, becomes necessary to the comfort of the
little  patient,  who perhaps can  breathe  only  when supported in its
mother's lap, or when much propped up in bed.   It is seldom when the
disease has reached this degree of severity that there is entailed so large
a measure of tubercular affection of the lungs  and other viscera, as to
render recovery quite  hopeless, and the characteristic signs of bronchial
phthisis become lost, by  degrees,  in those of ordinary consumption.
Sometimes, however, a long pause takes place in the progress  of the
disease, even though thus far advanced; the cough, which had acquired
fresh  intensity, gradually abates; the respiration is no longer habitually
wheezing; the  patient can repose in any attitude;  the flesh lost is re-
gained ;  and were it  not  that the cough still continues,  though less
frequent and less severe, that the breathing is more hurried than natu-
ral, and that auscultation contributes  still  further to undeceive  us, we
might fancy that all ground for anxiety was passing away, and that the
child  was on the high road towards recovery.   In some cases,  too, in
which symptoms such as have  been  described are  observed, recovery
does eventually take place.  It is seldom possible to say in any case by
what  means this recovery is  brought about;  sometimes no  doubt the
tubercular matter makes its way into the air-tubes, and is got rid of by
expectoration.   Once I observed the disappearance of most well-marked
general signs  of consumption  in the  case of  a girl eight years old,
during the copious expectoration of a tenacious  mucus in which were
small  quantities of a substance like broken down cheese, or grains of
boiled rice, and which attenuated with an expectoration of thick puri-
form matter more or less tinged with blood.  In the case of  this child,
an attack of measles,  while in her seventh year, had been succeeded by
cough, the formation of abscesses in her neck, and a frequent puriform
and sanguineous discharge from her nose.   These  abscesses had not been
long healed, when her mother's alarm was excited by her expectorating 
PULMONARY PHTHISIS.
367
blood, mixed with the phlegm which she brought up when  coughing.
Though not much emaciated, the child looked unhealthy, her pulse was
very feeble, and there were many small petechiae on her extremities.
The lungs, however, were tolerably free from disease; for nothing more
was heard during auscultation than a good deal of rhonchus mixed with
some moist sounds,  which were most evident  at  the upper part of the
chest.   Expectoration such as I have described continued for nearly
three months, in the course of which the child by degrees lost her cough
and acquired strength under the  use of steel and other  tonics.   Two
years afterwards no auscultatory signs of disease were perceptible, except
a little creaking under both clavicles, and at  the end  of five years  even
this had disappeared."1
  The signs  and symptoms which accompany this affection are by no
means always very characteristic; there may be but few signs present, or
the cough, dyspnoea, &Tc, may be owing to the coincident deposition of
tubercles in the lung, and if the latter be pretty well advanced, it will
be quite impossible to distinguish  between  them.   If,  however, the
patient  be of a tuberculous cachexia, and has been  placed in circum-
stances  to favor its  development, and if the general symptoms, such  as
cough, dyspnoea, expectoration, &c, exist without any physical signs of
disease  of the bronchi, lungs, or pleura, we may have ground  for sus-
pecting the existence of bronchial phthisis.  According to Mr. Barrier,2
the results of percussion  are completely negative, when  the  disease is
limited  to the glands, and in general auscultation is little more satisfac-
tory.  Sometimes, however, the swollen gland compresses a bronchus,
diminishing its  calibre, and then the respiratory murmur will be enfee-
bled in  that part of  the lung to which the tube is distributed.   In such
cases the clear  sound on percussion, combined with the feebler respira-
tion, cannot be attributed to tubercles of  the lung, but would  seem to
justify our considering the case to be one of tubercular deposition in the
bronchial glands. Both M. Becquerel and M.  Barrier have verified,  after
death,  a diagnosis founded upon this combination. Again, if  the signs
of a cavity appear in the neighborhood of the mediastinum, but nowhere
else, we may presume without much hesitation, that  they result  from
the suppuration of  tubercular masses in the glands, and which may be
voided through the  larger bronchial  tubes.
   The palpitations  and anasarca which are sometimes produced by the
tubercular matter in or near the mediastinum, pressing upon the larger
vessels, are not of much value as to diagnosis,  inasmuch as neither is
uncommon in pulmonary phthisis.  So that, upon the whole, it is evident
that the distinction during life between bronchial and pulmonary phthisis
is one of great difficulty,  depending upon minute symptoms and  close
and accurate observation.  At an advanced  period, this is of no great
consequence; but as the progress of the former disease is much slower,
it may be some  comfort at an early period to know  that the disease is
one which, at least,  admits of a considerable prolongation of life.  But
more than this, for it seems undoubted that bronchial phthisis is to a

             • Dr. West, Diseases of Infancy and Childhood, p.  295.
             2 Mai. de l'Enfance, vol. i. p. 657. 
368
PULMONARY PHTHISIS.
certain extent a more curable disease, or rather one in which recovery
more  frequently  takes  place;  and that,  in various ways,  either the
tubercular  matter may be  absorbed, or it  may  be  converted  into creta-
ceous substance, or the gland may suppurate, and emptying itself com-
pletely into the bronchial tube, may heal;  and,  if it be an isolated gland,
the child may recover ;  but such cases are rare.
   Death, however, rather than recovery, is the ordinary termination of
the disease, either  by suppuration of the tubercular masses  which ex-
hausts the  patient, or while the tubercles are yet  in a crude state; but
more commonly by the  participation of the lungs and  other organs in
the tubercular  degeneration.   The prognosis, therefore, is at best very
doubtful, and in most cases very unfavorable.
   6.  Emphysema  and  (Edema.—Rilliet and Barthez  mention that
both these secondary affections occasionally accompany tubercles of the
lung ; but  the former does not appear to hold any definite  relation to
them, whereas, the latter is either the direct result of the tubercles, or
of the pressure exercised by them upon some of the pulmonary vessels.
   8.  Morbid Anatomy.—The pathology of pulmonary phthisis in chil-
dren does  not vary very much from the same disease  in adults, and
therefore I feel it the less  necessary to enter fully into details.
   In the large majority of  cases, both lungs are  engaged ;  out of seventy
cases, M.  Barrier found six only in which one  lung alone was involved,
and of these six cases, five were of the left lung, and one of the right.  In
sixty-four  cases, both lungs were engaged, even though in a third of the
cases, the  disease was  but slightly advanced.   In twenty-two, the left
lung was most affected;  in nine the right, and  in thirty-three they were
about equally so.
   As in adults, the apex of the lung is the part first and chiefly affected,
the  tubercles  diminishing  in  number, and  being less advanced  as we
descend.
   Unlike adults, in whom death seldom takes place until after the estab-
lishment of  suppuration and the formation  of cavities (provided  there
are no complications), we  find death occur in children, in whom almost
all the tubercles  are in a  crude  state, or at least before large or nu-
merous cavities  are formed.  This many arise either from the greater
rapidity with which extensive depositions  of tubercle take place, causing
death before there has been sufficient time for  suppuration, or from the
coincident occurrence of tubercles in other organs  or glands.  In eleven
of thirty-three cases related by M.  Barrier, there were either no cavities
 or extremely small ones.
   When tubercularization  has  gone to a certain length, the  pleura is
rarely found in a state of  perfect health; adhesions are very common,
 and tubercles are by no means rare.
   The bronchial  glands, as I  have already remarked, seem to be more
 frequently affected than  the  lungs themselves;  for  M. Barrier states
 that of seventy-nine cases, sixty-nine had  tubercles  in the  lung  and
 bronchial  glands, four in the bronchial glands only, and one in  the lungs
 only.  Dr. West mentions that tubercle existed in the bronchial glands
 in fifty-four out of fifty-five cases in which it was  present in  some organ
 or other;  in eleven, it was in an incipient state;  in twenty-five, all the 
PULMONARY  PHTHISIS.                  369
glands were affected by it; in twelve,  the  tubercle was both generally
diffused and was more  or  less softened; in  two, the tubercle was in a
firm, friable cheesy  state; and  in  four, it had  begun to undergo  the
cretaceous change.   Any of  the  glands  may be thus affected; but the
most important are those lodged in the mediastinum.
  As a general rule, the enlarged  glands  produce less  inconvenience
from compressing the neighboring parts than we might expect;  never-
theless, we have sometimes to complain of  such effects.   The bronchial
tubes may be compressed and flattened, or their coats may be thinned,
eroded, or destroyed, the covering of the gland supplying  their place
and completing the wall of the tube.   This, in the  course of time, may
give way, and the softened tubercular  matter be poured direct into the
bronchial tube.   M. Guersent is  said to  have found the entire  gland
enucleated and passed into the tube.   The pulmonary artery and veins
may be compressed,  and to this they are peculiarly exposed from their
connection with the glands.   The  aorta may also be compressed, and
its caliber diminished.   M. Becquerel mentions a case of M. Durand's,
of a girl  whose trachea, large bronchi and aorta, were  compressed by
tubercular glands, which had thus apparently given  rise to hypertrophy
of the left ventricle.   Compression of the  vena cava thus effected may
give rise to partial or general dropsy.   The oesophagus is rarely altered
in volume.
  As to the tubercles  themselves, as  in the adult, they may present
themselves in the lungs in the form of miliary tubercles, or in masses,
or diffused more generally through the substance of the organ.   Whe-
ther in  the lungs or bronchial glands, the  matter  may  be in either  a
crude or a softened state.  In a  crude state, the  tubercles are  either
gray and  semi-transparent or whitish or  yellow, with a carious appear-
ance, which generally succeeds the earliest stage.   In  the glands,  the
matter is  sometimes deposited in such quantity that, instead of remain-
ing isolated, several are joined, and form irregular masses of large size,
in which, by dissection, we  can  trace the fibrous envelopes of each
gland; but in the end these often disappear, and then the tumor will be
simply surrounded by a general cyst.
  After a time, suppuration occurs, commencing generally in the  centre
of the tubercular mass, and proceeding to the centre until the whole is
softened and evacuated  by means of a  communication with some  of  the
bronchial  tubes.  A  similar  process  takes place  in the  tuberculous
glands; but, after the mass is softened, the attempt  is made to evacuate
the matter by perforating the cyst and reaching the nearest bronchial
tube, through which the  puriform  matter  is evacuated.   An  empty
bronchial  cyst may be mistaken for a true pulmonary cavity, if care be
not taken; but it may be distinguished by its fibrous capsule, and also,
according to Rilliet and  Barthez, by the perforation into the bronchial
tube being situated laterally.   Occasionally, the suppuratory bronchial
glands have perforated the oesophagus, and even the pulmonary artery,
according to M. Berton.
  Tubercular matter, whether in  the  lungs or bronchial  glands, may
undergo calcareous transformation, though it is rare ; and this has been
mentioned as one mode of cure.   M. Becquerel has occasionally ob-
       24 
370
PULMONARY PHTHISIS.
served a steatomatous condition of  the  glands, which he regards as a
transformation of  tubercular matter.
  Dr. West enumerates  four  points in which tubercles in the  lungs of
children  differ from those in the adult:  1. In the greater frequency
with which gray granulations and crude miliary tubercles exist in the
lungs independent of each other and of any other form of tubercular
deposit;  2.  The greater frequency  with which yellow infiltration of
tubercle  is observed in  early life;  3. The greater rarity of cavities;
and 4. The abundant deposit in  the bronchial glands.1
  I do not presume  to present  this sketch to the reader as anything
like a complete account of the pathological anatomy of tubercle, which
will probably be already familiar to them from the perusal of the various
valuable  works we possess on pulmonary diseases, but rather as  a notifi-
cation of the  peculiarities  which it  assumes in children,  and  of some
points in which it differs from  the disease in adults. Neither do I deem
it at all advisable to enter into the  causal origin of tubercles,  how far
they are independent of or how far they result from inflammation, &c,
&c.  Such questions are doubtless of deep interest, and much light has
been of late years thrown upon them, but they would be unsuitable in
a work like  the present;  and I  must refer my readers to the  various
works on diseases  of the chest, where they will find the subject treated
with knowledge and acuteness far beyond mine.
  9. Causes.—There can be  no doubt  that a  scrofulous  constitution,
whether inherited or acquired, is the  most influential predisposing cause.
Neither can we be surprised that close, dark, damp, unventilated dwell-
ings, insufficient clothing, and scanty or improper  food, should induce
that condition of  body which  renders the liability to phthisis so fear-
fully greater among the poorer population of towns and cities.
  The immediate cause of the attack is very often, if not generally, ex-
posure to cold in  some form  or other;  or the disease may succeed to
some of  the eruptive diseases, or to ordinary bronchitis or pneumonia
in children in whom the predisposition exists.
  10. Diagnosis.—1. In the early  stage of the disease, the difficulty
will be to distinguish between phthisis and bronchitis;  but in  the for-
mer, we  may have some  degree of dulness at the upper portion of the
lung, and a mixture of the crepitus  of tubercles, neither of which will
be found in bronchitis.   The  constitution of the child  will also some-
times throw light on the  diagnosis.  At the  same time,  we must not
forget that both diseases  may be present.   At a later  period, the pa-
thognomonic characters are very different.
  2. From pneumonia.—A similar  difficulty besets us here, for pneu-
monia may complicate the case as resulting from tubercles, and to dis-
tinguish  this from  simple pneumonia is  by no means easy.  We may
derive some guidance from previous auscultation, if the lungs were then
free from the secondary disease,  and  also from the duration of the pneu-
monia ;  or, if it be prolonged  with alternations of increase and diminu-
tion, we  may suspect that it is tubercular.
  Again, tubercles are at an early stage confined to the upper part of
1 Diseases of Infancy and Childhood, p. 288. 
PULMONARY PHTHISIS.
371
the lung, simple pneumonia more  frequently occupies the inferior por-
tions, and the small crepitus of the latter disease is quite distinguishable
from  the tubercular  rales; and, lastly, the  amount of fever is much
greater in pneumonia than in uncomplicated  phthisis.  At a later pe-
riod, when the tubercles are softened and perhaps cavities formed, the
diagnosis from simple pneumonia is comparatively easy.
   3. I have already enumerated  the distinctive  points, slight  as they
are, between bronchial and pulmonary phthisis; and I may add that in
many cases such a diagnosis is not only very difficult, if not impossible,
but somewhat unnecessary, as the diseases very seldom  occur  or con-
tinue long  separately.
   4. As to some other  diseases from which it is desirable that  phthisis
should be distinguished, Dr. West observes that " it is important to bear
in mind that strumous dyspepsia, as it has been called by many writers,
is of more  frequent occurrence in childhood than in adult age, and that
its symptoms may be all that mark the advance of phthisis in the lungs
until within a month  or two  of the  patient's  death.  A  definite  com-
mencement can always  be  assigned to the  commencement of remittent
fever; and the  great heat of skin, the very rapid pulse, the  intense
thirst, and the delirium at  night which  attend it, even in its less severe
forms, are  symptoms which, if borne in  mind, would  prevent our mis-
taking for  it those slighter and more vague ailments that are experienced
during the first stage of phthisis.   The referring the symptoms of in-
cipient consumption to the presence of  worms in the intestinal  canal is
a mistake even less excusable. The natural temperature of the skin and
natural frequency of  the respiration, the appetite at one time as raven-
ous as it is deficient at another, the tongue either  clean  and moist  or
thickly coated, the condition of the  bowels, which is generally one of
constipation, and the marked relief  which almost  always follows  the
action of purgatives, are indicative of the presence of worms sufficiently
characteristic to guard the attentive observer from error.''1
   11.  Prognosis.—The prognosis is of course more or less unfavorable
in all cases, absolutely so in most, as many more cases prove fatal than
the contrary, few of those in whom the disease is fully established being
rescued from an early death.  Yet cases of restoration do occasionally
occur, not  frequently, but just in  sufficient  numbers to induce us to tax
to the utmost our care and skill to give the  patient the  benefit of the
slight chance in  his favor.  We should be a little guarded in attempt-
ing to fix the duration of life, as we have seen that in some cases the
disease seems almost indefinitely prolonged.
   12.  Treatment.—I need say but little on this subject, as in principle
the treatment of the disease in adults and in children is substantially the
same, differing only in details.
   Perhaps the first and most  important point to which  our attention
should be  directed, is the  air which the child breathes,  and the atmo-
sphere in which  he lives.   We must take care that  this  be pure, fresh,
dry, and warm ; the rooms should be thoroughly ventilated and  cleaned
in the absence  of  the  patient, and then when sufficiently warmed, the
1 Diseases of Infancy and Childhood, p. 294. 
372
PULMONARY PHTHISIS.
child may be brought back.  During the winter months, I am strongly
in favor of confining the  child, not merely to the house, but to two or
three rooms on the second or third floor if possible, so as to avoid expo-
sure to draughts of  cold air, and  to sudden atmospheric changes and
cold winds.   If circumstances permit a  change of climate, it is often of
very great service.   The South of England or Ireland, and still more
the South of Europe, offer all possible advantages of this kind to the
invalid.
   Even in summer, in this climate, undue exposure may do great mis-
chief, and a prevalence of north or east winds, or damp weather, should
be the signal for confinement to the house.   When the wind is mild, the
air dry and genial, then  exercise in the open air, in the  early stages of
the disease, is beneficial, but at a more advanced stage, it should be very
moderate, for obvious reasons.
   Inner garments  of spun silk, web, or  flannel, should be worn both
winter and summer, as securing an equable warmth, and as a protection
against a sudden chill, but they should never be worn in bed, as they
then only increase the perspiration.
   Careful attention must be paid to the diet; it should be at once simple
yet nutritious,  as very few patients recover who are not able to  take  a
full share of nourishment.   Milk in any form, farinaceous food,  certain
leguminous vegetables, jellies, broths, beef tea, and even solid  animal
food may be allowed, subject to the condition of the  patient, the  state
of the digestive system, the stage of the  disease, &c.   Nay, in some cases
even wine or beer may be advisable.   On the other hand, if the stomach
and bowels be weak or out of order, a careful selection must be made of
those substances which experience has shown to be best tolerated by the
stomach.
   As to the most suitable remedies, I shall not attempt to go through
the list of those which have been proposed.   It will be  quite sufficient
to point out a few of them which appear to deserve  our confidence the
most.   In very few  cases indeed is bloodletting admissible, and then
only to the extent of a few leeches.  These cases are generally those in
which the disease is complicated by pneumonia, but even then our espe-
cial object must be to exhaust the patient as little as possible.
   Counter-irritation  is  useful, and it  may  be practised  by means of
small blisters, the size of a watch glass, below the clavicle, or by the lini-
ment, or by daily painting the same part  with strong tincture of iodine.
   Much stress has been laid upon emetics, purgatives, chalybeates, &c,
by different writers, and although I doubt not there are cases in which
 they may be beneficial, I fear their success has in no degree  kept pace
with the hopes which have been excited.  The three remedies upon which
 most reliance seems to be placed are iron, iodine, and cod-liver oil.   M.
 Barrier, however, speaks disparagingly of iodine, and even attributes to
 it an injurious influence upon the digestive  functions.   Iron has been
 supposed to counteract in some way the tuberculous  cachexia, and Dr.
 Dupasquier, of Lyons, has derived more advantage  from the iodide  of
 iron than from any other preparation.  My  own experience is confirma-
 tory of his—and I have found a convenient form to  be a grain of the 
PULMONARY  PHTHISIS.
373
salt to an ounce of syrup, of which a teaspoonful may be given three
times a day to a child of three years old.
  At the present moment the most popular remedy is cod-liver oil, and
whether from the iodine it contains, or from its nutritive qualities, it is
not easy to determine, but we certainly have quite evidence enough  to
prove its great value in this disease.
  As a tonic, bark in some form is often useful, and for the relief of
the cough, a mixture may be ordered containing ipecacuanha  squills,
and  a little laudanum.  Hydrocyanic acid has considerable control over
the paroxysmal cough.
  Chalk mixture,  with opium and some astringent, may be employed, if
the bowels are  relaxed.
  13.  As to prophylactic measures, these consist  mainly in  incessant
care and watchfulness—securing pure air, warmth, or even temperature,
good diet,  and guarding against cold, damp, improper food, &c.   A very
important  point with infants who are likely to have  inherited  this pre-
disposition, is to secure a healthy wet  nurse  from the country, and to
let her suckle the  child somewhat longer than the usual  time, until the
distress and irritation of teething be over.  As the  child advances, the
opposite extremes  of carelessness and over-care should be equally avoided,
and when  the intellect develops itself, we ought to  be  careful that the
child be  not stimulated to over-exertion or to too close application. 
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 irregu-
larly 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 millimetres  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  three to one or as four to one, 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 open-
ing ; 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
right, increases somewhat more  regularly, and  presents often the  same
dimensions as the distance from the base of  the  heart to its apex. 
DISEASES OF THE HEART.
375
   " 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 consid-
erable."1
   Rilliet and Barthez found no perceptible difference in their measure-
ment between the two sexes.
   530.  I shall now extract their account of the results of auscultation
of the heart and percussion:—
   " The praecordial 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 vertically,
and from four to eight transversely.   This comparative dulness,  there-
fore, occupies a  space, circular  or  elliptical, whose greater transverse
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, accord-
ing to the  distance, although we can generally perceive the sounds, or
at all events the second sound, all over the thorax anteriorly.
   " Ordinarily they are as audible, if not more so, beneath the right
clavicle as  the right  nipple, owing, doubtless,  to their being conveyed
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 child ; some transient irregularities were merely exceptional
and without value.  Lastly, the radial pulse was always felt by the finger,
just as the  ear  applied to the praecordial region perceived the end of
the first sound;  or, more correctly, the pulse corresponded to the com-
mencement of the interval which separates the two sounds."2

                 1  Mai. des Enfans,  vol. iii. Appendix, p. 662.
                 2 Ibid., vol. iii. p. 265. 
376
MALFORMATIONS.
                        CHAPTER  I.

       MALFORMATIONS.—INTRA-UTERINE DISEASES.—CYANOSIS.

  531.  It will be sufficient to enumerate very briefly the principal mal-
formations to which the heart is subject, referring the reader for minute
details to the elaborate works of Meckel,1 Geoffroy St. Hilaire,2 and to
M.  P. II. Berard's excellent article in the Diet, de Medecine, in thirty
volumes.
  These malformations may be  divided into—
  I. Anomalies as to Number.—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.
  When 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 pro-
jected  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
(ectopie cephalique of M. Breschet) as in the case related by MM. Bres-
chet, Beclard, and Bonfils, where, it was found in one between the bones
of the jaw, 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   When  the abdominal  parietes are incom-
plete, 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 cavi-
ties, &c.6

       1 Manuel d'Anatomie Gene"rale, &c.
       2 Hist, des Anomalies de l'Organization.
       3 Journ. de M6d. de Chir. et de Pharmacie, 1778, vol. xlix. p. 423.
       4 Journ. de Med., vol. xxvi. p. 275.       6 Philosophical Trans., 1789.
       6 Paget on the Congenital Malformations of the Heart. 
CYANOSIS.
377
  iv. Malformations which permit the Mixture of Arterial and Venous
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 Mauran,5 and
Breschet.    3.  Where the foramen ovale remains open.   I shall  return
to the consideration of  this latter case and its consequences presently.
4. M.  Billard has included  among the malformations 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 circu-
lation, and certain aesthetic affections.6
  532.  Let us add, here, that during  intra-uterine life the serous mem-
brane of the heart and pericardium may be the seat of  inflammation.
I examined a  foetus recently in which  I discovered intense pleuritis and
pericarditis.   Organic  diseases, also,  are  occasionally  observed.  Bil-
lard mentions a case of scirrhus ;  Denis,  hypersarcosis ;  Cruveilhier, of
aneurism of the aorta;  and Billard, of aneurism  of  the ductus arterio-
sus,  &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 neces-
sary 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 com-
pletely 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 diminished by a re-
markable  thickening of their parietes.
   "Infants of Two Days  old.—Of twenty-two, there were  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 arte-

       i Manuel d'Anat., vol. ii. p. 305.       2 Philos. Trans., 1798, p.  346.
       3 Ibid. 1805, p. 228.
       4 London Medical and Physical Journal, June, 1829.
       5 Philadelphia Med. Journ., Aug., 1827.
       6 Mai. des Enfans, p. 605.
       7 Gra'tzcr, Krankheiten  des Foetus, p. 160.
       8 Mai. des Enfans, p. 605. 
378
CYANOSIS.
riosus was free; in six, partially obliterated;  and in three, completely
so.   In all,  the umbilical arteries were more or less  closed, but the um-
bilical vein pervious.
  "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  arte-
riosus 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 umbili-
cal 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  fif-
teen ; largely so  in ten  of them; partially obliterated  in  five; nearly
completely in seven;  and quite so in seven others.   The umbilical ves-
sels closed in all.
  "Infants of Eight Days old.—Of twenty cases, the foramen ovale was
free in five  only;  it was incompletely closed  in  four; and completely
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 gene-
rally 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 con-
sequence.
  " 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, which 
CYANOSIS.
379
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  projects 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  modi-
fying the action of the organs, will impress  a  new direction upon this
fluid.  Now, if  we examine the umbilical arteries  and the ductus  arte-
riosus, we shall  find  that in progress of obliteration their coats become
thickened.   This thickening of the umbilical  arteries is especially re-
markable 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 circula-
tion.   2. The modification of structure which the umbilical arteries un-
dergo.  Moreover, there is  an  experiment which proves  that the con-
tractility of the  umbilical vessels can  suspend the flow of blood through
them.   If we divide the  cord, after  birth, at  some distance  from the
naval, the jet of blood is at first  very strong,  then it becomes  slower,
and afterwards stops altogether;  and if we 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 exist near the um-
bilicus and within the  abdomen 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 degrees, 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 be-
come 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  ob-
structed passes into  the pulmonary arteries.   At  this  period the duct
presents the appearance of a pipe, whose walls  are very  thick and perfo-
ration very moderate."  .   . • .  " If it be necessary that the foramen
ovale and the ductus arteriosus should undergo organic changes  which
prepare and lead to  their obliteration, one can easily perceive that the
modifications may sometimes be effected prematurely, in others, very tar-
dily ; 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  uncertain time  for the  com-
pletion  of these changes.   Thus  we  may explain  the  irregularity ob-
served in the time at which  an independent circulation is established, 
380
CYANOSIS.
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 suitable
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 progres-
sive  establishment of independent life ?   I think so, and see no reason
for rejecting the opinions which result from the examination of the cir-
culating system in new-born  infants.  These  conclusions  are supported
by another consideration, viz:  that the lungs might be exposed 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 inde-
pendent life by the persistence of those arrangements which were neces-
sary 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 provided for, so that no sudden
and  unexpected change disturbs the harmony of the vital phenomena.
   "If  those openings persist much beyond the period already indicated,
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 surface
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 serious
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  effu-
sion.
   The respiration is consequently and equally disturbed; hurried breath-

                1 Mai. des Enfans, p. 605.
                * Copland's Dictionary, p. 199.   "Blue Disease." 
CYANOSIS.
381
ing, panting, dyspnoea, with a  sense of suffocation, follow the  least ex-
ertion, 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 as-
signable cause, and  are more frequent in winter than in summer.
   " The length of the paroxysm varies; it sometimes last 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 effected in various ways :—
   1.  The foramen ovale may remain open or  may have been reopened ;
and  INI. Gintrac2 remarks that  along with this patency there  is gene-
rally an obstacle to  the passage of the  blood  from the  right auricle 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  impediment 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-ventricu-
lar septum, or,  as Haller5 mentions, with one auricle  for the  two ven-
tricles.  In one of  M. Gintrac's cases, the two auricles opened into  the
right ventricle, between which  and the left  ventricle  there was a con-
siderable 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.
   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.

            > 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 Auatom., vol. ii.    5 De Monstris, vol. i. 
382
CYANOSIS.
  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 situa-
tion ;  or the opening of the veins into the left  ventricle, the pulmonary
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
batrachiae.
  11. There may be two  superior venae cavae, 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-ventricular
communication by ossification of the  tricuspid valves, which were per-
forated in many places.  The narrowing of the pulmonary artery may
be  owing to the ossification of the sigmoid valves, united by their free
edge, or to a species of diaphragm pierced in  the centre, or by an  ap-
proximation of the parietes of the artery to the corresponding 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 twenty cases were all
examples of aneurism of one or more of the cavities of the heart.   Dila-
tation of the right auricle occurred in nineteen cases, with hypertrophy
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 hypertrophied
also; in five others it  is not stated ;  in five there was hypertrophy ;  in
five others it is not stated.  In ten cases the right ventricle was  hyper-
trophied, 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 and granulations on the surface of the right auricle.
   539.  There is some difference of opinion as  to whether the communi-
cation between the two sides  of the  heart is congenital  malformation,
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
it is an original malformation;  but M. Bouillaud thinks that the per-

            1 Mem. et Recherches Anatomico-pathologiques, p. 334.
            2 Traite des Mai. du Cceur, p. 685. 
CYANOSIS.
383
foration  of the  intcr-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 malformations, 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 however, very justly replied to this, that  he has often  dis-
sected children in whom these malformations existed, but  in whom  the
symptoms never occurred.  He differs from M. Louis,  in  thinking  the
absence of any traces of disease  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 intercommunication 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 hypertrophy  and
dilatation of the right side of the  heart, with 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  for-
mer, 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  ori-
fices, 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 circu-
lates, 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 constriction of  the orifice of the
pulmonary  artery,  in  consequence  of ossification, must have caused
great embarrassment of the circulation;  that the blood  stagnated in the
right ventricle,  right  auricle, and consequently  in  the entire venous
system."3  Corvisart seems to doubt whether the blue  color is owing to
this admixture of blood.

                 i Diet, de Med., en 30 vols., vol. ix. p. 536.
                2 Bibliotheque de Med. Prat., vol. v. p. 379.
                8 Recherches  sur plusieurs Mai., pp. 336, 344. 
384
CYANOSIS.
  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 cya-
nosis as essentially due to a deficient oxygenation of the blood, whether
the structure of the heart be  perfect  or not.
  The late Dr. Stille thought that no one lesion is to be considered as
the anatomical character of cyanosis, but that it depends simply upon
any cause, which, acting at  the centre of the circulation, will produce a
stasis of blood in the capillary system.
  Dr. Chas. D. Meigs regards cyanosis as asphyxia resulting from black
blood in the brain, and not in the lungs; that the danger consists in the
cerebral condition, and  is  to  be removed by supplying  the  brain with
oxygenated blood; and, lastly,  that  the blue  color  is  caused by the
presence of black blood in the capillaries.
  The prolongation of life,  according to M. Louis, bears no  relation to
the symptoms, nor to the supposed condition of the blood.   The  sub-
jects 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 develop-
ment of the intellectual  faculties.
  542.  Treatment.—As  far as the disease depends upon organic imper-
fection  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 sto-
mach and bowels.
  M. Bouillaud recommends bloodletting 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  stimulants.
In one or two instances, I conceived  that some advantage was derived
from the preparations of iron,  combined with the  fixed alkaline car-
bonates."1
  Dr.  C. D. Meigs's remedy as  applied to infants at  birth is very inge-
nious.  It occurred to him when in attendance upon a  case. He thought,
" If I bring the septum auricularum into an horizontal attitude, will not
the blood in the left auricle press the valve of Botalli down upon the fora-
men ovale, and thus save the  child by compelling all the blood of the
right auricle to pass by the  iter ad ventriculum, and  so  to the lungs to

              1 Dictionary of Practical Medicine, part i. p. 201. 
PERICARDITIS.
385
be aerated."1  He accordingly placed the infant on its right  side,  the
head and trunk inclined upwards about twenty or thirty degrees.  Im-
mediate  relief was afforded; the child became quiet,  breathed more
naturally, and acquired shortly its natural color.  Dr. Meigs states that
he has thus  repeatedly succeeded, and he quotes  abundant testimony
from his pupils to the same effect.
                        CHAPTER II.

         INFLAMMATION OF THE PERICARDIUM.—PERICARDITIS.

  543. The only diseases of the heart of which I shall treat are inflam-
mation of the investing and lining membrane,  i. e., pericarditis  and
endocarditis, with a slight  notice  of  their consequences.  It is only
since Laennec's brilliant discovery of  the  power of auscultation in de-
tecting disease that we have had the means of acquiring information
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. Krukenbergius2 and Roux3 detailed some which
occurred during the course  of  scarlatina and measles,  and Vieussieux,
Davis, and Wells, others which occurred during an attack of rheuma-
tism. 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 Bouil-
laud, 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 Trouvcs, he  found  seven presenting  evidences  of pericarditis.4
Dr.  West states, " In six out of 170 cases in  which the  state of the tho-
racic viscera was carefully examined, he  discovered evidences of inflam-
mation of the pericardium or endocardium, or both."5
  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

  1 Obstetrics,  p. 641.
  2 Jahrbucher d. Ambulatorischen Klinik, vol. i.  Halle.
  3 De Carditide exsudativa, p. 47.                    4 Mai. des Enfans. p. 623.
  s Lectures on Diseases of Infancy and Childhood, p. 317.
      25 
386                       PERICARDITIS.
opinion that  the pericardium was  oftener the seat of inflammation in
young than in older persons, and by no means rarely so in infants.1
  The disease 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.
  Ao-ain, it may be either primary or secondary, the former being ex-
ceedingly 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 eruptive  fevers, pleu-
risy,  &c.                                                   .    .  .
  545. Dr. West has given a case of idiopathic or primary pericarditis,
which I may be excused for copying, on account of its rarity and inte-
rest.   The subject of it was "a healthy boy, eleven years  old, who, on
May  8,  1843, complained of  feeling cold, and  began to cough.  The
chilliness was succeeded by fever, and he continued  gradually  getting
worse till the 13th, when I visited  him for the first time.   He  had had
no other medicine than  a  purgative powder.   On May 13th,  I found
him lying in bed, his face  dusky and  rather anxious, his  eyes heavy,
and his respiration slightly  accelerated ; coughing frequently, but with-
out expectoration;  skin burning hot, and pulse frequent and hard.  He
made no complaint, except of slight uneasiness about the  left breast.
On examining the chest, there was found to be very extended  dulness
over  the heart, with slight  tenderness on pressure.  A very loud and
prolonged rasping sound was  heard in the place of the first sound, loud-
est 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 else-
 where, being obscured by the loudness of the bruit.  Respiration was
 good in both lungs.
   "  The child was  cupped to 3vj. 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 were still
 heavy and suffused, and his skin was less hot and less dusky.  His pulse
 was  114, thrilling, but not full.   There was now slight prominence of
 the cardiac  region, and the heart's sounds were obscurer and  more  dis-
 tant 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 condition  continued through the
 15th to be much the same as it had been on  the previous day.   On May
1 Medical Gazette, Dec. 25, 1846. 
PERICARDITIS.
387
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 dimi-
nished.   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 con-
tinued, and was heard a month afterwards, with no  other  change than
being rather softer and more prolonged.  Four years afterwards, I saw
him again.  He had continued well in the interval,  and  had never  suf-
fered from palpitation of the heart, nor from any other ailment referable
to the chest; but his pulse  was small, jerking, and not always equal in
force, and the natural character of the first sound was altogether lost in
a loud, prolonged bruit."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 striking,
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 maybe  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 illustration 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 commencement 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 expressed  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's cases it was pretty
severe; in Puchelt's, not very acute; and  in Rilliet and Barthez's cases
it occurred but  rarely, and was not severe.
   It will be less marked, or at least less  pathognomonic, when  the pri-
mary 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 sus-
picions, 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 respi-
ration, but it is high, rapid, yet restrained and suffocating, with quick
1 Lectures on Diseases of Infancy and Childhood, p. 307. 
388
PERICARDITIS.
movement of the alae nasi, and a  difficulty of speaking  sentences, as
though the interruption  to the  short, quick inspirations, necessary in
speaking, were 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 separate
and distinguish the symptoms peculiar to each disease.
  Palpitation, owing to irregular action of the heart, is seldom trouble-
some, but the violent action of the organ is Sometimes felt in a distress-
ing manner.
  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 physical
signs ; but then it is  satisfactory to  know that these  are  amply  suf-
ficient.
  The natural sounds of the heart are dull or muffled, though generally
distinguishable.  This obscurity increases for  some days, occasionally
varying; its maximum  is  just beneath the mamma, and it appears to
depend either upon the effusion of fluid, or upon the  exocardial mur-
murs 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, corre-
sponding with ^he 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, cor-
responding with the movements of the heart, which is  like that of the
 saddle when one rides  on horseback ; and when, as it generally  hap-
 pens, the friction sound becomes harder, and more like the creaking of
 leather,  its  resemblance to the noise of  a  new saddle is quite ridicu-
 lous.  In some cases the noise is crackling, like that of crumpled dried
 membrane or parchment." " These friction sounds are certainly caused
 by the rubbing of  lymph  on the pericardium proper, and on its sac."1
1 Diseases of the Lungs, p. 235. 
PERICARDITIS.
389
   When 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 portion 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 two cases Rilliet and  Barthez found them more evident
 in a sitting posture.
   Along with these exocardial murmurs we occasionally hear  a bruit
 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 ex-
 tent,  displaced.
   Dulness  on percussion  is  another sign of considerable value; it is
 almost  always more  absolute  than usual in the praecordial region, but
 its extent will depend upon the amount of effusion.  When this is con-
 siderable, the dulness will be proportionally extensive, and not only so,
 but the praecordial region acquires a degree of prominence;  the inter-
 costal 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 percussion, and ful-
 ness or prominence of the praecordial 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 im-
 portant 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, aet. 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, abdo-
 men, 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  difficult; the alae
 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  sinking of the pulse, were said
 to have existed from an early hour the preceding  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 ad- 
390
PERICARDITIS.
herent to the  heart  by fresh  lymph, except in one small space which
was filled with milky fluid.   The lungs and pleurae 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 become
less and  less audible, or the dulness becomes more limited and less abso-
lute, and the child recovers  its usual health.   These are the most for-
tunate 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 repair,
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 con-
sequences.
  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 dis-
organization, 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 disease 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 pe'ricarditis, the heart has been found apparently surrounded
with  many little separate abscesses, which have turned out to be col-

  ' 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,
conveyed in a manner more simple and intelligible. 
PERICARDITIS.
391
lections of purulent matter between the folds of the pericardium, where
it had here and there failed to contract adhesion after a former inflam-
mation."
  " Thus, the thought of a healthy child first seized with acute rheu-
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."
  552.  The  symptoms which indicate partial or  complete adhesion  of
the pericardium are   by no means definite.   When  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 action is  gene-
rally 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 ca3e, 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."1
  553.  The  symptoms which mark the  accession  of a  fresh  attack  of
inflammation are likewise vague in character, though affording  sufficient
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 inflammation of the
pericardium, exocardial murmur there is none, and none can  there be
if its surfaces  adhere completely; and  if they adhere partially, and
there be a murmur,  it will not have the proper attrition in it, and  so
will  want the proper exocardial character."  We must,  therefore, infer
the secondary attack from the local  symptoms, 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, ret.  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
ierking; swelling, and slight redness, 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 praecordial region^ increased by pres-
sure 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 cartiTages of the third and fourth  ribs on the left side, the systole
of the heart was heard, accompanied by an unnatural sound  of an in-
definite kind.  The  sound was lost when the stethoscope was  removed
from this spot in the least degree."   The  boy had had an  attack of
1 On Diseases of the Chest, p. 240. 
392
PERICARDITIS.
rheumatism a year and  a half  before, with inflammation of the peri-
cardium, and after  death there was  found evidence of two distinct in-
flammations occurring at distant periods;  certain  old, firm, close adhe-
sions, and, in other parts, recent lymph deposited  on the surface.
  554.  in. Lastly, we may have not merely a difference in  the extent
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 im-
pediment, and  an incurable  one, to  the  accurate performance of the
heart's functions, though  compatible with life; and moreover, the peri-
cardium in this condition is peculiarly exposed to  the perils of second-
ary inflammations.
  555.  iv.  So much for  the organic changes, the consequences of peri-
carditis, with their dangers;  but in  pericarditis we have irritations of
other organs complicating the primary disease.   For example, various
and severe nervous symptoms sometimes arise.   "Wild delirium, epi-
leptic or tetanic convulsions, chorea, coma, fatuity, are the greatest and
the rarest;  and muttering, reveries, transitions  from torpor  to excite-
ment, 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."1
  556.  Morbid Anatomy.—The morbid changes discovered  by dissec-
tion, resemble closely those of other  serous membranes;  the  pleurae,
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 ulcer-
ation, as in Schmidel's case, to depressions in this adventitious layer.
  A quantity of serum  is almost always 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 in-
flammation is very intense, it will be more abundant: generally yellow-
ish, 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 peri-
cardium; 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 that attack,  either become victims of a second
or of some other disease.
Latham on Diseases of the Heart, p. 18. 
PERICARDITIS.
393
  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  unfrequent 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 were 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.
  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 pericar-
ditis is  by far  the  most frequent, and  if we  know the diseases in the
course of which we may expect it, we shall be  prepared 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
accompaniment 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  swell-
ing 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 indications 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 
394
PERICARDITIS.
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.
  III.  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 con-
tiguity of the tissues affected.   Thus, it is not very rare to find it com-
plicating  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 addition,
we  are able to examine the chest with the stethoscope, we shall gene-
rally  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 con-
dition of  the lungs, and  the resonance of all parts of the chest  except
the praecordial region.   When complicated with pleuritis,  we shall have
all  the signs of each disease present.
  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, we have  the souffle of a narrow valvular orifice.  In simple  en-
docarditis there is no increase of dulness on percussion.
  560.  Prognosis.—Although a very serious disease, yet pericarditis

            1 Lectures on Diseases of Infancy and Childhood, p. 304.
            2 Lectures, &c, on Diseases of the Heart, vol  i. p.  358. 
PERICARDITIS.                      395
is not as frequently fatal as we might a priori suppose;  nay, a  consi-
derable 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 primary
disease;  yet even of such cases a proportion recover.  Rilliet and Bar-
thez 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 repara-
tion.   Subjects of this unhappy constitution will struggle through a com-
bined 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 longtime 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."
   561.  Treatment.—Fortunately the treatment of pericarditis is simple
and intelligible, so that, having ascertained the  nature and stage of  the
injury, we 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, accomplish
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 secondary,  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.
   But when the child has been run  down by measles, scarlatina, pleu-
 risy, &c, or was originally of a weak, scrofulous constitution, we must
 be "more cautious; perhaps three or four leeches may be  borne,  applied
 to  the  praecordium, 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, oi4 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 
396
PERICARDITIS.
under its influence.  Mercurial inunction may be used at the same time
that calomel is given internally, and both  should, if possible, be con-
tinued 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 re-
sumed, for the purpose of removing the  fluid effused into  the  pericar-
dium.  Dr. Latham has some valuable observations upon this  subject,
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
wre 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  suffer-
ing 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.
  I  would most strongly advise my readers  who wish to obtain a prac-
tical knowledge of this disease  to study carefully  the  chapter on the
subject, in  Dr. Stokes' admirable work on Diseases  of the Heart,  &c.

            1  Diseases of the Heart, vol. i. p. 260,  et seq. 
ENDOCARDITIS.
397
                      CHAPTER  III.

    INFLAMMATION  OF THE LINING* MEMBRANE OF, THE HEART.—
                           ENDOCARDITIS.

   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 six-
teen cases, and in two others  the  disease existed, but was only disco-
vered 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 former, and
more  frequent than primary pericarditis, according to  Dr.  West.
   565.  Symptoms.—The phenomena which indicate the commencement
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  pericarditis; obscure
pain in  the  praecordial region; and some difficulty in  lying upon the
left side, may be all the symptoms developed;1 on which account it be-
comes 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 independently of it,
and may scarcely give warning  of its approach until it is almost, or alto-
gether,  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 commence-
ment 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 disease will call your attention to  it long after the
ailment has become chronic.2

            1 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 232.
            2 Lectures on Diseases of Infancy and Childhood, p.  308. 
398
endocarditis.
  5QQ.  The physical signs are pretty decided and characteristic.   The
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 dis-
tinct 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 upwards, 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 in-
jured 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 disappear.
  In simple  endocarditis the praecordial  region is not more dull on per-
cussion 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 uneasiness  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 alae  nasi
were  in action,  and  in  all  the countenance  expressed anxiety  and
suffering.
   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 violent palpitations.
   In all cases a  bruit de soufflet accompanies or  immediately follows
 the first sound of the heart.   Heard  from  the beginning,  it persists 
ENDOCARDITIS.
399
after the patient has apparently recovered, or until death, if the disease
prove fatal.
  568.  Unlike acute endocarditis, when the chronic form has continued
for some time, there is a diminution of resonance on percussion, amount-
ing in many cases to absolute dulness, and  much more extensive  than
natural.
  The following case,  given by  Dr.  West, affords an excellent picture
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  degress become more and  more  distressing, and
that for the past three months  she had  suffered likewise from cough.
The child, when  brought  to  me, was greatly emaciated ; her face was
anxious and distressed ; her  breath  short, so that it was with difficulty
that she walked even  a short  distance.   She had frequent short cough,
without expectoration, and she  suffered  much from palpitation of the
heart, and a sense of discomfort at the chest.   The  heart's action was
violent; dulness in the praecordial region was extended ; a very  loud,
harsh, rasping sound  accompanied the first  sound of the  heart, loudest
towards and to the left of  the nipple, but heard over  the whole of the
chest, both  before and behind.  Various remedies brought slight but
temporary relief to her sufferings,  and she grew worse every month.
She became more and  more emaciated; the distress at the chest and the
palpitation of the heart increased; her cough  became more violent, and
once she had an attack of haemoptysis.   For  about  a month before her
death the cough altogether ceased, but she was now altogether unable
to leave her bed  from increasing  weakness; the palpitation  continued
unmitigated, and her extremities  became slightly anasarcous.  During
the  last week of her  life, her respiration was extremely difficult, and
became increasingly so till she died  on the 10th of  October.
   " The  lungs were  very emphysematous, and much congested, but
not otherwise diseased.   The heart was  extremely large, but  its  right
cavities did not exceed the natural  size.   The pulmonary valves were
healthy, the edges of the  tricuspid  valve were slightly thickened; the
left  auricle was  enormously dilated, but  its walls were not all attenu-
ated ;  the pulmonary  veins  were  much dilated; the left ventricle was
dilated, its  walls were  thickened; the chorda? tendineae  of the mitral
valve were  greatly shortened, so  that  the valve could not close ; the
valve  itself was shrunken,  thickened, and cartilaginous ;  and  there
existed likewise a slight thickening of the edges of the semilunar valves
of the  aorta."1
   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 obstruc-
tion to the  circulation, constant dyspnoea, palpitation, exhaustion, ema-
1 Lectures on Diseases of Infancy and Childhood, p. 309. 
400
ENDOCARDITIS.
ciation, 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
improved  nor getting worse, suffering from  palpitation, dyspnoea, and
some pain on exertion  or mental emotion.   " The child who has  had
the praecordial murmur ever since it suffered a certain rheumatic attack,
is  just the same child it was before, except that it cannot join  in  any
pastime requiring rapid movement, for then its heart palpitates, it loses
its breath, and  is obliged to sit down."1  Dr.  Lathani 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 rheumatism 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 recover, 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 can-
not run so fast or so far  as the rest, or use bodily exertion beyond  a
certain amount, without dispnoea and palpitation, 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 excite-
ment,  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 praecordial region, 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 hard in the carotids.  From the apex the murmur
extends far round  towards the left axilla and the back.  Here I pre-
sume  that the rheumatic inflammation has done a permanent injury to
the endocardium on both  sides of the heart, and that  the mitral valve
and  the  semilunar valves  of  the pulmonary artery  have  undergone
change of structure."
   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 groiving heart, whereby it can accommodate its form and
manner of increase to material accidents, and to repress or  counteract
their  evil  tendencies ?"
   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
1 Latham on Diseases of the Heart, vol: ii. p. 89. 
ENDOCARDITIS.
401
such cases.   There are certain consequences which seem to be the ne-
cessary 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, dyspnoea, 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 val-
vular 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 ad-
vanced 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."
  II. 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.
  III.  But a more common result, with children at least, is the produc-
tion 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 walls 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 interruption.
  " A loud, systolic,  endocardial  murmur, and an  excessive impulse of
the heart, and  a larger space of praecordial dulness than natural there,
are the sure  and authentic signs of an injured valve, and  hypertrophy
of the left ventricle."1  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-
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 organs,
of an active character, and attended by very serious consequences. The

               1 Latham on Diseases  of the Heart, vol. ii. p. 296.
       26 
402                      ENDOCARDITIS.
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 dis-
ease, we find the lining membrane vascular, and of  a red color  gene-
rally, 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 vas-
cularity nor any traces of  recent lymph, but  the valves are thickened,
irregular, retracted, or incomplete, sometimes cartilaginous, and  occa-
sionally, but rarely, osseous.  Now and then there are vegetations upon
them, or the chordae tendineaa may be shortened.  Whatever be the pe-
culiar 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  conse-
quences of obstructed circulation.
  When the valvular  disease is of old  standing, we may find hypertro-
phy and dilatation about equally frequent, according to Rilliet and Bar-
thez, who also mention that they have found the hypertrophy limited to
the inter-ventricular septum, and to the columnae carneae in connection
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  endo-
carditis, 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 have much if any predisposing  influence.   Of eighteen pa-
tients 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-
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 endocardial
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 sud-
denly.  A few  hours  before, the child was  going on very well, without

  1 Mai. des Enfans, vol. i. p. 220.  Dr. Hope on Diseases of the  Heart, 3d ed., p. 203,
tt seq. 
ENDOCARDITIS.
403
any local affection, when, suddenly, dyspnoea, very quick pulse, pain in
the chest, and bruit de soufflet, made  their appearance.
  ill.  In like manner, we may find it complicating any of the eruptive
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 circu-
lation, 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  conf&sion
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 consequence.
   The general symptoms are  much the same, but the presence of endo-
cardial murmurs,  the  bruit de  soufflet,  de scie, and  de rape, writh 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,  oedema or anasarca,  with palpita-
tion upon the least exertion.
   There is a class of cases among adults which seems a little puzzling
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 anaemia.  This I  have  often found in women laboring under
amenorrhcea; but we have the satisfactory testimony 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
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,
increase the dyspnoea 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. 
404
ENDOCARDITIS.
  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,11
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-
forate  anus, which is a malformation.   These  are of too much import-

  1 Seance de l'Acad. Roy. de Med., June 28, 1825.
  2 Anat. Pathol., liv. 15, p. 13.         3 Mai. des Enfans, p. 274.
  4 Journal fur Geburtshiilfe, vol. v.
  5 Dissertatio de proeternaturali et raro intestini recti cum vesicae urinaria coalitu, &c,
1779.
  6 Bull, de la Faculte de Mdd. 1821,  vol. x.
  7 Recherches des Mai.  des Nouveaux-nes, 1821.
  8 Gynsecologie,  vol. ii. p. 251.          9 Anat. Pathol., liv. xv. pp. 2, 3.
  10 Edin. Med. and Surg. Journal.        ll Obs. Med. Pentecost., p. 137.
  " Spicilegium Anat. Obs., 57.         '3 M. N. C. Dec. 1. An. 6, 7, p. 355.
  14 Descriptio Anat. Embryon., 1761,  Obs. 1.
  16 Beitrage zur ausiibeDden Arzneiwissenschaft, vol. i. p. 29.
  16 Mai. des Enfans, p. 421.           17 Graetzer Krankheiten des Fo'tus, p. 155. 
406
INTRA-UTERINE DISEASES.
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 perpendi-
cular or oblique division  of the upper lip,  either directly below the sep-
tum  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 " double
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.
  Every one, 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  in-
fant  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 reme-
died by a surgical operation; and as all mothers are naturally anxious
to have it relieved as soon as possible, the first question relates 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  con-
vulsions, 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 suc-
cessfully operated  upon a child five months old, and upon another a year
old.   Le Dran, B. Bell, and others, operated upon infants even at ear-
lier  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 two
months old.  I removed the needles the third day;  I, however, applied
adhesive plaster, to prevent accidents.  The child has been able to suck
well since.  In cases of single hare-lip I always prefer operating early;
the operation is much easier of performance, as the child can make no
resistance, the wound heals  faster, and deformities of the 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:
1 Clin. Chirur., vol. iv. p. 90. 
HARE-LIP.
407
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 un-
pleasant 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 coro-
nary 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."
  Dr. O'B. Bellingham, Prof.  R. Smith, and  others, agree with Mr.
Smyly in  preferring an  early  age  for  the  operation, but other sur-
geons 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 oppo-
sition to  the  sutures, but notwithstanding,  the twisted  suture  is now
generally  used.  "No modern  surgeons doubt that a hare-lip may be
cured by  means of  adhesive plaster and uniting bandages quite as per-
fectly 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 succeeding.  But it is considered
far more uncertain  in its effect.  To accomplish 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 contributes  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 the forceps  are preferred,
the surgeon must of course leave out of the upper blade just as much of
the edo-e of the fissure as is to be removed, so that it can be cut off with
one sweep of  the knife.   This  is to be done on each  side of the cleft,
Cooper's Surgical Dictionary, p. 656. 
408
CONGENITAL MALFORMATIONS.
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 re-
moved by transfixing  the  lip  with a  long, sharp-pointed, narrow bis-
toury, 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 remove 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 introduced
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 obliquely, 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 maintaining  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  between them and the  skin.   In the University College
Hospital  Mr. Liston  employs  largish common  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.   " In-
stead of  pins made with steel points, Dr. Barton, of Philadelphia, pre-
fers using a  piece 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 pens,  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 sub-
stance 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 perhaps having them to screw off and  on is the
best mode, as removing 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 
HARE-LIP.
409
forward the cheeks are sometimes employed, but they may in general
be dispensed with, because irksome to children, and the occasion of rest-
lessness.
   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 de-
stroys the  harmony of the upper and lower jaw, it has been  proposed
and practised successfully by Desault, 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 pro-
jection 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 drew 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 bistoury
the fold of mucous membrane uniting the labial tubercle to the osseous
one, and then, with a  pair of cutting  forceps, removed  all such por-
tions 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 por-
tions of the lip were now brought together and  united with two pins ;
and the fresh cut bleeding middle  tubercle was laid over the bony par-
tition 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 flap 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 common su-
ture can be cut and easily removed.  When the hare-lip is double, the
operation  is the same in principle, and had better be completed 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.
1 Cooper's Dictionary, p. 657. 
410              CONGENITAL  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  inter-
space between the lateral portions, and almost always a  fissure  in the
alveolar process  and the upper lip.   The operation for each respectively
has been termed staphylorraphy, staphyloplasty, and uranoplastic.
  583.  I. Staphylorraphy.—Mr. Cooper describes  MM.  Roux's and
Berard's, Mr. Smith's, and Mr.  Liston's  method of performing this
operation.
  In  M. Roux's plan, the apparatus required  consists—I.  Of  three
broad flatfish 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 threaded.   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 applied  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 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, which is first to be  tied  in
a simple knot.   As soon as this has been duly tightened with the fore-
finger, 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 liga-
ture 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 
CLEFT palate.
411
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  drawn through.
Another ligature is passed in like  manner  through  the opposite  edge,
and as many ligatures are thus inserted as the fissure 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  in-
strument 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 will  be  expe-
rienced 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

      ' Cooper's Surg. Dictionary, p. 1078.  Liston's Practical Surgery, p. 472. 
412
CONGENITAL MALFORMATIONS.
securing the ligatures, and from the usual treatment subsequently.  Mr.
Hamilton, who relates the cases, observes: "The difficulty 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 mus-
cles  of the  palate, has  always been  acknowledged.   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 ligatures were thus firmly secured,  without a knot, at
the required degree of tension.  The other and most important peculi-
arity in the treatment 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."1
  587.  Professor Fergusson, 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.2  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 the ordinary ope-
ration, 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."3  Mr. Fergusson 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 instru-
ment, 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 carried through the aperture opposite to that
where it was first  introduced.  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

   1 Dublin Journal, Jan. 1843, p. 324.
   2 Trans, of Royal Med. and Surg. Society, vol. 27.  Practical Surgery, p. 530.
   3 London Journal of Medicine, No. 1, p. 21. 
IMPERFORATE ANUS.
413
are sponged free of blood and mucus, the various threads are fastened."
Mr. Fergusson  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. Miitter, of
Philadelphia, succeeded  in nineteen out of twenty-one operations;  Dr.
J. M. Warren, of Boston, in  thirteen out of  fourteen; Mr. Fergusson
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. Staphyloplasty.—Dieffenbach's method of performing this  ope-
ration consists in making an incision along the palate on each side of the
fissure, and afterwards drawing the edges together by ligatures.
   " The Indian staphyloplasty 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 substance 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 chil-
dren.
   589. Imperforate  Anus.—In this  malformation the lower 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 discernible,  and
there is a feeling of fluctuation or something very like it 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 de-
scend lower  than the upper  part of the sacrum.   " Dr. Palmer  dis-
sected a case where the colon, after  reaching the vicinity of the  left
kidney, began, as  it descended, to form  a sigmoid  flexure, but,  previ-
ously to its arrival  at  the  concavity of the left ilium, made  a sudden
turn to  the  right,  and crossing the psoas muscle, reached  the projec-
tion of  the sacrum, where it terminated without entering the sacrum at
all.  With  this malformation was combined an imperforate meatus  uri-
narius and  other considerable deviations of the genital organs  from the
natural struciure."2 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

                1 London Journal of Medicine, No. 2, p. 117.
                - Med.-Chir. Journal, 1816, vol. i. 
414
CONGENITAL MALFORMATIONS.
into the bladder, as in a case lately under my care, or into the urethra,
in the male, or vagina in the female.
   In a fatal case lately under the care of Dr. Sawyer, of this city, and
of which he has  made  a careful  dissection, he found that the rectum
opened into the urethra, anterior to the membranous  portion.
   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. Hutchinson 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. When the anus is merely closed by a membrane projected down-
wards by the meconium, whose color is discernible, the operation is sim-
• ple, 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 upwards,
 nor in the axis of the  pelvis, for the vagina or bladder might thus be
 wounded.   On the contrary, the operator  should  cut backwards along
 the centre of the concavity of the os coccygis, where there is  no dan-
 ger 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 feces,
 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 introducing upon the finger a middle-
 sized trocar in the direction, but calculated to reach the rectum, with-
 out 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 feces.   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 dis-
 pensed with,  a sponge tent, or a piece of bougie, to be worn twelve out
 of the twenty-four hours." 
IMPERFORATE  ANUS.
415
   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. Mil-
ler, of New Haven, had to repeat the  operation ten times  before "the
child was 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 feces pass through the
anus  the less will escape by the supplementary passage; it is rarely
necessary to do more.  In my case the  feces  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.
   The attempts to remedy this formidable  defect do not appear  to have
been  as successful as we might have hoped;  by far the larger number
of children die after the operation, but how far the operation has  a share
in the mortality it would be difficult to say.  A small number recover,
and I am inclined to think that  those upon whom the operation  is  per-
formed with the least delay have the best chance.  The little boy upon
whom I operated is now seven or eight years old and  healthy.  A case
of recovery is related recently by Dr. Thompson, of Tennessee.1
   594.  But  suppose that  we cannot reach  the  intestine in  the  way
already pointed out, and that we must conclude that  there is some ex-
traordinary malformation, as in  Dr. Palmer's case, what is to be done ?
If we 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.2
   " 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, aponeu-
rosis  of the external oblique muscle, the  lower  fibres  of the internal
oblique and transverse muscles, the fascia transversalis, and the  peri-

           1 Philada. Med. and Surg. Journal, Aug. 15, 1853, p. 81.
           * Velpeau, ISouv. Eldm. de Med. Ope"rat., vol. iii. p. 983. 
416
DENTITION.
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 with  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 mesen-
tery is sometimes advised, but as my observations apply  only to  open-
ing the sigmoid flexure of the colon,  such expedient is  out of the
question."1
   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 matter in-
creases, to form the body:  last of all the  roots are formed.   The teeth
are inclosed in a capsule consisting of two lamellae, from the  union of
which the pulp is developed: and the entire, at  birth, are inclosed in
and covered by a considerable thickness of gum.
  " The membrane which secretes the enamel invests the course of the
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."2
  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
1 Cooper's Surgical Dictionary, p. 211.
2 Ashburner on Dentition, p. 39. 
DENTITION.
417
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 four first molar teeth appear, and from the sixteenth
to the twentieth the lower and upper canine teeth; last of all the four
last 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.
   The  lower incisors generally appear first,  and  Dr.  M'Clintock  has
suggested that  in this order there is a beautiful provision for the pro-
tection of the mother.   The tongue of the child protects the nipple from
irritation by the lower teeth when sucking, but it cannot from the upper ;
if, therefore, the upper teeth appeared first, the nipple would be exposed
to injury from which, for a considerable time at least, it is now guarded.
   M. Trousseau states the succession thus :  1. The two inferior median
incisors. 2. The four superior incisors.  3.  The inferior lateral incisors,
and the first four molars.   4.  The canine,  and 5.  The last four molars.
   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  others who
cut two and four the first fortnight of their life.   Dr.  M'Clintock  saw
one child, at the Hospital,  born with the two middle upper incisors cut.
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 lower 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 late-
ral 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 appear.
Van Swieten mentions a healthy child  that  did  not cut a  tooth until
it was 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 teeth until he was seven
years old.   Dr. Ashburner saw "a  child twenty-two months old be-
ginning 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.
   Very frequently, this order of succession is violated; the upper inci-
sors 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 
418                        DENTITION.

pairs to succeed each other rapidly, and then for a considerable  period
to elapse before the rest advance.  In general, the later the commence-
ment  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 important 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, what-
ever may be its real nature, it leads to the tooth, and becomes continu-
ous with the  external  layer of the dental membrane."   " The gums
grow, they enlarge;  as their volume  increases, the germs of the per-
manent  teeth continue to develop the organs they have to form.   These
germs are inclosed 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 completed
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 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 some-
times 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
1 Diseases of Infants, p. 73.
2 On Dentition, p. 02. 
DENTITION.
419
loosen and fall out;  and, the same  process of absorption extending  to
the roots of the other deciduous teeth, they are likewise shed success-
ively, 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.
   Now  " 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 serrated—an ap-
pearance 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.   Irregu-
larities  in this respect  are very numerous,  for the perfect consent be-
tween  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 towards each other.  In most cases,
the jaw increases in time, and the teeth assume their  proper stations.
About a year is occupied in shedding the four central incisors, and ano-
ther 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  cuspidati 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 nine and a half till twelve.   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 thirteen and a half 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 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  septenary
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 sapientiae."
   Deviations from the ordinary rule are just as common with the second
dentition  as with the first,  and all we can attempt is an approximative
estimate. 
420
DENTITION.
   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 separate,
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 ap-
pearance of a vesicle.
   The second dentition gives much less  trouble, and for obvious reasons.
The  teeth which supply the place of the first set have little more  than
the,resistance of their own capsules to overcome.  The vacancy 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 abundant
flow  of  saliva from the mouth; the child dribbles, as it is called,  inces-
santly,  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 hereto-
fore, 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 feeling of
tension  and itching,  which makes the infant anxious to close them upon
something, or to press something against them, even though this be ac-
companied 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 drib-
bling continues until the tooth is cut through.   The irritation  may ex-
tend to the lining membrane of the nose, or to its nerves, and the child
be observed to sneeze frequently and to rub its nose.
   It would seem that dentition is commonly more severe in the winter
than in the  summer,  and certainly more so  in  large cities than in the
country; and its consequences are more serious in badly nurtured child-
ren  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 
DENTITION.
421
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 ac-
count 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 ; sometimes
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 ap-
pearance 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 two 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 operator
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 the lateral  incisors and first molars, it  is quite necessary
to  make a crucial incision down to the  tooth, so as to free it com-
pletely.                                             .           .
   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. 
422
DENTITION.
  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  resisting
to  the tooth  than if it  had net been lanced, unless  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 may be necessary, either because  the gum
has healed,  or because  the first  operation was  ineffectual, or  as a  pre-
caution 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  suffering  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 pressure, 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 irrita-
tion 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, taking  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  the
mouth; if it  exceed  a certain amount, or in children of  an  irritable
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  certainly
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 discharge
are great, we  shall find it necessary to interfere with a mixture of chalk
and laudanum, as just recommended, increasing the laudanum  if neces- 
DENTITION.
423
sary, or adding tincture of kino  or  catechu.   If  there  be much pain
and flatulence, an occasional warm bath and the use of a liniment com-
posed of half a drachm of laudanum to two ounces of  compound cam-
phor 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 coexist 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 reme-
dies difficult, so  long as it continues.   As a general rule, it is the con-
sequence  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-irritation 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 dentition,
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 fo-
mentations, 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 arrow-
root made with  milk, bread jelly, &c.
   604.  II.  Next to the stomach  and intestinal canal, and often coinci-
dent, the most frequent  seat of irritation is the skin.  Patches of papu-
lar 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, eczema, &c, espe-
cially of the scalp, which, while  it affords relief  for the time, becomes
itself  a very troublesome disease,  requiring  special treatment,  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 impossible,
to cure it, until that process is completed.  Even when apparently cured,
the irritation of teething will  cause the eruption to reappear.   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 mat-
ter 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. 
424                        DENTITION.

  605.  ill. 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  divided 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 permanent counter-irri-
tation be desired, a seton of three threads of silk inserted 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 treatment
have already been  described;  the most important point to remember is,
that although dentition may be the sole  cause, lancing the gums, warm
bath, and purgatives may not be all that is necessary for the cure, but
we may be obliged to have recourse to bloodletting or  leeching, with
subsequent counter-irritation.
  Lastly, the distress of teething may give rise to paralysis of an arm
or a leg or both together, or of the muscles of one side of the face.  It
may occur with the  first dentition; but asDr.Fliess has observed, it is more
common during the second.   It is remarkable for the suddenness of its
attacks;  the child may appear quite well the  previous day, but during
the night  it is  uneasy and restless, grinds its  teeth and screams or
groans.   There may be some  thirst, a degree of heat about the head,
and feverishness.   The next morning it is found to have  lost the power
of an arm or leg, or in rare cases of both: the limb is warm but hangs
powerless,  and  from  the gravitation of  the blood is of  a darker  color
than the other.   Sensibility is either much  diminished  or altogether
lost:  the  child  rarely complains of pain,  but sometimes  of a  sense of
dragging from the shoulder.
  When one side of the face is  affected, the distortion will attract im-
mediate attention,  the mouth  is drawn to one side whenever the  child
attempts to speak or is excited, and the  greater the excitement, the
more marked the distortion.   When  perfectly quiet, the face  in  most
cases appears quite natural.
  The attack does not often prove fatal;  if  the teeth  be cut through
naturally or liberated by the lancet, the paralysis may gradually wear
off and the child recover the use of the limb or  face, or  the paralysis
may become chronic, without  any very obvious disease of the  nervous
system, the limb remaining powerless  or nearly so,  and  gradually be-
coming atrophied,  or the distortion of the face  continuing during life.
  Lastly, when the paralysis resists all  treatment, we  find symptoms 
DENTITION.                        425
gradually developed which indicate disease of the spinal cord and brain.
The child is attacked with dyspnoea, palpitations, twitching of the eyes,
squinting, and at length becomes comatose and dies.
  We have seldom an opportunity of ascertaining the state of the spinal
marrow by a post-mortem examination, but in one case of the kind, who
was killed suddenly, Dr. Fliess found  a remarkable  degree of vascu-
larity  about  the roots  of  the brachial nerves,  the  membranes were
reddened  and the whole circumference  seemed  congested,1 but there
was no real organic change.  It is clear, therefore, that this is a disease
of reflex irritation.
  The proper treatment consists in relieving the irritation of the gums,
in the  first instance by a very free scarification, and if necessary by the
removal of the primary teeth, then by cupping or leeches to lessen the
vascular congestion about the roots of  the  nerves.   The limb may  be
wrapped in flannel, and mild purgatives given.  The  application  of
stimulants  or electricity to the affected limb is  of no benefit at first;
when the disease has  become chronic they may be worth trying.
  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 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 dentition,
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 dis-
order.   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 Dr. Marshall 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 system thus affected we know
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 persist-
ence 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 obsti-

  1 Journal fur  Kinderkrankheiten, June and July, 1849. Lond. Journ.  of Med., Jan.
1^50. 
426                        STOMATITIS.
nate during dentition, and it will be well always to ascertain the state
of the teeth whenever we find  such diseases do not yield to our treat-
ment.   This applies  equally to most  of the  diseases of infancy, and
especially to diseases of  the skin, during both the first and second den-
tition.
  With the exception of diseases of the skin and the bowels, the second
dentition rarely excites any sympathetic affection, nor is the local irri-
tation 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.—ERYTHEMATOUS 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, aphthae or
ulcerated stomatitis, and gangrene or cancrum oris, described by authors.
  In  simple  or  erythematous stomatitis, the mucous membrane is  ob-
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 begin-
ning, 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 swollen 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 danger,
and is easy  of cure.   The bowels should be freed by a brisk purgative, 
MUGUET.
427
if they be at all confined ; but if  there be irritation and diarrhoea, we
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  bowels  to their healthy con-
dition.
  Generally  speaking, the attack subsides  easily, but  if neglected or
badly treated,  or  if more than  usually  severe, it may give  rise to
muguet,  aphthae, or  ulceration.
                       CHAPTER  IV.

             MUGUET.—PSEUDO-MEMBRANOUS STOMATITIS.

  611.  This common affection of infancy and childhood has long been
known  to  practitioners under various names, as  aphtha lactantium,
aphtha  lactamen, aphtha infantilis, although its true nature and seat is
a modern  discovery, due  chiefly to  the  labors  of Guersent,1  Lelut,2
Billard,3 Valleix,4 &c. v
  By many it has been and still is confounded with the vesicular aphtha,
or thrush, though no two diseases  can be more  distinct, muguet 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 aware 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

              1  Diet. deMed., art. Muguet, Stomatite.
              2 Arch. Gen. de Med., vol. xiii. p. 335, 1827.
              3  Traite" des Mai. des Enfans, p. 199.
              *  Clinique des Mai. des Eufans Nouv. Ne"s, p. 202. 
428
MUGUET.
cover more or less of the mouth and fauces, as  by a false membrano;
or, after disappearing for a short time, they may return and increase.
  This pellicle is of a white color when unstained; but it is occasionally
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 derangement
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  red
color; and if we  detach a portion of the pellicle,  the surface underneath
will be seen to be highly inflamed.
  In addition to the local condition of the  mouth, there are few consti-
tutional  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 impossible.
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 symptoms  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, tuber-
cular phthisis, hydrocephalus, &c."
  The local phenomena, then, which characterize the disease, are pre-
cisely the same, whether the  latter  be primary or secondary, but the
general symptoms are often  much more severe than I have  described,
especially when  the disease is epidemic, in  hospitals, or when  it  occurs
as a secondary affection, as will  appear presently.
  613.  Pathology.—Careful and repeated  investigation has established
beyond dispute essential difference between muguet  and aphtha.  Mu-
guet is not seated beneath the mucuous  membrane generally, nor does
it involve the destruction or disorganization of that tissue.   It is  a
curdy matter  deposited  upon the surface,  quite removable, and which,
in fact, is constantly thrown off, leaving  an unbroken surface beneath.
   Whatthenis  the 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 
MUGUET.
429
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 epithe-
lium 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 in-
ternally or externally, to the secretions of the  mucous membranes, 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
inside of the lips and cheeks, and on the central portion of the palatine
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 fibrin.
   615. M. Bouchut  rejects the opinion of  Lelut that muguet is analo-
gous to other false membranes secreted by  the mucous membrane, and
considers 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 Academic des Sciences,  the exactness of which he states
he has many times proved:  "A  portion 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 one consisting of separate portions, provided with roots,
 branches, and sporules.
   " The  roots are  implanted in  the colls  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 steins which grow from the surface of the epithelium are
 equally transparent,  interrupted  at distances by divisions, and inclosing
 in their cavities corpuscles.  Like  the roots,  they are  cylindrical  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  subdi-
 vide, bifurcating at a very acute angle.   The branches are composed of
 oblong distinct cells, inclosing in their interior one, two, or three trans-
 parent 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  crypto-
 o-amia have considerable analogy with the mycodermia of the porrigo
 favosa, and resemble the genus  sporotrichium of botanists."2

                1 Archives Ge"n. de Med., vol. xiii. p. 360.
                2 Manuel Prat, des Mai. des Nouv. Xcs, p. 174. 
430
MUGUET.
  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, oeso-
phagus, and stomach; and he mentions distinctly having seen the disease
in the large intestine and around the anus, thus  confirming  the  obser-
vations  of Lediberder, Billard, and Valleix.
  Dr. West observes: "I cannot pretend to decide, from personal ob-
servation, the point at issue between the supporters of these two con-
flicting  theories,  but my opinion decidedly  leans to  the adoption, as
generally correct, of that view which sees in the deposit of aphthae and
muguet the result of an inflammatory process ending in the 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 confervae  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 own part, I should greatly
hesitate to answer it in  the negative."1
   Dr. Berg,  of  Stockholm, in a  valuable  work  upon the thrush in
children, but which appears to me to be rather a description of muguet,
regards it as a parasitic disease, and has given at great length  its mi-
croscopic characters.  " The white coating,"  he says, " consists of epi-
thelium thickened by the swelling of its constituent cells, and from this
epithelium there  springs a parasitic fungus of greater or  less quantity,
so that  the chief  portion of a patch of aphthae is composed either of
epithelium or else of parasitic growth.  Now,  the relative proportions of
these two substances seem to depend upon the length of time that has
elapsed since the growth  of the parasite commenced, which varies in
different children, and it is also  in relation to the  diversity of the epi-
thelial thickening.   More  or less  of  molecular albuminous matter is
also to  be found in these patches.   When the parasitic growth and the
epithelial condensation is  confined merely  to  the extremities of the
smaller papillae (as at the point of the tongue), they have the appear-
ance of small isolated specks, but  when they appear  upon portions of
the mucous membrane where the papillae are  less prominent, and where
the intervals between them are  filled by a denser epithelium, the  white
coating then assumes those forms of circles,  of  interlacing bands, or of
hemispherical elevations, so frequently observed in parasitic vegetations,
when they  are permitted to increase freely without  any mechanical
obstacle to their  growth.   Lastly, when both the epithelial and  para-
sitic growths alike proceed vigorously, those spots which at first were
isolated, coalesce more  and more into a continuous covering, the  cohe-
sion of  which is maintained not  merely by the natural  adhesion of the
1 Diseases of Children, p. 337. 
MUGUET.
431
epit 'V*1 cells, but also by the interlacing of the parasitic fibres among
themsoives and between the cells of the epithelium."1
  Further, Dr.  Berg concludes that,  " 1. The aphthous parasite  can
propagate itself in appropriate menstrua out of the body, and this not
only when the aphthous crust is mingled with  various animal fluids, but
also  when completely separated  and  cleansed from these.   2.  Its
growth in such cases proceeds not only in a temperature equal to that
of the human body, but likewise in one that is much lower.  3.  Aphthae
seem to require for their  growth  the  presence of a body containing
azote, such as albumen, as also that of materials for the generation of
acid.   4.  Out of the body, aphthae seem to develop themselves in two
different forms,  either in that of a great  preponderance of  sporules—
when a white  filmy membrane forms on the  surface of the fluid—or,
again, they appear chiefly as  stems  ramifying through the  fluid or
aggregated  into a  felt-like mass.  A solution of potassa will always
dissolve the molecular  deposit of albumen, leaving the fibres and cells
of the parasite totally unchanged.
  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, c. g. to  the  nip-
ples of the nurse, I have  no doubt,  because  I have seen  it,  and  this
agrees with the experience of MM. Guersent  and Marlay.
   Dr. Berg considers the parasitic growth to be favored by the  large
proportion of sugar and  starch  in the  food of children, and  he believes
that the disease may be  conveyed from  one child to  another by spo-
rules or fragments of sporules in  the dried state,  floating in the atmo-
sphere, but that it is more frequently propagated by the  bottles from
which children having  the  thrush have  been fed,  or  by  the nipple,
especially Avhen two children are  suckled by one nurse.   He succeeded
in propagating it also by applying aphthous crusts to the mucous mem-
brane of the mouths of healthy children.
   It may also  prevail either  epidemically or endemicaily.   In places
where many infants are congregated,  I may say it prevails  at  all times.
1 British and Foreign Med. Review, vol. xxiv. p. 423. 
432
MUGUET.
According to Billard " it prevails with almost equal intensity ancrJet 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 t 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 influ-
ence from temperature.''1
   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 myself
of the minute researches of M. Valleix.   I  am  tempted, however, 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 Trouvcs.
All the infants were less than a month old, and  were strong and  vi-
gorous.   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 papillae 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  was at first
adherent, and any  attempt  to detach it made the mucous membrane
 bleed, but afterwards it  could easily be removed.  During the develop-
ment of the false  membrane the former symptoms (erythema and diar-
 rhoea) persisted, and new ones were added.  The stools almost always
 became green, but in no case  could any  portion  of  false membrane be
 detected in them.
   The heat of the mouth was rarely increased, but the  tongue was dry
 in thirteen cases.
1 Mai. des Enfans, p. 167. 
      ■,                       MUGUET.                         433
      >
  Wi;ln the muguet was very abundant it occasioned considerable dis-
tress, 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 intro-
duced 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.
  " 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  di-
minished 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 extremi-
ties, 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 ap-
pearance of decrepitude.
   " About this  period  were developed in certain cases inflammations,
not very acute, characterized by  cedematous  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 inte-
guments of the limb occurred.  At last death closed the scene  without
pain. *
  The mean duration of the disease was 17J days in the fatal cases, and
16£ in those who recovered.  Three distinct periods were remarked. 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 mem-
brane, the result of inflammation.   In  a small number ulcerations were
found!  The liver, the spleen, the kidney, the bladder, the larynx, tra-
chea, and bronchi, presented nothing abnormal, but in eight cases there
was hepatization 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."

              ' Clinique des Mai. des Enfans, &c, pp. 209, 210.
       28 
434
MUGUET.
3 cases]
2  ■•   u
1 case  J
3 cases 15
2  «   J
2  "
1 case

5 cases
   I shall add M. Valleix's resume of the special condition of the gastro-
intestinal canal in twenty-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 membranes of the stomach, there was found—
  1. Softening of the mucous membrane, with thickening  and redness, or
        some other  alteration of color, in 6 cases, j. e.,
      Occupying almost the entire stomach, with redness, in
      Occupying a limited portion of the surface, with redness, in.
      Occupying a limited portion, with brown discoloration, and soften-
        ing of the other coats  of the stomach, in      ....
  2. Softening, with redness, without thickening, occupying the entire
        extent of the stomach, in    .......
      Occupying a limited portion, in.......
  3. Softening, with neither redness nor thickening, occupying the entire
        extent of the stomach, in    ......    .
      Occupying a limited portion, in.......
  4. Alterations of color without thickening or softening, i. e.,
      General rose color,  in........
      General brown color, in    ........  1 case
      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 .
   2. Considerable softening, with thickening  and redness, in .
     Considerable softening, with thickening, but without redness, in
     Considerable softening, with redness,  but without  thickening, in
     Considerable softening, with neither redness nor thickening, in
   3. Slight softening, with thickening, but without redness, in
     Slight softening, with redness, but without thickening, in
     Slight softening, with neither redness nor thickening, in  .
   4.  The natural color and consistence, in.....

   ill.  The condition  of the mucous membrane  of the  large intestine is
thus stated:—
   1.  Extreme softening, with thickening, and of a punctated brown color, in
      Extreme softening, without thickening, and of a bright red color, in
   2.  Considerable softening, with thickening and  redness,  in  .
      Considerable softening, with thickening, but without redness, in
      Considerable softening, with redness, but without thickening, in
      Considerable softening, with neither redness nor thickening, in
   3.  Slight softening, with thickening, but without redness, in .
      Slight softening, with redness, but without thickening, in .
      Slight softening, with neither redness nor thickening, in .
   4.  The natural color, consistence, and thickness, in

   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
3 5 3	cases.
1	case.
2	cases.
1 1	case.
4 2	cases. n
in 1	case.
1	tt
2	cases.
4	"
2	!<
2	It
1	case.
2 cases.	
3	"
3	<ti
1 Clinique des Mai. des Enfans, &c , p. 267. 
MUGUET.
435
cesopnagus, whilst Guyot and Billard have found it through the entire
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 second-
ary 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 when once
the false membrane is formed, inasmuch as  the only disease with which
it can easily be confounded is aphthae, and  from  this it is distinguished
by the integrity of the mucous membrane underneath  the creamy depo-
sition, and by  the fact that  the latter is  seated upon the membrane
generally; whereas,  in aphthae, we shall have small  grayish ulcers or
pustules in the mucous membrane.
  Previous to the appearance of the muguet, the disease of the mucous
membrane resembles some  forms of gastro-enterite;  nor is it of conse-
quence 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 membrane
becomes thinner  and  less continuous, resembling in appearance the
patches or points by which it commenced; by degrees it peels off,  leav-
ing the mucous membrane moist, and somewhat smoother and redder
than natural; and the little patient, relieved from the soreness and dis-
tress  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-
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 affection
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 addi-
tion, 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 pneu-
monia, four of acute  entero-colitis, three of  pneumonia, and one of hy-
drocephalus.   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 
436
MUGUET.
the one is  a local affection, dependent, no doubt, to a limited entent,
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 mu-
cilaginous wash, 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 ne-
cessary.
  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 provide a
healthy nurse for it.
  In  some  cases, we must add to the wash  or to the  honey either
chloride of soda (one-fourth part), as Guersent and Darling recommend,
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 applica-
tion of a powder consisting of half a grain of calomel triturated with a
few grains of sugar, three  or four times  a day. Dr. Condie prefers
borax rubbed up with white sugar.
  Alkaline  remedies are favorites with  Dr. Berg,  as  he found them
arrest  the formation of the  parasite,  and at the same time soften the
epithelium and aid in throwing off the crusts;  but after this treatment
has been employed for some time, he advises a change to  acid  and
astringent applications.
  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 3j),  or muriatic acid  and water or honey (3j  of the former to 3j 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 mix-
ture, of which a teaspoonful may be given three or  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  pow-
ders 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, arrowroot, 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 mem-
brane. 
APHTHA.
437
  Aft the false membrane is only an accidental accompaniment in second-
ary muguet, our first care must be directed to the primary disease, and
the local affection of the mouth will follow its course, diminishing  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.

           APHTHJ3.—THRUSH.—FOLLICULAR STOMATITIS.

  622. Aphthae, 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,  Aretaeus, and Cel-
sus, 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 aphthae, and simple thrush  with  ulceration, or
even gangrene of the mouth.
  Like muguet, aphthae of the mouth may occur at any period of infan-
tile life from birth, or it may attack adults, but certainly it is more fre-
quent 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 regard
muguet as more common  with young infants, and aphthae about the
period of the first dentition.
  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  aphthae,  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.

           1 De Morbis Infantum, p. 81.
           2 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.
           5 Traite des Mai. des Enfans, p. 213. 
438                          APHTHA.
                                                              j
  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 disagreeable, and
the bowels will generally be found to be  out of order.  In the milder
cases, however, there is no fever or constitutional disturbance.
  624. But when the aphthae 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 anxious,
with a restless, fretful, and distressed expression, irritable and whining,
unable to suck  or to swallow 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 proper nutrition ; vomit-
ing 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 aphthae, the dribbling is excessive, and the pulse  quick but feeble.
  When  the disease extends  to the pharynx, the glands are apt to en-
large, and the  irritation  or  inflammation may  extend to  the trachea,
altering the character of the  voice, and rendering it harsh or hissing.
  When  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 aggrava-
tion.
  625. Pathology.—I have  already stated  that  muguet  and aphthae
differ, in that the former is a vegetable growth deposited upon the sur-
face, and the latter an ulcerative process  beneath the epithelium.
  Dr. Bateman defines the disease thus: "The aphthae are small whitish
or pearl-colored vesicles, appearing on the tongue, the lips, and the in-
terior surface of the mouth and  throat, generally in considerable num-
bers, proceeding to superficial ulceration, and terminating  by an  exfo-
liation of white crusts."1
  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 papillae, 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 inflam-
mation of the muciparous follicles  of the mucous membrane.  In  an
early stage of the inflammation, " they appear on the internal surface
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, pre-
serving also their circular primitive form, and from their central  aper-
ture there soon issues a white matter, which is  at first  compressed by
1 On Cutaneous Diseases, p. 263. 
APHTHA.
439
the epithelium, but which escapes on that membrane becoming ulcerated.
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."1
   Berg, Robin,  Gruby, and Green,2 however, consider the disease as a
vegetable  growth, the spores of the plant adhere firmly to the isolated
or imbricated epithelial  cells, and that the  number of spores greatly
exceeds the filaments.
   The vesicular or  pustular character of the  aphthae, 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 aphthae 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 irre-
gular 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.  Moss3 and Underwood4 notice the appear-
ance  of aphthae at  the anus, and  assume this as a  proof that the dis-
ease  extends  through the bowels ;  and Bateman mentions that such
extension  of the disease is supposed to take place, but  very properly
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.
   Armstrong* 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 ran
its course to the verge of the anus ;6 and Gardien mentions this exten-
sion as  a  fact well known.
   Dr. Bateman notices  that  the trachea  is  occasionally affected with
aphthre, but that they very rarely extend to the nose.
   When  the  aphthae 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

      i Mai. des Enfans, p. 209.              z  Med. Times, July  20, 1851.
      5 On the Management and Nursing of Children, p. 188.
      * Diseases of Children,  p. 155.          5 Ibid., p.  24.
      e Ibid., p. 52. 
440                         APHTHA.
                                                              t
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 guand.  Billard  thus describes it: " Sometimes,
when the follicular points are ulcerated, the borders of the ulcers, in-
stead 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 gan-
grenous eschar."   "Before pronouncing these eschars to be gangrenous,
the nature and causes of the brown scabs covering the aphthous ulcera-
tions 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."1
   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 contagion," 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 aphthae 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
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 aphthae, 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  aphthae 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. contrayervae co. if they are in  the opposite state and  weakly.
At the same time the  nutriment of the patient should be regulated by
1 Mai. des Enfans, p  211. 
APHTHiE.
441
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, astrin-
gents 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 propor-
tion 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.  Etmuller and  Dr.
Shaw advise honey of roses and spirit of vitriol or  sea salt, but Under-
wood thinks no application superior to borax and honey.
  631.  In severe cases of the disease the same astringents may be 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. cretae 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 Avill 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
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,2 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 aphthae 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, re-
sembling 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  uni-
versal lassitude.  In this case I commenced with a dose of  castor  oil,
which was retained on the stomach and operated  well.   This was  fol-

     1 On Cutaneous Diseases, p. 267.          2 Diseases of Children,  p. 53. 
442                 ULCERATED SORE MOUTH.
lowed the next  day by an emetic, which brought away an almost in-
credible quantity of bilious matter for so young a child, after which  I
treated the case with bark and  ammonia.   The  only local application
used was a lotion  composed of decoction of bark and muriatic  acid.
The case got well."
   " When the aphthae assume a brown hue, or  appear in a state of de-
bility consequent on acute diseases, the general strength must be sup-
ported 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 with
the vegetable starches."1
   Chlorate of potash may also be given  in doses of from two to five
grains, three times a day.
   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 warm water, and, after being dried,
may be bathed with lead lotion or black wash, or powdered with  lapis
calaminaris, or anointed with zinc cream.
                       CHAPTER  VI.

         ULCERATED  SORE MOUTH—ULCERATIVE STOMATITIS.

  632.  At first sight there appears a similarity almost amounting to
identity between this disease and aphthae, 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.
Aphthae occur also in young infants, but Rilliet and Barthez have found
ulcerated sore mouth more common after five  years.
  633.  Symptoms.—According to M.  Taupin,2 the disease commences
in the gums, which  are swollen, red or violet,  bleeding, and soon  cover-
ed with a soft layer of grayish matter.   From the gums the inflamma-
tion 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,  and oftener the left than the right, according to

            1  Lateman on Cutaneous Diseases,  p. 268.
            2 Journal des Counois. MeU-Chir., No. 10, April, 1339. 
ULCERATED SORE MOUTH.
443
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 in-
crease in thickness by the secretion of additional layers, and the ulcer-
ation 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 epithe-
lium is reformed, and there  remains only a deeper redness,  marking the
situation of the ulceration.
  M. Taupin states that the mucous membrane in these places remains
thickened and somewhat hard, but Rilliet  and  Barthez regard the sub-
mucous 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 infe-
rior to what we observe in gangrene.
  In severe cases we find externally considerable swelling  correspond-
ing 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
distress and suffering of the patient, but materially influence his condi-
tion and add to the danger.
  When the inflammation is moderate, the heat of skin will be natural
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 constitu-
tional condition  of the child, upon the  primary or secondary complica-
tions, 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 re-
lapse.
  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; 
444
ULCERATED SORE MOUTH.
the gums are also swollen, red, and spongy.  After the inflammation
has continued for some time, we find a number of small whitish, or yel-
lowish patches, slightly prominent.   Beneath  the  epithelium, 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 smallpox
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 affected
they appear red or violet, swollen, softened, bleeding, and covered with
a pultaceous secretion.  The ulceration  spreads  transversely,  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 disor-
dered state of the stomach and bowels, or a  deteriorated  constitution,
which in children so certainly results from insufficient or improper food,
want of  cleanliness, vitiated air, damp or  unwholesome dwellings,  or
the crowding together too many individuals in too small a space.
   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 Trouve's,
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 apartment,
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 two to other parts of the mouth.

           1  Taupin, Jour, des Connois. MeU-Chir., No.  10, April, 1839. 
ULCERATED SORE MOUTH.
445
  If this be not necessary, or after it have been done, the mouth should
bo 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 finger,
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 beginning
to heal.  The mouth should be cleaned 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 purpose exceedingly
well.
  Dr.  West regards the  internal administration of the chlorate of pot-
ash as almost specific. He prescribes from three to five grains, dissolved
in water and sweetened, every four hours—previously giving a purgative,
if the bowels be confined.
  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.
  The diet must depend  a good deal upon the state of the constitution.
If the child be exhausted or broken down, broths  may be given freely,
and wine whey may  be necessary; but if  it be a local affection merely,
and the child otherwise robust and healthy, moderate or even low diet
will be advisable. 
446
GANGRENE OF THE MOUTH.
                      CHAPTER  VII.

GANGRENE OF THE MOUTH.—CANCRUM ORIS.—GANGRENOUS STOMATITIS.

   639.  This very formidable disease has been noted more or less cur-
sorily 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  re-
searches of Baron, Isnard,  Guersent,  Constant,  Taupin, Richter, Cu-
ming, 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, can-
cer agneux des enfans, &c.
   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 J. 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 worst
cases, however, though the sloughing is considerable, the ulceration is
always predominant, and by its means the destruction of parts is prin-
cipally 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
   I must say that this form of disease hardly deserves the name of gan-
grene ; it appears to me rather to have been an aggravated form of the
ulcerative  stomatitis first described.
   Another variety has been described by Richter3 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 disturb-

                1 Surgical Dictionary, p. 332.
                2 Dublin Hospital Reports, vol. iv. p. 341.
                3 British and Foreign Med. Rev., vol. vii. p. 470. 
GANGRENE OF THE MOUTH.               447
ance.  In some instances, there is a red spot for a few days preceding
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 measles, scarlatina,
smallpox, &c,  and generally heal without trouble.
   Dr.  Marshall Hall has published six cases, in five  of  which the dis-
ease commenced externally in the lip or cheek: " In  one case the pa-
tient  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 portion
of the jaw-bone."  " In this disease frequently, when the little patient
has appeared to be convalescent from  the previous  indisposition, some
part of the face has been  affected with pain, induration, swelling, and
erythema, and the child has become cross, irritable, feverish,  and rest-
less.   At no distant period, usually on the succeeding day, a dark purple
or livid spot has appeared, which has soon assumed a dark brown colour,
losing its purple hue, and at the  same time its vitality.   When the pa-
tient survives,  the  sphacelated part enlarges and becomes  black, sepa-
rated, 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 frequently 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  resembling 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  diarrhoea, but,
from the period of life corresponding often with the occurrence  of den-
tition, 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 pressure of manual exa-
mination, without inconvenience.   The alvine evacuations were  usually
unhealthy,  but they  differed in appearance  in different  cases.  Some-
times  they  were thin and watery, but not deficient  in bile : more gene-
rally 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-
1 Edinburgh Medical and Surgical Journal, vol. xv. pp. 547-8. 
448
GANGRENE OF THE MOUTH.
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 exa-
mination it would be found that the gums were ulcerated and the  fangs
of the teeth  exposed, and covered with a yellowish-white sordes.  Ac-
cording as the  disease  advanced 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 became  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 excessive. In no instance did I observe the teeth to fall out, pro-
bably because,  in fatal cases, death took place from the constitutional
irritation 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 appro-
priate 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 in-
tractable  persistence of the diarrhoea, than  to  any peculiar changes
effected in the  condition of the mouth.   In some of the cases the dis-
ease seemed to be arrested for a time, the diarrhoea being completely
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, resist-
ing all measures of a  remedial nature, hurry the victim to the grave.1
Even this epidemic  can  hardly be considered as a severe form of this
disease : if it were more than severe ulcerative stomatitis, it was a com-
paratively mild form of gangrene.
  At the risk of being tedious, I am tempted to extract a very graphic
description of the local phenomena of this disease, by M. Wunderlich.2
He describes two forms.  In the first, " the disease directly shows itself
to be  gangrene.  This is  noma,  using the word  in  a limited sense, or
stomatite charbonneuse of Taupin.  One-half of the  face (usually the
left) exhibits an indistinctly defined pale or violet  marbled swelling,
especially on the eyelids,  with a peculiar oily appearance of the skin.
An erysipelatous redness  of the  cuticle  is  also  frequently  observed.
The inner surface of the  cheek is livid and  of  a  dark red  color.  A
small  vesicle (which is often overlooked) now appears, generally on
the outer surface of the cheek, near the  mouth, but sometimes on the
mucous membrane, and lying on a hard, dark red, and often livid ground ;
this vesicle shortly bursts and becomes converted either into  a superfi-
cial erosion, or a  deepish ulcer, which usually becomes soon covered
with a slough of considerable size, measuring in diameter from several
lines to an inch.  It occasionally happens that there are several distinct
points of  origin of the morbid process, which  either unite  or remain
isolated.   The  hardness and oedema of  the surrounding parts increase
1 Dublin Journal, vol. xxviii. p. 3.
2 Handbuch des Pathologie und Therapie, vol. iii. p. 701. 
GANGRENE OF  THE MOUTH.
449
until the whole face and occasionally the neck are swollen.  An excess
of saliva, often bloody or of a bluish color and of a fetid smell, dribbles
from  the mouth.  Mastication is difficult  if not impossible, while the
voice becomes indistinct and speaking difficult.   The external sloughing
goes on extending, while the parts beneath  become so  rapidly affected,
that in a few days, the cheek, a part of the lips and the eyelids are re-
duced  to a gangrenous highly fetid pulp ; and there is then a lateral
opening into the mouth.  The teeth, which may be observed through the
opening, become loose or fall out after the destruction of the gum ; and
the adjacent portions  of bone become to  a greater or less extent ex-
posed and destroyed.   The whole neighbourhood of the gangrenous spot
has a sodden, livid appearance.   In this  destructive process, which is
almost always limited to one side of the face, and which extends much
more widely on the inner surface of the cheek and in the cavity of the
mouth than externally, there is a perfect absence of pain  or at most
a dull sensitiveness.  In the rare cases in which the gangrene is arrested,
there is formed an inflammatory (hyperaemic) line of demarcation, sup-
puration commences  in  the  circumference, and the gangrenous spot
becomes converted into an ulcer, which gradually assumes a clean and
healthy appearance, and  after cicatrizing for  some months, becomes
healed.  When there has been great destruction of tissue, cicatrization
is always attended with considerable disfigurement, and the pre-existence
of gangrene of the mouth may be recognized through life by the ugly,
strongly-contracted cicatrix, puckering the eyelid, the ear or the neck,
uncovering the eye and distorting the mouth, like  the  scars left  on the
face after deep burns.
  "The second form appears to be incomparably the more frequent of the
two.   It is however less strongly marked, and owing to its greater affi-
nity with other affections and  a deficiency in correct  observation, there
is much  discrepancy in what has been written  on it.   It runs a slower
course than the former, and does  not so frequently break out with sud-
denness during convalescence from acute diseases.  Instead of the gan-
grenous destruction with which the  first form commences, we here have
pseudo-membranes of unhealthy appearance on the inner surface of the
cheek, and  ulcers either there or on the outside of the cheek and at the
corners of  the  mouth.   They either gradually or at once assume a very
unhealthy character, emit a powerful and  fetid odor, and  become  co-
vered with  sloughs or viscid masses, while the neighboring parts become
livid and oedematous and the  destructive process affects the deeper tis-
sues.   From this stage its further progress is similar to that of the first
form, excepting, indeed, that the gangrene does not usually extend with
the same extraordinary rapidity."1
  641.  In  the  severe form, the disease always  commences in the mu-
cous membrane, preceded by stomatitis, aphthae, 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 swol-

           1 British and Foreign Med.-Chir. Review, July, 1850, p. 52.
       29 
450
GANGRENE OF THE MOUTH.
len and hard.   When 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 " putri-
lage,"  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
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  continually 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.
    " Premonitory symptoms,"  M.  Wunderlich  remarks,  " are  only
observed when the affection appears as gangrene  and is developed in
the advanced stage of  improvement  or  convalescence of a pre-existing
disease (measles,  &c),  for when there is pseudo-membranous or ulcer-
ative stomatitis,'the gangrenous mortification is only announced by a
gradual  exacerbation of the symptoms, or at most by a  shivering, an
increased  appearance  of collapse, hemorrhage,  &c.  When the gan-
grene supervenes at the height of some other disease, these premonitory
symptoms are rarely observed.  It even frequently happens that when
the earlier disease has abated to a very great degree  and convalescence
is  considerably advanced, this fatal  secondary  affection  will manifest
itself unannounced by any premonitory symptoms, commencing unex-
pectedly and  suddenly by  local swelling.   The  premonitory symptoms
when  they occur  in these  cases are not very severe, as for instance,
lassitude,  irritability,  loss of  appetite,  disordered digestion, rigors,
slight fever, and a somewhat suffering and collapsed appearance."
   In other cases the  child, already  weakened  by previous disease, is
cross,  feverish, and restless, with a quick pulse and hot skin, suffering
1 Observations on Midwifery, &c, p. 126. 
GANGRENE OF  THE  MOUTH.
451
 much pain from the mouth until the gangrene is completely established.
 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 deadlook  about it.  The  eyelids are not unfrequently swollen, the
 nares  incrusted, and the  alae nasi dilated in respiration.   The lips are
 swollen, and  frequently exhibit  their share in the  mischief  going on.
 Altogether the  face has  a singularly depressed  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 after-
 wards it becomes brown or black, mixed with gangrenous detritus.
   The breath is extremely offensive from the beginning, but when gan-
 grene is established both  the saliva and breath exhibit the characteristic
 fetid odor.
   The tongue is moist, sometimes yellowish or loaded, and occasionally
 exhibiting  the color  of the  gangrenous  spots.   The thirst is intense,
 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 present; sometimes
 griping, with watery  stools of a greenish or  yellowish color.   In a con-
 siderable 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 diminishes,
 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 wound gradually fill up and contract.
  Some writers have stated that the form of cancrum oris  which com-
mences 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 manageable. 
452
GANGRENE OF  THE MOUTH.
  644.  A peculiar  form of gangrene occurs from the use or  abuse of
mercury, but it is of importance to know that it may arise from  a very
small quantity.  Dr. Stokes has mentioned to me one case in which gr.
iss of calomel, and in another 7 grs. had been taken, and in a third 3j of
ung. hyd. had been rubbed in, and  all had the  disease  severely.  It
commences by a livid  tumor at the  angle  of  the  mouth  or behind  it,
which increases, ulcerates, and  eats away the  cheek and  even part of
the eyelids.   The gums are dry and hard,  and there is no salivation.
It may occur at  any age, but  Dr. Stokes has  seen it chiefly in  young
girls of  10 or 12 years.
  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  symptomatic
of the state  of the gastro-intestinal mucous membrane.
  Another very frequent and very important  complication is  pneumo-
nia ; 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  comparatively  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 condi-
tion.
  645.  Pathology.—MM. Rilliet and Barthez have given a minute
analysis of the pathological changes in the  different structures, effected
by  the gangrene, drawn from the post-mortem examinations of twenty-
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 rapidly
putrefy, and the cheek or the lip is swollen, purplish or greenish, tense
and shining, hard to the touch, and exhibiting a profound circumscribed
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 irregular, and more extensively.
The surface was reduced to a semifluid " putrilage," of a gray,  brown,
or  black color, removable with the  scalpel, and beneath which  loose
shreds of the mucous membrane were  perceived.   The  gums shared in
the destruction.  When the gums were thus destroyed the bones were
exposed and  became  black,  sometimes affected by necrosis, and  exfo-
1 Mai. des Enfans, vol. ii. p. 129, et seq. 
GANGRENE OF THE MOUTH.
453
Hated.  This destruction was commensurate with the extent of the gan-
grene 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 dis-
tinctly 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, losing their dis-
tinctive organization, and becoming homogeneous, whilst  nearer the
skin there is a layer of cellular tissue, hardened and infiltrated, 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 other tissues, and impossible to
distinguish from the softened gangrenous mass.1
   MM. Rilliet and Barthez give the following results of their investiga-
tion : " 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 gan-
grenous 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 possible 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  putrilage."   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 resisted 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)  was affected in     .    .    .11 cases.
  The right cheek      ..........10   "
  The lower lip...........4   "
  The lower lip and right cheek........1 case.
  The upper lip 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   "
1 Journal des Connois. Med.-Chirurg., April, 1830, p. 140. 
454
GANGRENE OF  THE MOUTH.
  647.  So much for the condition of the parts involved in the gangrene;
but the post-mortem examination revealed other  lesions connected with
this  disease, either as primary or secondary complications, and which
are of vital importance.   The principal coincident disease was pneumo-
nia,  and the following summary exhibits the character and  seat of this
disease, and of the gangrene, in  the  same cases :—
fOf these, gangrene of  the right cheek
Out of 20 cases there was found double
  lobular pneumonia in       .    .    4
Double  gangrene, but especially of the
  left cheek, in
Gangrene of the lower lip, in
Gangrene of the lower lip and right cheek
Double lobular pneumonia, especially on
  the right side (with carnification in 2
  cases)in    ....    .
Double lobular pneumonia, especially on
  the left side, in   ...    .
Lobar pneumonia of right lung in
Lobar pneumonia of left lung in
Carnification of left lung in
No pneumonia in
 ! Gangrene of left cheek in
   Gangrene of lower lip in  .

 f Gangrene of right cheek in
6 \ Gangrene of left cheek in
1  Gangrene of upper and lower lip in
1  Gangrene of left cheek in
1  Gangrene of right cheek in
n J Gangrene of right cheek in
 \ Gangrene of left cheek1 in
  Thus pneumonia (lobular or lobar) existed in eighteen out  of twenty
cases, and occasionally, though rarely, of the same side as the gangrene.
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, however, were discovered ;  as  for example :—

         Entero-colitis, or softening of the intestine, in
         Tubercles   .......
         Gangrene of the lung
         Gangrene of the pharynx
         Pleurisy    ....
         Pneumothorax
         Peritonitis   ....
         Pharyngitis  ....
         Nephritis   ....
         Infiltration of the pia mater  .
         Hemorrhage into the arachnoid
         Rachitism   ....
31 .
14	cases.
9	"
4	cc
1	case.
1	"
1	><
1	a
1	"
2	cases
]	case.
2	cases
  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 pervi-
ous ; 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  hyperaemia  rather than any struc-
1 Mai. des Enfans, vol. ii. p. 135. 
GANGRENE OF  THE  MOUTH.
455
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 exhibited were—
enlargement and hardening of the mesenteric glands; a scrofulous con-
dition of the glands of the neck;  and, in some  instances, tubercles  of
the lungs.  In  general the whole substance of the lung was thickly
studded with tubercles in various stages  of inflammation and  suppura-
tion.   The condition of the gastro-intestinal mucous membrane is not
recorded."1
   In  all the cases examined by Dr. Duncan, he found " either decided
ulceration of the intestinal mucous membrane, or enlargement and in-
creased 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 which intervened was of a bright crim-
son hue."2
   648.  Causes.—Cancrum oris is almost confined to infancy and  early
childhood.   Of twenty-nine cases recorded by Rilliet and Barthez, nine-
teen 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.
   As might be expected, we meet the disease most frequently among
the poor, and for obvious reasons.   Their children are badly nourished,
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 hospi-
tals for children, as, for instance, in the Children's Hospital at Philadel-
phia, 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 coasts 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 im-
portance, 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.

       1 Diseases of Children, p. 168.    2 Dublin Journal, vol. xxviii. p. 18. 
456
GANGRENE OF THE MOUTH.
  M. Baron observes that "it is never a primary affection, but  appears
in children enfeebled by previous disease."1
  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."
  Dr.  Willan refers to a gangrenous eschar of the oheek 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."2
  Dr.  Cuming  advances a similar opinion: " In every instance of this
affection that I have met with, the  constitution had been much debili-
tated by the existence of previous and long-subsisting disease.  In two
cases that fell under my 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 gene-
rally observed at the close of the exanthenr ta than at that of any other
of the acute affections to which children are liable."3
  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 accom-
panied 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, smallpox, and pneumonia.
We have also known it  follow intestinal affections, hooping-cough, scro-
fula, &c."   And they give  the following summary of the primary dis-
eases on which gangrene supervened :—
		12 cases.
Smallpox and measles		1 case.
Scarlatina	.	1 "
Scarlatina and smallpox		1 "
(Supposed) cholera		1 "
Pneumonia, primary and secondary		2 cases.
Pertussis, with or without	complication	3 "
Enteritis (chronic) and complications .		1 case.
Peritonitis and softening of the intestines		1 "
		1 "
Intermittent fever	.	1 "
Enteritis (acute)		1 "
		1 "
General tubercularization		1 "
  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."

              1 Bull, de la Faculte" de Me"d , 1816, vol. v. p. 158.
              2 Edin. Med.  & Surg. Journal, vol. xv. p. 548.
              3 Dublin Hospital Pteports, vol. iv. p. 232. 
GANGRENE OF  THE  MOUTH.
457
  Dr. Geo. Kennedy mentions that it occurred in the course of malig-
nant typhus fever.1
  "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  completely
broken down by ague, and one supervened in a tuberculous child, who
had been affected for  many weeks with ulcerative stomatitis in a severe
form."3
  We have already seen  that in ten  cases out of eighteen the pneumo-
nia 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,
smallpox,  &c, intermittent and remittent  fever, pneumonia, disorders
of the intestinal canal,  tubercles, and scrofula;  while, on  the other
hand, pneumonia and entero-colitis  are those which most frequently
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 suggested
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 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 perforation 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 twenty-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 without 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 character
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 applica-
tion of powerful caustics  ;  weak ones are of no  use.  Moreover,  merely
to touch  the gangrenous surface will have  no  effect;  to succeed, the

             1 Med. Report  of Cork Hosp.  for 1837-38, p. 25.
             2 Diseases  of Infancy and Childhood, p.  356. 
458
GANGRENE OF THE MOUTH.
caustic must reach the healthy tissue.   Therefore the  layer of gangre-
nous matter must first be removed, or if the situation permit, the gan-
grenous 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
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 pub-
lished 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 (muriatic
acid), which  was used with  benefit by Van Swieten  previously.   " I
began,"  he says,  " at first to give it in decoction of bark or infusion of
chamomile flowers, but I could not get children to take it for a continu-
ance, or in such manner as to give  it a fair trial.  I therefore 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 acidulated with the
spirit of sea  salt; and when  the gangrene  was  considerable and the
discharge large, dashing the parts  with the decoction, 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 exhibi-
tion 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  Hospital,
Philadelphia, nitrate of silver was the only local remedy employed, and
the majority  recovered.   Creasote was very  useful in the  Philadelphia
1 Observations on Midwifery, &c, p. 128. 
GANGRENE OF THE MOUTH.
459
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.
  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 will  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 di-
gestive 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 two or 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 ammo-
nia ;  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 compli-
cations.
  Dr. Duncan found great benefit from the hyd. c. creta,, with  Dover's
Powder, and, although not at the same time, from  acidulated decoction
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.1
   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-ventilated
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  bo
observed.
1 See also Dublin Journal, Nov. 1852, p. 265. 
460
TONSILLITIS.
  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
secondary) in connection with cancrum oris, we ought  daily to ascer-
tain the condition of these organs, that by detecting the earliest incur-
sion of the disease we may the more effectually apply the remedy.  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.
  Dr. Stokes has found the mercurial  cancrum oris manageable, if he
saw the patient within twelve hours from the setting in of the  disease.
He recommends that the patient should be  kept sitting up in bed, that
relays of leeches should be  applied to  the livid tumor as frequently as
the strength will  admit, and that the strength should be kept up by wine
and good diet.
  If the tumor be reduced before ulceration occurs, the patient will be
saved.
                    CHAPTER  VIII.

           TONSILLITIS.—CYNANCHE TONSILLARIS.—QUINSY.

  655.  This disease, which consists of inflammation  of those masses
of mucous follicles called, the tonsils or amygdalae, 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, continu-
ing 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 attempting to
swallow.
  Sometimes, however, as  Dewees  has observed, it  appears to  be a
purely local affection, without fever or any constitutional disturbance.
  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 papillae appearing through
the white coating.  The thirst  is great; but  there  is great  pain  and
difficulty in swallowing fluids especially.
  Upon examining the throat, to which we are led at once by the com-
plaints of the child, we find one or both tonsils enlarged, of a bright or 
TONSILLITIS.
461
deep  red  color;  the  uvula, velum, palate,  and pharynx, red, swollen,
and cedematous, but generally more painful on one side than the other,
and on the surface we find more or less of  thick,  viscid, mucous secre-
tion.  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;
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 tonsil 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  ordi-
narily 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 fortnight,
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  remarkable
degree of weakness and lassitude.
  II.  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  scro-
fulous children : they feel soft, but of two 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 popularly called " speaking
through the nose."
  Children in whom the tonsils are thus left, are very liable  to a return
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 in-
tensity, the inflammation seems to subside, but not the swelling ;  there
is less pain,  but  the mechanical obstacle to deglutition remains; the 
462
TONSILLITIS.
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 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 neighbor-
ing 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 at-
tack be mild, it will be easily subdued by gentle antiphlogistic measures.
A brisk  purgative, followed  by sudorifics, fomentations, or poultices ;
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 necessary.   The
former, I think,  are generally preferable, although Kopp speaks of the
latter as the  most prompt  and efficacious remedy we  possess.   Occa-
sionally, 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 fre-
quently  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 teapot,  with children,  on account  of the
danger of closing the lips and drawing up the water.
   Internally, after freeing the bowels 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.
   Lceffler  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 without 
TONSILLITIS.                       463
sufficient discrimination, and about which opinions have varied ; I mean
gargles and blisters.
  At the commencement of the attack stimulating gargles may be use-
ful, but afterwards I quite agree with Dewees that either stimulating 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 Hip-
pocrates, 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 interfere
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 subside, 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 aphthae 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  exter-
nally ;  others, their  removal by  operation.  Professor Hess,  of  Copen-
hagen, 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 ab-
sorption commences, gargles may be used.8  Each of these plans may
succeed, and we may try any or all of them, but I would  also suggest

    1 Diseases of Children, p. 451.         2 Rankiug's Abstract, vol. ii. p. 192. 
464
PAROTITIS.
that the internal application of the caustic 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 successful in several cases.
  As to the removal of the tonsils, I should be strongly opposed to such
an operation during childhood, as it is by no means generally successful,
and may leave consequences more troublesome than  the disease.  I do
not, therefore, think it necessary to occupy the  reader's time by a  de-
scription of the mode of operating.
  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, ac-
cording  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 prevails
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  down-
wards to the maxillary gland, involving the parotid gland and the sur-
rounding cellular tissue.   It feels  firm, hard, and hot, is  painful  on
pressure, but generally speaking  the  color of  the  skin is unchanged;
in severe cases it becomes slightly red or  pink.
  Not only is there  irregularity of the two sides  of the face  thus pro-
duced, but I have seen the lower jaw temporarily displaced,  and pushed
over towards the  sound side.
  There is great  pain and difficulty in opening the mouth and  in moving 
PAROTITIS.
465
the jaw, either to masticate or to swallow, although  the  dysphagia 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 coun-
tenance that the name "mumps" has been given to the disease.
   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 13
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 parotid
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 metas-
tasis.  The  pain and  swelling of the parotid gland  will sometimes
suddenly subside, and the mammae 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 prodigiously enlarged;
much suffering was 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   The same was observed by MM. Rilliet and Benguier.
   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 mem-
branes 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 mammae takes place.   This cerebral metastasis is highly dan-
gerous.  The child is attacked by coma or  delirium, and may die  in a
few hours if prompt measures be not taken for its relief.
   Two cases of this kind are recorded by Dr. Harvey Luidsly which
proved fatal.  In one of them  there were decided  marks  of inflamma-
tion and congestion of the cerebellum, but none in  the cerebrum.2
   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

    1 Diseases of Children, p. 143.       2 Amer. Med. Journ., April 1851, p. 542.
       30 
466
PAROTITIS.
some are prolonged to ten or twelve days.   The disease  is lengthened,
also, in those cases in which the two glands are successively 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 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
spring of 1849  it was very generally epidemic in Dublin and other parts
of Ireland.  I heard of one school in which there  were twelve, another
in which there  were sixteen children affected at one time, and there are
probably few practitioners of this city who had not abundant  opportu-
nities of witnessing different children of the same family attacked to-
gether or successively.  M. Rilliet has published an  account of  an
epidemic which prevailed at Geneva from  March  1848  to May 1849,
principally among children between five and fifteen years of age.   He
believes it to be contagious and analogous to eruptive fevers.
   An epidemic also occurred in Montpellier in February, March, April,
and May 1818, and has been  described by M. Ressiguier.1  Whether
it really be contagious at the time when it is epidemic, as Dr.   Stewart
and M. Rilliet and others suppose, is  a question not so easy of  solution
as might be supposed, because, although  children of the same family
are undoubtedly exposed to the influence of contact, they are  also ex-
posed to exactly the same epidemic causes.
   670.  Treatment.—The treatment required  by simple cases of paro-
titis is very slight.  We may  administer an emetic,  or a brisk purga-
tive, followed by calomel and antimonials in small  doses, with fomenta-
tions 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 mammae 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
1 Gaz. MeU, 1850. Brit, and For. Rev., Oct. 1850. 
PAROTITIS.
467
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 increased
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 parotidsea, and  by Mr. James as angina  externa.
In the beginning it is very like parotitis; there is pain, soreness, and
swelling near the angle of the jaw, but of one side only ;  great difficulty
in opening the  mouth ;  pain in mastication ; and febrile excitement;
but the tumor is generally below the parotid, more superficial, and the
skin is more discolored.  In some  cases the inflammation 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 occa-
sionally.  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, producing
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, dis-
tinct, deep-seated collections of  matter form, and the pus, mixing with
the dead cellular membrane, becomes putrid, and the_ evolution of gas
thus produced causes a kind of  emphysematous  condition  of the parts.
The febrile symptoms now assume a low, typhoid character, the strength
of  the patient is rapidly exhausted, and  death very generally ensues;
or, if recovery takes  place in these extreme cases,  an extensive  and
unsightly cicatrix deforms the patient for life."1
   672. In cases of 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 after-
wards.
   When the  inflammation is diffused, the  early stage will demand  a
1 Condie on Diseases of Children, p. 192. 
468
PSEUDO-MEMBRANOUS PHARYNGITIS.
similar treatment; but as soon as the swelling acquires a doughy feel,
especially if there be difficulty of swallowing, impeded respiration, 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.
                        CHAPTER  X.

PSEUDO-MEMBRANOUS  PHARYNGITIS.—DIPHTHERITE.—ANGINA PSEUDO-
                           MEMBRANOSA.

  673.  In a former chapter I described simple or erythematous pha-
ryngitis, under the name of cynanche tonsillaris, or at least the descrip-
tion 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 mem-
brane  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-
taeus 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.  Fothergill
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 intense, with
 general uneasiness, aching of the limbs, thirst, &c. ;  and  shortly after-
 wards the child will complain of soreness of  the throat,  increased by
 swallowing, especially if  the bulk be small.
1 Trans, of American Philosophical Society, vol. i. 
PSEUDO-MEMBRANOUS PHARYNGITIS.
469
  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,1 there was no
fever, but in  the observations of M. L'Espine2 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.3
  " The voice is commonly obscure and nasal, but not hoarse or whisper-
ing, unless the disease extends into the larynx, in which case the symp-
toms will  be those  of croup, already  described.   Cough  sometimes
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."4
  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 which, 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 in-
creases 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 pha-
rynx, in six ; the tonsils and the pharynx, in  five.
  675. The false membranes, and the parts covered by them, sometimes
present a  much more alarming  aspect  than the  one just described.
They appear as gray, reddish, or  blackish shreds, attached  to the  ton-
sils or  palatine vault; the soft parts of the fauces appear sphacelated;
the vault of  the palate, the tonsils, and  the mucous membrane of  the

  1 Thesis, 1827, p. 8.               2 Archives Gen. de MeU, 1830, vol. xsiii. p. 521.
  8 Do la Diphtherite, p. 113, etc.      * Meigs on Diseases of Children, p. 208. 
470           PSEUDO-MEMBRANOUS PHARYNGITIS.
 pharynx seem detached in part, and there are gray patches, with violet-
 colored  edges, resembling gangrenous eschars.   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 owing to
 infiltration of serum than to inflammation.   When the progress of  the
 disease is favorable,  the false membranes are thrown off, and not repro-
 duced ;  the swelling of the  submaxillary gland  subsides, 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 white mucus,
 through which the enlarged and florid papillae protrude.   There is  an
 increased secretion of saliva, which soon becomes dark-colored, from  an
 admixture of blood discharged from the mucous membrane  as portions
 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 ex-
 tend upward into the posterior nares, the child  cannot breathe through
 the nostrils; and if into  the Eustachian tube, the hearing will be imper-
 fect, 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 palatopharyngeal
 mucous membrane.   2. After an  uncertain  time, there  appear  upon
 the tonsils small whitish or yellow patches,  in  general thin,  superficial,
 and easily detached ;  most frequently limited to the tonsils, occasionally
involving  the  uvula  and  palate, and more rarely the pharynx.   Ac-

              1 Rilliet and Barthez, Mai. des Enfans, vol. i p 291
              2 Journal Gen. de MeU, vol. cix. p. 441.  '
              3 Condie on Diseases of Children, p. 181*. 
              PSEUDO-MEMBRANOUS PHARYNGITIS.           471

cording to authors, we find that  the false membranes  of secondary
pharyngitis, and  particularly in scarlatina, may assume  a  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 completely.
They adhere sufficiently firmly to the mucous membrane, vary in thick-
ness, 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 eccbymosis.   Rilliet and Barthez and Guersent conceive that in some
cases there is loss of  substance from ulceration ; such cases, however,
are very rare.  The submaxillary glands are enlarged, but rarely sup-
purate ; their tissue is tender, homogeneous, and of a whitish-red color at
an early period, and resembling 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 ton-
sils  enlarged, soft, and irregular;  not unfrequently, also, we find a
breach of  surface: ulcerations of various forms extend in different direc-
tions, 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  puru-
lent  matter.   Sometimes  the false membranes  occupy the  superior 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; Naumann  attri-
butes it to a change in the condition of the  blood, in consequence of
which the albuminous  portion is  separated and  exuded  ; and Andral
regards the disease as hyperaemia of the fauces, with exudation of coagu-
lable lymph.
1 Mai. des Enfans, vol. i. p. 295. 
472
PSEUDO-MEMBRANOUS pharyngitis.
  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.
  For fuller details, I must refer the reader to M. Bretonneau's elabo-
rate work.1
  680.  Complications.—These are of two kinds, those which consist of
an extension of the same disease, and those which result from the gene-
ral  condition of the patient.
  I. The secretion of false  membranes  may not be limited to the pha-
rynx, but may extend itself to the nasal apertures, or into the larynx,
trachea, and bronchi.  This coincidence and succession is very remark-
able in  some epidemics.   M. Bretonneau states that the angina or co-
ryza 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 epidemic that
these complications occur.
  I  am not prepared to  speak  positively as  to  the extension  of  the
cliphtherite 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 suppose,
have seen the diphtheritic deposit around  the anus.
  n. The disease  may also attack remote parts  of the body, particu-
larly parts  covered  by  mucous  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, alae 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, Bre-
tonneau 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, ery-
sipelas, 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 pha-
ryngitis 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 habi-
tation may give rise to it, as was observed at St. Denis, by M. Bourgeois.

  1 Des Inflam. speciales du Tissu Muqueux et en particulier de la Diphtherite, &c, pp.
240, etseq. 
pseudo-membranous pharyngitis.           473
  Most frequently, however, the disease  prevails as an epidemic, and
those cases which would  otherwise be simple pharyngitis take on this
character, and exhibit the curdy disposition.
  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 Vouvray,
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. Baud,
in the Canton de Vaud; by M. L'Espine, in the Royal Military School
of La Fleche, in the same year; and in the State of Ohio, by Dr. Welsh,
in 1847-8-9.1
  Some difference of opinion prevails as to whether the disease is con-
tagious.  From the facts collected  by M. Guersent, from  his own expe-
rience 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 distin-
guish diphtherite from simple or erythematous  pharyngitis, although,
on the first day of the attack,  the aspect of the parts may be  precisely
the same.
  n. 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 neighboring 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.
  When 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 epidemic
described by M. Trousseau, death may occur from  exhaustion.  A like
result may follow in those cases in which the disease appears at the oppo-
site extremity of the mucous membrane, the vulva,  or anus.
  In secondary diphtherite, the danger will probably depend more upon
1 American Journ. of Med. Science, July, 1850, p. 276. 
474           pseudo-membranous pharyngitis.
the primary disease, although, doubtless, the secondary affection will in-
crease it.
  684.  Treatment.—The indications of cure are not quite so simple 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 inflammation.
M. Bretonneau used the first of these applications ; and  he recommends
two thorough cauterizations, at an interval of twenty-four hours, after-
wards 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 distinct-
ive 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, judg-
ing 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  administered, the
bowels properly  freed, and the throat painted with a solution 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 commence with
the application of a few leeches to the  throat, followed by poultices.
Broussais, Emmangard,  and  others, have ordered the  application 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  inhaled 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 lini-
ment  sufficiently strong to redden the skin. 
PUTRID SORE THROAT.
475
  686. If the disease be epidemic, but not exhibiting a typhoid character,
the treatment will  be nearly the same;  a little more caution in apply-
ing leeches, the prompt use of caustics, and their  repetition each day
until the surface exhibits an altered appearance, the exhibition  of calo-
mel, mild purgatives, emollient or acidulated drinks, &c. will be equally
necessary.
  But if the epidemic show a typhoid character, we must make a consider-
able change from the above plan.  The parts must be cauterized, 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 circum-
stances of the child.
  Wendt advises enemata of decoction of bark, and Rilliet and  Barthez
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  XL

  PUTRID SORE THROAT.—GANGRENOUS ULCERATION OF THE PHARYNX.

  687.  There exists considerable confusion among writers as to 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  existence of
such a disease.   M.  Bretonneau, I  think, has proved  that the angina
maligna of many writers was a modification of diphtherite, but the ob-
servations 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" de-
scribed  by Dr.  Fothergill,  of London,  was really  this disease.1   He
states that the  disease was  first noticed in London,  and that it re-
appeared 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 inhabitants were
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 disease, which, from all the

    1 First published in 1748, and now included among his  collected works, p. 167. 
476
PUTRID SORE THROAT.
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 aphthous,
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 ulcer-
ation, which enlarges daily, and shortly presents its peculiar characters.
  Or, as in Dr. Fothergill's cases, it may come on "with such a giddi-
ness 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 faintness.  The dis-
ease 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 appear-
ance 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 com-
monly most observable on the posterior edge of  the palate, in the angles
above the tonsils, and upon the tonsils themselves.  Instead of this red-
ness, 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 white-
ness 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
  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
1 Works, pp. 202-205. 
PUTRID SORE THROAT.
477
glands on each side; and if the disease be violent, the neck and throat
are surrounded'with a large  oedematous  tumor, sometimes extending
itself to  the breast, and, by  straightening the fauces, increasing  the
danger.
  Delirium  was a frequent symptom in those cases;  occurring the first
night, bearing a  direct relation  to the  feveinsh  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 was of  a
deep  red or livid color, and a putrid sanies was discharged, so corrosive
as to excoriate the parts over which  it flowed.   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 dis-
appearance 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 laborious; 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, Guersant,
Rilliet  and  Barthez,  &c.   In the latter  the chief general symptoms
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.
   The local symptoms were 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 regurgitation
 of liquids through the nose.  In one case, where the gangrene was con-
1 Works, p. 220. 
478
PUTRID SORE THROAT.
siderable, 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 something that
annoyed him.   The swelling of the  submaxillary glands, and of the cel-
lular tissue, was not remarked except in one case, nor the abundant,
fetid, sanious salivation.
  As we might expect, the course of so serious a disease  supervening
upon another complaint, and in constitutions so enfeebled, is very rapid ;
sometimes, too, 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 coincidences;
nevertheless certain of the  complications appear to be either an exten-
sion 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. Guibourt mentions a case  in which oedema of the glottis occur-
red.
  iv. Pneumonia may occur, but it  is less frequent than in gangrene of
the mouth.
  v. In nine out of  twelve 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. Fothergill'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.1
  691.  Morbid Anatomy.—At the commencement of primary gangrene
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 posterior nares,  or the
commencement of the oesophagus; and as the disease 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  brown.   Dr. Fothergill ob-
serves :  " When the  disease is of the mildest kind, a superficial ulcera-
tion 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 ad-
vance ;  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
1 Edin. Med. and Surg. Journal, Jan. 1844. 
PUTRID SORE THROAT.
479
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 acces-
sion of the  symptoms I have mentioned.  The gangrenous spots are
sometimes oval, sometimes round, varying in size from a pea to a shil-
ling, and  it is very probable that the larger are formed by the coalesc-
ing 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 ex-
posed.  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.
   n.  Diffused Cfangrene.—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 below
the mucous membrane.   The surface is  unequal, of a grayish black,
easily removed by the  scalpel, and  of unequal  thickness.   The  sub-
mucous tissue is  of a  violet color ;  but when the  deeper  tissues 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.2

           1 Works, p. 237.
           2  Rilliet  and Barthez, Mai. des Enfans, vol. ii. p. 169, et seq. 
480
PUTRID SORE THROAT.
   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, accord-
 ing 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 complicates as a
 secondary affection.   These are the  eruptive fevers, measles, scarlatina,
 or  smallpox, and likewise pneumonia, peritonitis,  diphtheritis,  and
 typhus fever.
   I have already mentioned that the milder forms of ulceration of the
 mouth and throat do occasionally assume a gangrenous character, pro-
 bably owing  to the peculiar  state of constitution induced by previous
 disease.
   It  is said to prevail epidemically, but we have no very well authenti-
 cated information upon the subject.  M. Becquerel, indeed, has observed
 a kind of epidemic in the Hopital  des Enfans, and has recorded his ob-
 servations.1   Some writers seem to consider it contagious.  Dr. Fother-
 gill 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.  Fothergill's  cases,  there was
 cedema of the neck, and rapid sinking in the more serious cases, which
 were  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 investigating
 the throat, will increase the chances of our overlooking or confounding
 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 other parts free from
 disease.^  It  is  true, as Rilliet  and Barthez  observes, 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 com-
mencement,  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
1 Gazette Medicale, 1813. 
      ABSCESS BETWEEN THE PHARYNX AND THE SPINE.   481

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. Fothergill's experience was that,
however acute the symptoms  might be, the patient was never  relieved
by bleeding.   He  gave a mild emetic, occasionally following by wTarm,
aromatic,  and stimulating medicines, wine, broths, &c.  Locally, he re-
commends 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 detritus
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), ammo-
nia, wine, broths,  &c.
                      CHAPTER  XII.

           ABSCESS BETWEEN 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.
  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

  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.2
  698.  Symptoms.—The  symptoms are very  characteristic,  although

              1 Dublin Medical Journal, vol. xvii. p. 41.
              2 Dublin Hospital Gazette, 1845, March 1, p. 20.
       31 
482   ABSCESS BETWEEN THE PHARYNX AND THE  SPINE.

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 affec-
tions of the throat, complained of or otherwise, according to  the age of
the  child,  and, on  examination, not  accompanied with proportionate
visible lesion.   The essential, often  very suddenly supervening, and
indicated by derangement of the cerebral, circulating, and respiratory
symptoms, alternating with  the  comparatively healthy condition  of
those systems, according to the alteration in the position of the indivi-
dual ; fixed and  retracted state of the head, with rigidity of the mus-
cles  at the back of the neck, and more or less locked  state of the jaws;
painful  deglutition,  impossibility of swallowing, solids and  fluids con-
vulsively darted forward 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 vas-
cular appearance behind the soft palate, usually occupying the median
line, but occasionally inclining to either side.   These essential symp-
toms, accompanied  with  the ordinary characteristics of suppurative
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 pro-
duced 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 child-
ren.  I have  known them not to complain of any uneasiness in the
 throat, and attention to  be directed  to  it from the raucous breathing
 during  sleep.   In fact, the symptoms much resemble those of  common
 scrofulous induration of the tonsil.   They are, hence, cases of compara-
 tively 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 sequelae of those cutaneous diseases, and,
 like them, may be accompanied with suppuration of the internal or ex-
 ternal 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 examina-
 tion 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 surgical 
DISEASES OF THE  STOMACH.
483
  interference is as effectual as it appears to be essential from the symp-
  toms ; and " not alone from the fact of certain fatal results from me-
  chanical pressure on, and interference with, vital organs, but also from
  the  situation of the abscess being  particularly favorable  to extensive
  diffusion."  In one case only has Dr. Fleming seen a spontaneous open-
  ing  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 trocar 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 screw,  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 trocar, so as to  place it on the most prominent part of the tumor,
  when pressure on the  stiletto will effect the object in a moment.
    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 trocar is thus readily guided to the point  intended to be  punctured,
  and thus all danger to the surrounding parts is avoided."  "  Dr. O'Fer-
,  rail, in similar cases, would in future prefer a straight bistoury, having
  the  cutting part short, as the  density of the covering of such abscesses
  renders the plunge of a trocar unsafe."
    For fuller details, illustrated by very interesting cases, I must refer
  my  readers to Dr.  Fleming's  excellent paper.
                      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 raucous 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  internal
membrane soon shows 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 membranes, may be separated 
484
DISEASES OF  THE STOMACH.
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 incloses a quantity of
ropy  mucus, with which there is sometimes mixed some small gruraous
particles, apparently composed of concrete mucus. In  stillborn 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, doubt-
less, what several authors,  and Capuron  in  particular, mean by the
name saburra, the removal of which it was necessary to effect imme-
diately 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, pro-
ceeds 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 valvulae  conniventes ;  the  villi are equally  developed,  and  very
often in the  jejunum are found some  separate mucous follicles, 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-caecal valve  is a  little  projecting, and the  opening which it  sur-
rounds extremely small; in most children it would be  difficult to pass
even a crow-quill.   At  this  age it  prevents  the  regurgitation of sub-
stances 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 insur-
mountable obstacle.   Neither do  the  ccaeum 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 abun-
dant 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
1 Mai. des Enfans, Stewart's Trans., p. 238. 
DISEASES OF  THE  STOMACH.
485
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-caecal 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 cer-
tain practitioners regard as vitiated matters,  or saburra, for the expul-
sion 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
aliments, 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 lamellae, which, being
rolled together, form the small white flocculi  so frequently met 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 remainder 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 pur-
gative, 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 costiveness 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 sub-
mucous  tissue is  of a dull white  color, rather thin in  general,  resisting,

                 1 Mai.  des Enfans, Stewart's Trans., p. 273. 
486
DISEASES OF THE  STOMACH.
and intersected by venous arborizations, more voluminous but less nume-
rous than those of the mucous membrane.  The muscular  coat  under-
neath 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 appearance 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 diminishes
towards the inferior termination.  Its adherence to the subjacent tissue
is  but slight, and slips may easily be  raised  even close to  the valvulae
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, always visible
along the free border of the intestine, and increasing in number towards
its inferior portion,  as  in the adult.  Numerous small 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 caecum coli; and from each of these points it
gradually increases in  thickness until we  arrive  at the next  obstacle.
The  mucous membrane of the caecum  permits a number of venous rami-
fications, which disappear lower down, or only  reappear in the rectum;
and we find a considerable number of follicles, each marked by a gray
spot, with a small opening of a darker color, which leads to its cavity.
   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 appearance.
   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.
   in.  At a later period the  blood escapes from the vessels and  colors
the mucous membrane, which it penetrates as if by imbibition, forming
large spots of a dull red color, in which no vessel can be discovered. 
DISEASES OF THE STOMACH.               487
In other cases the blood distils through  the  membrane, and  colors the
mucus of the intestinal canal; or it may be effused beneath the mucous
membrane, following  the sinuous track of the  vessels from  which 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 abdo-
minal 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 phenomenon;
but that, considering the circumstances of temperature and putrefaction
in which we ordinarily find it, we regard it, when discovered by dissec-
tion made  twenty-four or forty-eight hours  after death, as  more fre-
quently cadaveric than morbid.   The intestinal  mucous membrane, on
the other hand, undergoes this change  more  frequently from disease
than as  a cadaveric change."
  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 uni-
form red color.
  III. 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 supposed,
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  faecal matter.
  v.  Ulcerations.—These are sufficiently  common in typhoid fever and
tubercular  disease, and may be  seated either in  the mucous membrane
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.
  vii. Softening, non-inflammatory.—Three forms have been  noticed
by the authors  just  quoted:—1. Simple  or pultaceous ;  2. Gelatini-
form ; and 3. White or opaline ramollissement. 
488
INDIGESTION.
  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.
                       CHAPTER  XIV.

             INDIGESTION.—VOMITING.—WEANING BRASH.

   707.  The affection which has been described under the term vomiting,
and  more  recently termed indigestion,  differs very considerably  from
the adult disorder so designated, although it appears equally independ-
ent of organic disease in many cases.
   Vomiting is, no doubt, the prominent symptom, but we must distin-
guish between that which results from an unhealthy or irritable condi-
tion  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 after-
wards acquired.   " The milk  is generally thrown off  in an unchanged
condition, and the infant is so  little annoyed 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 salutary 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 regu-
larly relieve itself hj throwing 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
Eberle on Diseases of Children, p. 205. 
INDIGESTION.
489
still at the breast, the earliest symptoms of the disorder we shall be able
to observe will be  a pallid look, languor, and considerable discomfort.
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 re-
ceived it, or curdled (and not  a  small portion—the 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 separa-
tion  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 excess  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 superabundance
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 coagula-
tion 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 want of vital activity  and nervous action which is  dis-
played 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 indi-
gestion, without inflammation 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

                   1 On Diseases of Children, p. 223.
                    Mai. des Enfans, Stewart's Trans., p. 243. 
490
INDIGESTION.
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 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 unfre-
quently a portion passes through  the nostrils."1
   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 nipple hav-
ing 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 condition 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 exhaustion
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 dis-
order, however, is  not confined  to the stomach, but involves, apparently,
the entire  intestinal canal.  It may come on a few days after weaning,
or not for  some weeks.   Dr. Cheyne has given an admirable 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 constant feverishness, the effect^of increasing griping pain,
expressed  by the whine of  the] child, but especially by the settled dis-
1 Diseases of Children, p. 3^4. 
INDIGESTION.
491
content of its features; and this expression of discontent is strengthened
towards 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, and  at other times
slimy and ash-colored, and sometimes lienteric.  Towards the end of the
disease the extremities swell, and the child becomes exceedingly drowsy;
but these I rather conceive to arise from debility, than to be pathogno-
monic symptoms.   It  is remarkable, in  the  advanced  stages of  the
disease, that the  purging sometimes ceases for a day  or  two, but with-
out 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 miserably 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
bowels."1  To this graphic description I have little to add, except that,
in many instances, the symptoms of gastric disturbance  precede those
which indicate intestinal derangement,  and which  is  the reason why I
have introduced the disease here rather than under the head of diarrhoea.
The disease, as Dr. Cheyne observes, is by no means rare, and, if neg-
lected, is very fatal, but if taken in time is sufficiently manageable.   It
is more common with children who have been weaned  abruptly, and at
an unusually early period.
   712. At a later  period, the child's stomach may become disordered,
and an effort may be made for relief by vomiting  or  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.  I have noticed the prevalence of this form
of indigestion, somewhat modified in different cases, during  the  hot
weather  of summer.
   If this state of things continue, the intestinal canal  becomes irritated,
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, con-
' Essay 2.  On Bowel Complaints, p. 16. 
492
INDIGESTION.
stituting the disease called lientery.   In some cases the  purging alter-
nates with constipation.
  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 common
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  treat-
ment, than these cases; and, do what we may,  a  large proportion 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 soft-
ened.   " The want of color," Dr. Stewart remarks, "is  almost always
the first degree  of a species of softening, which  should not be con-
founded 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 symp-
toms, to be a  violent species of the disease now under consideration.
M. Duges, in his Manuel 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 observers 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 described
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 exceed-
ingly 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 intussusceptions were entirely of a spasmodic
 nature,  as,  in the latter, the contained  part of the gut was easily dis-
 engaged from  that which formed its sac, and in no part of the entangle-
 ment 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 them.   Th^se appearances  lead  me to imagine
 that weaning brash, in its confirmed state, is imputable to an increased
1 Diseases of Children, p. 184. 
INDIGESTION.
493
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 explana-
tion."1
  714.  Causes.—Before weaning, indigestion may be  caused by excess
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 indolence,
luxurious  habits, giving way to passion, by  the  presence of the  cata-
menia, 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 stomach be-
comes permanently  deranged, and  that which was a healthy  process
becomes a  symptom of a morbid condition.
  Another cause, and doubtless a frequent one, is  dentition.  The sto-
mach and bowels 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.
  Underwood and others have attributed  this vomiting to the suppres-
sion of accustomed  discharges, or  the  sudden cure of cutaneous  erup-
tions.   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 confounded
at a certain period, and  from which  it is of  the highest importance 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 remarkable  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 examin-
ation, 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
1 Essay ii. p. 23.
2 Vide chap. iii. 
494
INDIGESTION.
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 tranquillizing the gastro-intes-
tinal  disturbance as the following mixture:
                    R—Mist, amygdal.,
                        Aquse carui, iia ^ss.
                        Spts. ammon. arom. gutt  v.
                        Tincturse opii, gutt. ij. vel. iij.—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 in-
 ordinate  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 epigastrim."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 pur-
 pose, also, mvrrh 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 rhu-
 barb, at intervals of two days, and a half or  third  of a grain of ipecacu-
 anha, with six or eight of prepared chalk, and some aromatic  powder,
 every four or five hours.  If there be much  griping, an anodyne enema
 may be given.  The diet must also  be regulated  carefully, and animal
 substances are  better than vegetable.   Eggs, fine  ship  biscuit, arrow-
 root custard, the juice of lean meat, plain animal jellies, and milk,  are

     1 Diseases of Children, p. 210.               2 Diseases of Children, p. 225. 
INDIGESTION.
495
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.  When the child is still  older, if his stomach  have been over^
loaded,  or if he have taken indigestible food, it will be well to commence
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 evi-
dence 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.
   With children of three or four years old, I have succeeded very well
by combining an alkali with some vegetable bitter, after the irritable
state of the bowels has been relieved.
   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 lini-
ment or blister, is of great use;  and if there be colic, laudanum may be
applied  externally as well  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 may be 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 hydrochloride
of iron, which appears to have frequently succeeded  in  restoring the
healthy functions of the stomach in the hands of Pommer, Herzt, Cam-
merer,  Droste, and others."1
   The  diet must be carefully regulated, and it is far better to retrograde
 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.   Mus-
tard  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 disease 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.
   If the child  be greatly reduced,  more nourishment must  be given;
1 Condie on Diseases of Children, p. 203. 
496
GASTRITIS.
jellies, broths, or beef-tea will be necessary, and  sometimes wine whey ;
nor  have I  found the head symptoms increased by it, but frequently
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 recent
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, Sandifort, and
Hunter, described a softening occurring at the larger extremity  of the
stomach;   and since their time Ramisch,6 Vogel,  Hufeland,  Cruveil-
hier,7 Billard, Bouchut, Barrier, Rilliet and Barthez, &c, have  thrown
much light upon the subject, although there are still questions left un-
decided.
  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 characteristic,
and in some cases are very obscure.  In certain cases  Rilliet and Bar-
thez 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 containing tartar emetic
or ipecacuanha; or  vomiting, apparently sympathetic, at the commence-
ment of the primary malady.   Among these  cases we find erythema-
tous, 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 common
occurrence, both  at the beginning and during the course of the disease,

         1  Mern. de la Soc. de Med. 1786, p. 327.
         2  Die Entziindung, &c, p. 230.     3 Diseases of Children, p. 277.
         *  On Diseases of the Stomach and Bowels in Children, 1824, p. 180.
         5  Hufeland's Journal, May,  1811, and Jan. 1813.
         6  Aug. Lit. Zietung, No. 56, May, 1826, p. 447.
         7  Anat. Path., Livraisons 4-7,  &c.
         8  Mai. des. Enfans, vol. i. p. 405. 
GASTRITIS.
497
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 trouble-
some 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
existence of a cerebral affection.  To these symptoms succeed a general
state of prostration  and insensibility, occasionally disturbed by a  return

                  1  Mai. des Enfans Nouveaux-ne*s, p. 46.
                  2  Condie on Diseases of Children, p. 204.
       32 
498
GASTRITIS.
of 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 recently
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 "ramollisse-
ment gelatiniforme," which is thus described by M.  Cruveilhier:  " This
softening  always  proceeds from the  interior   towards  the  exterior.
There is at the beginning simple separation of the fibres by a gelatinous
mucus, and in consequence the parietes are thickened and semi-transpa-
rent.   Shortly after, the fibres  themselves are involved and disappear,
so that the softened stomach or intestine resembles transparent gelatin
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 inorganic, completely deprived of
vessels, and exhaling an odor resembling 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  accu-
rately to the  above description  of M.  Cruveilhier,  he regards as patho-
logical, 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 ?
  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;"4 and further  on  he gives his opinion

  1 Mai. des Enfans, Stewart's trans., p. 267.
  2 Rillet and Barthez, Mai. des Enfans, vol. i. p. 459.  Denis, Mai. des Nouveaux-n6s,
p. 56.
  3 Anat., Path., livr. 4-7, &c.            * Guide de Med. Prat., vol. v. p. 188. 
GASTRITIS.
499
that it is the  result, either pathological  or  cadaveric, of  chronic
gastritis.
  M. Billard observes: " What inference shall be drawn from  the pre-
ceding 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 dis-
organization is characterized by an accumulation of serosity in the walls
of the organ, a swelling and gelatinous consistence of the mucous mem-
brane 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  disorganization
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."1
  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.2
  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 patho-
logical, 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 pathological,
that it is the result of an anterior morbid condition.3
  Dr. Dunglison considers that  there  is  little difficulty in pronouncing
it the result of previous inflammation.4
  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."4
  Dr. Stewart regards this softening,  as  well  as the other morbid
changes, to be the result of inflammation.6
  Dr. Condie remarks: " Without  denying that the  stomach may be
dissolved after death, in consequence of the generation in its cavity of
an excess of acid; and being well aware that a softening of the tissues
of the stomach and of other parts of  the alimentary canal may be pro-
duced by  causes affecting the nutrition, and impairing the cohesion of
the various tissues, altogether independent of inflammation, we are still
convinced, from the result of our  own observations, that  the gelatinous
softening, so  frequently observed in  children  who have  died  of acute

  1 Mai. des Enfans Nouveaux-nes, &c, p. 232.
  2 Mai. des Eufans Nouveaux-ne"s, p. 231.       3 Mai. de l'Enfance, vol. ii. p. 118.
  4 Diseases of Stomach and Bowels, p. 183.
  5 Cyclop, of Pract. Med., vol. iv. pp. 13-15.     6 Diseases of Children, p. 249. 
500
GASTRITIS.
gastritis, is invariably the effect of intense inflammation of the raucous
and other tissues of the stomach."1
  Dr. West "has not been able to  discover  any peculiarity in the cha-
racter  of such symptoms (of disordered functions), nor even any con-
stancy in their occurrence; nor have I observed  that  the disease of
which the infant died has exercised any appreciable influence in predis-
posing 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 Popp's work5 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 discovered 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 circumstances 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, ulceration,
and gangrene are equally conclusive evidence of previous or accompany-
ing gastritis;  but  that  pale, gelatiniform  softening  may be  either the
result of disease or a change which takes  place after  death.  The ba-
lance 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 improper
food converting the indigestion described in  the last chapter 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  and croton  oil, in secondary affections, gave  rise to gastritis,
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 administration.
   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

  i Diseases of Children, p. 206.        2 Diseases of Infancy and Childhood, p. 366.
  3 Die Magenervreichung der Saiiglinge, Stutgard, 1816.
  4 Diseases of Infancy and Childhood, p.  366.
  5 Der plotzlichen Tod, aus inneren Ursachen, p. 330. 
GASTRITIS.
501
  Rilliet and Barthez, twenty-three were boys, and eight girls; and  of
  twenty-seven  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 constitu-
  tions,  or who  have been exhausted by disease, seem  more liable to the
  complaint.
    The usual exciting causes, cold, damp, exposure, bad food, crowding,
  &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 principal
  diseases in the course or towards the termination of which it occurs are,
4 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.
    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 bowels
  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 bleed-
  ing, and, after that  has stopped,  applying a  light, warm, linseed-meal
  poultice.
    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, less painful, as well as more effectual.
  Great advantage is sometimes  derived from dressing the blistered  sur-
  face with ointment in which there is a small quantity of opium or mor-
  phia.
    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) 
502
GASTRITIS.
&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 calo-
mel, 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 mix-
ture 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 with 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, mu-
riate of morphia is to be  sprinkled over a small blistered surface at the
epigastrium.
   Dr. Lion, of Breslau, depends principally  upon external  means and
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 sto-
mach, and internally the decoction of acorns, carbonate of iron, or the
tinct. ferri muriatis.2
   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, ipecacu-
anha, and hyoscyamus.   The state of the bowels must be carefully regu-
lated.

      ' Diseases of Children, p. 207.
      8 Ranking's Abstract, vol. i. p. 177, from Casper's Wochenschrift, No. 34. 
DIARRHOEA.                         503
                       CHAPTER  XVI.

            DIARRH0ZA.—CHOLERA INFANTUM.—ENTERITIS.

   730. There is no  complaint so common in infancy and  childhood as
disordered bowels, anjl 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 looseness,
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 indicate the presence of inflam-
mation, 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 grada-
tions  and the symptoms significant 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.
   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-

  1 M. Billard divides the disease into erythematous gastritis, with or without altera-
tion of secretion, follicular enteritis, and enteritis properly so called.   M. Valleix de-
scribes simple enteritis,  and enteritis combined with muguet.  Rilliet and Barthez treat
all varieties under the title of gastro-intestinal infiammation.  M. Barrier  speaks of
acescent, follicular, serous, flatulent, and verminous diacrisis.  M. Bouchut and Dr.
West made 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, choleriforra diarrhoea, or cholera infantilis.  M. Legendre regards the
majority of cases as alterations of secretion, and the morbid lesions rather as their conse-
quence than their cause. 
504
DIARRIICEA.
rhoea, according to the character of the discharges,  in  the following
manner :—
   I. Feculent Diarrhoea, in which the discharges are increased in quan-
tity 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 fasces are loose, copious,
and of a bright yellow or green,  and the bowels are stimulated to inor-
dinate 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 faeces are observed
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 formation
of bile goes on almost indefinitely, or fever be provoked."1
   III.  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
is generally some little tenesmus, and occasionally a little blood.  Ordi-
narily, their color is greenish, or light green, and very  offensive.   Some-
times they resemble chopped spinach; at other times yellowish or green-
ish clay, with a very bad odor.2  Dr. Graves regards this green matter as
a secretion from the mucous membrane of the small intestines, and not
bile.   Drs. Simon and  Golding Bird3 consider it owing to blood which
has undergone a chemical change.  In common'with the latter physician,
I have  observed that in many cases these  green stools  are originally
yellow, but become quite green in an hour or two.   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.
   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.

               '  ' Dewees, Diseases of Children, pp. 381-2.
                 2 Hamilton,  Management of Infants, p. 69.
                 8 Med. Gazette, Sept. 1845. 
DIARRHOZA.
505
  A child thus attacked becomes  rapidly weak and emaciated, and, if
not soon relieved, sinks from exhaustion.
  V. Lienteric Diarrhcea.—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 diarrhcea, by showing, perhaps,
that some one article of  diet only has passed  the bowels unchanged, 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 secretion,
as in the last variety; but with this  opinion Dr. Dewees' 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 according
to  the  peculiar discharge.  There is  generally a  certain  amount of
uneasiness and pain; sometimes this  is very considerable, accompanied
by  rumbling in the bowels, and  an escape of flatus.
  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  discharges, 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 diarrhcea i3 relieved.
  If the discharge be considerable, the  child is rapidly reduced in flesh,
and in young infants the  muscular substance becomes  quite 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, de-
pression, and sinking about the  face,  in some cases resembling collapse,
until reaction  takes  place.   The  eyes are  sunk, surrounded by dark
circles, the features are sharpened, and in  prolonged cases the  child
acquires an appearance of age.   The tongue may be  either white and
coated, or red, and occasionally there is a curdy matter, something like
the  commencement of muguet.   The thirst is greatly increased, some-
times quite intense, with great dryness  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
1 Diseases of Children, p. 3cj1.
* Ibid., p. 392. 
506
CHOLERA  infantum.
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, however, another  variety of diarrhcea 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 common
in other warm climates.   The reader will find most valuable  informa-
tion 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 of  ten 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 dis-
ease 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, ac-
cording as the summer varies in the period of its  commencement and
close.   Thus  in Pennsylvania, Maryland, and Virginia, Kentucky and
Ohio, it commences  sometimes  early in  the month of  June, and con-
tinues  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 commonly con-
fined 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 un-
usual 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
   In Massachusetts, in  five years from  1844  to  '48,  inclusive, there
were 852 deaths from this disease,  and in Baltimore it  was epidemic in
1848.

  1 Diseases of Children, p. 233.  During the present epidemic of Asiatic cholera (1840),
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.J
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.
507
  734. The disease is often preceded by diarrhcea, but in the majority
of cases, according to Eberle, the vomiting  and purging commence to-
gether, with no other premonitory symptoms than languor, fretfulness,
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 disease
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 violence
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 dis-
ease 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 two or three times daily, while the  diarrhcea 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 pain-
ful and  distressing  sensations  in the stomach and bowels; and when
the  discharges are violent and very  frequent, the muscles of the  abdo-
men 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 in-
animate and sunk, the nose sharp, and the lips thin, dry, and wrinkled.
   " The thirst is  always very great, more  especially after  the disease
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 be-
comes 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 re-
sembling those of acute hydrocephalus.   When the disease is of pro-
tracted 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.
Aphthae  finally appear on the tongue and  inside of the cheeks; the face
acquires a  bloated or (Edematous appearance ; the abdomen becomes 
508
CHOLERA  INFANTUM.
tumid  and tympanitic ;  the  parts  about the  anus are  excoriated  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 simi-
larity and also the dissimilarity between the  symptoms and course of
cholera in infants and  in adults ; but there  are one or two other symp-
toms, 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 ap-
pearance of this eruption is  to imagine a vast collection of vesicles ap-
parently 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  witnessed  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 com-
plaint, 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  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."2
   735. The duration of this disease varies very much, sometimes  ter-
minating 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, with uneasiness and restlessness, or stupor
and insensibility, we may fear  the worst.

   1 Eberle on Diseases of Children, p. 283.  I may just observe upon this last symptom,
which, with the half-open eyelid, gives such a distressing look to the child; that any one
who  has watched a baby go to sleep, or even carefully traced  their own physical sensa-
tions during the initiatory part of this process, must have observed that the turning up
of the eyeball is almost invariable ; that in fact, it is  one of the natural and healthy phe-
nomena of sleep.
   2 Diseases of Children, p. 417. 
ENTERITIS.
509
                            ENTERITIS.

  736.  At the commencement of a bowel complaint, it 13 by no means
easy to  decide whether it be  an  ordinary case of diarrhcea, 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 difficuly lessened by the fact, that when
the diarrhcea 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, diarrhoea,
pain in  the bowels, fever, thirst, and  loss of  appetite.   Or as I  have
seen in  young infants, and verified by post-mortem examination, it may
present at first  neither pain, vomiting,  purging, nor tenderness, but
merely profound collapse.   Other symptoms, as pain, diarrhoea, may
subsequently be developed, but it is important to bear in mind that in-
fants may die of enteritis with  but little pain, and  with no vomiting,
purging, or tenderness, but in them the vital collapse is most marked.
  The ordinary symptoms then are vomiting, diarrhoea, heat, and tension
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  epi-
gastrium, according to Rilliet and Barthez, but rather in the umbilical
region or iliac fossae.   The temperature of the abdomen  is increased in
proportion to the intensity of the inflammation, and is  greatest when
the disease is at its height.
  The  color, consistence, and odor of  the discharges vary  much, nor
do I believe that any very  important inferences are deducible therefrom.
They are sometimes green, sometimes yellow 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,  incompletely di-
gested.   2.  A secretion of serosity, which is  not always  present.  3.
Mucus,  wdiich is almost always present, enveloping the more solid  por-
tions ; 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 fecal matter be somewhat 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, 
510
ENTERITIS.
but mixed with fecal matter, in striae, 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 consciously,
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 supposed to have
involuntary motions.
  As the disease advances, the skin becomes dry, pale, yellowish; the
face wrinkled, old-looking, and  expressive  of depression and distress;
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, where it loses
itself;  the second,  the nasal lineament, extends from the inside  of the
alae 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 violent pain, there is a  corrugation of the skin
of  the  forehead; and indeed  the sudden appearance of wrinkles in any
part of the face almost always indicates the presence of abdominal pain,
and demands the  attention  of the physician, for they are invariably
marks  of distress 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 diarrhcea;  acute enteritis
may also be succeeded  by the chronic phase  of the  disease, and  the
similarity between  these chronic disorders is even greater than between
the acute forms.  The bowels  continue relaxed, with a  considerable
variation in the character, quantity,  color, and consistence of  the dis-
charges,  occasional griping pain, tympanitic inflammation of the abdo-
men, 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  denomi-
 nated, 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, aphthae, ulceration  of the
 gums,  cancrum oris, pseudo-membranous pharyngitis, &c, that in a great

   1 Mai. des Enfans, vol. i. p. 494.      * Mai. des Enfans Nouveaux-nes, &c.,p. 202.
   3 M. de Salle's translation of Underwood.  Stewart on Dis. of Children, p. 253. 
DIARRHOEA.
511
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 diarrhcea,
where no decided evidences of actual inflammation are present.
  II.  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 pri-
mary 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 sleepi-
ness, 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  obser-
vations of Rilliet and Barthez, that this is a comparatively rare compli-
cation.  No doubt a child suffering  from  diarrhcea  will occasionally
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 beyond
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 pro-
longed secretion.1
   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 appearances recorded
as having been noticed  in cases of diarrhcea, were the result of inflam-
mation, and prove the cases  not to have been mere irritation, or to have
transcended those limits.   We shall presently enumerate them.
   Dr.  West has quoted in a note the experience of  Messrs. Friedleben
and Fleisch, from the Zeitschrift fiir  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  exclusively, or  in a
great  measure, on artificial food,  and  who died, after long-continued
illness, in a state of atrophy ;  or else sank rapidly under profuse watery
diarrhcea.   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 condition of the same bodies,
betokening, as they believe,  their recent  inflammation,  was almost
1 Recherches, &c. sur quelques Mai. de l'Enfance, p. 367. 
512
CHOLERA  INFANTUM.
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 yel-
low patches.2
  II.  In cases of cholera infantum, the liver is almost always engorged,
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 with-
out perceptible change of structure.  There are abundant evidences of
inflammation in the stomach and small intestines ; red, inflamed patches,
inclining to purple, may be observed, especially in the duodenum ; nor
are they limited to the small intestines, as Drs. Jackson and  Dewees
thought, Dr. Horner and others having found them  in the large intes-
tines.   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 AVagler.
   III.  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 small
portion of  the intestine, with  or without ramollissement.   This erythe-
matous inflammation  is the most common ; pseudo-membranous enteritis
is more rare, and is seated at  the lower portion  of the intestine.  Sim-
ple ulceration is comparatively rare ;  most commonly the ulceration is
follicular.   But here again we meet Avith 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  occasionally some-
what  larger.  They are more voluminous in  the upper than the lower
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 mammelonated 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.6
   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 ori-

             1 Diseases of Infancy and Childhood, p. 395, note.
             2 Recherches sur quelques Mai.  de l'Enfance, p. 376.
             3 Diseases of Children, p. 400.
             4 American Journal of Medical Science, vol. xxiv. p. 305.
             5 Ibid, for February, 1829.
             6 Rilliet and Barthez, Mai. des Enfans, vol. i. p. 478. 
ENTERITIS.
513
fices of  the  solitary glands.   In other  instances,  the surface  of the
reddened mucous membrane appears slightly roughened, as if sprinkled
over with fine sand ; while near to the caecum 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 intestine;  and their surface
presents  a punctated appearance, due to the unusual  distinctness  of
the orifices of the sacculi which  compose each gland.   Occasionally a
few of them  are congested  and swollen, and once or  twice I  have ob-
served one or two spots of ulceration on  that cluster of Peyer's glands
which is situated close to the ileo-caecal valve ; but in every instance the
affection of the small intestine  has appeared  to be secondary and  quite
subsidiary to the disease in the colon."1
   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 infants,
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 Si post-mortem examination.
   The lungs  are almost invariably healthy, and the mucous  membrane
free from infiammation, quite justifying the remark I  made as to the
rarity of such complication  with  diarrhoea.
   741.  Causes.—All 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.2
   The chief  causes  of diarrhoea are, cold, damp, improper  food, or
excess  of proper food, dentition, and variations  of atmospheric  tem-
perature.
   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. diarrhcea formed 7.2 per cent, of all  cases of disease.
     lob. 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.

              1 Diseases of Infancy and Childhood, p. 394.
              2 West, Diseases of Infancy and Childhood, p. 388.
      33 
514                        ENTERITIS.
  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.1
  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
3576; namely, in infants under one year  of age, 2122; between one
and two years, 1186 ; 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 with 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 diminish, if not entirely suppress it."2
   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 an
attack, and probably the irritation of dentition may be among the pre-
disposing 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 diarrhcea, 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 pur-
gatives.
   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 diarrhcea, 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 condition
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,

  1 Mai. des Nouveaux-nes, p. 196.        * Condie on Diseases of Children, p. 215. 
ENTERITIS.
515
tension and enlargement of the abdomen, with  a  disproportionate de-
gree of tenderness (so as almost to lead us to suspect peritonitis), 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.
  II.  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.
  ill. The  previous history will  almost always  show 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 pro-
longed diarrhoea, and the gradual development  of nervous symptoms,
are very unlike the course of the disease when primary.
  745. Prognosis.—I.  In simple diarrhcea, if we see the  case 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, sub-
sidence  of the abdomen,  and the return of appetite,  constitute the
favorable  symptoms, while an increase of these  symptoms with higher
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 termination 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 proportion
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 even when  at  some
distance, if  the child suffer from irritation of the gums, they ought to
be freely divided down  to the teeth, and rather  bey< nd the limits of
those  coming to the surface.   Very often the irritatit n  which a  child
would bear in health without  any inconvenience will be  quite sufficient
to neutralize the effect of our remedies when diarrhoea is  present. 
516
ENTERITIS.
   747.  These points  being attended to, we have next to consider what
medicines we shall employ, and, on  the supposition that irritating mat-
ters 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  two 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 take 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 answer equally well, with the advantage of being slightly
stimulant.  Or the hyd. c. creta; may be combined with the pulv. cretae
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
relieve the irritation quicker than anything else, and, given at bedtime,
will  secure a  good  night's rest.  It  may be repeated as  often  as ne-
cessary.
   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 ex-
ternal irritation, either by mustard and meal poultices, or the compound
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 tincture
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 substance
is prepared from the sulphate of ammonia and alumina, by exposing it
to a  strong red heat  in a crucible.   Argil in the form of a white powder
possesses great  astringent  powers.   Riecke recommends  the formulae
which are subjoined."1

                   R.—Emuls. sem. papav. 3iijss.
                       Argillae purse,  Qij.
                       Syr. althaese, ^ss.—M.
                 A teaspoonful for a child two years old.
1 Stewart on Diseases of Children, p. 198. 
ENTERITIS.
517
                   R.—Argill. purie %*a.
                       Gum. Arab. gj.
                       Sacch. alb. gij.
                       Aqure foeniculi, 3 Lij.—M.
                 A teaspoonful for a child a year old.

  748.  The foregoing treatment seems so far suitable to any of the va-
rieties of diarrhcea;  but some modifications have been suggested in the
different species.  In mucous  diarrhcea, 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 diarrhcea is somewhat chronic;  and Dr. Con-
die 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. cret'a
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.
  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 diarrhcea 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 twen-
tieth of a grain of opium."   "We have thought we  derived advantage
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
diarrhcea;  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 decoc-

      1  Ranking's Abstract, vol. iv. p. 202.   * Diseases of Children, p. 391. 
518
ENTERITIS.
tions  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 tranquillize the
stomach; until that is done not only is the disease unchecked, but  the
suitable remedies cannot be exhibited.   For this purpose Dewees recom-
mends warm 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  advo-
cated the same plan, I believe it to be an error, or at all events an assump-
tion 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.  cretS,
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  stimulants
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 inter-
vals, seldom fail in removing it.  When  the  vomiting is violent and
frequent the application of a few leeches  to  the epigastrium 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 solution."
  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  we suspect the  existence  of  acid  in the stomach and bowels we
may combine ehalk 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. "&\v.
             Pulv. g. Arab. 9j.
             Sacch. alb. 5[ij.
             Aq. menth. pip. gss.
             Aquaa font. §ijss.
             Aqua? ammon. pur. gtt. xlviij. to gtt. clxiv., according to the age of
              the child.
  The dose is a teaspoonful every two hours.

  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, propor-
tionate to the age of  the child, will be found the best;  and when  these
watery discharges  are diminished  or  changed  for those  containing 
ENTERITIS.
519
feculent or bilious  matters, the treatment will then be the same  as for
diarrhoea.
  When cholera infantum becomes more chronic we may have recourse
to warm baths, frictions or blisters to the abdomen, anodyne injections,
astringents, and a slight improvement in the diet.   Some of the prepa-
rations of iron may be  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 proportion to
the*age and circumstances of the child.
  750.  The treatment of enteritis differs but little from that of gastritis
detailed in the last chapter, except that, when it has been preceded  by
exhausting diarrhcea, we must be cautious not to push  antiphlogistic
remedies too far.
  If  the  pulse be  pretty good, and the prostration not  too great, we
may apply leeches to the epigastrium, in number according  to  the age
and strength of the infant, intensity  of the disease, &c.; and the bleed-
ing 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 succession
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. cretae  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 accumulate
nourishment; if  this be given too soon  the disease will  rather  be  in-
creased.   Mucilaginous  drinks, or milk, with very light, thin,  farina-
ceous food, appear to be the most suitable; and when the disease is  on
the decline, then  we may gradually give more nourishment,  and wine if 
520
ENTERITIS.
necessary.   Of course every possible exciting cause must be  removed,
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, ipecacuanha
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 persesquinitrate 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  prolapsus
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.   Now,  in order to remedy this effect-
ually, 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  repeatedly 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
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, pre-
viously oiled.
   Another very troublesome  occurrence, as Dr. West  has remarked,
is  the intertrigo occasioned by the contact  of acrid  faeces.  Generally
this results from want of due cleanliness, but I have seen it in children
with an irritable skin in spite of the utmost care and watchfulness.  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 impress
most forcibly upon  all, the importance  of carefully  watching for the
first inroads  of cerebral complications, and  of  promptly applying the
very few 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 re-
course to counter-irritation to  the scalp  or to  the  extremities,  and to
calomel, if the stomach and bowels will bear  it, or to mercurial inunc-
tion 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. 
DYSENTERY.
521
  Again, the head symptoms show themselves very often  at  the  time
when the constitution of  the child has been so much weakened as to re-
quire 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 re-
commend, 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  constitu-
tion  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, is  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 diarrhcea from a swathe of
new  flannel being worn round the abdomen next  to the skin.
                      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 occurrence
than either element separately ; and some evidence of the morbid lesions
was brought forward 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  impressing  upon my
junior readers  the difference between a written description 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: 
522
DYSENTERY.
    Enteritis alone, in..........2 cases.
    Colitis alone   ...........  32   "
    Entero-colitis alone     .     .    .     .    .    .     .    .     .  11   "
    Follicular enteritis alone.........12   "
    Follicular colitis alone.........3   "
    Follicular entero-colitis alone........10   "
    Enteritis and follicular enteritis    .     .    .    .     .    .     .   8   "
    Colitis and follicular colitis........12   "
    Enteritis and follicular entero-colitis......2   "
    Colitis and follicular enteritis  .    .     .    .    .     .    .     .  17   "
    Colitis and follicular entero-colitis  .     .    .    .     >         .  11   "
    Entero-colitis and follicular  enteritis     ......   7   "
    Entero-colitis and follicular  colitis  .......   4   "
    Entero-colitis and follicular  entero-colitis.....7   "
    Softening of the large intestines    .......   8   "
    Softening of the small and large intestines    .    .     .    .     .  10   "
    Enteritis and softening of the large intestines .....   1 case.
    Colitis and softening of the small intestines   .....   2 cases.
    Colitis and softening of the large intestines   .....   1 case.
    Enteritis, colitis, and softening of the large intestines    ...   2 cases.
    Softening of the small intestines and follicular enteritis  ...   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   .     .   lease
    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 enteritis     .   1 case.
    Colitis, softening of the small intestines, and follicular colitis .     .   3 cases.
    Colitis, softening of the small intestines, and follicular entero-colitis   3   "
    Entero-colitis, softening of the large intestines, and follicular enteritis1  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, there-
fore, in making  a distinction, we must rather be  guided by the history
and symptoms of the disease than  by the result of post-mortem examina-
tion.   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 wish,  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
less frequent in infants than older children.
1 Mai. des Enfans, vol. i. p. 488. 
DYSENTERY.
523
  It may present itself in either an acute or chronic form, and may be
either primary or secondary.
  756.  I shall first  notice  Acute Primary Colitis.   This may  be
developed 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 diarrhcea, 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 fecu-
lent matter, until  they consist of little more  than  small quantities of
mucus mixed with blood, or even of  blood chiefly.  They are preceded
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 surrounding
parts become red, hot, painful, and excoriated.  M. Bouchut  observes,
that " erythema of the thighs and buttocks exists 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 papulae, 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 papulae becomes eroded, and superficial ulcerations, whose red  and
bleeding surface is on a level with the surrounding skin, are the result.
These ulcerations spread and unite until they sometimes form an ulcer
of considerable extent, and  constitute in themselves 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 cleanliness, 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
' Mai. des Nouveaux-nds, p. 221. 
524
DYSENTERY.
stage of the disease we  also not  unfrequently find aphthous  patches
around the anus.   Prolapse of the gut, also, is by no means uncommon.
  The fever continues; the pulse  is quick;  the heat of the surface un-
equal; the extremities often cold; the thirst considerable;  the mouth
hot and dry, often attacked by aphthae, especially at the angles;  there
is great depression of strength, and 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 symp-
toms supervene, and carry off the  patient.
  The principal complications of dysentery are affections of the mouth,
such as muguet, aphthae, 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 symptoms,
but in a minor degree.  Frequent discharges of mucus mixed with blood,
occasionally of faecal matter; uneasiness and pain in the bowels, tenes-
mus,  more or less tension and tenderness of the abdomen; a dry mouth,
thirst, no appetite, aphthae 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 re-
maining 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 were scanty,
passed  with great effort, 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 quan-
tities of stercoral matter, or  the remains of membraniform concretions.
At the same  time there were griping pain, tenesmus, 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 was there headache, singing in the ears, stupor, epistaxis,
lenticular eruption (maculae), sudamina, or the sibilant rale in the chest,
which so  constantly occur in the course of severe fevers.  The intellect 
DYSENTERY.
525
remained  intact until  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 inflamma-
tion, 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 intes-
tine 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 inflammation.
The color of the  membrane varied from  a pale rose to a bright scarlet,
interrupted  by the  enlarged,  whitish,  prominent  mucous crypts,  de-
pressed in the centre, and filled  by a grayish fluid.   At the edges  of
the folds erosion  and ulceration occurred, of an irregular form, super-
ficial 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 probably  occupying
the mucous follicles.  In those infants  who died quickly the mucous
membrane was of a  marked thickness;  but  in cases which  were pro-
longed, 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 gene-
rally 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  membrane
on the surface of  the large intestine.   In all, the mucous membrane 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 peritonaeum,  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 some-
times small  and isolated, in others superficial and  extensive, and, in a

    ' Gazette Me"dicale, 1836, p.  101.         z Mai. des Enfan?: vol. i. p. 530.
    3 Mai. de? Nouveaux-nes, p.  210. 
526                        DYSENTERY.

third variety, large, irregular, ragged, and penetrating.   The small in-
testines were generally healthy; the liver was sometimes extremely con-
gested.1
  761.  Causes.—I do not know that  either age  or  sex  have 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, dentition,
&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 Poor-house  between  April, 1846, and
August, 1848, during which 127 male children  under  ten  years  were
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  smallpox.
  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.—FiVen as a primary disease  the  prognosis must of-
ten be unfavorable, and still more when it supervenes upon a  disease
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 faecal 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 strength and
the severity of the attack.   Some writers have recommended these ap-
plications 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.
1 Dublin Journal, May, 1844, p. 298.
2 New York Med. Repository, vol. ii. p. 127. 
DYSENTERY.                       527
  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 faecal matter above  the  diseased portion of
the intestines, which must be evacuated;  it is true also  that the  dis-
charge of faecal matter is a first symptom of improvement; but I con-
fess I prefer, as in diarrhcea, 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 mucilaginous
or chalk  mixture with laudanum, or acetate of lead and opium, or calo-
mel, ipecacuanha, and hyoscyamus, or Dover's powder, in  doses propor-
tioned, 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 con-
tinued until the evacuations exhibited a beneficial change, or until saliva-
tion occurred.   Next to mercury, alkaline medicines were most useful;
the liquor potassae, 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 potassa 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 intestines,
are strongly advised by M. Trousseau and others.   These may be com-
posed  of the  acetate of lead, with  or  without laudanum, sulphate of
zinc or copper, the  ammonide of copper, &c.; but the one M. Trous-
seau 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 with 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,
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 evacuate
the bowels, and I do  not know a better means than  castor oil diffused in
mucilage, with a few drops  of laudanum, as suggested by Dr. Stewart
1 Dublin Journal, May, 1840, p. 302, et seq. 
528
DYSENTERY.
and Dr. West.  Dr. West's formula for an infant a year  old is as fol-
lows :—
                  R.—01. ricini, £j.
                      Pulv. acacise, Qj.
                      Syr. simp. gj.
                      Tinct. opii, gutt. iv.
                      Aquae flor. aurant. gvj.—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 diarrhcea, as being useful as tonics as well as in re-
straining the discharges.
  " In an epidemic of dysentery that occurred among children in Wash-
ington county, New York, an infusion of white oak bark, blackberry 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, ^ss.
                      Fol. achill. milleflor. gij.
                      Coque in lactis,  3).
               A dessertspoonful to be given frequently.

  In the epidemic of  1835,  at Paris, the treatment consisted of local
bloodletting, 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
  Dr. J. Cummings, of Mass., U. S., speais  highly of tannin in dysen-
tery.   It may be given along with Dover's powder, or chalk powder, in
doses of J to \ grain three times a day.3
  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.4
  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

             1 Condie, Diseases of Children, p. 244.
             2 Rilliet and  Barthez, Mai.  des Enfans, vol. i. p. 533.
             3 London Journal of Med.,  Nov., 1850, p. 1069.
             4 Clinical Medicine, vol. ii.  p. 226. 
DYSENTERY.
529
for drink, and  for food, some farinaceous substances  in  very limited
quantities.
   After a wdiile, indeed, the diet must be improved, as it will be essen-
tial to keep up the strength; and it  may be necessary to give wine or
brandy.  Dr. West observes : " As to the time when stimulants are to
be given, or the quantity in which they are to be employed, no definite
rule can be laid down.  Each case must be treated for itself;  and to be
treated successfully it must be watched most closely.  The necessity for
stimulants may  arise  suddenly, or the need of their administration may
be but temporary; while the infant's state in the morning affords, in
cases of severe diarrhcea, no sure criterion 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 instances."  " About half a drachm of brandy
given every two or three  hours to a child of a year old, in a quantity
of a few drops at a time, mixed with the cold milk and water, or the
thin arrowroot with which  it is fed, will often have the effect of arrest-
ing the sickness as well as of rallying the sunken energies of the system.
No stimulant has  appeared to answer  the  required ends better than
brandy, and,  when sufficiently  diluted,  children take  it very readily.
Sometimes, however, 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 aro-
matic 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 sweetened."
   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  kind, often renders 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 sup-
ply it with suitable food.  Farinaceous articles, such as arrowroot, sago,
&c are less easily assimilated in  early life than in adult  age; and in
cases of this kind they  not  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 excited to increased action,
in cases of chronic diarrhoea  or dysentery, by animal  broths, yet this
is a smaller hazard than that of the child dying  for want  of  sufficient
nourishment."1

              1  Diseases of Infancy and Childhood, pp 398, 400.
34 
530
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 with  them; and that  not  only by the people,
but by medical authorities, with whom, indeed, popular prejudices gene-
rally originate.  Even at the present  time, any disease 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 abracada-
bra 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 symptoms
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 irritation  which
gives  rise to worms.   Again, I  do not believe in the existence 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, Ru-
dolphi, Bellingham, &c.
  767. The ascaris lumbricoides  occupies  the small intestines princi-
pally, and is  found sometimes  in great numbers, occasionally accumu-
lated  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 occa-
sionally finds its way into  the stomach, and may be discharged through
the mouth or nostrils.
   The bothriocephalus latus, taenia 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 conceives to be organs
for the absorption of nourishment.   It is  an inhabitant  of the small
intestines, and is said to be  very  common in  Poland, Russia, Switzer-
land,  and some parts of France. 
WORMS.
531
  The taenia solium, or common tape-worm, is white and flat; its ante-
rior extremity long and slender, with a narrow neck and a minute head,
armed with four suckers, between which the  mouth  is situated, sur-
rounded 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 ca-
pillary extremity, which is  always adherent to the intestine.  The sexes
are in different 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 com-
mon 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 faseiola, the
scarabaeus, or beetle grub,  and the oestrus, or  bots; and he  alludes to
worms or larvae  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 follow the appearance  of worms.  Indica-
tions 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 eruc-
tations, sero-mucous vomitings, very acid; borborygmi, umbilical colic,
sometimes  constipation; at others, glairy  or  mucous  stools, meteor-
ism,  &C.1
  These  symptoms continue,, and to them are added pallor and puffiness
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 disor-
dered, the child  complains of a good deal of pain, and of a troublesome
itching about the anus.   The urine may be turbid, yellowish, or whitish.
like milk and water.  Finally worms may be detected in the alvine dis-
charges.
  M. Legendre has published an  analysis of the symptoms produced by
1 Barrier, Mai. de l'Enfance, vol. ii. p. 207. 
532
WORMS.
tape-worm in 33 cases.  Disorders of the cerebro-spinal system occurred
in 20 cases, swooning in 7, disturbed vision in 6, buzzing in the ears in
3, and a pricking or gnawing sensation at the epigastrium in 14 cases.1
I may  also refer my readers to the  abstract of  a paper by Prof.
Wawzuch, which  gives the result  of very extensive experience.2
  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, itch-
ing 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 pre-
sence ? 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.3   According to
M. Roman, the tongue has  a  pathognomonic character,  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.4  M. Guersent mentions  the  glairy evacuations mixed with
blood, and  of  a  greenish-yellow color, with the  abdomen sometimes
tumefied, sometimes flat.5   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.
  Now 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 per-
fectly agree with Rilliet and  Barthez, who, after ample personal expe-
rience and  extensive research, remark:  "The examination of  our own
facts, compared with those published by authors, has led us to  the con-
clusion that there is  no  other pathognomonic sign of the presence of
worms but  their expulsion."6  When any  are expelled it is presumable
that there are more, although this is only probability, not proof.7
   769. Suppose we  find the symptoms I have enumerated, or a suffi-
cient number of them, including the decisive  one of worms in  the eva-
cuations, are  we quite sure that the symptoms  are caused  bv  the
presence of worms  ?  That similar  symptoms may arise from gastro-
intestinal irritation  we know, and may not the worms, when present, be

      1 London Journ. of Med., Nov. 1850, p. 1073.
      * Ibid., p. 1074.                   s Page 162.
      * Ann. de la Soc.  Med. Prat,  de Montpellier,  vol.  xxii. p. 110.
     s Diet, de Med., vol. ii. p. 243.        « Mai. des Enfans, vol. iii. p. 609.
     7 Barrier, Mai. de l'Enfance,. vol. ii. p.  206. 
WORMS.
533
an accidental and harmless  complication, or may they not even be  an
effect of the previous condition of the mucous membrane ?  It is a diffi-
cult 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 probably be
the consequences of the preceding disorder of the intestinal canal.
  It is right, however, that I should notice some other very inportant
effects of worms, or what have been supposed to be such.  MM.  Mon-
diere" and Charcelay2 have advocated the opinion that worms may perfo-
rate 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, Scoute'tten, 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,  concludes 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 worm  is a painful sensation of puncture in one
particular spot, followed by a colorless  swelling, which  gradually sup-
purates.
  M. Charcelay has  published a case of  fatal  hemorrhage from  the in-
testine, 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 occasioned
by the accumulation of worms;  and Rilliet and Barthez regard this sup-
position as " not irrational," although their researches have not furnished
them with an incontestible 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 shortest
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;  Hal-
ler, Arronsohn, Bland,  and Tonnelle', of  their presence in  the air-pas-
sages, 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 ; con-
vulsions, chorea, pseudo-meningitis, meningitis, &c.
  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 satis-

              1 L'Experience, June 25, 1838.
              2 Recueil de la Soc. Med. d'Indre et Loire, 1839.
             » Diet, de Med. et Clin. Prat., vol. vii. p. 3S8. 
534
WORMS.
fied 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 quaestio 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 sufficient  for my
purpose to say, that one party believe that they or their germs  are de-
rived from without, but that they undergo certain modifications 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 what  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 have formed.  Cruveilhier admits that a superabundance
of nutrient materials may have something to do with their production.
  It would appear that an hereditary  predisposition to worms is  trans-
missible.  The age at which they are most frequent is from three to ten
years, although we meet with 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 localities,
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 taenia solium; the oxyuris and lumbricoides are more  fre-
quent in Great Britain, America, West Indies, and India.
  According to Bremser, worms prevail more in cities than in the coun-
try, 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 expect 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, complicated
by a  discharge of worms, whether essential or accidental, it would be
hard to say.
  Roederer and Wagler found worms in the intestines  of most of those
who died of the  epidemic mucous fever of  Gottingen; and in a  similar 
WORMS.
535
fever which prevailed at Naples in 1836, Thibault detected worms very
frequently.
  771.  Treatment.—Recollecting what I have said of the little yalue 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  reme-
dies  against worms in a  case in which we  have no proof of their ex-
istence.  But further, as we are not certain that  the disorder 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, therefore, 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 pursuing this plan  for  a
number of years, and have seldom been disappointed in promptly and
effectually  curing our patients, and have had but little  necessity for
resorting to either of the  articles which strictly appertain  to  the class
of anthelmintics.1
  With 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
diarrhcea.   But  if the irritation be not so great, in addition  to  bread
and milk, rice, and  arrowroot, we  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 the
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 diarrhcea,
with much  intestinal irritation, the remedies  already recommended must
be employed—counter-iritation, poultices, opiates, &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 columba root, with as much bicarbonate
of soda, two or three times a day, for a child two years old.
  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 destroy-
ing the  vitality of worms,  and those which merely remove them.
1 Diseases of Children, p. 254. 
536
WORMS.
  Dewees and others divide them into, 1, those which act medicinally
upon worms; 2, those which act mechanically;  3, those which prevent
the development of their ova or injure  the young of the viviparous, or
act beneficially upon the stomach and bowels.1
  Among the former we may  include turpentine, which may be 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 completely mechanical, the
minute  hairs wounding and irritating the worms; it is said to be chiefly
useful against the ascarides and lumbrici.2
  The fucus helminthocorton  is  a favorite remedy with French physi-
cians, and their opinion is  confirmed by Dr. James Johnson of London,
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 worms, particularly when there is want of ap-
petite and mucous diarrhoea.3
   " The  oleum chenopodii is a remedy in considerable repute with
American practitioners.  We have employed it in some cases with con-
siderable advantage, as follows :—
           " R.—Olei chenopodii, jj.
                Sacch. alb. pur., gum acacise, aa sjjss. M.
                Dein adde aq. menth. sativ. ^ijss.  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 lumbrici.  He gave  the infusion with
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 :—
           R.—Sem. santon., fol. tanaceti vulg., contus., 3a §ss.
               Rad. valer. pulv. ^ij.
               Rad. jalap, pulv. gjss.
               Sulph. potass, sjij.
               Oxymel scillae, q. s. ut fiat electuarium.
     A teaspoonful to be taken  two or three times a day for six or seven days.

                 1 Diseases  of Children, p. 493,
                 2 Neligan,  Medicines and their Uses, p. 20.
                 3 On Diseases of Children, p. 266.
                 * Condie, Diseases of Children, p. 256. 
WORMS.
537
  It is more effectual, however, when so given as to produce consistent
evacuations rather than watery stools.
  The empyreumatic oil of Chabert is regarded by Bremser, Brera, and
Rudolphi, 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 be-
fore eating is a most efficacious remedy.
  The Stannum granulatum 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  occasional ca-
thartic.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 taenia,
in nine months.2
  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 pome-
granate root, in cases of taenia,  with  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 taenia solium."   We
must, therefore, endeavor to suit  our  medicine  to the  peculiar kind of
worm.3
  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.
  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, solution
of common salt, aloes,  or sulphate of iron, lime-water and milk, assa-
foetida and milk, olive oil, sulphuret of potash,  &c.

         1 Dunglison, Diseases of Stomach and Bowels in Children, p. 60.
         2 Edinb. Monthly Journal, June, 1852, p.  559.
         3 Eberle, Diseases  of Children, p. 264, et seq. 
538
JAUNDICE.
  A bougie smeared with mercurial ointment, and passed into the rec-
tum, 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, with 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 be-
cause it seemed useless to make several chapters about diseases concern-
ing 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, he 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 continue 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 (maculae hepaticae), 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 occa-
sionally assume a very dark hue (melasina); in some instances they are
accompanied with a prickly or tingling sensation.  The disease appears
to be  most generally connected  with derangement of the  digestive
organs; the color of the skin being  dependent upon a morbid secre-
tion from the cutaneous vessels;  it has little  or  no  affinity with jaun-
dice."1                                                 J
 ^ In other cases, the infant is born jaundiced, the  skin and conjunc-
tivae 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 can-
not easily mistake the disease.  The skin is yellow, or greenish-yellow;
the conjunctivae the same color;  the urine  and perspiration  contain a
1 Condie, Diseases of Children, p. 698. 
JAUNDICE.
539
large quantity  of bile, and stain the napkins  and shirt of the  child
yellow.   The face looks thin, wrinkled, and old; the appetite is dimin-
ished ; 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 consti-
pated ; but I have seen an attack ushered in by diarrhcea, which ordi-
narily 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.
   The spirits are generally depressed, and the child may be more irrita-
ble than usual, but I have never seen delirium or convulsions result.
   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 advanced
stage there  are occasionally spots  of purpura, or bleeding from the
mucous membranes.   Induration of  the  cellular tissue also  sometimes,
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 appe-
tite returns.  But although, in general, it is a mild disorder, unattended
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, as first  described, I believe, by Sir Henry
Mark in his excellent essay,2 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 mem-
brane 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.  The
symptoms do not differ  much from those  already enumerated, except
that in addition there is a degree of fulness and tenderness of the hepatic
region.
   We must not forget how important a part the liver has played during

           1 Traite" de PIcterus ou Jaunisse des Enfans de Naissance.
           2 Dublin Hospital Reports, vol. iii. p. 292. 
540
JAUNDICE.
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 with 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 umbilical vein, after
it is tied, may become corrupted, and give rise to engorgement  of the
liver and jaundice.   M. Andrieu attributes it to 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. Con-
stipation, 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  fre-
quent and most intense, are the immature and  the feeble ;  while in none
is it so often met with, or in such an intense degree, as in infants affected
with induration of the cellular tissue, in whom the yellow color is often
so  deep as  to be manifest in the serum  infiltrated into their cellular
tissue, or poured  out into the cavities of the chest or abdomen.   Inter-
ruption  of the  function of the skin and  great impairment of that of
the lungs are, as  you know, the  grand characteristics of that  affection,
while in many instances of it, the foetal passages are still pervious,  and
the blood circulates in part through the 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 perform-
ance of the  function of  the  skin, of which  the  hepatic disorder  and
consequent jaundice are but the  effects.1
  I have known it occur near the termination of gastric fever, and its
nature was evident from the  previous  intestinal disturbance, the subsi-
dence of the pulse  and heat of  skin,  although the  icteric color  of the
skin and clay colored stools persisted for weeks.
  779.  Prognosis.—In  those cases which  proceed from mechanical ob-
struction, from irritation extending from  the duodenum, or from tempo-
rary congestion of  the  liver, the prognosis upon  the whole would be
favorable if we could distinguish them; 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 be-
comes emaciated  and exhausted,  the appetite is lost, the bowels are per-
manently deranged, and the  child is gradually worn  out;  it may be
carried  off finally by an attack of convulsions.
  Dr. A. B. Campbell  has related three fatal cases.  In one case the
1 Diseases of Infancy and Childhood, p. 372. 
JAUNDICE.
541
gall-duct was obstructed by inspissated  bile, and the other two by con-
genital 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 recover.
Or if necessary, we may aid this by a dose of  purgative medicine, rhu-
barb, castor oil, or what I  have found even better, a single grain of calo-
mel, repeated every  day or every second day.
  If  we have reason to suppose that there is irritation or inflammation
of the duodenum, we must first endeavor to  relieve that by fomenta-
tions, poultices, counter-irritation, and internally by mucilaginous or
chalk mixtures, with opium, the hyd. c. creta with Dover's  powder, &c.
When 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 blis-
ters, accompanied by the internal administration of calomel or the hyd.
c. crettt, 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  vegetable
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 mercu-
rial 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 invigorat-
ing diet.
  781. Enlargement of  the  Liver, $c.—Comparatively  little notice
has been taken of enlargement 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 following
details :2—
  Dr. Graves describes hypertrophy of the liver, as "that state in which
1 Northern Journal of Medicine, August, 1844.
» Dublin Journal, May, 1849, p. 308. 
542
JAUNDICE.
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, fret-
fulness, emaciation, loss of sleep, and impaired nutrition.   It is only a
form of general cachexy, connected with the scrofulous diathesis, affect-
ing secretion and nutrition  in general, and  the digestive  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 instance,
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-
tivae, 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 dulness 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, however,  soon dis-
appears.   The icteric coloration is in part effaced; the urine  recovers
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 foregoing
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 affected
with  laryngismus stridulus.   The  children  were  generally  languid,

              1 Clinical Medicine, p. 566.
              * Diseases of Infancy and Childhood, p. 432.
              8 Mai. des Enfans, vol. i. p. 578. 
JAUNDICE.
543.
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
ribs  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 con-
tinuance 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 observed 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 sto-
mach 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 duration 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, anaemic, and waxy, the abdomen enlarged.
The bowels 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 ap-
parently hereditary, and  unconnected either with nursing or disorder
of the stomach or liver.
   In two  cases the hypertrophy of the  liver originated in disease of
the heart,  and in another it was  complicated with  pleuritis and pericar-
ditis.
   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 application 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. 
544
ENLARGEMENT  OP 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 ap-
pearance  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 yel-
low-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 long time, 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 itj" 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 frequent  attacks
of fever subsequently.   The enlargement of her spleen  had first  become
apparent at five  years of  age; and  when I first saw her, a few weeks
after her return from Africa, it had attained so considerable a size that
her abdomen measured  twenty-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.   Inde-
pendently of the patient's  history, which, in a case  of this kind, would
be of  itself sufficient to prevent an erroneous diagnosis, the relations
of the swelling were characteristic;  for, although  situated at the side
of the abdomen,  it did not extend backwards into  the lumbar  region,
so as to fill it up  completely,  as an enlarged kidney  would do, but a

            1 Traite de Diagnostique et de Semeiologie, p. 287.
            2  Dr.  Battersby, Dublin Journal, May, 1844, p. 318. 
TABES  MESENTERICA.
545
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 percussion
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 intermittent
fever, which  is rare in Dublin.
  785.  Treatment.—The only treatment which Dr. Battersby has found
of any use is weaning the child when oversuckled, and giving nourishing
food; sending it out freely into the open fresh air,  and administering
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.

                        TABES MESENTERICA.

  1. If the reader will take the trouble of referring to the chapter on
pulmonary phthisis, he will find that the  mesenteric glands were more
frequently the seat of tubercular deposit  than any other organ of the
body, except the lungs and bronchial glands; that in one hundred cases,
MM. Rilliet and Barthez found the mesenteric glands affected in forty-
six.
  This tubercular deposition into  the mesenteric glands is the disease
which has been termed tabes mesenterica,  although, as it is generally  a
complicated affection, the description is  generally more or less uncer-
tain, inasmuch as the symptoms essential to tubercle have  not  always
been distinguished from those which  result from the intestinal or peri-
toneal irritation or inflammation.
  Among  the children of the poor, it is  by no means uncommon in
these countries, though among the richer classes it  is  comparatively
rare.  Rilliet and Barthez found it in one-sixteenth of all the children.
  Out of  144 cases, twenty-seven  were between the ages of one and
two and a half, forty-one from three to five and  a half, fifty-seven from
six to ten  and a half, and twenty-one from eleven to fifteen years of
age.   Of  this number, ninety-three were boys and fifty-one girls.
  They further state that the younger the child is the slighter is the
attack.  Dr. Merriman speaks of it as occurring in infants at the breast
as well as in older children; but this I must believe to be  rarely the
case.  From my  own  experience,  I should say that it is most frequent

                 1 Diseases of Infancy and Childhood, p. 436.
       35 
546
TABES MESENTERICA.
from three or four to eight or ten years of age.   M. Barrier remarks
that it is very common in phthisical children.
  2. Symptoms.—Let me again observe that  the  symptoms which ac-
company this  disease are not referable simply to the condition of the
glands, but arise from the intestinal disorder which so generally precedes
and accompanies the affection, and from certain other  more  rare com-
plications of the peritoneum, &c.
  In some cases,  however, there is a singular absence of all indications
of disease, the first discovery being made on examination  after death,
as,  for example, in the case related by M. Bayle of a little girl who died
from a burn, in apparently good health, but in whose mesentery was
found a dozen tubercles of considerable  size in a state of partial suppu-
ration.   Similar cases are mentioned by MM.  Morgagni and Guersent,
and probably most of us have found more or  less deposition in these
glands which had yet attracted no attention during life.
  In other cases, however, the symptoms not only excite suspicion, but
are at  length sufficiently well  marked  to enable us to determine the
nature of the essential disease.   Probably the earliest symptom which
excites  attention, is  a failure  in the  health and healthy looks  of the
child :  it  is  uneasy, pale, fretful, the appetite diminishes, the  bowels
are disturbed, and it loses flesh.   For a time this may  be all, and it is
evident that the  cause is  disorder of  the  digestive system, and not
necessarily tabes mesenterica.  However, sooner or later other symptoms
are superadded, and the  most significant is a dull, deep-seated pain
about the centre of the abdomen increased by  firm pressure, but which
is not  necessarily accompanied  by tension or vomiting,  nor  does it
resemble  the  tenderness of peritonitis.  It  may persist  a  long time
without much change, and with  no more peculiar characteristics, but,
according to M.  Guersent, it  is  most  remarkable  during  spring and
autumn, often diappearing during the heats of summer.1
  If the bowels  be  much disturbed,  we  may have some tympanitic
enlargement of the abdomen; at the same time in estimating this, all
through  the disease we must not forget that a  child's  abdomen  is
naturally somewhat prominent and disproportionate.   At this  period
we  shall rarely find any fluid or solid enlargement.
  3. As the disease advances, the symptoms all become aggravated, and
the constitution deeply suffers.   The  appetite is variable,  sometimes
slight, in other cases almost voracious, with a  desire for depraved food,
as  chalk, earth, &c. in  some cases, but this  I do not think so com-
mon as  in  disease  of the pancreas.   The bowels are very irregular,
sometimes constipated, at other times  too frequently moved ;  the dis-
charges  being  frequently slate,  or  clay colored, or  brown, and highly
offensive.
   The pain  in the  abdomen  continues, or even  increases;  sometimes
there  is a  tympanitic  enlargement, in  other  cases, but more  rarely,
fluid may be detected. If the abdomen be tense, of course  the tumefied
mesenteric glands cannot be felt; but if not, we may frequently ascer-
tain their presence, especially  if much deposition have  taken  place.
1 Diet, de Med., in 30 vols., vol. vi. p. 444. 
TABES MESENTERICA.
547
   MM. Rilliet and Barthez  remark upon this subject: "Although the
 tuberculous masses which occupied the glands were often very volumi-
 nous,-we were far  from being able always  to appreciate them by the
 touch.  There it was  impossible to recognize these tumors when the
 tension of the abdomen was very considerable;  and in other cases in
 which it was less,  a  repeated  and minute examination failed.   There
 are, however, cases in which we could ascertain the presence of abdomi-
 nal tumors even though small, but then the abdomen was very flaccid,
 and extremely soft, allowing itself to be depressed even to the vertebral
 column.   In  other cases, modifications arising from  meningitis,  facili-
 tated the palpation of the abdomen, and permitted us to  recognize the
 tumor in its cavity.   In the case of a boy of five years,  the  abdomen
 was very  unequal,  knobby,  projecting at the hypogastrium, depressed
 at the epigastrium, flaccid and soft.  Immediately beneath  the umbilicus
 we perceived  a tumor which passed  the median line on  either  side  a
 finger's breadth and a half.   This tumor was  very hard, slightly  move-
 able, and its tense edge rather sharp.  The next day it appeared more
 superficial because  of the sinking and softness of the abdominal parietes.
 The superior portion was very movable, but the deeper portion was les8
 so.  It appeared larger than on  the preceding  evening, probably be-
 cause  we  could  circumscribe  it more completely.    On making  the
 autopsy, the mesenteric glands formed a mass as large as  the fist, com-
 posed of a number of tuberculous glands the  size of a small egg.  Some
 were entirely tuberculous, in  others, tubercular matter  occupied  the
 centre,  and  the  surrounding glandular tissue  was enormously  deve-
 loped."
   These  distinguished  observers further  add, that  " the  abdominal
 tumors, resulting from tuberculization  of the mesenteric glands, are
 always situated near the umbilicus; they are more or less voluminous,
 but generally unequal on their surface; we can perceive that  they are
 formed by the agglomeration of a number of tubercular masses.   One
 might believe, d priori, that the fixity of the tumor was a  constant cha-
 racteristic, but it is not always so ; sometimes, because the glands are not
 sufficiently enlarged to maintain the mesentery immovable against  the
 vertebral column; in other cases because the  glands themselves do not
 change their place.   But this apparent mobility, according as the  ab-
 dominal parietes vary in tension according as the intestines are full or
 empty, affords us varying results, from an examination of  the abdomen
 after a few days' interval."-1
  Let me repeat the caution, that the disproportionate size of the  abdo-
 men which is remarkable in rickety and scrofulous children, should not
 be mistaken for the enlargement from mesenteric disease.
  With this enlargement of the abdomen, there is a corresponding ema-
ciation of every other part of the body; the skin becomes loose and flaccid,
its color changed to a dirty, sallow hue; the face is wrinkled and the fea-
tures become sharper, so as to produce a very distressing expression of
suffering.
  The  pulse  is permanently quick,  but  more rapid towards  evening,
1 Mai. des Enfans, vol. HI. p. 443. 
548
TABES MESENTERICA.
when a kind of hectic fever sets in, lasting till near morning, and ter-
minating in profuse sweat.  The urine is scanty, and contains an excess
of phosphates.
   Thus we have disorder of  the  stomach  and bowels, increasing in
amount and varying in character, deep seated pain in the centre of the
abdomen, tumefaction of the abdomen by air or fluid, sometimes enlarge-
ment of the mesenteric glands, and hectic fever.
   4.  But we may naturally inquire what are the mechanical or other
effects of this enlargement and degeneration of  the glands ?  How far
it offers an impediment to the  circulation through  the lymphatics and
bloodvessels ?   Sommering, and other authors, do not believe that the
lymphatic circulation is  injured at all, but  that when  the glands are
entirely obstructed, it is  completed by  the anastomosing branches and
the chyle thus conducted to the thoracic duct.  Barrier, however, sug-
gests, and  I think reasonably, that the  defective nutrition in tabes me-
senterica may be owing partly to this state of the glands.  I may add,
that it may also be owing to the impediment in this situation that we
sometimes find fluid effused into the peritonial cavity without evidence
of inflammation.
   It does not appear that the mere pressure  of  the  tumors  ever pro-
duces stoppage of the intestines, although M. Guersent  mentions that
he has known  adhesions  between the mesentery and the peritoneum
produce strangulation, or even  complete occlusion of the intestines.
   It sometimes happens that an adhesion is formed between the  tuber-
cular mass  and the intestines, when the  former suppurates, and  Rilliet
and Barthez mention that they have seen the commencement of perfo-
ration of the intestine at this part.   Others mention that through such
a perforation the softened tubercle is discharged.
   We are told on the authority of Sir  A. Cooper, of  this tubercular
matter making its escape  by an abscess which burst  at  the umbilicus,
and was afterwards cured by adhesive plaster.1
   When the diseased mass is very large, it is said to give rise not merely
to ascites, but to anasarca of  the lower extremities, from  its pressure
on the veins, especially at an advanced stage of the disease.
   Lastly, the patient is obnoxious to inflammation of the intestines, but
more especially to chronic peritonitis, partial or general,  with its train
of symptoms to be noticed presently.
   I must not omit to mention also that as tubercles are seldom deposited
in the mesentery alone we may have a complication of diseases, such as
tubercular meningitis, bronchial and pulmonary phthisis, &c.  &c.2
   The duration of the disease will depend very much upon the presence
or absence  of these complications.   In many cases the disease may go
on for months before we are  quite certain  of  it, and the child may
linger until fairly worn  out by the hectic  fever  and  want of  nutri-
tion ; in other cases the occurrence of enteritis or peritonitis, acute  or
chronic, will hasten the fatal termination.
   5.  Morbid Anatomy.—The appearances found  on dissection  vary a
good  deal, according to the period of the disease, and even at the same
period.
1 Coley, Diseases of Children, p. 223.
Rilliet and Barthez. 
TABES  MESENTERICA.
549
  At an early stage we may find the glands but little, if at all, enlarged,
of an oblong shape, pale, of a natural color,  and with no appearance of
inflammation.  On cutting them open, we discover tubercular matter,
either in the form of small grains  or  in  larger irregular masses, not
mixed with nor adhering intimately  to the proper tissue of the glands,
but rather compressing it, and lying between it and the peritoneum.
  Again, the glands may be inflamed, and then they will present a dif-
ferent appearance, the proper tissue will  be found red, enlarged, and
gorged with  blood, more resisting to the  scalpel than is  natural, and
increased in volume.   The tubercular matter may  assume  the form of
rounded or irregular  grains, or we may find it,  but  more  rarely, as
patches, or  irregular laminae  which insensibly  merge  into the proper
glandular structure.
  Whether the glands be inflamed or  not, and whether the  tubercular
matter be deposited in their substance or only on the surface, it is some-
times surrounded by a cyst, more or less  distinct; in  other  cases the
cellular  tissue  which  surrounds it  is  gradually confounded with the
glandular substance, and is partly in contact  with the peritoneum, which
serves to complete a kind of cyst.
  When this mesenteric disease is  extreme  and of long standing, M.
Guersent observes that " the glands are often completely destroyed, or
transformed into isolated or agglomerated  masses of tubercle, of  differ-
ent sizes, from that of a pea  to that of an  egg, in which no trace of
glandular structure can be  detected.   The  tubercular  matter is  occa-
sionally  effused between the laminae  of  the mesentery,  and then  forms
patches of greater or less extent, which have sometimes been mistaken
for a kind of abscess when the  tubercular matter was  softened.   True
abscesses in this situation are very rare.
   " Mesenteric tubercles undergo all the stages of degeneration to which
this morbid product is exposed.   At first crude, they are of a dull white
color, or opaline or yellowish.   When the  tubercular matter  is scanty,
and as it were infiltrated in the tissue of the gland,  it  is  sometimes
traversed by small, delicate capillary vessels, which subsequently dis-
appear.   In the latter stages we find every degree of softening, from
a curdy pulp to fluid pus.   It is rare, however, to have  very fluid pus in
mesenteric tubercles, either because  it is partially absorbed or because
the patients die before the last change  has taken place.  We find occa-
sionally a dry and pasty matter, analogous to what  we see in tuberculous
bronchial glands.
   " At whatever stage the tubercles may have occurred, the peritoneum
is almost always healthy, transparent, or slightly  tinted  with  a pink
color.   In some few cases it is red,  inflamed and adherent to  the intes-
tines."1
  M. Papavoine mentions a case in which the mesenteric glands were
converted into greenish-yellow tubercles containing a limpid fluid of the
same color in the centre.   The same author saw in  a scrofulous boy, the
mesenteric glands enormously enlarged, with a central  cavity, with  un-
equal parietes containing a deep red opaque  fluid, analogous  to bile.8

             1 Diet, de Me"d., in 30 vols., vol. vi.  p.  437.
             2 Rilliet and Barthez, Mai. des Enfans, vol. iii.  p. 407. 
550
TABES MESENTERICA.
   M. Barrier mentions that the changes connected with the peritoneum
 are  generally either  tubercles, adhesions,  or serous or sero-purulent
 effusion.1
   The mucous membrane of the intestine is  not uncommonly red and
 inflamed, especially towards  the end of the small intestine, where  the
 mucous glands are most largely developed.  In some cases we find small,
 round, superficial ulcerations and traces of  former ulcers.   But besides
 these small ulcerations, there are occasionally deeper ones involving all
 the coats of the intestine and piercing sometimes through the peritoneum.
 These larger ulcers are generally placed circularly  and parallel to the
 transverse valves of the intestine.   In appearance, they resemble very
 much the ulcers we find in the intestines of phthisical patients.   They
 occur, according to M. Guersent, in more than half of the cases of tabes
 mesenterica.
   On the other hand, the mucous membrane is often perfectly healthy,
 even in cases where the glands are the seat of considerable tubercular
 deposition.
   If the child have suffered from chronic peritonitis, we shall  of course
 find the  usual morbid changes, and the same  may be said of  the other
 complications, but upon these I need not dwell as I have noticed them
 in detail elsewhere.
   6. Diagnosis.—After a careful analysis of the  symptoms of this
 disease,  M. Guersent remarks,  "it results from this  discussion upon the
 physiological characteristics of tabes, that almost all the symptoms which
 have been hitherto  assigned to  this  disease, do not  really belong to  it,
 but depend upon other affections of the intestinal canal  with which it is
 often confounded, because they ordinarily accompany it.  The  only
 pathognomonic  symptom, the only positive character by  which tabes
 mesenterica can be recognized  in its last stage, is feeling the tubercles
 by the touch: all others are more or less doubtful,  and mark the dis-
 orders with which it is complicated."2
   Although it is true, to  a certain extent, that many symptoms  have
 been too lightly attributed to this disease which are not essentially con-
 nected with it, and  also that but little stress can be laid  upon any single
 symptom (except the one) taken alone; yet  I can hardly doubt that we
 may assume the presence of the disease with strong probability from the
 constitution of  the  patient, the history, the  sequence, and  combination
 of certain symptoms.
   2. In  the earlier  stages,  it  may be quite impossible to decide whether
 the intestinal irritation is connected with tabes or depends upon chronic
 enteritis  only, because the  two diseases  constantly coexist.  M. Guer-
 sent mentions that in the former the diarrhcea and pain are increased by
 the slightest errors  of diet, but  not  by movement, whereas in the me-
 senteric disease, the pain is augmented by pressure but  not  by flatulent
 distension or diarrhoea.   Add to  this a scrofulous constitution, perhaps
 the presence of tubercles  in  some  other part, the persistence of the
symptoms, notwithstanding appropriate treatment and unusual dulness
1 Mai. de l'Enfance, vol. ii. p. 331.
* Diet, de M6d., in 30 vols., vol. vi. p. 447. 
TABES MESENTERICA.
551
on percussion around the umbilicus, and we have ground, I think, for
suspecting very strongly the presence of this disorder.
  3. The history of  the  disease will aid us in distinguishing it from
chronic peritonitis in some cases, but no  doubt a degree  of  obscurity
will often remain, inasmuch as the two diseases may coexist.
  4. At a more advanced  stage when  the tumors are perceptible, the
diagnosis will of  course be much more easy and certain, and  yet some
confusion may arise  between them  and tubercles of the liver and kid-
ney.   The principal points of difference laid down by MM. Rilliet and
Barthez are, 1,  the  seat of the latter tumors in one or other hypochon-
drium  ; 2, by the form of the tumor which terminates in a sharp edge;
3, by the possibility of pushing back these tumors under the ribs ;  4,
by the increase of dulness in one or other hypochondriura ; and 5,  by
the absence of tension and distension of the abdomen.1
   Still, there are some cases in which the diagnostic is and will remain
very obscure; and I may say the same of the  distinction between pan-
creatic tumors and mesenteric disease.
   7.   Causes.—Whatever causes favor the development of scrofula,
or tubercle generally, will no doubt aid powerfully in the production of
mesenteric disease.   When the general and local tendency to tubercu-
larization exists, we can  easily understand its  being stimulated into
activity by improper and insufficient food, dirty and  badly ventilated
dwellings, exposure to cold, insufficient clothing, &c;  but we cannot tell
why in one  person the lungs are affected and in another the abdominal
organs or the mesenteric glands.
   8. Prognosis.—Nothing can  be more serious than  the  prognosis in
mesenteric disease,  at an advanced stage, when the tumors can be felt.
Almost all the cases prove fatal, either by gradual exhaustion  or by the
occurrence of some  complication.  At an early stage, patients  recover
from the  intestinal disturbance, &c.;  but then  the question arises whe-
ther the disease was really tabes, and the answer in many cases is very
doubtful.
   M. Barrier thus states his experience:  "The prognosis of tubercular
affections of the abdomen is at least as grave as that of tubercles of the
thorax.   In fact, the first rarely exist without  the second,  although the
latter  may occur without  the  former."   "In some cases, abdominal
phthisis runs its course with great rapidity, especially when the mesen-
tery, the  peritoneum, and the intestines are all  affected; but when these
are singly affected,  their  course is slower."  " That which proves fatal
in many cases before the tubercles of the abdomen have completed their
stages is the coincidence of tubercular affection of the thorax,  head, &c,
or certain local or general complications, as perforation of the intestine
followed by acute peritonitis, meningitis, eruptive fevers, &c.   There is
no reason/however, to disbelieve in the possibility of a cure, or at least
of rendering  the malady stationary.  The cure may take place, 1, by
the softening and elimination  of the tubercular matter; 2, by its trans-
formation into cretaceous matter ; 3, by its absorption."2
1 Mai des Enfans, vol. iii. p. 393.
2 Mai. de l'Enfance, vol. ii. p. 351. 
552
TABES  MESENTERICA.
  Rilliet and Barthez mention a case in which a portion of the tumor
had been absorbed and the remainder  had undergone the cretaceous
transformation.1  A similar case has been recorded by Dr. Carswell,
who states that " the patient, who, when a child, had been affected with
tabes  mesenterica, and also with swelling of the cervical glands, some
of which ulcerated, died, at the age of twenty-one, of inflammation of the
uterus, seven days after delivery.   Several of the  mesenteric glands
contained a  dry cheesy matter, mixed with a chalky  looking substance;
others were  composed of a cretaceous substance ; and a tumor,  as large
as a hen's egg, included within the  folds of the peritoneum, and which
appeared to be the remains of a large agglomerated mass of glands, was
filled  with a substance resembling a mixture of putty and  dried mortar,
moistened with a small quantity of serosity."
  Unfortunately, all these modes of cure are rare, and I fear that the
true explanation of the many cases of cure which have been recorded is
to be  found  in the fact that the disease was really only chronic enteritis
or gastro-intestinal irritation.
  9.  Treatment.—Very much will depend upon the state of the  child
and upon the stage of the disease.
  During the early stage, or when the  intestinal irritation is the most
prominent symptom, our efforts must be directed  to quiet that, and to
regulate the secretions and actions of the bowels.  Some of the anodyne
astringents I have mentioned, when speaking of diarrhcea, if the bowels
are too  free, with  perhaps  some counter-irritation to the surface, will
often  succeed.
  When the bowels are quiet, the secretions may be corrected by hyd.
c. creta, combined either with  rhubarb or columbo; and, as a change,  I
have  seen much benefit from some bitter tonic, as  columbo powder and
an alkali.
  When the bowels are confined, mercurial purgatives are of great use;
and many authors lay great stress  upon purgatives  and  emetics as  a
means of removing the disease.  This may be the case in the earlier
stages, but it may well be questioned whether they  have this effect, if
deposition have taken place.
  In  some cases, when the abdomen was beginning to enlarge, after I had
regulated the bowels, 1 found  the  iodide of iron  of great use, in  the
proportion of one grain  of the salt to an ounce of syrup;  a teaspoonful
to be given  three times a day, to a child three or four years old.
  It  is  doubtful in such cases whether the benefit does not altogether
depend  upon the action of the medicine upon the mucous  membrane of
the intestinal canal rather than upon  the mesenteric  glands.
  All British authorities are agreed, I think, upon  the value of mercury
at some period of the disease, although they differ  as to the stage in
which it  is most serviceable.  French writers, however,  seem very
doubtful.
  I have not myself had recourse to much mercury in  the earlier stage of
the disease, but Dr. Coley speaks well of its effects.  He recommends
a scruple of the ung. hyd. first to be rubbed  over the  abdomen every
1 Mai. des Enfans, vol. iii. p. 421. 
TABES MESENTERICA.
553
night for half an hour, and that the patient  should  take every night
from two to four grains of Dover's  powder, and three or four grains of'
hyd. c. creta.   Every second or third morning, a dose of castor oil is
to be given, or a grain of calomel and  three  or  four  of rhubarb, and
this  treatment must be  continued  for some time, unless the gums be
touched.1   Dr. Merriman advises calomel  in  large doses at first, and
then smaller ones for a considerable time when  the belly is enlarged,
until some favorable change takes place in this particular.
   M. Wendt advises a combination  of sulphur with calomel in the pro-
portion of one part to twenty.
   A light bitter tonic has  also been  found very useful, either alone or
in combination with an alkali.
   After the deposit of tubercular matter has fairly taken place, or after
we believe it has done so, the principal remedies are said to be mercury,
iron,  iodine, acetate of potash, &c.  &c. sulphur, iodine, or sea baths.
   The mercury may be  given in form of  calomel, blue pill, or hyd. c.
creta, or we may have recourse to inunction, and the extent to which it
Bhould be  carried will depend upon the  condition of the child and the
state of the bowels.
   Various preparations  of iron have been recommended by different
writers.   The  tincture or salt of steel or  chalybeate waters are pre-
pared by Dr. Munn; others prefer  the carbonate or the tincture of the
muriate, &c. &c.
   The same may be said of iodine, some advise one form, some another;
the great point appears to be to guard against any injurious action
upon the gastro-intestinal tube.
   I have found the iodide of iron in syrup apparently better than either
element separately.   Some prefer Lugol's solution in doses of  three to
six drops three times a day, or the  hydriodate of potash in decoction of
sarsaparilla, adding a minute dose  of opium if the bowels be irritable,
or suspending the medicine altogether.
   As an  external  application, Dr. Condie advises the iodide of lead
(5ss  to 3j of lard), or the ung. hydriod. potassae.2   Or the abdomen may
be rubbed or painted with  the tincture.
   Ioduretted baths  have been highly recommended ; they are formed by
dissolving  one grain of iodine and two of hydriodate of potash in a
gallon of  water.
   From the benefit derived from cod-liver  oil  in phthisis,  we may natu-
rally expect similar effects from it in mesenteric disease ; but although
I have found it useful in some  suspected cases, yet they have been too
undecided  and too  few to  enable me to speak positively, and I  have
not as yet seen any record of an adequate trial  of the remedy by any
one else.
   But as a general rule  the success seems  very limited;  in  many cases
anything like active treatment is injurious, and the utmost we can effect
is the palliation of  the more distressing symptoms.
   Inasmuch as bad air, inferior or innutritious diet, and exposure have
much to do with predisposing to or  producing the disease, our attention
1 Diseases of Children, p. 226.
* Diseases of Children, p. 627. 
554                        PERITONITIS.
must be carefully directed to these points.   Fresh pure air, well venti-
lated  comfortable apartments,  and warm  clothing, are all  absolutely
necessary.
  Bland' mild food must be selected until the fever and  intestinal irri-
tation  subside.  A mild diet is generally the  best, or arrowroot  with
water or milk.  Broths must be given with great caution, and  generally
speaking animal food is objectionable.
  Frequent washing portions of the body, warm or cold baths, will also
be found very useful, both as  prophylactic measures, and also as reme-
dies if the disease be not too far advanced.
  The indications of treatment for the  different  complications will be
found in the respective chapters.
                       CHAPTER  XXI.

                            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 Barthez met with a
dozen cases of acute peritonitis.
  In  certain seasons it seems more common than  in others.  I met with
three cases in one winter within a short time of each other, and judging
from  them, I suspect that cases that are put down as enteritis are as
frequently peritonitis.
  M. Thore found that acute peritonitis existed in about six  per cent.
of all the infants who died at the Hospice des Enfans trouv&s.
  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.1  Meissner2 has entered pretty  fully  into the subject.
Heyfelder,3 and  Malespini,4 and Thore,5 have published some interesting
papers.
  It is  noticed by Drs. Stewart and Condie.
  Peritonitis  may be  either  acute  or chronic, the latter occasionally
being of a scrofulous character, and accompanied with  the deposition of

           ' Wochenschrift fur die ges. Heilkunde, 1833, Nos. 17, 18.
           2 Ibid., vol. ii. p. 66.
           3 Studien in Gebiete der Heilwissenschaft, 2, B. D. S. 190.
           * Archives G6n. de Med., 1840.
           5 Archives Ge"n. dc Med., Aug. Sept. 1846. 
PERITONITIS.
555
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 Dug&s,  Billard, Simp-
Bon, &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 abdomen, and
greatly increased by any movement.   In very  young infants it is some-
times 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; some-
times dull, sometimes resonant  on  percussion.   After effusion has taken
place it is always dull.   This dulness and tension are 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  common  a symptom in adults,  is not general with
children. Rilliet and Barthez met with it only in  two cases.  Constipa-
tion 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 after-
wards.
   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, and
an entire  loss of appetite.  The skin is hot, and  occasionally at the
commencement there are rigors, but not always.
   The breathing is quick, high, and short, not from  any thoracic affec-
tion, but from the pain caused  by  the pressure  of the descending dia-
phragm in a fuller inspiration.  After  effusion  has  taken place, there
may be a mechanical impediment to full and free respiration.
   The  pain  occasioned by any movement gives a sort of fixity to its
position and  to an  intolerance of any change  of posture.  Dressing,
changing napkins, nay, raising the  arm  even, will give rise  to shrieks
of  agony so  acute  that  a  suspicion naturally arises of injury or of
some affection of the parts, the moving of  which gives so much pain.
This symptom, so significant, should never fail to direct our attention to
the peritoneum.
   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- 
556
PERITONITIS.
serves:1  "The active symptoms diminish in intensity;  the abdominal
parietes grow thin at some spot, where a passage at length is formed,
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-Chirur-
gical Society, in November, 1846.2  A few similar cases may be found
in medical journals;3 and one has come under my own observation in
the person of a little girl, whose history I  formerly related,4 as afford-
ing 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 twenty-six days ;  in two, in  twenty-six and  twenty-seven days ;
in two, in thirty-six and thirty-seven days.5
   There is  no essential difference between the symptoms of primary
and secondary peritonitis; the former is, perhaps, more frequently cir-
cumscribed, and  the latter, supervening upon other serious affections,
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 quan-
tity 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 coexist  with effusion, slight,5 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 dis-
 covered.

   1 On Diseases of Infancy and Childhood, p. 416.
   * Medical Gazette, November, 1846.
   3 Bernhardi in Preuss. Med. Zeitung, No. 10, 1842; and Beyer, Casper's Wochenschrift,
 1842, No. 5.
   4 Lecture vii. p. 81.                     * Maif des Enfans,  vol. i. p. 564. 
PERITONITIS.
557
  790.  Caunes.—Any of the ordinary exciting causes of inflammation
may give rise to peritonitis, exposure to cold or wet, falls, blows, &c.
  Or it may be the consequence of a surgical  operation, and occasion-
ally it follows the perforation of the gall-bladder, the stomach, or intes-
tines.   Thus, Rilliet and Barthez state  that in one case it was the re-
sult of tapping ;  in another, of a fall; in a third, of the rupture of the
gall-bladder; in a fourth, of ulceration perforating the intestines.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 fol-
lowed on erysipelas, and in four, on phlebitis of the umbilical vein.
  791.  Diagnosis.—I.  Acute peritonitis is more likely to be confounded
with enteritis or entero-colitis than with  any other affection ;  in both
there is pain and tension of the abdomen,  with vomiting  and diarrhcea;
but in  peritonitis  the   pain  is far more intense,  the tenderness far
more acute: the aggravation of  suffering by the least movement; the
drawn,  anxious face, the quick pulse, and the fluctuation in  the  abdo-
men, 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  evacuation, in-
ternally 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 may be 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  inflam-
mation 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 secondary 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 distress,
in  which case we must substitute frequent fomentations.
   Next to bleeding, the most important remedy is mercury, given so  as

                  1 Mai. des Enfans, vol. i. p. 568.
                  * Stewart, Diseases of Children, p. 263. 
558
PERITONITIS.
to affect the constitution, as indicated either by tenderness of the gums
or mercurial diarrhoea.  I have generally found frequent small  doses of
calomel better than larger ones, and in  conjunction with mercurial in-
unction more effective than alone.  For example, to a child of two years
old, half a grain of calomel, with a grain of the pulv. cretae 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 pre-
sent, 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 diarrhcea 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 gene-
ral, I much prefer trusting to the calomel  acting sufficiently upon the
bowels as well as upon  the constitution.  Moreover, if the peritonitis
be the result of perforation of the intestine, it will be of great conse-
quence 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 calculated
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 mat-
ters from the intestines into the cavity of the peritoneum.
   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 mode-
rate, 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. in.  Chronic Peritonitis.—Slight allusions to this form of disease
may be found in some of  the writers on  diseases of children, and more 
PERITONITIS.
559
details by Baron,1 Abercrombie,2 Gregory,3 Billard, Rilliet and Barthez,
Sir II. Marsh, West, &c.
  M. Billard gives a short notice of chronic peritonitis, and relates the
following case:—
  " Josephine Perrine, aet. 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
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 diarrhcea, consisting of green and mucous faeces.  On the
23d, the diarrhoea became more light colored.  On the 24th,  the same
general symptoms, but without fever; tension of the abdomen, 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 be-
tween  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 striae, 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 obliga-
tion to Sir H. Marsh.
   Mary----, aet. six, a healthy  child, of delicate, fair complexion, fair
hair, &c, about  December, 1840, was observed to be somewhat unwell;
she suffered from occasional attacks of diarrhoea, which, after a time,
either  subsided or were relieved by the usual remedies.  Occasionally,
she complained of shooting pains through the abdomen, coming on irre-
gularly, and  lasting  but a short time,  but not accompanied with tender-
ness or swelling.  Her appetite became  delicate and fastidious, with
some thirst.  The pulse was scarcely quickened; her  countenance be-
came pale, and she became thin.  Matters continued in much  the same
state for  about  a month—occasionally attacks of pain and diarrhoea,
with loss of appetite, &c.—but, after  this time, I observed that the ab-
domen became  gradually swollen,  with a distinct sense of  fluctuation,

             1 On Tubercles, &c, p. 131.
             - I>isenses of the Abdominal Viscera, p. 191.
             * Med.-Chir. Trans., vol.  ii.  p.  259.
             4 Mai. des. Enfans, and Trans., by Dr. Stewart, p. 354.
             5 Dublin Journal, March, 1843, p. 1. 
660
PERITONITIS.
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 symp-
toms continued much the same.
  By Sir H. Marsh's advice, hyd. c. creta, gr. ij, P. Jacob, gr. j, 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 con-
tinued 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, was 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 ointment
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 dis-
appeared ;  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 benefited
by similar  treatment.
  796. Chronic scrofulous peritonitis, with effusion,  may follow acute
inflammation, or it may occur without our being able  to recognize any
  receding acute stage, coming on so gradually, in fact, that we may not
  e aware of the nature of the disease until it is fully developed.   As M.
Dug&s observes, "there may be occasional pains, colics, irregular 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 with-
out pain; the appetite is pretty good, the temperature natural, and the
pulse quiet; but at length—it may be weeks or months—we hear com-
plaints 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.
   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.

> Diet, de Me"d. et de Chir. Prat., vol. xii. p. 295. 
PERITONITIS.
561
  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 omaciated.   In
many cases, indeed, the early symptoms are so slight that no attention
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 questioning 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 complaint 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 complete
relief; beginning in some one part of the abdomen, and gradually spread-
ing 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 dis-
tension, and requires  the dress to be left loose; and then, if an  exami-
nation be made, the abdomen will be found more  or less swollen.   Per-
cussion 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
o-uard against the action  of the abdominal muscles,  and the natural
elasticity  of the integuments.  The best mode is to lay the child on its
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

         1  Diseases of the Abdominal Viscera, p. 192.
         8  Mai. de 1'Abdomen, Clin. Med., vol. iii. p. 587.
         1  Med.-Chir. Trans., vol. ii. p. 263.     4 Ibid., vol. ii. p. 264.
       36 
562
PERITONITIS.
the pressure of the forefinger upon the skin effectually arrests the vibra-
tion wThich 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 softness,
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 examination 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 majo-
rity 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 con-
stipated, 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  evacuations
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 with-
out 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 frequently con-
tinues for six weeks or two months, the body of  course wasting the
whole time, until diarrhcea at length comes on, attended with petechiae,
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 may be  rendered
rapid and laborious, owing to the pressure upon the  diaphragm.  There
may be another cause for the  dyspnoea, 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 fulness.  The heat of  skin is increased.
   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.
1 Med.-Chir. Trans., vol. ii. p. 265. 
PERITONITIS.
563
  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 terminate
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 fecal  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 cas^s, however, are not the most common.
  II.  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 countenance
becomes sunken, the extremities cold, the surface covered with a clammy
sweat, and  occasionally  dotted with petechias, 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 per-
foration of the intestines, which convert the chronic peritonitis into
aeute.
   799. Morbid Anatomy.—Occasionally the vessels of  the peritoneum
are injected, though sparingly;  there is more or less serum effused into
the abdominal cavity, with shreds of lymph  floating therein.4  The in-
testines are more or  less  agglutinated together, and often thus assume
the appearance of sacs of matter.   Where there has been perforation of
the intestines, we  find fecal matter  mixed up with the serum, and can

      1 Burns's Midwifery, p.  811.                  * Midwifery, p. 811.
      3 Diseases of the Abdominal Viscera, p. 195.
      * Burns's Midwifery, p.  811.  Denis, Mai. des Enfans nouveaux-ne"s, p. 119. 
»
564                       PERITONITIS.

generally detect the communication with the intestine through which it
has passed.   The peritoneum itself is often thickened, 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 mem-
brane is intact, in  others, ulceration  has advanced to different stages.
The mesenteric  glands may be free, from disease, or they may be en-
larged, and contain tubercular matter.
   Dr.  Abercrombie states as the result of his experience, that  " on dis-
section 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  ulceration 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 por-
tions of the intestines, cavities full of purulent  matter, which is gene-
rally  of an unhealthy or scrofulous character.  There is frequently
diseas* of the mesenteric glands of the liver or lungs."1
   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, appears
 thickened, and on cutting through the diseased mass, very large quanti-
 ties of scrofulous matter will  be found.   The mucous membrane of the
 bowels, particularly of the small intestines, appears ulcerated in various
 places, and at these points of ulceration the  convolutions of the intes-
 tines  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 membranes 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."2               #         # #
    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  myown ob-
 servation, it appeared to be the result of an extension of irritation from
 the intestinal mucous membrane.
    It  also  occurs as one of the sequelae of febrile diseases, such as scar-
 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 fluc-
  tuation, are present, the  diagnosis will be easy; but in those cases in
  which there is  no  pain, and but slight tenderness, with little disorder of
1 Diseases of the Abdominal Viscera, p. 193.
2 Med.-Chir. Trans., vol. ii. p. 266. 
PERITONITIS.
565
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  generally be perceived.
When there is much dyspnoea, or when the diarrhoea is severe, we must
be on our guard against supposing  the  disease limited to the chest  or
mucous membrane of the  intestines.  We know that both may be seri-
ously 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 swell-
ing (at least to the same extent) nor the fluctuation.
  802.  Prognosis.—The  prognosis, in the  majority of cases, is unfa-
vorable.  Where the peritoneum  alone is affected, the patient has cer-
tainly a chance of recovery; but if the mesenteric glands, or the mucous
membrane of the intestines, or the pleura, be involved, the case will
probably terminate unfavorably.
  803.  Treatment.—The treatment usually recommended is comprised
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, absorbents, &c.
Such is the catalogue usually given.  The question, however, deserves
a little more detail, inasmuch as  a certain number of the cases are
curable, if we 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 bowels be confined, a dose of castor oil,  or Gregory's powder,
must be given occasionally; but if diarrhcea be present, it may gene-
rally be checked by the pulv. cretae cum opio, or any  other  astringent
combined with an  anodyne.  Dr. Gregory advises  laudanum 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 mer-
cury in this disease is due to Sir Henry Marsh, as I have found no allu-
sion to it in any authority.  It may be exhibited internally or by inunc-
tion ; in many cases the latter is preferable, as when diarrhoea  occurs,
the Dowels are too irritable.  A scruple of  the strong ung. hyd. should
be  gently  rubbed in over  the  abdomen, night and  morning, and con-
tinued 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, 
566
PERITONITIS.
which up to this time should be bland and unstimulating, though nutri-
tious, 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 cloth-
ing should be warm, with flannel next the skin.  At  a more  advanced
period of convalescence a removal to the country  will 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.   Although
I ao-ree with those who  object to  many points of the  classification 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 ques-
tion can hardly be considered as settled.
  Commencing, therefore, with the slightest of these diseases, we shall
consider successively the  papular, squamous, vesicular, and pustular dis-
eases 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;
thus, at an  early period, it seems to be  owing to the assumption of their
proper functions by the stomach and intestinal  canal; at a later period,
to some disorder of these organs, or  to  dentition,  &c.
  Willan and Bateman have described five varieties: the strophulus

  1 Willan on Diseases of  the Skin.  Bateman  on Cutaneous Diseases. Britt, Abrege
pratique sur les Maladies de la Peau, by Cazenave and Stredel.  Lecons sur les Mai. de
la Peau, par P. L. A. Cazenave.   Eruptions of the Face, Head, and Hands, by Dr. Bur-
gess.  Portraits of the Diseases of the Scalp, by  W. C. Dendy. On Diseases of the skin,
by Dr. Neligan. 
568
PRURIGO.
intertinctus " is characterized by papulae 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 (strophulus
albidus); or the eruption is  more extensive and general, of a more vivid
red,  and sometimes  in large,  irregular patches  (s.  confertus);  or  it
occurs in small circular patches or clusters of papulae, arising  and exfo-
liating on different parts of  the body (s. volaticus); or it may  consist of
large papulae,  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.  This disease is characterized by an eruption of papulae of the
same color with the surrounding cuticle, accompanied with severe  itch-
ing.   There is but one  variety, the  Prurigo mitis,  which frequently
affects young  persons.   It is " accompanied by  soft, smooth  papulae,
somewhat larger and less acuminated than those of lichen, and seldom
appearing red and inflamed, except from violent friction;  hence an  in-
attentive observer may overlook the papulae 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
papulae  are removed by the  violent  rubbing or  scratching  which the
severe itching demands.  This constant friction also sometimes produces
inflamed pustules, which are merely accidental, however, when  they
occur at an early period  of the complaint.   The itching is much aggra-
vated 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."2

         1 Bateman on Cutaneous Diseases,  p. 2.         2 Ibid., p. 15. 
PITYRIASIS.                        569
  It appears to be most frequent in spring or the beginning of summer,
and certainly with children occasions great distress.  It is quite distinct
from scabies 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, but I think the most effectual remedy for it is the zinc
cream, which consists of white wax 4 oz.; spermaceti 4 drachms; almond
oil and distilled water 16 oz.; otto of roses one drachm, and oxide of zinc
16 drachms.   The wax, spermaceti, and oil should be melted together
in a water bath, and poured still hot into a mortar previousy heated, and
the water added  by degrees, whilst the mixture is  assiduously beaten
with a twig until  it assumes a granulated appearance.  The oxide of
zinc finely  powdered may then be added, and the otto of roses.   I have
given this formula in full, because I have found the cream afford  great
relief from the itching  in all the eruptions  of children in measles, scar-
latina, &c.   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 bowels;  if  they are not too free,
the hyd. c. creta, with rhubarb and a little carbonate  of soda, will act
kindly and beneficially.


                           II.  PITYRIASIS.

   This eruption  is  characterized by irregular  patches  of thin scales,
which exfoliate and reform, but which neither form  crusts nor are ac-
companied with excoriation.  The first variety of Bateman (p. capitis)
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 re-
moved 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 erup-
tions in that region.  Even Avith infants  who are carefully tended, it
requires patience and constant watching to prevent the formation of a
layer of scaly secretion.
   Dr. Nelio-an 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 
570
ROSEOLA.
finer than the preceding, that we arrive at the  reddened and inflamed
surface of the scalp, which is somewhat depressed."1
   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 yelk  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  (liv) and acetate  of lead (gr. xij).
   For the ordinary dandriff,  or for this disease, when it has  so far sub-
sided, I have found a lotion of  two drachms of borax to a pint of water
very useful.
   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 varieties ;
but we are principally concerned with  two of them, the roseola autum-
nalis, which " occurs in children in the autumn, in distinct circular 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 desquamation :
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 some-
times a limited space, in other cases  being very general, and accompa-
nied 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 smallpox, 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.
1 Dublin Journal, August, 1848, p. 41. 
HERPES.
571
  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
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 dentition
or disordered stomach and bowels, 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  which 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 elevation
 of the cuticle, containing lymph, which is sometimes clear and colorless,
 but often opaque and whitish, or pearl-colored.   It is succeeded 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. arcuatus, II.
 labialis, and  H. praeputialis: but as the majority of these affect children
 only incidentally, I shall enter into details concerning one species only,
 the herpes arcuatus or ringworm, which Dr.  Neligan considers to be
 the true  ringworm of the scalp.  As we  generally see it, it appears in
 small  circular  patches, with  the vesicles best  marked at  the  circum-
 ference;  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 appearance of a ring.  The vesi-
 cles 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 re-
 main 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 
572
ECZEMA.
a considerable size, and filled with transparent lymph.  The pain, heat,
and irritation in the part are very distressing, and there is often a con-
siderable 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 flatten, 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 ringworm is contagious,
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 com-
pletely proved as that of smallpox.
  It certainly attacks more than one member of a family or school con-
secutively, and in some cases I have thought was  undoubtedly commu-
nicated 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 well.
  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 appear-
ances, because probably of the increase of  the inflammation from rub-
bing, scratching, &c, so  that  it often resembles the eczema  impetigi-
nodes of Willan and Bateman,  an intermediate stage between a vesicular
and pustular disease.
1 Mai. de la Peau, by Cazenave and Shedel, p. 110. 
ECZEMA.
573
  The appearance of the eruption is preceded by itching, tingling, and
heat; then the minute vesicles are seen crowded  together  in  irregular
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 vesi-
cles 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 cemented together.  In the acute form of the
disease the 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 furfura-
ceous scales, which are pushed forward by the hairs as they grow.  With
the progress of the affection, the appearance 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 constantly 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 itch-
ing ;  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 un-
injured ; 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  intes-
tinal 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 sufficient.
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, fomentations,  or
the warm-water dressing.   When the  surface  is  less red and angry
looking, we may try the  alkaline applications recommended by Biett
1 Dublin Journal, August, 1848, p. 37. 
574                          rupia.

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 sarae children, the
same remedies in the form of  lotion will succeed 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 twenty to thirty grains
to an ounce of lard, 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 inflam-
mation, 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.
  Dr. Burgess recommends the alkaline lotions instead of any greasy
applications, but  as he  regards  eczema as a constitutional and not a
local  affection, he lays great stress  upon "restoring the tone of the sys-
tem by means of a course of mild tonics and alteratives."   If the secre-
tion be abundant, and the parts  irritated, he advises barley water  with
sulphuric acid (half a drachm of the former to a pint of the latter), com-
mencing  with small doses, and taking a little water after each until the
stomach is accustomed to the acidulated drink.  If these remedies  fail,
then we may try  alteratives, as  sarsaparilla, and hydriodate of potash;
active purgatives if the patient be strong; and lotions of the  nitrate of
silver, or the bichloride of mercury.
  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 bowels must be regulated, and in some obstinate  cases a few
alternative doses  of mercury may be advantageously given.   M. Biett
recommends acid  drinks.
                            III. RUPIA.

  817.  Dr. Bateman states that " rupia is characterized by an appear-
ance 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 con-
cretes  into  thin  and superficial  scabs, that are easily rubbed off  and
presently regenerated."2
1 Dublin Journal, August, 1849, p. 45.
2 On Cutaneous Diseases, p. 243. 
0
                               rupia.                          575

   We are only concerned with 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 pemphi-
 gus gangrenosus.  Dr. Bateman says that " it affects only infants and
 young children when in a cachectic state, whether induced  by previous
 diseases, especially the smallpox,  or by imperfect  feeding and clothing,
 &c.;  whence, among the poor, where it is commonly seen, it  often ter-
 minates fatally.   The vesicles generally occur on  the loins, thighs, and
 lower extremities, and appear to  contain a  corrosive sanies; many  of
 them terminate with  gangrenous eschars, which leave deep pits."1
   It  is not stated by writers in general to be either  a very frequent  or
 fatal affection; yet in Ireland it appears to be both  in a very high de-
 gree, for I find in  Dr. Wilde's Report  that in ten years the mortality
 amounted to 17,779, in the proportion of 100 males to 78.93 females.
 The country people give it the significant names of  "white blister," "eat-
 ing or mortifying hive," "burnt holes," and among  them it appears  to
 prevail as an epidemic occasionally. Dr. Whitley Stokes, who published a
 valuable paper upon this  subject in 1808, states that "the causes  of
 this malady are rather obscure, it seems exclusively confined to children.
 Dr. Spear observed that it was confined to children of three months and
 from that to five  years, but it has been observed,  near Dublin, in chil-
 dren  of nine years old.  It attacks the finest children in preference: the
 children of the poor  more frequently than  those of the affluent:  those
 who live in damp situations  seem more particularly subject to  it than
 others.  It appears to be infectious, though obscurely so in general, but
 in the year 1800 Dr. Spear observed it to spread epidemically."   Dub.
 Med. $ Phys. Essays, vol. i. 1808.
   MM. Cazenave and Shedel 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 bullae, flat,  and of irregular form,
 surrounded by a  livid circle.   These vesicles break, and expose irregu-
 lar ulcerations, varying in depth  and extent, with red border and un-
 healthy surface.   There is severe pain, much fever,  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 borders were
 slightly red.   When I saw  the case, the  bullae had  burst and exposed an
 irregular  ulceration with  defined edges  slightly inflamed,  and with a
 tolerably healthy surface.
   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  muri-
i
1 On Cutaneous Diseases, p. 244. 
576
IMPETIGO.
atic acid, &c.—so as to change the  surface and arrest the ulceration,
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 vesicular
appearance, although  really  pustular.   Impetigo,  moist or running
tetter, is marked by small psydracious pustules, neither accompanied 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 pus-
tules 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  erup-
tion occurring in groups of pustules, but the individual pustules are also
different  in character,  being  of the variety which have 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 dis-
ease from presenting the truly pustular character of the first stage.   The
eruption  usually commences  on  the forehead, involving 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 
IMPETIGO.
577
they contain is not so consistent, and is of a richer yellow color.   They
usually become confluent before they burst, and the resulting greenish-
yellow (when chronic, greenish-brown) scab is consequently much more
extensive.   When the eruption has continued for any length of time,
large quantities 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 disease
be of long standing, the roots of the hair are  injured, and its growth
checked;  it becomes thin and poor-looking.
  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.
  I have no doubt  that occasionally a brisk  eruption on the head may
prove a salutary counter-irritation, and hence I suppose has arisen the
popular objection to curing them.   But I  do not  conceive that there is
any  danger if due care be taken, and I am quite sure that many evils
follow their long  continuance.  Sore eyes or ears, otorrhcea, glandular
swellings, &c. may, I believe,  often trace their origin to a chronic erup-
tion  neglected.
  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 irritation.

                   1 Dublin Journal, August, 18-18, p. 39.
37 
573
PORRIGO.
                    II. PORRIGO, OR SCALD HEAD.

   By Bateman and  the  older writers, porrigo has been regarded  as a
pustular disease,  the  result of  inflammation.   Comparatively  recent
researches  with the microscope, however, seem to have established the
fact of two varieties, at  least,  being  of vegetable origin, and not the
result of inflammation.   We are indebted to the investigations of Schon-
lein, Gruby, Bennett, Corrigan, Miiller,  Lebert, Robin,  &c, for the
amount of  our  present knowledge.  But it follows, if this view  be the
true one, that some of the varieties usually included under  porrigo must
either  be made a separate order, or included among the  impetiginous
eruptions, leaving the porrigo scutulata and porrigo favosa (or perhaps
the p. favosa alone) as an oMer of vegetable  productions of the  scalp,
the result of constitutional causes chiefly, and not of inflammation.
   Dr. Bateman describes six varieties, the porrigo larvalis, or  crusta
lactea, the  porrigo purpurans,  the porrigo decalvans, the  porrigo lupi-
nosa, 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
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. Neli-
gan, 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 recommended for impetigo
is well suited to the present species.
        THE PORRIGO SCUTULATA, OR RINGWORM OF THE SCALP,

  823.  Has given rise  to great difference of opinion as to whether it is
a pustular or vesicular  disease, and whether the pustules or vesicles are
at all essential to the disease.   Willan, Bateman, Biett, and the older
writers, class it among the former;  some of the French writers, espe- 
PORRIGO.
579
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.  When 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 negated, become thick and hard by accumulation.  If
the scabs are removed, however, the  surface of the patches is left red
ancl shining, but studded wjth slight elevated poinds or papulae, on some
of which minute globules of pus> again appear 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  covering  them becomes lighter in its
color, and sometimes breaks off  short;  and as the process of pustula-
tion 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 de-
scribes  the disease:   "We have  seldom  an opportunity  of  seeing ring-
worm  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 dis-
lodgement of a thin scruff in the act of  scratching.  It  is this  circum-
stance 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 cir-
cular patches are always  few in number and  limited  in  extent; fre-
quently 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 dis-
ease 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 projections are enlarged and dis-
eased 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 condition described, does not attain
any length, but breaks spontaneously at a short distance from the skin,

               1 Eruptions of the Face, Head, and Hands, p. 176.
              2 On Cutaneous Disease, p. 109. 
580
PORRIGO.
leaving an exposed patch of the scalp, which always maintains a circu-
lar, disk-like form.   The ends of the  broken hairs are jagged, disco-
lored, twisted, and not unlike the filaments  of flax and tow.  If  the
disease has not been arrested at this stage, the furfuraceous, scaly mat-
ter will become agglomerated,  and form dry, thick, dirty, yellow-looking
scabs or incrustations, thicker at their circumference than towards  the
centre.  It is the irritation produced by these scabs, but more particu-
larly by the action of the nails in scratching or trying to dislodge them,
that produces the pustules, and subsequently the discharge  of the con-
tents 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 dis-
ease, 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 degenerations
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 existence of which
there can  be no doubt, is a secondary product, and not the disease itself."
   Let  us  now see what  has  been observed of  this "vegetable para-
site."   M. Gruby remarks : " On examining attentively with the micro-
scope this grayish-white  powder which is seen on the  morbid surface,
you will be surprised to find that it is composed of a number of crypto-
gamia.  On submitting the  hairs wdiich grow on this surface to the same
method of examination, we shall observe a great quantity of these cryp-
togames 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 estimated at the five-
thousandth part of an inch in  diameter, and the shaft of the hair is dis-
tinctly enlarged or  hypertrophied.   The cryptogame  surrounding  the
hairs at their bases, 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  surprising rapidity.   On
issuing from the follicle, the hairs become grayish 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, vesi-
cles, and  the secretion of the sebaceous follicles."

             1 Eruptions of the Head, Face,  and Hands, p. 177. 
PORRIGO.
581
  According to M. Robin,1 the seat of this vegetable (trichophyton ton-
surans) is in the interior of  the roots of the hair, and he has  described
another (microsperon audonini) which is seated round the  roots of the
hair like a cylinder.
  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 pustules,
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 secre-
tion 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  cryptogame.
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 ap-
plications must be adapted to soothe; poultices, emollient fomentations,
&c. will  be most suitable.   The hair must be clipped as short  as pos-
sible, which  is much  better than  shaving,  though more  tedious, and
requiring more frequent repetition.
  When the inflammation is subdued, or the disease has become chronic,
we  may proceed with more  direct attempts to act upon  the diseased
portion.   " In the more irritative states, the milder ointments, such as
those prepared with the cocculus Indicus, with the submuriate of mer-
cury, 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. praecip. albi, or the oint-
ment of calomel,  or  a lotion of lime-water with calomel,  are advantage-
ous.  According  to the different degrees  of inertness which ensue,
various well-known stimulants  must be resorted to, and may be diluted
or  strengthened, or  combined, according  to the  circumstances.  The
mercurial ointments, as the ung. hyd. praecip., 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 sulphates of
zinc and copper, or the oxymuriate of mercury in solution, are likewise
occasionally beneficial."2

                  1 Des Vegetaux qui croissent sur PHomme, &c.
                  2 Bateman on Cutaneous Diseases, p. 172. 
582
PORRIGO.
  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 mercury,
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 commonly
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 effectual in the
treatment of this  obstinate complaint is the vapor of iodine and sulphur,
conveyed  directly to the morbid patch through a caoutchouc 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 dis-
eased 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 afterwards increased according
to circumstances:—

                    R.— Sulphur giij.
                       Iodini, gr. xij to gr. xxiv.
      To be divided into six powders—one to be applied three times a day."1

   M. Bazin first removed the hair by an ointment of lime and carbon-
ate  of soda, of each one part, lard thirty parts ;  and then a solution of
bichloride of mercury (1 part to 250 of water), or an ointment of the
acetate of copper.
   Dr. Parker has recommended a  solution of pernitrate of mercury (1
part to 30 or 40 of water), or an ointment of sulphate of  copper (1 part),
alum (3 parts), and lard (20 or 30  parts).2  Dr. Jenner has successfully
employed sulphurous acid.3
   The local applications  I  have  found most useful, after the redness
had subsided, are the black wash,  diluted citrine ointment, ointment of
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  vege-

                 1 Eruptions of the Head, Face, and Hands, p. 182.
                 2 Brit, and For. Med. Rev.,  Oct. 1853, p. 418.
                 3 Med. Times and Gazette, Aug. 1853. 
PORRIGO.
583
table, 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 that nothing marks its  having existed  but the bald spots
and a slight excess of furfuraceous scales, I have derived much benefit
from a weak 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. Notwithstanding the opinions of Willan, Bateman, Alibert, Biett,
and others, of the pustular character of porrigo favosa, it seems clearly
established now that this variety at least is of vegetable nature.   It is
true  that Dr. Mahon  considers it a morbid secretion of the sebaceous
glands, and Drs. Bennett and Burgess  and M. Erichsen as a tubercular
disease; but  the  researches of Schonlein, Gruby,  Remak,  Corrigan,
Robin, &c, seem  to have pretty well set the question at rest.
  The confusion as to  the nature of the disease may have partly arisen,
as Dr. Corrigan suggests, from the presence of two species of eruption
on the scalp at the same time. . He considers  the disease as essentially
pustular, but  that the growth upon the skin is a vegetable parasite, and
he describes the growth from the beginning.   If the  scalp be shaved
and the scabs removed, we  may soon observe the whole process of repro-
duction.  "Within some days, a few, often not more than three or four,
very minute  pustules  will  show themselves, scattered far asunder over
the red surface;  they  are not  raised above the surface, and they seem
like dots of transparent amber-colored  matter bedded in the skin.   In
twenty-four hours after, they become solid, depressed in the centre, and
of a  pale yellow color, very often with a hair in  the  centre of each.
They then rapidly increase in number and size."1   These crusts consti-
tute  the vegetable parasite, underneath which the skin is red but un-
> Dublin Hosp. Gazette, Aug. 15, 1846, p. 2. 
584
PORRIGO.
broken, and not  secreting matter.  Dr. Corrigan has established  the
fact that the appearance of the matter under the microscope is distinct-
ive of  this variety.
   In the first stage, it neither gives rise 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  possibly be
mistaken for any  of them.  It first appears in the form of small, yellow,
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 concave 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 somewhat 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 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
circumference of  each crust, which  thus retains its  hemispherical cha-
racter, until it attains a diameter of  two or three lines, 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 increase, 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 qhanged in appearance, and, instead of the  cup-shaped depres-
sion, the entire surface is covered  with  alternate elevations and depres-
sions, or, so to speak, ridges and furrows, concentrically arranged.  The
eruption thus increasing, the whole of the scalp—often, too, the  fore-
head, neck, and parts of the trunk—become 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 projections  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. 
PORRIGO.                         585
and readily removable with the crusts of the disease, in which they 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 irritation of the
scalp is produced; small pustules form here  and there in spots as yet
unaffected with the eruption ; the tingling and heat are so unbearable
as to compel  the patient to tear the surface with 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 ulcer-
ated 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 crooked,
but not tortuous tubes, sometimes, but rarely, branched, containing gra-
nules, or small  rounded  cellules, or  elongated cellules,  placed end to
end, so  as to represent partitioned tubes, with  or without jointed articu-
lations  (receptacles or sporangia in  various  states  of development?)',
3, Finally, sporules,  free,  or united  into bead-like strings.    The myce-
lium 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 f).  We often find
mixed with them mycelium tubes, but in small quantity.  All these ele-
ments 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 arrange-
ment."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

  ' Neligan, Dublin Journal, August, 1818. p. 52.
  2 Des Vegetans qui croissent sur l'Homme et sur les Animaux vivans, 1847, p. 8. 
586
PORRIGO.
state of constitution produced by filth, close air, bad feeding, and insuf-
ficient clothing.
  It is  a very rare disease in Ireland, as Dr.  Corrigan observes, and
almost never met with in persons of a respectable station.  " Can it be,"
Dr. Corrigan asks,  " that, like the cow-pox, it  is a disease propagated
from some inferior animal, perhaps  the  mouse, on which Dr. Bennett
has discovered the same parasitic plant as in porrigo ? while the disease
in the human  subject, as if to  strengthen the supposition, gives  out so
strongly the odor of the mouse, that it forms a well-marked diagnostic
sign of  the disease ? and that to favor its production,  poverty or sickli-
ness must have  reduced the living body  to  a  state fit  to constitute  a
nidus for a parasitic plant; as in  parasitic growths, the more feeble  or
more sickly the animal is, the more will such  growths develop  them-
selves."
   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 changed
as often as they become dry.   The hair  should be cut as close as pos-
sible previously, but not shaved at this period.
   Dr. Bateman recommends the  application of the ung. zinci,  or  the
ung. hydr.  praecip.  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 superacetatis,"
varying the proportions of the ung. cerae according  to the degree of
inflammation.
   M. Biett speaks most favorably of alkaline or sulphurous applications,
or acid  lotions.   The subcarbonate of soda  or  potash, in  form of oint-
ment at first,  and afterwards more diluted as a  lotion; or the following
lotion, which is  much used at St. Louis:—
                     R.—Potass, sulphuret. gij.
                         Sapon. alb. gijss.
                         Alcohol, rect. gj.
                         Aquse calcis, ^vij.—M.

   Muriatic or nitric acid much diluted, sulphurous douches; or, if more
powerful applications are  needed, solutions  of  sulphate of zinc or cop-
per, 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
   Dr. Corrigan speaks highly of  the oxymuriate  of mercury, which he
employed because of its power of destroying the sporules of cryptogamic
plants.    " I have used it," he says, "in the form  of ointment  in the
proportion of five grains in very fine powder  to an ounce of ung. cetacei.
I have  used it in the proportion of ten grains to the ounce, but it some-
times gives pain in this large proportion.  A small  portion of the oint-
ment is rubbed  in on the part affected every day.   It has not salivated
in any  instance in which I have employed  it;  its action in the first  of
these cases was peculiarly satisfactory,"  &c.
1 Cazenave and Shedel, Mai. de la Peau, p. 244. 
PORRIGO.
587
  M. Mahon has a depilatory which removes the hairs very completely.
M. Chevalier believes it to be chiefly composed of lime and carbonate of
potash.   The carbonate of potash, the lotion recommended 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 re-
moved, the head  is well 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 proportion 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 disappears, I have not seen it again
recur, although the use of the ointment had 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."
  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 reappear 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 covering 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 excoriations), 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 epidermic 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 quicklime, 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 
588
PORRIGO.
 iodine applied in its stead, and continued for  several weeks, until the
 parasite ceases to be produced."1
   Dr. Burgess speaks favourably of alkaline lotions and iodide of sulphur,
 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 consti-
 tutional remedies.   After due care in the removal of all irritation from
 teething, or  gastro-intestinal disturbance, and  a  careful regulation of
 the stomach  and bowels, we must afford  the child the relief of cleanli-
 ness, pure air, and a more invigorating diet, at the same time avoiding
 crude vegetables and fruits, and all stimulating substances.   Milk pud-
 dings, broths, and plain  animal food, may be given, according to cir-
 cumstances.   Dr. Neligan confines the patient  entirely to a milk diet.
   The medicines recommended  by Bateman  are alterative doses of mer-
 curials, " especially when the biliary secretions are  defective, the abdo-
 men tumid, or the mesenteric glands enlarged."  Small doses of 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 chalybeates, 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 increased; 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 powder, 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 adminis-
 tered.   When, however, it gives rise to the symptoms above mentioned,
 its use should be intermitted for some days, and an active purgative
 administered."2
   When the condition of the child is deteriorated and the nutrition feeble
 much benefit  is derived from the use of the cod-liver oil.  It will not
 only aid in the cure, but may prevent  the evil  consequences of  a long-
 continued eruption of. whatever nature.  Dr. Hess  has occasionally found
 it act with remarkable benefit.

           •  Burgess on Eruptions of the Face, Head, and Hands, p. 195.
           2  Dublin Journal, August, 1848, p. 56. 
SECTION  VI.

ERUPTIVE FEVERS.
                        CHAPTER  I.

                 MEASLES.—RUBEOLA.—MORBILLI.

  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 generally attack-
ing 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 natural
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 smallpox, 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 Hoff-
mann (1718).
  It has been  confounded with scarlatina so recently as in the writings
of Morton and Watson; indeed, as  Dr. George Burrowes has remarked,
the distinction between the two diseases was not thoroughly established
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 mea-
sles and scarlatina.   According  to the Fifth  Report of the Registrar-

            1  Var. Antiq. ab. Arab, solum repetend., sects 7, 14, 17. 
590
MEASLES.
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 diseases; 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."1
  Now, 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
Dr. Panure, who had opportunities for unusually accurate observations,
found the period  from exposure to contagion to the appearance of the
eruption to be either thirteen or fourteen days.3  As a general rule  it
will, I think, be found that  the fever commences from the fifth to the
eighth clay.
  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 weari-
ness, 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 there is  occasion-
ally some little remission at the appearance of the eruption.   The face
soon becomes flushed, the eyes  injected, suffused, sensitive to light, and
with incessant lachrymation;  the eyelids  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

  ' Report upon the Tables of Deaths, &c, p. 13.
  2 Mai. des Enfans nouveaux-nes, p. 487.
  3 Mode of Propagation of Measles, by Dr. Panure, of Copenhagen, Edinb. Monthly Jour-
nal of Medicine, June, 1S51, p. 589. 
MEASLES.
591
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 begin-
ning 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 symptom alone.
Ileberden and Peter Frank met with cases  in which the cough did not
appear till after  the eruption.   These symptoms  do not come on gradu-
ally, 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 smallpox;  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  OAving 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 scarla-
tina, 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 tymphatic  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 in-
creased  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 pre-
dominate, and we m'ay have delirium, stupor, or  convulsions;  in  other
cases,  the pulmonary  or gastro-intestinal may  be more marked, as will
be shown by great dyspnoea, and frequent  cough; or  by vomiting 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 symp-
toms ; 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
  Dr. Panure observed the catarrhal symptoms in the majority of cases
from two to four days before the  eruption, but  in some they  occurred
four or six days,  and in others six or eight  days  previously.

    » Hufeland's Journal, 1812.              2 Diet, de MeU, vol. xxviii. p. 338.
    3 ibid.                             4 Mai. des Enfans, vol. ii. p. 681. 
592
MEASLES.
  836.  Period of Eruption.—About the third  or  fourth  day we may
observe a few distinct, elevated, red papulae on the face  or forehead,
resembling flea-bites in size and color, very like  those at the  commence-
ment of variola or  in typhus fever, but speedily acquiring  a very dif-
ferent appearance.   These rapidly increase in number, more profusely
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
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 papulae 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 convulsions.
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 white or yellow fur, interspersed with the
enlarged, red papillae; 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 suffused
and  weeping,  the mucus secreted by the conjunctivae  is  more abundant
and  thicker, and, drying during the night, the eyelids  are temporarily
glued together; the secretion from the  nasal mucous membrane is of
thicker consistence, but not less  copious;  the  cough continues, but is
a little softer;  the  voice is still rough and hoarse; there is no diminu-
tion in the dyspnoea 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.
Bateman on Cutaneous Diseases, p. 60. 
MEASLES.
593
  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
was as vivid as ever on the tenth day.1   The disappearance is gradual,
and follows  the same order as their  appearance ;  they become fainter
in color and flatter ; the slight red areola around the papulae disappears,
and the whole acquires a yellowish tinge.
  In those parts where the eruption was most intense, certain yellowish
spots, stigmata or  maculae, remain, and which have been noticed by MM.
Guersent and Blache, Rayer and Trousseau.   They are not very appa-
rent when the child  is quiet,  but when excited they assume a deeper
color; they seem to be seated in the cutis, and do not  disappear 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.2
  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 process
is scarcely marked at all; in others, it  is confined to the face and chest,
where the eruption has been most severe.   Unlike the desquamation in
scarlatina, in measles we find very small furfuraceous lamellae, 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 become 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 expec-
toration free.
   It  not unfrequently happens  that at  this time diarrhcea 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 coinci-
dent  irritation of the mucous membranes ;  by a semicircular or cres-
cendo eruption of red papulae, with a continuance  of the  fever and irri-
tation ;  and  by the final desquamation of the cuticle, with subsidence of
the fever, local irritations,  and general symptoms: the  entire process
occupying from ten  days to a  fortnight.   Such cases  are most favor-
able, 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 disease, or upon a defective con-
stitution in the child, or upon some complication.
   840.  Let  us then consider—
   I.  The Modifications of  Measles.—a. The eruption may vary as to

                ' Gazette  M£dicale, 1835, vol. iii. p. 360.
                2 Bouchut, Mai. de l'Enfance, p. 294.
        38 
594
MEASLES.
extent; in some it  is abundant and  universal; in others it is  limited,
and consists of but few distinct papulae or rings.
  b. The  color may differ  much in  different cases ; ordinarily it is 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 saw, 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 observed 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
papulae become flattened about the third or fourth day.
  e. In some rare cases the spots resemble pupura,  being really ecchy-
moses underneath the cuticle, just as blood  may be at the same time
effused into other organs.   The spots are blood-red at  first, but gradu-
ally become yellow as absorption goes on.   In other instances they are
brown, or nearly black : according to Rayer, this hemorrhagic  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  im-
portant 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 clays  elapsed
in this instance before the renewal of the exanthematic action."2  The
disappearance may be owing to some accidental  cause, as cold, irregu-
larities of diet,  &c, or may result from internal organic disease.
  Whenever it occurs, we should never rest until, by repeated and care-
ful  examination, we have assured ourselves  of the integrity of  every
organ of the body, or have detected the seat and  nature  of any  internal
disease.
  Such deviations are not unfrequent when measles occur 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

              > Bull, de Ferrussac, 1829,  vol. xxvi. p. 286.
              2 Dr. Gregory on Eruptive Fevers, p. 104. 
MEASLES.
595
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 vul-
garis, 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 oppor-
tunities 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  character-
istics of measles,  for the eruption  of roseola may  present  the  serai-
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 uncom-
mon during  the prevalence  of epidemic measles to meet with fever at-
tended 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 subse-
quent progress  of the epidemic."2
   It  would, of  course, be difficult to pronounce such  to  be cases  of
measles, nor have wTe 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.
   in. Many writers mention the occurrence of measles  more  than once
in the same individual, but we must reject all  such histories  as were
written before the distinction between scarlatina and measles was dis-
tinctly  laid  down, and also all reports not authenticated by medical
evidence and then it  seems  probable that the cases will be much re-
duced in number.   Rosenstein  says that  in forty years' practice 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
seems doubtful  about it, except where the first  attack  may have been

   1 Bateman on  Cutaneous Diseases, p. 63.      2 Diseases of Children, p. 429.
   * Trans, of a Society, &c, vol. iii. p. 253. 
596
MEASLES.
the rubeola sine catarrho.  Dr. Home mentions a case in which gland-
ular 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 disease
before; and Duboscq de la Roberdiere prescribed during the epidemic
at Vire, in 1777, for the 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  two  months afterwards,  was ex-
tremely 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
Bhe 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 symp-
toms of the usual duration, followed by the characteristic eruption, 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.
  The prevalence of either of these types in any given epidemic, doubt-
less depends upon what has been called the atmospheric constitution of
the time, and, as this will determine the character of  the treatment, it
is essential that  a well-informed physician should at all times ascertain
this  point.
  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 many fold.   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  run-
ning ; 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.

            1 Med. Facts and Experiments, Mai. de la Peau, p.  148.
            2 Loco Citato, p. 677. 
MEASLES.
597
  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 habit,
who have been highly fed, and kept in close  or warm  rooms,  or who
suffer much from teething.  The complications most common are con-
vulsions, 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.
  III.  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 weak and quick; the skin is dry and burn-
ing, and petechiae  may  be observed  in  different parts.  Colliquative
sweats, diarrhcea,  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 shown itself,  and partially reappears.  The sto-
mach is irritable ; vomiting is both severe and protracted ; there is deli-
rium with wildness of eye, or coma;  the belly is tender; there is purg-
ing of unhealthy stools ; the extremities  are cold, the pulse small and
wavering.  On the  surface appear petechiae  or ecchymosed patches of
eruption; the fauces assume a livid or dusky red color; blood passes by
stool;  there is  much oppression at the praacordia, and abundant muco-
serous discharge from the chest, indicating the congested condition of
the lungs and their  mucous membrane.   In  these almost hopeless  cir-
cumstances 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 diarrhcea 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 com-
mon, 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,  and  consists
of a single convulsion;  but in others the convulsions are repeated with
a train of symptoms indicating an inflammatory affection of the mem-
branes of the brain, and in these we can discover traces  of cerebral  or
meningeal congestion or inflammation after death.  In almost all cases,
the abstraction of blood by leeches, or counter-irritation of some kind,
1 On Eruptive Fevers, p. 109. 
598
MEASLES.
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-
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 ulcerated,  but the mucous  membrane of the larynx
is often  red, ulcerated, softened, or covered with false membrane con-
stituting true croup.1   In  some few cases  the croup may be spasmodic.
  The attack generally occurs  about the third or fourth day;  sometimes
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 propor-
tion are cured when the measles are of a mild form; and in many child-
ren who  are  carried off by some complication  at a late period of  the
disease, very severe lesions of  the larynx are observed to be in progress
of cure.  Much, however,  will  depend upon the constitution of the child
and the character of the epidemic; occasionally we find this complica-
tion prove very fatal.  I have already indicated the treatment of second-
ary croup.
  in.  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.  When 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 disease, 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.   Dyspnoea increases.  The
child  becomes drowsy; the feet cold.  The pulse sinks.  Florid effusion

  1 Dr. Battersby's paper  in Dublin Journal, vol. xxviii. p. 67; and Dr. Lee's, ibid., vol.
xxvi. p. 6. 
MEASLES.
599
now takes place from the bronchial membrane.   Another  and another
fit succeeds.   Rattles are heard in the throat.  The child dies I"1
  In some cases we find bronchitis alone, or mixed with some nodules
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.
  During an epidemic in 1844, of 48 cases of measles under two years
of  age, treated by  Dr. Lees,  forty  presented symptoms  of pneumo-
bronchitis; out of  these, eighteen died ; four died on the second day of
the eruption, and in  them I found extensive lobar pneumonia in the  se-
cond stage, of the postero-inferior portion of both lungs, which I presume
must have  commenced previous to  the  eruption.   In the other cases,
a low form of secondary fever would appear, from  the fifth to the eighth
day of the disease; on the decline  of  the eruption, the infant had been
going on well, when  the mother would complain that it had passed  a
restless night, starting and burning  with heat, particularly its  hands,
crying for drink or the  nipple ;  the cheeks were flushed, there was slight
cough, hurried respiration, restlessness.  A loose mucous rale could be
heard all over the back of both lungs, which soon became a loud crepi-
tus, with slight dulness; the cough increased, and the infants died as if
exhausted;  in two of the cases, where the ordinary symptoms of bron-
chitis were absent, but where the dispnoea was extreme and great pallor
of the  countenance existed, I found extensive lobular pneumonia; but
in most of the cases I found vascularity of  the  pharynx, larynx, and
bronchial mucous membrane ; patches of lobular pneumonia, in various
stages, diffused through all parts of both lungs, with a tendency to be-
come lobar at the postero-inferior portion of one  or both lungs, and in
the greater number of cases, tubercles scattered through the lungs, or
infiltrated with cheesy deposits  in the bronchial glands."2
  The  symptoms are  those of pulmonary disease: cough, dyspnoea;
moist bronchitic or pneumonic  rales,  more or less  intermingled, bron-
chial respiration, vocal resonance, dulness on percussion, &c, as here-
tofore laid down, but wrhich may be overlooked  in these cases, or con-
founded with the ordinary catarrhal symptoms by superficial observers.
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  during 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.  Occa-
sionally pneumonia is the characteristic of an  epidemic.   Dr. Dewees
says: "We  remember to have seen it epidemic in the spring of 17S5 or
1786, at which time almost every case was marked by pneumonic symp-
1 On Eruptive Fevers, p. 106.
2 Dublin Journal, vol. xxvi. p. 9. 
600
MEASLES.
toms of greater or less violence.  This disease was of  difficult manage-
ment;  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 in-
clined to think it much more common than has been supposed.   I was
consulted lately about some children who had  got over  the  measles
pretty  well, but who were not  recovering  satisfactorily.  Their princi-
pal 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 carefully,  I de-
tected in each, pleurisy of the left side with great effusion, and displace-
ment of the heart.
  The attack may occur during the first or second  period, but I suspect
that it is more frequent after the measles are over, as one of their sequelae.
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, unequal 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 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, §c.—When speaking of the various forms of stoma-
titis, ulcerated sore mouth, gangrene, &c, I mentioned that they occa-
sionally 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  fre-
quently the result of the gastro-intestinal disorder  than dependent upon
the measles, and in treating them we must have respect to both complica-
tions.   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 gan-
grene  of the  lung, but Wunderlich  mentions  it as occasionally  occur-
ring on recovery from measles.
   vi.  Ciastro-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  bowels;  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 characterizes summer  and
1 Diseases of Children, p. 508. 
MEASLES.
601
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 irritation of
the bowels continues,  or both may persist.
  Again,  as  we have seen, diarrhcea not  unfrequently occurs towards
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 especially of the
epigastrium.
  Guersent and Blache found such cases  rare ; in the majority  there
were no post-mortem evidences of inflammation. They remark that gas-
troenteritis 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, accompa-
nied 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
entero-colitis ;  in six, the chronic and cachetic  ; in two, the dysenteric ;
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. Aber-
crombie, 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  uncommonly
fatal."2
   846.  vn.  Ophthalmia.—We have seen that  injection and suffusion of
the conjunctiva, with increased secretion both of the mucous membrane
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 few 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 may, however, have more serious results.  Dr.  Battersby

               1 Diet, of Practical Medicine, part ix. p. 815.
               2 Dictionary of Practical Medicine, part ix. p. 816. 
602
MEASLES.
relates a case which ended in prolapse of the iris and staphyloma, and
two  others  in which  sloughing of the cornea occurred,1 one of which
died.  It has been remarked as prevailing very extensively 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.  Fomen-
tation 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 con-
dition 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 compli-
cation, 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 disappearing,  and is
caused probably by cold.   Dr. Condie speaks  of its occurring in chil-
dren of a scrofulous habit, and of its becoming chronic.
   Leeches, fomentations,  and blisters will  probably be found sufficient
to relieve the  disease ; but for further details of these two  last  com-
plications I must  refer  my  readers to the special wrorks 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 import-
ant in themselves,  but far more as indications of a broken-down consti-
tution, or a  change in the composition of  the  blood, which  may ulti-
mately prove fatal.
   X. Eruptions.—Measles is followed by a variety of eruptions—herpes,
eczema, porrigo, &c.; either because the cutaneous excitement has left
a disposition to morbid action,  or because the state  of the constitution
is  peculiarly favorable to  these affections.   " Porriginous  eruptions on
the head, and serous  ulcerations behind the ears, also  frequently occur,
and, in some instances, induration of the  mesenteric glands, and ma-
rasmus.   Among   the  occasional  consequences  are  herpes,  boils  on
different parts of  the body, discharges from the ears, and anasarcous
swellings."2
   Dr. Lees mentions  that, in most of his cases  " an eruption of vesicles
appeared on the wrists and spread over the  body ; particularly large on
the feet and ankles :  it resembled  scabies in appearance,  but it was not
itchy, and the vesicles were flattened."

                  1 Dublin Journal, vol. xxviii. p. 77.
                 2 Eberle on Diseases of Children, p. 435. 
MEASLES.
603
  Nor are these unfavorable.  Dr. Armstrong  remarks, that " when
any cutaneous affections arise after measles, the internal organs remain
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."1
  xi. Tubercles.—In scrofulous children a rapid development of tuber-
cular deposit  not unfrequently dates from  an attack of measles.   It
may show itself in glandular enlargement, mesenteric disease, or phthisis.
Dr. Stokes states that more cases of tubercular phthisis come under his
notice, who date their first symptoms from an attack of measles than
from any of the other exanthemata.  The occurrence has no essential
connection with measles, but  originates  in the condition in which  the
eruptive disease leaves the  constitution.
  xii. Anasarca.—This, which is so common a complication of scarla-
tina, 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 albuminuria, it ter-
minated in death, and after death the kidneys  exhibited the appear-
ances of Bright's disease.
  Xlil. Ulceration of Labia Pudendi and Rectum.—In foundling hospi-
tals or poor-houses where many children are crowded together, and the
atmosphere  becomes vitiated,  we  occasionally find  ulceration  of  the
rectum, or, in girls, of the labia pudendi, which  may either be simple
or gangrenous, similar to that described by M. Kinder, Wood, and others.
Sir William Watson mentions that, in the putrid  form of measles which
prevailed in  the London foundling hospital,  the girls who died most
usually became mortified in the pudendum, and that one  died of a mor-
tification of  the rectum.
  Dr. Lees relates two cases  of ulceration of the rectum, and one in
which both organs were affected, where " on  dissection  he  found deep
unhealthy ulceration situated  in the inferior chordae vocales; the mucous
membrane of the trachea and larynx appeared in other  respects to  be
normal.  A large mass of crude  tubercles occupied the centre of the
left lung; there was vascularity and thickening of the whole extent of
the rectum, with superficial ulceration extending from the margin of the
anus up the mucous membrane: there was great destruction of the labia
with extensive ulceration in the surrounding parts."
  Thus, at the beginning of  measles, the most formidable complication
we have to fear is convulsions or meningitis ;  during the early stage of
the disease, laryngitis and broncho-pneumonia; at a later period, broncho-
pneumonia and intestinal affection; and during recovery, disease of the
lungs, intestinal tube, affections of  the eyes, &c.
  847. Morbid Anatomy.—M. Fabre has given the following summary
of the pathology of measles,  independently  of  the  eruption.  When
measles terminate  fatally  without  any complication, the  organs  are
generally found in  a state  of congestion, more or less  marked, some-
times of a blackish red color.  Occasionally the  follicles of Peyer and
1 Practical Illustrations, &c, p. 175. 
604
MEASLES.
Brunner are  enlarged, as in scarlatina and smallpox, '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 correspond to
these characters; the fibrine preserves its mean proportion (3 parts in
1000).  M. Andral found  in  several adults  attacked by measles, that
the fibrine preserved  the proportion of from 2| to 3J  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.l
  Vogel  placed the seat  of the eruption in the epidermis;  more recent
researches have shown 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  are infectious  is admitted by all,  but
how soon the infectious effluvium is formed, and how far it  may extend,
is not settled.  Dr. Williams thinks that the blood throws off infective
emanations during the eruptive fever,  and prior to any eruption.  In
the epidemic among the Feroe Islands, Dr. Panure  states that it was
communicated from one  person to another, and  that out of 6000 there
was not one tending to prove the existence of " morbillose miasmata."
No  case occurred to prove that the contagion was  communicated either
during the period of incubation  or of desquamation ;  but  in all  during
the eruptive  stage.   Much will probably depend upon  the virulence of
the disease.   It may also  be carried  from the sick and communicated
to third parties; the party conveying it participating in the attack with
the others, and  at the same time.   It  is said  also that it may be con-
veyed  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 woollen 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  occasionally
mixed with the eruption.  It was hoped  that inoculation  might be as
successful with measles as with smallpox, in exciting a milder form, but
this has not been found to  be the case, and the practice has never pre-
vailed.
  " 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 vacci-
nation.   The operation succeeded in about 93 per cent, of the cases in
Bibliotheq. du M6dicin.-prat., part xvii. p. 448. 
MEASLES.
605
which it was performed, producing  a mild attack of measles.   A red
areola at first formed around the puncture by which the fluid was in-
serted,  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,  desquamation
commenced, with a decrease of the febrile symptoms; and by the seven-
teenth day the  patients  were very  generally well.  In no  one of the
inoculated cases did the disease terminate fatally."
   It occurs  also as an epidemic,  owing probably to some  peculiar state
of the atmosphere, and  is certainly conveyed  and propagated by it,
and frequently  an epidemic of measles follows immediately one  of hoop-
ing-cough, both commencing with an affection of the bronchial  mucous
membrane.   The following are some of the principal ones :—
   An epidemic was observed in London in 1769, 1770, 1773, 1774, 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.  In
 Boston it first appeared as a very fatal epidemic in 1713; and again in
 1730, 1757, and 1772.   Of late it was most frequent in the years 1821,
 '25, '29, '32, '35, and '46.
   Dr. J. Duncan has described  an epidemic of  measles which  occurred
 in the  North Union Poor-house, between March and June, 1842 : 56
 children were  attacked,  and 15 died ;  11 were under one year, 10 be-
 tween 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   Dr.  Lees  has published
 a valuable  paper upon the complication of measles in the epidemic of
 March, April,  and beginning of May, 1844, at the North Union  Poor-
 house of Dublin; 147 children were attacked, of whom  35 were between
 2 and 5 years  of age of age, and 6 died: 112  were between 5 and 12,
 and of these onlv 5 died.   The chief complications were broncho-pneu-
 monia, laryngitis, enteritis, peritonitis, &c.  Dr. Coley has described a
 malio-nant epidemic which prevailed in London during the winter 1847-8.
   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 attri-
 buted to minute insects  in the air,  or  to some  unknown  composition of
 the atmosphere ; but we can prove nothing.   It is transported  either
 bv atmospheric influence or by individuals, to distant countries, although
 it is not always possible to mark  its transit, and some distant  lands
 seem to escape it altogether.                      >         .
   Thus it  is stated by M. d'Angheira to have been imported into Ame-
i Dublin Journal, vol. xxii., Sept. 1842, p. 26. 
606
MEASLES.
rica in 1518;  and Dr. Stewart says there are no records of its appear-
ance 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. Copeland,  " measles were introduced
into  the Cape of Good Hope,  where they had not appeared  for about
thirty years, by a vessel from Europe,  in which several instances  occur-
red during the voyage."1
   In Australia, Van Diemen's  Land, and New Zealand, I believe, it is
unknown to  this day.
   Sporadic cases of measles are observed at all seasons; but epidemics,
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 predisposing
cause, that more  infants are attacked than children, and more children
than adults;  and I endeavored to explain  this without supposing a
greater inherent liability.  Nor is the foetus  in utero exempt from  the
disease.   Hildanus,  Roesler, Vogel, Rosenstein, Osiander, Girtanner,
Orfila, Billard, and others, witnessed cases of this kind.2
   I saw a case in which  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,  analo-
gous to the cases of inoculation.
   From the  calculations of Emerson3 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  occur
red in London in 1842,4 93.8 per  cent, occurred in children under five
years, and 99 per cent, in those under ten years.
   Rilliel;  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.
  I have, however, repeatedly met with cases in which  for some time

            1  Diet, of Pract. Med., part ix. p. 822.
            2 Ueber der Krankheiten des Foetus, by  Graetzer, p. 46.
            3 American Journal of Medical Science,  1827, vol. i.
            1 West on Diseases of Infancy and Childhood, p. 476. 
MEASLES.
607
the diagnosis was extremely difficult.  The eruption may resemble either
disease, or one  disease on one  part of the body,  and  the  other on
another, and there may be an absence  of  the  usual affections of the
mucous membranes.
  As a general rule, if there is neither coryza, sneezing, nor coughing,
I should conclude that the disease was not measles; but I am not sure
that this rule is absolute.  There  are, however, two circumstances, either
of which  may determine  a doubtful  case.   1.  Other members of the
family may exhibit the disease in  its orthodox form, and so clear up our
doubts; or, 2. Some of the definite sequelae may follow, and be equally
conclusive as to the nature of the previous eruption.
  II. Some cases of roseola strikingly resemble measles,  and no doubt
have been mistaken for them; but, in general, there is little or no run-
ning 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 always  favorable; but, although a considerable num-
ber 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 another, 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 disease,
and  its complications.
  The concurrence of pneumonia, croup, gastro-enteritis,  or dysentery,
whether they prevail epidemically or not,  diminishes  the chances of
recovery very seriously.   The typhoid form  of the disease  is also by far
the  most  fatal.  And children  of broken-down  constitutions are more
likely to fall victims to the complaint than those who were previously
healthy.
  Upon the whole, measles are far less  fatal than either  scarlatina or
smallpox.
  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 respiratory
or digestive organs, is very easily cured.  2.   Normal primary, but com-
plicated measles, is cured  about as often as it proves fatal.   3. Anoma-
lous  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 measles 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 mu-
cous  and easy expectoration; a free and unembarrassed respiration;  a
1 Mai. des. Enfans, vol. ii. p. 744. 
608
MEASLES.
free state of the bowels,  and moderate relaxation of them towards the
close  of the  disease;  hypostatic urine;  a regular succession of the
changes of the eruption;  and no appearance of any irregularity or com-
plication 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."1
  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, and plenty of diluent  drinks allowed; the
patient to be kept in  bed, lightly covered, and only a very light diet per-
mitted.
  The heat and prickling or itching of  the  skin,  when the  eruption
appears, may be relieved by small doses of the liquor ammoniae acetatis,
and spiritus aetheris nitrici.  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 uni-
formly active when the eruptive fever is developed; and  that we should
be more fortunate in the main if we interfered less with the operations of
nature in cases of a mild and regular character."2
  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 neces-
sary, and these of an antiphlogistic kind.
  Sydenham advises bleeding, when the fever is violent, with pulmonary
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 bloodletting 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 accord-
ing 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 charac-
ter the measles assume, and must be treated  accordingly.   If fever be
1 Copland, Diet, of Pract. Med., partix. p. 821.
2 Practical Illustrations of Scarlet Fever, Measles, &c, p. 115. 
MEASLES.
609
high, cough and oppression severe, blood should be drawn immediately,
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 compli-
cation exists.
  The quantity of blood to be taken must depend partly upon the inten-
sity of the febrile or inflammatory action, partly upon the organs prin-
cipally affected, and partly  upon the stage  of  the disease and  the con-
stitution of the child.   If the child be strong, the  lungs considerably
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.
  In Germany much benefit is said to be derived from mustard poultices
after leeching*; and in my own practice, I have found them very useful
applications.
  Other antiphlogistic remedies must also be adopted; low diet, cooling,
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  bedtime, or
twice in the day.
  Cold affusion has been  strongly recommended, or  sponging the 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 in-
flammation.2  Dr. Armstrong does not think  it as suitable as in scar-
latina,  but he has derived great benefit from tepid affusion.3
  854.  In  the congestive  form of measles, if we detect any organic in-
flammation, it may be found necessary to bleed, and  it will generally 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 cutaneous
circulation, and so relieving  the  internal organs; and, moreover,  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, bloodletting will
be out of the question.   Our object must be to support and stimulate the
vital powers, for which purpose we must give  ammonia, camphor, bark,

                 1 Diseases of Children, p. 570.
                 2 Bateman on Cutaneous Diseases, p. 61.
                 3 Practical Illustrations, p. 163.
       39 
610                      SCARLET  FEVER.
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 pecu-
liarity of the  epidemic of measles.  Thus, purgatives must be cautiously
administered  when gastro-enteritis, or diarrhoea, or dysentery prevails ;
bloodletting used warily when diseases have  a typhoid or adynamic cha-
racter.
  In  inflammatory epidemics, such  as that  described  by Mead, Arm-
strong,  &c, bleeding is  highly beneficial; but in the one that prevailed
in Paris in  1828, although it was frequently complicated with  inflam-
mation of the lungs  and other  organs, M. Biett states that it was  not
benefited by bloodletting.1
  857.  Special treatment  will be  required for each of the complications,
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 a 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; maybe  propagated by
infection or contagion, and ordinarily attacks a  person  but once in  a
lifetime.  Its cause and history have so much resemblance to  measles
that for a  long time they were confounded,  but the eruption  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 believe
for  the  reason I have already mentioned, viz:  that being highly infec-
tious as well as epidemic,  the child takes it the first time it is exposed 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
were 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 published an
Report in Jour. Hebdom., No. 42. 
SCARLET FEVER.
611
account of an epidemic which resembled scarlatina, and which prevailed
in Poitiers in 1557.   And Forestius states that the epidemic at Amster-
dam in 1517, which was described by Tyengus, was this malady.1 Mer-
catus (1672), Heredia (1626),  Sgambatus (1620), iEtius Clerus (1636),
Senner (1625), Sydenham, Sibbald, Morton, Fothergill, Heberden, De
llaen, &c. &c, have since described the disease.  It first appeared in
Spain in 1610, in Naples in 1618, in London in 1670, and in Edinburgh
1680.
   859.  We can only form an approximate estimate of the frequency of
scarlatina.
   Dr. Copland has given the number of deaths from scarlatina, measles,
and smallpox, in the eleven years from  1838  to  1848 inclusive, and
those are: from scarlatina, 20,962 ; from  measles,  14,632 ; and  from
smallpox, 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 smallpox 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 epidemic
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 specified  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  contagious dis-
eases." ....  "In the years 1835-36, and part of 1837, the mortality
from this  disease rose from 620 to 840, 1074, and 1040, being then the
forerunner of the  fever  and smallpox which  prevailed  in  1837, 1838,
and 1839, during  the continuance  of which diseases it fell, but again
rose up, then  declined in 1840."2
   In the  tables of mortality  of Philadelphia, U. S., published  by Dr.
Emerson, it appears that in twenty-four years the mortality from  scar-
latina was 143 under twenty years of age;  and during the first  twenty
years of this period, there were 654 deaths  from measles.3
   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 vario-
loid.4
   Dr  Gregory mentions that the deaths  from  scarlatina  in 1837 in
London we°re 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

           1 Diet, of Pract. Med.,  part xiv. p. 665.
          2 Report on the Table of Deaths, p. 13.
          3 .American Journal of  Medical Science,  1827, vol. i.
          4 Diet, de Med , vol. xxviii. 
612
SCARLET FEVER.
disease.   The irregular occurrence of an epidemic of either disease, or
its unusual  severity, will effectually disarrange our statistical calcula-
tions.
  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 mo-
ment of receiving the infection to the development of febrile symptoms,
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 unea-
siness,  lassitude, depression, aching in the back and limbs, rigors, loss
of appetite,  and  thirst.   Soon afterwards the patient complains of stiff-
ness and pain in the throat, with difficulty and  pain in  swallowing.
  The  skin becomes very hot, the  pulse quick and full;  occasionally
there is 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 latter especially, if the infant be teething—but
seldom more than one  or two.
  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 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 commonly
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.  II. 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 irregular
patches on the limbs.
  Neither the minute red points, nor the large patches, nor the generally
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 papulae; very
different from  the irregular, semicircular or crescentic, somewhat ele- 
SCARLET FEVER.
613
vated 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 secretion in
patches:  the swelling of the tonsils  may be perceived  externally, 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 papillae, something like  the  surface of
raspberry jam, if I may use so homely a comparison.
   On certain parts of the body, as the neck, axillae, 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.
   "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 papillae, and the
 characteristic redness.   The swelling  of  the parts  diminishes simulta-
 neously, but gradually."1
   862. ill.  Period of Desquamation.—Somewhere, then, between the
 fourth and  ninth  day desquamation commences.   If 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 perhaps 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-
 times  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.
1 Diet, de Med.,' vol. xxviii. p. 153. 
614
SCARLET FEVER.
  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.  Occasionally
the skin becomes universally sensitive  during  desquamation, 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 respi-
ratory mucous membrane  diminish, and  finally disappear.  The throat
ceases to be painful, the swelling of the tonsils subsides, and the pharynx
and vault of the palate lose their scarlatinous 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  case
of scarlatina.  Our next point is to  notice  the principal modifications
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 papulae, but very rarely with pustules.
   " Reuss, Raimann, and Hildenbrand  have observed, in rare instances,
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 scarlatina pemphigoides of
Hildenbrand.
   In  the severe forms of  the disease, the eruption may assume a dark-
red or livid color, occasionally interspersed with petechiae 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;

                1 Diet, of Pract. Med., part xiv. p. 668.
                2 Diet, de Med. et de Chirt Frat., vol. xiv. p. 541. 
SCARLET FEVER.
615
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.
  In four out of  seven  children in one  family, the children were free
from any symptom whatever until vomiting took place, after which the
disease ran its usual course.  Two of my own children were apparently
quite well up to 5 P. M., when they were  suddenly attacked by vomit-
ing, followed by fever;  and in the morning they were scarlet, but with-
out sore throat, and had little or no  desquamation.  This absence of
sore throat, or any other specific complication, if the rash be not very
characteristic, renders the  case very puzzling, and, in fact, we may not
be able  to pronounce positively upon the case  until either the  disease
attacks  other members of  the  same  family, or some of  the peculiar
sequelaa make their appearance.
  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 occupy
weeks.
  864. It appears also, from very good evidence, that a child  may have
scarlatina without the eruption, or die before the eruption appears.  Some
have doubted this ; but it is maintained  by Huxham, Fothergill, Stoll,
Dance,  Guersent, Graves, Trousseau, and others.  We may see the dis-
ease run its regular course with several  members of a family, and per-
haps one of them will exhibit  all the constitutional symptoms, fever,
sore throat, &c, without any rash upon the skin.
  I have seen one well-marked case of this kind.
  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, or
so slight and so  evanescent as to  escape  notice."  This  Dr. Copland
believes to  be  true scarlatina, though latent.
  Dr. Graves  has related a case of a  young lady who was in constant
attendance upon  her  sisters during  scarlatina, and who  exhibited no
symptom of the disease, but who was attacked by the anasarca of scar-
latina after the other children were convalescent.1
  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 spo-
radically 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."2

    ' Clinical Medicine, vol. i. p. 347.     2 Diet, of Pract. Med., part xiv. p. 8C8. 
616
SCARLET FEVER.
  865.  The modifications which depend upon the type of the epidemic,
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.
  This peculiar type varies in different epidemics, owing to the " consti-
tute morborum," as  it has been called.  Thus, for years, all the scarla-
tina may be  attended with inflammatory symptoms, then  an epidemic
may occur of a typhoid  character, and as other diseases illustrate the
prevailing constitution, by ascertaining  that, we  may and ought,  in
some degree, to be prepared for the type of the epidemic of scarlatina.
  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 symptoms 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 examina-
tion 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 imprudence some  of
the usual complications or sequelae should  occur.
  II.  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 papillae.   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 burn-
ing, 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 character
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.
  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 begin-
ning, especially in autumn  and winter, in  patients of a debilitated con-
stitution.  "  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 
SCARLET FEVER.
617
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, espe-
cially 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 fretful-
ness,  restlessness, anxiety, lipothymia  or faintness, and remarkable de-
jection of spirits.   The pulse, from the first, is quick, small, and flut-
tering ; in some, soft and full, but weak and  irregular, but always with-
out 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  yellower, as if bile  were
diluted  with it, or  turbid, scanty, high-colored, and sometimes it con-
tains  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 constitutional disturbance
presents an extremely typhoid or  asthenic character, 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  progress
very  favorably to all appearance, when suddenly the throat again be-
comes sore, and the parotid and submaxillary glands swollen and  pain-
ful, 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
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 petechiae, or some degree of oedema.  The parotid and
submaxillary glands are  swollen  and tender, and the neck  and throat
become oedematous,  with great dyspnoea.  There is an acrid discharge
from  the nostrils and mouth, the angles  and edges of which are exco-

  i Diet, of Pract. Med., part xiv. p. 670.        2 Clinical Medicine, vol. i. p. 318. 
618
SCARLET FEVER.
riated 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 destroyed by it, an acrid
offensive discharge escaping from the ear.
  " When  the disease has assumed a particularly violent character, col-
lapse 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 diarrhcea often  takes place; and, in some
cases, hemorrhages from various parts, and petechiae, occur towards the
fatal termination of the complaint."1
  The febrile excitement  in children may  run on into a low muttering
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 frequent,
watery, and most offensive, sometimes bloody; the latter putrid, brown-
ish, or suffused.  The  surface becomes cool;  the  countenance bloated,
cadaverous, or  oedematous; the parts pressed upon, excoriated or sphace-
lated ; the tongue  brown, hard, or dry; the breathing labored, or inter-
rupted 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
  In several cases of fatal  malignant scarlatina that I have seen, the
eruption was not unfavorable, perhaps less florid  and profuse than usual,
but not unusuallj'-  so, and the patients had but very  slight sore throat;
but the case  exhibited  marked typhoid symptoms, with dry, dark, loaded
tongue  and sordes about  the teeth, and ran on  into coma,  and  some-
times convulsions.
  Death may occur  as early as the second day, either  from  the laryn-
geal, pharyngeal, or  cerebral complications, or at a later period from the
cerebral or pulmonary complications, or from the morbid state of the
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  abdominal
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.
  867. Dr.  Armstrong has described three varieties of malignant scar-
latina :  the  inflammatory,  the congested, and  the mixed.   The first
commences,  like  scarlatina  anginosa, with  considerable inflammatory
excitement,  but,  after  a  few days,  collapse  and a typhoid condition
supervene;  the vital powers sink, the throat becomes gangrenous, and

  1  Eberle, Diseases of Children, p. 449.     2 Diet, of Pract. Med., part  xiv. p. 671. 
SCARLET FEVER.
619
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  gid-
diness in the head, extreme  oppression, and much uneasiness in the
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 occur-
red, 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 disordered with delirium ;
or an indifference to surrounding objects and a stupor  succeed, under
which patients finally expire.  From the beginning the pulse is gene-
rally low, quick, and irregular,  and commonly 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 undulating.   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 dis-
tended with flatulency, constipated or irregular in  the  first stage, but
frequently loose in the last.   The faeces 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 degluti-
tion becomes more difficult as the disease advances.  This form of the
 scarlet fever frequently 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 petechiae, or gangrenous spots upon  the skin.  A few
 hours before death there is often a superficial glow of heat diffused over
 the body,  accompanied  with  a darkly  flushed  face, high breathing,
 accelerated pulse, and partial  or general  sweats.^   But  this mere  sem-
 blance of excitement soon subsides ; the extremities grow 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
    In this form  the eruption is of a purplish or copperish color,^ deepen-
 ing 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  disproportioned to the
 amount of general disease.
    These varieties, as I  have already observed, depend partly upon the

                1 Practical Illustrations of Scarlet Fever, &c, p. 21. 
620
SCARLET FEVER.
condition of the child and partly upon  the character of  the  epidemic,
some assuming the form of scarlatina anginosa, and others of scarlatina
maligna.
  A very interesting question is as to  the increase  in the intensity of
the poison in proportion to the number of children affected in the same
house.   In one family where seven were attacked, the two last affected
exhibited the worst typhoid character of fever, but with very slight sore
throat; one died on the third day, and the other on the sixth.
  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 re-
cord 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 Ileyfelder,
mention one case each.1  Dr. Burns mentions two instances.  Dr.  Bate-
man regards such cases  as exceptions to a general rule.   Bicker,2 New-
man,3  and Burns, deny that  the susceptibility is invariably removed by
one attack.   Richter observes that a second and even a third attack has
occurred.4
   Dr.  Meigs,  Jun., mentions the  case of a person who had  the  disease
two year previously under the care of his father.5
   869. Complications.6—The complications of  scarlatina vary much as
to the period at which they occur, ranging from the earliest  incursions
of the disease until weeks after its apparent cure.  They differ also  in
character, in part owing to  the violence of the attack, in  part to the
character of the epidemic, and a good deal according to the constitution
and habits of the patient.   They  are quite different among the poor, ill-
fed, scantily-clothed  children of the poor, from  those met with among
the rich.   Something also depends upon the age of the child, as an in-
fant who is teething is much more  liable to convulsions or head affections.
   a. Affections of the  Mouth.—When speaking of  muguet, aphthae,
ulcerated sore mouth, and cancrum oris, I mentioned their occurrence
during the  course of scarlatina.7  In  ordinary 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  character,  and  become converted into  cancrum oris.
Such  a complication would  probably itself insure a fatal  termination,

  1 Diet, de Med., vol. xxviii. p. 173.
  2 Beschreibung eines Scharlachfiebers,  p. 162.
  3 Aufsiltze und Beobacht. fur Aertze, p. 284.
  4 Specielle Therapie, vol. ii. p. 440.            5 Diseases of Children, p. 448.
  6 I would take the liberty of referring my readers to Dr.  H. Kennedy's little volume on
scarlatina, as containing a valuable series of facts illustrative of almost all the complica-
tions of scarlatina, as they occurred for a number of years in this city, carefully noted
and simply related.
  7 Section iv. chapters 4, 5, 6, 7. 
SCARLET FEVER.
621
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 a
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 tonsils,
which may coalesce and extend to  the neighboring parts ; the submaxil-
lary glands  and tonsils are felt  externally to  be  much  enlarged and
tender; deglutition is impeded; the fluids, or a portion of them, are re-
gurgitated ; and the speech is less clear than usual.   If the complication
be very extensive  and severe, it will predominate over the other  symp-
toms :  "the febrile reaction becomes intense ;  the oppression great;  re-
spiration  impeded ; the cough frequent, rarely clear and sonorous, but
also rarely hoarse  or  lost; the face is excited; but in  some  cases ex-
presses 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 worst
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, tonsils,
and fauces, covered more or less with  grayish or brownish patches, un-
derneath  which ulceration of an unhealthy character is  going on ; and
by  and by, when these membranous laj'ers are thrown off partially or
wholly, we may discover ulcers of various  shapes and extent,  but gene-
rally deep, which  assume a gangrenous appearance.   In whichever way
it commences, we  may have very shortly to deal with that very  formi-
dable and fatal affection, gangrene of the pharynx, 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 abdominal
tenderness, and he attributes it to cerebral irritation and congestion, as
in hydrocephalus.
  Dr. Gregory speaks of a low degree of mucous enteritis accompanying
the decline of scarlatina,  and, in bad cases, ending in ulceration  of the
mucous membrane, with bloody stools.3

  1  Rilliet and Barthez, Mai. des Enfans, vol. ii. p. 604.
  2  Section iv. chap. 11, p. 478.                 3 On Eruptive Fevers, p. 134. 
622
SCARLET FEVER.
  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-entefic affection does not consti-
tute  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 is irritation,
sneezing,  &c,  with a  mucous or muco-purulent discharge.   In the ad-
vanced stages  of scarlatina maligna there is an acrid discharge, which
excoriates the edges of the nostril.   But  this complication is of no im-
portance ; 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  oedematous swelling of the neck, the glottis and neighbor-
ing 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 as in the
cases  described by Mr.  O'Ferrall.   Such an addition  to the  original
disease will, of course, add to its formidable 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.
  /. 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 pneumonia are
of such importance that  we should be ever on the watch to detect  their
earliest symptoms.
   871. h.  Cerebral  Affections.—I 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.

                    1 Graves,  Clinical Med., vol. i. p. 320. 
SCARLET FEVER.
623
One child of a patient of mine died suddenly of apoplectic congestion of
the brain just as the eruption was appearing.  Her sister  sank into a
state of stupor and died suddenly without convulsions.   MM. Guersent
and Blache  mention a case in which delirium, with loud cries, came on
during convalescence, with vomiting, but no other symptom, and lasted
some  days.   Rilliet and Barthez mention that cerebral complications
proving fatal are more frequent in scarlatina  than any other fever.
   I saw a case  in  which the head symptoms were relieved by bleeding,
and the  child was 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   Generally speaking, there are but one or two  convulsions;
but, in other cases, I have known the convulsions continue with all the
other symptoms of meningitis, and prove fatal.  Low, muttering deli-
rium  occurs in scarlatina maligna.   During the desquamation and con-
valescence,  the nervous symptoms which occur, the  coma and paralysis
which come on suddenly, 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 owing
sometimes to excessive congestion of the brain, and sometimes to inflam-
mation of its membranes,2 or effusion into the ventricles.
   i. Diffuse Inflammation and Glandular Swellings of the Neck.—We
have  seen that the tonsils  and submaxillary glands are more  or less
swollen,  and in some cases the parotids, one  or both, participate in this
enlargement, which may be very considerable.   And not only that, but
the entire  neck may be so  much swollen from cellular oedema  as to
place the patient in great danger of suffocation.
   Dr. Graves and Dr.  H. Kennedy describe this as a very formidable
 complication.  Sometimes it attacked the patient during the height of
 the eruption, in others after the constitutional  symptoms had in a great
 measure subsided.   It spread with great rapidity round the neck, which
 became immensely enlarged, the swelling extending from the face to the
 clavicles, in some  cases, and in one, involving even the pectoral muscles.
 At first it appeared to consist of serum, afterwards unhealthy pus, either
 infiltrated through the tissues or collected into small abscesses, or form-
 ing one large one.  In many cases, sloughing of the  most formidable
 character set in, with great destruction of tissues, and occasional and even
 fatal hemorrhage  from disordered  vessels.  * The edges of the sores while
 sloughing were°either of a dark red or livid hue, and  in two  or  three
 instance? quite black.  Dr. Kennedy has mentioned another species of
 swelling which was caused by the effusion of lymph; the  neck became
 swollen and very  hard, and very rarely small abscesses formed.   It was
 also sometimes more limited in extent than the diffuse inflammation.
   Dr. Asbery has described  a very formidable and fatal  complication
 of diffuse inflammation of the neck  which he noticed in the epidemic of
 1840-41.   "The  progress," he says,  "of the inflammation was very

   ' Clinical Med., vol. i. p. 313.
   2 Guersent and Blache, Diet, dc Med., vol. xxviu. p. 161.  Rilliet and Barthez, Mai.
 des Eufuns, vol. ii. p.  620. 
624
SCARLET FEVER.
 insidious, in most cases  commencing as an indurated swelling behind
 the angle of the jaw on one side, wrhich was at first very indolent, with-
 out any  discoloration of  the integuments, but as the affection  advanced
 the swelling increased much more rapidly,  often extending to  the oppo-
 site side; the  integuments then  assumed a  dusky red appearance,  and
 became very tender to the touch; there was much  oedema, so that  the
 part readily pitted, when pressed by the finger, and there was an obscure
 sense of fluctuation communicated to the touch.   In the advanced stage
 of the complaint, sensibility, which was previously great, diminished to
 such a degree that the child did not seem to suffer much pain, if inci-
 sions were made into the swelling.  When the patient survived till about
 the tenth  day from the commencement of the affection,  sloughs  fre-
 quently formed, commencing in  dark purple specks over the surface of
 the swelling, the sloughing  rapidly spread, diarrhcea then set in;  the
 abdomen became tympanitic, spots of purpura appearing, at times, over
 the surface of the body, until the occurrence of passive hemorrhage from
 the mouth and bowels.  The child either died comatose, or exhausted by
 diarrhoea,  in case dissolution was not quickened by the supervention of
 sudden hemorrhage from some of the large vessels  of the neck  giving
 way in sloughing.  An attack of convulsions sometimes preceded death,
 the period of which, unless precipitated by exhausting  treatment to
 which  it had been submitted previous to my seeing the child, varied from
 the seventh to the twenty-eighth day; the medium  time being about  the
 twelfth day from the commencement of the inflammation."1 Dr. Graves
 also  relates a case of this kind, and he agrees with Dr. Asbery that all
 our efforts should be directed to support the strength of the patient
 until sloughing takes place,  and  afterwards.
  Dr.  West observes that " in  the  majority of instances, however,  the
 glandular swellings, which come on after the lapse of a week  from  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 cellular  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  expe-
 rience  difficulty in deglutition,  which  goes  on increasing until  the
 attempt  to swallow becomes quite  impracticable.   As  the dysphagia
 increases, respiration also becomes very difficult, but the dyspnoea con-
 tinues 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  modi-
fication 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  in-
1 Graves, Clinical Med., vol. i. p. 333. 
SCARLET FEVER.
625
crease in redness, or  other  token  of inflammation."1  I have already
laid before the reader Dr. Flemyng's remarks  upon the retropharyn-
geal abscess, with the mode of cure, and I must refer him to that chap-
ter for fuller details.2  A teasing consequence  of this affection of the
neck has been noticed by Mr. 0. Ferrall and Dr. H. Kennedy, viz:  wry-
neck remaining when the patient was becoming convalescent.   Whether
it be mechanically owing to the remains of the swelling, or the effect of
inflammation upon  the  muscles, or  the consequence of  disease of the
vertebrae, as Mr. 0. Ferrall suggests, it is difficult sometimes to decide.
The neck is crooked, and any attempt to straighten it gives great pain.
  872. j. Dropsy.—Albumen.—The dropsy which accompanies or fol-
lows scarlatina has  been noticed from  early times by all  authors.  It
was  a subject of special  investigation  to  Plenciz, De Borsieri, Yieus-
sieux, Meglin, &c,  and  is  treated  of by Underwood, Dewees, Eberle,
Stewart, Condie, Maunsell and  Evanson, Coley,  West, Barrier, Rilliet
and Barthez, Legendre, Johnson, Bush, Toynbee, Simon, &c.3
  The complication is  a very interesting one, and worthy of ample
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  resistant.  The face does not present
that dead paleness which is observable in passive  anasarca; on the con-
trary, from the  accompanying febrile action, there is generally 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 subcutaneous cellu-
lar tissue becomes considerable, accompanied with paleness and  trans-
parency 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 have not elapsed, the skin will present some
traces of desquamation  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,

       1 Diseases of Infancy and Childhood, p. 474.
       2 Chapter xii. p. 440.       8 Med.-Chir. Trans., vols, xxix and xxx.
       40 
626
SCARLET FEVER.
these febrile symptoms disappear, either under the influence of treat-
ment, or naturally; but when they  are prolonged, and accompanied by
new  symptoms, either cerebral, pulmonary, or abdominal, there is  rea-
son 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
  In some jases, the anasarca may  be  very slight, and yet the attack
prove fatal from the effusion  of fluid into some of the  cavities.   In two
cases under my care, soon after, a moderate degree of anasarca showed
itself, with suppression of urine at first, then bloody,  but  not albumin-
ous  urine, and at the same  time cerebral  symptoms were developed,
heaviness, constant stupor, insensibility, and, in one  case,  convulsions
and  death ; the other child recovered.
  In another  case, convulsions occurred after the urine  had become
natural, and the anasarca had nearly disappeared.
  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 ma}T, however, occur much earlier, even during the eruption.   Dr.
Asbrey  relates a case who died  anasarcous  on the fifth day from the
commencement,2 and another when  it appeared on the second day.
  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  two or three
days.
  873.  Plehciz 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 condi-
tion  of the urine, and its connection  with the  dropsy,  and different
views held of,  the condition of the kidneys in this disease.   Seymour,
Barlow,  $pittal, Graves, Lees, and others, regard the  renal  disturb-
ance in  the dropsy of scarlatina as   functional, on account  of  its cura-
bility,  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  albumi-
nous 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 exist-

        1 Recherches Anat. Path, sur plusieurs Mai. de l'Enfance, p. 343.
       2 Dub. Journal, vol. xxiii. p. 239. 
SCARLET FEVER.
627
ence 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 instances  related by Fischer,1  Hamilton,2  and
(jthers ;  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 ana-
sarca, without albuminuria, of albuminous urine  without any change in
the kidneys, as in Dr. Graves and Dr.  Lees' cases, and  also of albumi-
nous nephritis 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. Ken-
nedy,3 and as I have repeatedly seen.
   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 anasarca
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, something  like
 muddy beer ; and as time  elapsed, and the disease diminished, the urine
 became  of a lighter color,  until, about  the  fifteenth or  eighteenth  day,
 it was paler than  natural; and  when  the renal affection 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, colorless 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  present  in the urine is,
 according to  M. Legendre, a  fundamental difference between the albu-
 minuria of scarlatina and  that in Bright's disease.  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. Legen-
 dre found the kidneys enlarged and  less  brown than usual;  in some
 parts grayish.   Divided lengthwise, it  was evident that the increase

   1 Hufeland's Journal, Feb. 1824.
   2 Edinburgh Medical and Surgical Journal, 1833.           _
   3 Some Account of the Epidemic of Scarlatina which prevailed m Dublin from 18d4 to
 1842. 
628
SCARLET FEVER.
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 surrounding
parts.  The cortical substance was more easily torn  than usual, and was
somewhat  less firm.  The tubular substance was unchanged.
  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 by 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.
  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
  Dr. Graves denies that albuminous urine always results from organic
disease of the  kidneys :  he regards it, as does Dr. Blackhall, as merely
an indication of a peculiar inflammatory condition of  the whole system,
and in this opinion Dr. Lees concurs.
  875. Dr.  West  has  thus described  the severe  cases of anasarca:
" The swelling, after having undergone many  apparently causeless fluc-
tuations, becomes extreme  as  well as universal; the features are dis-
figured 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, however, is referred to the chest;
the respiration is labored and  accelerated, and the child is frequently
unable to resume the recumbent posture, and  is,  moreover, distressed
by  a  frequent short and hacking cough.   Under these circumstances
life is sometimes  prolonged for several days,  though in a state of ex-
treme suffering, remedies proving unable either to increase 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 tem-
porary improvement takes place, the anasarca 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 un-
noticed during the acute stage of the affection."
   Dr.  West does not state  exactly what he considers to be the connec-
tion of the albuminous nephritis with the anasarca,  but he has described
what  he  believes  to be the pathological  stages of the former: " The
microscope has shown us that the morbid  process begins in the cortical
parts of  the inflamed kidney, the urinary tubules of which are stimu-
lated to an increased production of their epithelial lining, or even to a
 pouring out of solid fibrous matter into their cavities.   The urine car-

            1 Recherches, &c, sur quelques Mai. de l'Enfance, p. 316. 
SCARLET FEVER.
629
ries 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 be-
come dilated and varicose, and afterwards  (in part, probably, from the
formation of fibrinous clots  within them, in part as the result of a pro-
cess  of adhesive inflammation) they become obstructed  and even oblite-
rated.   Supposing this morbid process to have gone on to any consider-
able  extent, the kidney must be left by it permanently and irreparably
injured, while, even in its slighter degrees, 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 preternaturally deep color, and has regained much
of its healthy appearance, albumen should  still exist in any quantity,
there will be reason for apprehending that some 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, when
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 unassimilated
materials  in the blood, the  mortality in  the early stages  is probably
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 efflores-
cence to that existing  in the vascular rete  of the skin; and that this
efflorescence on the surface of the uriniferous tubes, &c, and the asso-
ciated 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 occasion an accumulation of
excrementitial and  contaminating materials in the blood, and consecu-
tively 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
  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 sequelae of  scarlatina are the result  of this condition

                1 Diseases of Infancy and Childhood, p. 422.
                2 Diet, of Pract. Med., part xiv. p. 673. 
630
SCARLET FEVER.
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
Thus, then, we find, 1,  scanty urine, loaded with lithates and  varying
in color; 2, containing  very often blood, which gives it a color of rusty
iron or porter brown; 3, containing albumen, which does not depend
upon the existence of Bright's  disease in the kidney, but from a high
degree of general congestion  with inflammation of the tubes; and  4,
containing epithelial casts or debris of the  same,  thrown off from the
tubes, constituting a  true desquamative nephritis, as Dr. Geo. Johnson
has termed it.
  More recently, Dr. George Johnson has minutely described this affec-
tion, which he terms  "acute  desquamative nephritis," and  I would
strongly recommend a perusal of this section of  his valuable work.2
  876.  In addition  to  effusion into  the  serous  cavities, M. Legendre3
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 commencing by
cough and some oppression in breathing when it  precedes general ana-
sarca ;  after this occurrence the  cough and dyspnoea  increase greatly,
and threaten suffocation.   When oedema of the  lung  and general ana-
sarca set in together, the child is suddenly attacked by  cough and dys-
pnoea, 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 extent 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.
   Dr. Lees alludes to  this complication as causing the oppression  of
breathing in one of his patients.4   He  believes that the fluid  may  be
effused either into the cellular substance of the lungs or into the cavity
of the thorax.
   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

  1  Diet, of Pract. Med., part xiv. pp. 779, 780.      2 Diseases of the Kidney, p. 84.
  8  Recherches sur quelques Mai. de l'Eufance, p. 324.
  4  Dub. Journal, vol. xxiii. p. 232. 
SCARLET FEVER.
631
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 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 impure  blood, or blood  with the
natural and healthy proportions of its constituent parts destroyed.
   I think we possess sufficient evidence to prove the existence of con-
gestion or inflammation of the  kidneys, but  not enough to  lead to the
inference that the albuminuria  accompanying scarlatinous  anasarca is
always owing to Bright's  disease, nor that this state of  the kidney is
very 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.  Ophthalmia.—Mild  attacks of ophthalmia not unfrequently
occur during convalescence from scarlatina, but in general they give but
little trouble, unless the child should be of a scrofulous constitution or
much worn  down.   Occasionally, however,  the attack  is  much more
severe,  and may end in sloughing  of the cornea, as in the  case related
by Dr. Asbrey  "in which,  simultaneously  with the gangrene  of the
neck, sloughs formed on  both corneas, and rapidly extended, involving
all the other textures of the  eyes."3   Dr.  Gregory also alludes to simi-
lar cases.4
   I. 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; inflamma-
tion, ulceration, and perforation of the tympanum; chronic otitis, with
offensive discharge; inflammation and ulceration of the membrane  lining
the cochlea and semicircular canals;  caries  of the petrous portion or
mastoid process,  or other parts of the temporal bone; and  even the ex-
tension of  infiammation,  suppuration, or ulceration to the  membranes
and substances of the brain  may supervene;  and, as respects these lat-
ter 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 advanced 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

  ' On the Dropsy following Scarlet Fever, by Dr. Scott Alison, Lond.  Jour, of Med.,
No. iii. p. 227.
  2 London Jouv. of Med.,  No.  v. p. 454.        3 From Clinical Med., vol. i. p. oo4.
  * On Eruptive Fever, p. 128. 
632
SCARLET FEVER.
parts, the affection of which often occasions great and protracted suffer-
ing, and ultimately fatal results."1
   Otorrhcea is stated to be frequent, but of no importance, by Heyfel-
der ; it is even regarded as favorable by Berndt, when the nervous sys-
tem is much affected.  Guersent and Blache have  rarely met with it.
   m. 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 hemorrhage
from the nose or mouth has sometimes carried off the  patient, and a
similar result has occurred from bleeding from the  ear.2  Dr. Graves
mentions a case of Mr. Porter's in which hemorrhage from the ear proved
fatal, and another fatal result from  epistaxis.  Drs. Hunt and Chas.
Johnson met with a case of fatal hemorrhage from an ulcer of the throat.
Drs. Asbrey and Kennedy cited fatal hemorrhage  from the vessels des-
troyed by the sloughing of the neck.
   n.  Vaginal Discharges.—At the decline of the eruption of scarlatina
girls are occasionally though rarely liable to vaginal discharge.  Papers
on this subject have  been published by Dr. Barnes3 and Dr. Rose Cor-
mack,4 and in Dr. Miller's  late work on scarlatina, he mentions that he
considers it very rare, as he  has not observed  it.   Dr. Cormack, how-
ever, frequently met with it in the epidemic of 1848-49.  It is  a simple
and very manageable affection; its  only importance being the  question
that may be raised as to its being blennorrhagic; those who know how com-
mon similar vaginal  discharges are among young children will  hesitate
before attributing this character to it.   Fomentations with hot water, a
little black wash, or  in obstinate Cases, a weak solution of nitrate of sil-
ver will be sufficient  for the cure if convalescence progress favorably.
  o. I think I have noticed at sufficient length all the principal compli-
cations of scarlatina.   There are  undoubtedly other sequelae  which
occasionally occur, as Eberle remarks: "At times the disease 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 cutaneous eruptions, herpes,
gutta serena, and rheumatic pains."5
  Small ulcers about the nose and at the corners of the mouth, purulent
discharges from the  nostrils,  tenderness of the skin, severe pains in the
limbs, arthritis, and erythematous eruptions are  by no means uncommon.
In the epidemic described by Dr. Kennedy purulent effusion into the joints
was a favorable sequelae.  One or more joints were attacked  and filled
with pus; the synovial membrane being sometimes healthy, sometimes
inflamed, coated with lymph, and  the cartilages ulcerated.  In  other
cases the swelling was caused by lymph effused round the joints.6  Prof.
R. Smith has brought similar cases before the Pathological Society,  and
recently I have met with two cases of the kind.

     1 Copland's Diet, of Pract. Med., part xiv. p. 678.
     2 AVorks, vol. i. p.  376.             3 London Med. Gaz., July 12, 1850.
     4 Ibid., Aug. 2.                  6 Diseases of Children, p. 454.
     6 On Scarlatina, p. 22. 
SCARLET FEVER.
633
  Dr. Armstrong has noticed that the hair is very apt to fall out after
scarlatina, and to be very imperfectly reproduced.
  Dr. Huxham mentions "excoriation of the anus and buttocks;" and
Dr. Graves  relates  a case in which  aphthous  ulceration of the anus
occurred.1
  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 network
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 mesen-
teric 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 which 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 describe
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  certain organs
were pale, and  contained little blood.
  Andral, Gavarret, and Lecanu analyzed the blood of  persons in scar-
latina, but the result did not differ much from that  of  healthy individ-
uals.   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 some-
times of a deep red hue.   In the mild and inflammatory forms  it  has
generally an acid reaction, but  in the asthenic or malignant scarlatina
it is either neutral or alkaline, and very  turbid, sometimes albuminous,
and containing  blood-globules.   In most cases, even early in the dis-
ease,  it rapidly becomes ammoniacal;  and in the malignant cases it  de-
posits a  viscid, whitish  sediment, consisting  of the  earthy phosphates
and mucus,  and containing urate of ammonia and uric acid.
  " Durino*  the advanced  stages of the  mild and more sthenic form of
1 Clin. Med., vol. i. p. 341. 
634                      SCARLET  FEVER.
scarlatina, the urine becomes more abundant, of greater specific gravity
from the abundance of saline matters, and present the characters usu-
ally observed  during  the decline of inflammatory or continued fevers.
In asthenic, septic, or malignant cases, the urine becomes, with the pro-
gress 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  alka-
line reaction, with a disagreeable ammoniacal odor, and it occasionally
contains blood and mucus, or partially dissolved haematoglobulin, 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 super-
venes,  the urine generally becomes albuminous;  and when this occurs,
we may expect that certain organic complications, to which I have be-
fore 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 mate-
rial 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 color, in conse-
quence 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 kid-
ney has  been in a  softened condition before the occurrence of the in-
flammatory 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 examination the con-
voluted 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 trans-
parent and  healthy, but the vessels of the tuft are sometimes rendered
opaque by an accumulation of  small cells on their surface.   Some  of
1 Copland's Diet, of Pract. Med., part xiv. p. 681. 
SCARLET FEVER.
635
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  be-
comes 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 scar-
latina supervene  upon pneumonia, and that,  unlike measles, it  never
exasperated  the  pulmonary disease;  nay, in one case  a slight pneumo-
nia appeared to be cured by the eruptive fever alone.
   Hooping-cough may be cut short, and  chorea disappear, on  the  ap-
pearance of scarlatina.
   As to the influence of scarlatina upon tubercles,  Rilliet and  Barthez
give the following conclusions  as the result of  their  experience: " 1.
That scarlatina rarely gives rise  to tubercles.  2. That tuberculous
children rarely take scarlatina, and when they  do  it is anomalous.   3.
Children cured of tubercles are more liable to scarlatina than the pre-
ceding, 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 these cases, the tubercles have  a tendency
to become cretaceous in a  short time."2
   883.  Causes.—Among the predisposing causes, we 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 believe
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 room where the  infection  exists; and we occa-
sionally 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 Graetzer, 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.
' Cyclop, of Anatomy and Physiology, Art. Ren.
2 Mai. des Enfans, vol. ii. p. 634. 
636
SCARLET FEVER.
  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. Cop-
land never met with a case between the tropics.  It was introduced into
North America in 1735, and its progress was slow but fatal.
  It is as yet, I believe, unknown in  New Zealand, as it was until lately
in Australia.  In the year 1848, however, it prevailed at Sydney,  as I
am  informed by  Dr. Silver, late  military and colonial  medical officer,
now of Gala, Co. Galway; and Mr. Gryles informs me that cases oc-
curred before  this time.  He  is not aware of any other part of  that
continent having  been  visited by the disease.
  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 experi-
ments 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 disappointed in producing a
milder disease.
  Dr.  Copland met with 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  l'Amboise  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 combination
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  per-
sonal contact, are the  atmosphere surrounding  the sick, or substances
impregnated with  the  miasma  from  the sick.   The distance to which
infection may be  carried, and the duration of  the infecting power  pos-
sessed by fomites, is 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.
  But an  important  question  arises—granted that a person visiting a
locality where it has prevailed, or using clothes of a patient, may  take
it, can a third person not having the disease carry it from a person who
has it to others who have  not ?   I should not like to speak positively, 
SCARLET FEVER.
637
but during the  late epidemic in Dublin, I saw one instance which it
seemed difficult to explain in any other way.
  Cazenave considers that the greatest activity of the contagion is dur-
ing 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 Sib-
bald 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 first appeared in Boston, U. S.,  in  1735-36 ; it is  stated  that
4,000 were attacked, and one  in 35  died.   In  Baltimore  it  was epi-
demic in 1847-8.
  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 llaen, Kirchvogel); in the city of Cephalonia in 1763 (Zu-
latti);  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 England 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  undi-
minished  violence, in Ireland, from 1835 to 1846, resisting  every kind
of treatment, but that in 1847, 1848  it had become  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  appearance
of a general rash of an intensely red color, not  elevated, and with dis-
turbance of the renal functions.
  1. It may be distinguished from ulcerated sore throat, by the occur-
rence of the rash, but when that is  absent, as in  scarlatina sine exan-
1 Diseases of Children, p. 448.
2 Appendix to Dr. H. Kennedy's work on Scarlatina. 
638
SCARLET FEVER.
themate, 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 semicir-
cular 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 additional  evidence  that
the disease is scarlatina.
   3.  From roseola.  The  eruption in this  disease is sometimes  an ad-
mirable 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 subsequently no
desquamation.   In scarlatina the florid redness is general and equable,
and if any miliary vesicles are seen  they are comparatively few ;  and
the sore throat, intense fever, disordered  urine,  and desquamation, will
sufficiently prove the nature of the disease.
   5.  But suppose the patient has  the disease very lightly, the eruption
fainter than usual, and no  sore throat: in such cases it is often impos-
sible  at once to say whether  the  disease be scarlatina  or not.   There
are three circumstances, however, any one of which may clear away all
doubt.  1st, the desquamation of the cuticle in large flakes, which is  so
unlike the small, scaly or powdery desquamation of measles.  2d, other
children of the same  family catching the  disease, and  exhibiting its
peculiar characteristics; and  3d, the occurrence of the distinctive  se-
quelae, anasarca with albuminous urine, &c
   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
complications, render it extremely difficult to treat  the  case satisfac-
torily.
   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 sweep down whole families  occasionally, and  during their preva-
lence, even cases that commence mildly are by no means to be regarded
as safe. 
SCARLET FEVER.
639,
  The mortality has varied from 1 in 6 to  1 in 40, according to the
character of the epidemic.
  888.  Treatment.—As a preliminary  to the  successful  treatment  of
scarlatina, as of other epidemic diseases, the physician ought to be fully
acquainted with the  prevailing atmospheric constitution of disease, and
of the type of the peculiar epidemic, as  this  knowledge alone will often
determine, beforehand,  whether antiphlogistics or stimulants, whether
depletives, or tonics, are to be employed.  That the importance of this
may be more fully understood, I  would  recommend strongly, the
perusal  of Dr. Graves' 22d  Lecture " on scarlatina," which is worthy
of the pen of that distinguished physician.   Moreover, it will be neces-
sary also to understand the constitutional peculiarities of the patients.
I have seen cases, and so I am sure have others, in which  it was neces-
sary to  use stimulants  very freely from  the  beginning, and  throughout
the disease.  I have a  strong notion  that Dr. Stokes' observations on
the condition of the heart in  typhus  fever as an indication for  wine,
apply also to the typhoid form of scarlatina.  1.  Mild cases of scarla-
tina, when the fever  is slight, the sore  throat trifling, and the eruption
favorable, require but little treatment  beyond a dose of aperient  medi-
cine, 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, and its
action should be  promoted by diluent  drinks, and subsequently by dia-
phoretics.
  When 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 bowels 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.  Macintosh, 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-
fitted 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. 
<540
SCARLET FEVER.
  Or the throat may be carefully fomented, or a poultice applied exter-
nally, 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 cinchona,
red wine and water, 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 purga-
tive of rhubarb and magnesia, infusion of roses, or senna, with  manna
and salts, or castor oil, &c, so as to evacuate the bowels completely.
  Saline, diaphoretic, or diuretic mixtures may then be given, in a state
of effervescence or  not, as the patient pleases, although  Dr. Bateman
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
far as my experience has  taught  me  (not excepting  even  the  use  of
bloodletting 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 scar-
latina.  General bloodletting is  out of the question,  and  even local
cupping or leeching seems to do more mischief, by weakening and  de-
pressing the patient, than good.   We should commence  with an emetic,
followed  by purgatives and  diaphoretics, and have recourse to stimu-
lating 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
1 On Cutaneous Diseases, p. 81. 
SCARLET FEVER.
641
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 disease, bearing
in mind the distinctive individual  or epidemic character of the scarla-
tina,  and modifying  our  treatment accordingly.   Leeches to  the part
affected, fomentations, embrocations, poultices, &c, may be used gene-
rally Avith benefit.
   in. 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.
   When it commences with  high fever, full, quick  pulse,  Dr. Armstrong
advises cold affusion, and if that fail  in reducing the heat, he recom-
mends bleeding.  This, however, will rarely be necessary or justifiable.
   Even local  bloodletting, Avhich seems called for by  the symptoms, is
rarely of any use, and  may be  injurious, either  by weakening the  pa-
tient, or from diffuse inflammation attacking the leech-bites, and spread-
ing to the neighboring parts.
   An emetic may be given  immediately, with  an  ample  supply of dilu-
ents,  and a mercurial purgative;  and the liniment, or a  turpentine em-
brocation applied to the neck or loins, or both.
   But more than this must  be  attempted.  The  decoction of cinchona
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 suppressed,
and if it  be alkaline, and contain  phosphates, the cinchona should be
cdnjoined 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, how-
ever,  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 ammonise
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 sub-
dued, and the disease shows itself in its true form, then assuredly tonics
are beneficial.
  Dr. Garnett formerly recommended the chlorate of potass,  and  Dr.

                  1 Diet, of Pract. Med., part xiv. p. 693.
       41 
642
SCARLET FEVER.
Clutton the hydrochloric ether, with or without decoction of bark, in
malignant scarlatina.
  Dr. Peat and Dr. Stewart  speak most highly of  the sesquicarbonate
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 stimulant,
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, 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 restless-
ness and nervous irritation.
  Dr. Schneemann, of Hanover, has strongly recommended the inunction,
morning and  evening, of the outer surface (except the face  and scalp)
with fat of bacon, so that the body is to be coated with fat.   This may
be done at the commencement of  the eruption and continued until des-
quamation is complete.   Various are the good effects said to result; the
prevention of cold, relief of the itching and brittleness of the skin, pro-
motion of its functions, and of  the oxidation of the blood;  preventing
infection and diminishing infection, &c.   Of course  this does not super-
sede more active treatment if necessary.
  The local applications to the  throat are are  of various kinds. Exter-
nally the liniment 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 gargle of alum  and water, port wine and water, chloride of  lime
and water, 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 may be 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. 
SCARLET FEVER.
643
  Cool drinks should be  permitted.   Cold water, iced water, or water
acidulated with lemon-juice, dilute sulphuric or muriatic acids, is exceed-
ingly 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 consti-
tution of the child, the character of the epidemic, and any  complication
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 during the
period of desquamation, by carefully avoiding cold, prohibiting the too
free use of animal food and stimulating beverages, and by promoting the
healthy action of the skin by warm clothing, warm baths, &c.
  But when the disorder actually exists, antiphlogistic remedies  and
diet must be adopted, unless the strength of the child be much reduced,
or the type  of the scarlatina be typhoid.   Bleeding, cupping 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  apply-
ing a blister to the loins,  if the scarlatina have  subsided;  or a liniment
of oil and turpentine, or the compound camphor liniment, and the occa-
sional use of the warm bath.
  Internally, diaphoretics should be administered and gentle purgatives.
  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 afterwards mild diuretics, as the acetate  of potash, ex-
tract 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  diminu-
tion 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 convalescence.
   General bleeding, if the pulse be full and the child strong, as advised
by Sydenham, Richter, and others, or  cupping or leeching with dia-
phoretics, 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 scald-
ing the child; then place the child, naked, upon the seat,  and envelope
the chair and the child (except his head) in a blanket.
   In  a  few minutes the child will have a comfortable   and complete 
644
SCARLET FEVER.
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, the child
still continues pale, and languid, and feeble, the tincture of the  sesqui-
chloride 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 scarlatina
should be restricted, and of a  bland character; in  angina maligna we
may have to give broths, beef-tea, jelly, or even wine and brandy.
  I would wish, in this edition, to express even more strongly than in
the former one, the necessity  which exists for a moderate and  bland
diet, during convalescence, especially  where there is any  tendency to
anasarca.  By a stimulating diet, any febrile action is kept up, and the
stomach and bowels become disturbed.   Milk, farinaceous  food of any
kind, and occasionally a little  weak broth, will be sufficient for a week
or two, after which the diet may be increased, and if tonics be deemed
necessary, I am inclined to think  a weak decoction of bark  is  better
than wine.
   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 sequelae of the dis-
ease arise, and therefore great care should be taken that  the child  be
warmly clothed and not exposed to cold or damp.
   Even when convalescence seems going  on  satisfactorily, I would re-
 commend that  the child should be confined to the house for two or three
 weeks.  I have repeatedly seen children, who appeared  perfectly well,
 allowed to go out with due precautions, who yet caught  cold, and were
 attacked by some of the sequelae  of scarlatina.
   891. Prophylactic Treatment.—Many plans have been suggested for
 preserving individuals from scarlatina.   Dr. Withering recommends the
 frequent expectoration of the  mucus that collects upon the mucous mem-
 brane of the fauces and nose, and that when the infection  has been im-
 bibed, the person should take  an emetic, wash the mouth with soap-leys
 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 dispersed, 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 chambers,  have universally
 been found sufficient to check the further progress 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. Williams
 thinks this precaution as effectual as that of Hahnemann, if not much
 more so.

               1 West, Diseases of Infancy and Childhood, p. 43-1. 
VARICELLA.
645
  Belladonna.—Hahnemann recommended a minute  portion  of bel-
ladonna  to  be taken  twice  a day.  Ettmuller, Berndt,  Korrf, and
Hufeland believe in its good effects.   Salzer and others have found it
useless; and Hildenbrand and others treat it with ridicule.
  Dr. Stievenart of Valenciennes tried  it upon 200 individuals during
an epidemic of scarlatina near Valenciennes, and all escaped the disease.
  "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 was 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.
  Dr.  Sneeman dissolves gr. iij. in an ounce of water, and gives  to the
child the number of drops + 3 that it is years old.
  My friend, Mr. Tuffnell, has mentioned to me two trials that he made
of it.  In the first, scarlatina of a very  malignant form broke out in an
establishment where there were 29 children  of different ages who had not
.previously had the disease.   Ten were attacked and the remainder  put
under the influence of  belladonna, not one  of whom contracted the dis-
ease.  On the other hand, in a family of children, five of whom had not
had scarlatina, the eldest being  attacked, the others took belladonna,
but all successively sickened and had  the disease  more severely than
the first.
   Calomel has been recommended by Kreysig  and Selig; Theussink,
calomel and the golden sulphuret of antimony; Eichel, emetics, followed
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 6ure 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.—SWINE-POX.

  892.  This is  a trifling disorder, hardly  worthy of the name  of an
eruptive fever.    It was confounded with smallpox until Dr.  Heberden
' Condie on Diseases of Children, p. 441. 
646
VARICELLA.
  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, Willan, Heim, Mohl, Thompson,
  Gregory, &c
    Dr. Gregory defines the disease as " a slight disorder, the offspring
  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  accom-
  panies the matured stage, and no secondary fever follows.  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. Bate-
  man  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 fretfulness 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 exertion, 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 few 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
  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
  ?calp, 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 exposed
  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 granu-
  lar scabs.
    There are few or  no constitutional  symptoms   accompanying the
  eruption; the  little disturbance that preceded it generally subsides on
  ■ts 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.

    1 Trans, of College of Physicians, London, vol. i.
    8 Ou Eruptive Fevers, p. 225.                3 On Cutaneous Diseases, p. 213. 
VARICELLA.
647
  893. The modifications of the disorder  have reference principally to
the form  of the vesicles.   Willan  described three varieties : the lenticu- •
lar, conoidal, and globate; which are thus  characterized by Dr. Bate-
man : " 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.   Few of them remain entire on the fifth day, but the orifices
of several broken vesicles are closed, or adhere to the skin so as to con-
fine a little opaque lymph within  the puckered margin.   On the sixth
day small brown scabs appear universally, in place of the vesicles.  The
scabs on  the seventh and  eighth  days become yellowish, and gradually
dry from the circumference  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 successive 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 tneir
appearance, acuminated, and contain a bright, transparent lymph.   On
the second day, they appear somewhat more turgid,  and are surrounded
by more  extensive inflammation ; the lymph contained  in many of them
is of a light straw color.  On the third  day, the vesicles are shrivelled ;
those which have been  broken exhibit at  the top slight gummy scabs,
formed by a concretion  of the  exuding lymph.  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 sepa-
rate,  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 duration 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 inflamma-
tion 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 
648                        VARICELLA.
  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
    A more severe form is occasionally  seen in which, owing probably to
  the  bad  constitution  of the child, more or less of  the vesicles become
  round, clear cut ulcers.   Dr. Chas. Johnson mentioned to me a case in
  which each  vesicle in the  course  of 24 hours became an  ulcer like
  " burnt holes."
    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 inocula-
  tion 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 smallpox, inoculated during the
  eruptive fever of varicella, proceeds regularly in its course without oc-
  casioning any deviation  in the latter;  but that when  variolous and
  varicellous virus is inserted at the same  time, the smallpox  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 dis-
  ease by inoculation, but failed in all.3
    895.  I have already mentioned that, up to  the time of Heberden, the
  disease was confounded with smallpox.  Since  that time many persons
  have regarded it as a modification of smallpox, and recently Dr. Thomp-
  son 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 smallpox.   As to the first,
  Dr. Mohl states that from 1809 to  1823,  chicken-pox was  observed
  annually at Copenhagen without variola.   M.  Eichhorn mentions vari-
  cellous epidemics without variola,  and  Mr. Burnes relates a similar oc-
  currence 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.   Further, the inoculation of chicken-pox never pro-
  duced 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 smallpox, may be " a
  last effort of the variolic medical constitution."4
    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 smallpox.5
    MM. Guersent and Blache regard varicella as a  disease sui generis,
  and have refuted the  positions of Dr. Thompson.6
    896.  Diagnosis.—The very slight fever, or its  entire absence,  the

                 1  Bateman on Cutaneous Diseases, p. 210.
                 2  Willan on Vaccination, p. 97.
                 5  Thompson on Varioloid Diseases, p. 74.
                 i  Diet, de Med., vol. xv.
                 5  Monographic des Dermatoses, vol. ii. p. 342.
                 6  Diet, de M<5J., vol. xxx. p. 548. 
SMALLPOX.
649
vesicular eruption, the clear, watery contents of the vesicles, and the
insignificant character of the attack, distinguish it from all other erup-
tive fevers.
  There is some resemblance  between it and that variety of smallpox
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.

              SMALLPOX.—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.  Ilahn, Dr. Willan, and Dr. Baron believe  that  the  disease was
known to the Greeks and Romans.   Dr. Mead, Dr. Friend, Dr. Gregory,
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 merely as  an  accu-
rate observer, but as having applied his sound judgment to the improve-
ment 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 Anglicus
(1280) and John of Gaddesden (1310 or  1320) allude to the disease  as
one well known.  Dr. Monro mentions that some authors have main-
tained 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

              1 A Practical Essay on the Smallpox, 1740, p. 19.
              2 Monro on the Smallpox, p. 48. 
650
SMALLPOX.
have been in existence long prior to the date of the English and Latin
authors of the fifteenth and  sixteenth centuries; for the Irish manu-
scripts refer to it at the beginning of the fifteenth century ;  it is  de-
scribed in the Book of O'Shiel under the name ofbolgach, which means,
literally, blisters or pustules containing matter ; but water-blisters (vesi-
cles or bullae) are generally termed clog.   One of the Irish translators
in the  fifteenth century states that smallpox 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 smallpox is produced from a vitiated state of  the
red blood alone, and measles  from a depraved condition of the humors.
The work of Bernard on the  smallpox  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."1
   Smallpox has been divided into discrete and confluent, mild and  ma-
lignant, with several subdivisions.  I shall first describe the disease 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,
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 incu-
bation 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 smallpox, 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 praecordial oppression, dyspnoea, dry cough, with
a sense of heat and soreness in the larger bronchial tubes, flying pains
in the chest, and palpitation.
1 Report upon the Tables of Death, pp. 11, 12. 
SMALLPOX.
651
   Or this period may be marked by the predominance of nervous symp-
toms, 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 stu-
por  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 smallpox.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 few 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
   in.  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,
solid, and prominent papulae, of  a more or less vivid  red color, which
disappear under pressure to reappear immediately.   We observe them
first on the face, then on the neck, and  by degrees  upon  the  limbs,
body, hands,  and feet.
   These papulae gradually increase  in size and change their character.
The  epidermis on each is slightly elevated by a drop  of serum of a yel-
lowish-white color, not  so transparent as  that of varicella.  The time of
this  change is  not the same for all the papulae, 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 succes-
sion, occupying from twenty-four hours to two or three days in the pro-
cess.  Rilliet  and Barthez think that the length of this period  is in-
versely as the length of the prodromi.
   At first  the vesicles are small,  especially upon the papulae  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 become
opaline.  The vesicles  are surrounded by an inflamed  base,  sometimes
flat,  in other cases  somewhat elevated above the  level of the skin: if
the vesicles be not too distant,  their areolae 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 what is called "confluent smallpox,"

   1 Works, vol. ii. p. 153.           2 Traite des Mai. de la Peau, vol. i. p. 516.
   8 Mai. des Enfans, vol. ii. pp. 441, 442. 
652
SMALLPOX.
and  exhibiting just such  severity of symptoms as might be  expected
from the extent of inflamed and suppurating surface.   This confluence
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 smallpox."
  The papulae assume the character of vesicles about the second day;
sometimes, though rarely, a day later, and in about two 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  ap-
pearance, 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, we may see in the same case  papula?  and vesicles, or
vesicles and pustules, but  never papulae and pustules, because  the time
required to convert  the vesicles into pustules has been sufficient for  the
transformation of all the papulae 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 eruption,
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, pharanx, and  larynx.   Some-
times the tongue  is  much swollen, and there is  a profuse discharge  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 preserve their
opaline  character during  the  entire 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
"pointillSs 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  pustules  of  the
hands, feet, and arms, instead of  these points, we may observe concen-
tric  circular marks, gray and  semi-transparent, or clear yellow, alter-
nately.   When two pustules touch, the outer yellow circles of each are

            1  Rilliet and Barthez,. Mai. des Enfans, vol. ii. p. 449. 
SMALLPOX.
653
broken and confused.  The gray circles are broader at the commence-
ment, 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 papulae; 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 con-
tact with each other; and  many parts which were very distinct 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 smallpox, 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.
   "In a large portion of confluent and in some semiconfluent cases, the
 mucous membrane of all these parts to which the atmospheric air  gets
 access (the nose, mouth, and  trachea) is  occupied with the  eruption,
 sometimes distinct,  more generally confluent.   The only symptom^ oc-
 casioned by this mucous complication  are  as  follows: numerous 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 is great pain and
 swelling, and, in bad cases, cough and dyspnoea. _ The cough is at first
 dry and teasing; as the  disease progresses, there is expectoration; about
 the eighth day, a  copious viscid  secretion takes place  from all the
 affected structures."1
   In many  cases there is  delirium, agitation,  coma,  &c, so  that  at  a
 later period of the  disease we seem to have its first acute febrile and in-
 flammatory character  reproduced, and this  continues  until the desicca-
 tion 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 resuit
 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 analo-
 gous 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-
1 Gregory on Eruptive Fevers, p. 47. 
654
SMALLPOX.
demic of 1674 :   " Of this  I am certain, that the present smallpox
exactly resembled that of the preceding constitution, only it seemed to
be of a grosser nature, and attended with a much greater degree of  pu-
trefaction.   And from these two causes it followed that when the erup-
tions 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.1
  " 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 matura-
tion of the pustules goes on  for a day or two, with very slight reaction;
and were it not that this extreme mildness of the  secondary fever, in
cases where the eruption has been abundant,  is itself a suspicious cir-
cumstance, we should be disposed to express, without hesitation, a most
favorable  opinion as  to the patient's condition.   Suddenly, however,
the pulse begins to falter, the pustules, which before seemed full, col-
lapse ; 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 extremest restlessness, which
contrasts remarkably with the extreme quietude of the child's manner
for the two or three previous days."2
   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 arrived
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 fur-
furaceous 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 con-
fluent smallpox, some  blood may escape, which will give  to the crusts a
black color; and  when  they fall off, we find  the skin irregularly de-
stroyed, 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 part of the body,
because it is there that the eruption is  more  abundant and confluent,
and that the inflammation, being more intense, 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 impossi-
ble to  observe great  cleanliness ; and  the accumulation of purulent
matter, the extent of  suppurating surface, the fetid breath, occasions 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.

    1 Works, vol. ii. p. 322.         2 Diseases of Infancy and Childhood, p. 468. 
SMALLPOX.
655
  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 desic-
cation takes place.2   I. In the first, the epidermis of the pustule cracks
in the centre or circumference, and the pus  and false membrane, 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 afterwards  occupying the entire: it is connected with the neighbor-
ing ones at  its  circumference.
  II. In other cases, a small, dry, yellow, 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 de-
tached.  This mode  leaves no mark.
  IV.  Lastly, the pustules do not  break, but become gradually flattened
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 epidermis, dries and
falls off in large scabs, leaving a smooth and slightly red surface under-
neath.
  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 super-
ficial 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 twenty-second and
thirty-eighth, in  16  cases.
   901. Modifications.—The preceding description embraces only ordi-
nary cases of smallpox, but we find in practice that in  many cases the
appearance and course of the disease deviates widely from the  ordinary
standard, and  in others, whether normal or anomalous, it  is very seri-

     ' Mai. de la Peau, vol. i. p. 520.          2 Mai. des Enfans, vol. ii. p. 4G5. 
656
SMALLPOX.
ously complicated with some organic affection.   Let us inquire 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.
  b. 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 charac-
ter, 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 smallpox of Sydenham).
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
worth while extracting the following graphic description  from Dr. Hil-
lary's work:—
  "The bleeding smallpox is the very worst sort, and seems to proceed
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 infection.''
" The invasion is mostly  attended with convulsive, racking, lancinating
pains in the lower part of the back and loins, so intolerable that at every
spasmodic shoot the patient cannot  refrain from  starting and crying out
as if he were stabbed with a sword; he has also  a violent shooting pain
in his head; his eyes  are extremely inflamed; 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 but the  two  last,  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
petechiae 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
1 On the Smallpox, p. 123. 
SMALLPOX.
657
unusually large.   In the latter case they  are  flattened and not  dis-
tended, and the false membrane has not its  usual character.
  Occasionally large bullae 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 completely,
when the eruption appears, in  other cases continues unabated in in-
tensity.
  /. Suppuration  may not take place satisfactorily;  it may be  incom-
plete 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 smallpox, which is termed vario-
loid, occurs occasionally either after vaccination, inoculation, or casual
smallpox, 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 not ordinarily very extensive,
and chiefly occupies the face and trunk.   It does not assume the flat-
tened  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 indentation 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
Bpots;  others, as I have seen, are pretty well covered with 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  smallpox in another person.
  It is doubtful whether an attack  of varioloid affords protection from
smallpox subsequently.
  h. Ordinarily smallpox attacks  an individual but once in his  life;
there are, however, well-authenticated cases on record where it occurred
a second or even a third time, though in general these assume the form
of varioloid.2
  i. " During the prevalence of epidemic  smallpox numerous cases of a
febrile affection frequently occur, marked by tenderness  of the  epigas-
trium,  pain in the back and limbs, some degree of soreness of the  throat,
salivation, profuse perspiration from which no  relief results, and  not
unfrequently petechiae.  This has been denominated variolous fever with-
out eruption.   This fever generally begins and ends with the variolous
epidemic.  "We have  repeatedly met with such cases, as  well in the un-
protected as in  those who have been vaccinated,  or who had previously
had the smallpox.   That the disease results from the same infection as
the  smallpox 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 accompaniment
         1 Monro on Smallpox, p. 233.
         2 Gregory on Eruptive Fevers, p. 73; Monro on  Smallpox,  p. 77.
         3 Condie, Diseases of Children, p. 509.
       42 
658
SMALLPOX.
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."1
  Of 112 patients  who died of the disease in 1825, M. Guersent did not
find a single example of meningitis  or encephalitis, but occasionally a
kind of passive  injection of the membranes.
  I need not add that any  cerebral attack is a most formidable compli-
cation, and may in itself prove rapidly fatal.
  II.  Coryza—Epistaxis.—A sero-sanguinolent discharge from the nos-
trils is by no means unfrequent, owing to the inflammation and pustula-
tion of the mucous membrane of the nose.
  in. Laryngitis.—Croup occurs occasionally in the course  of small-
pox, but  not very frequently.
  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 convalescence.   In the
first cases, the variola was secondary and anomalous, two patients hav-
ing varioloid, one normal, the other abnormal, so  that  it  may be ques-
tioned whether the irregularity depended  upon the primary 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 pneu-
monia occurred at an intermediate  period, i.  e., on the  eighth day of
the eruption ;  the  variola was abnormal;  the  effect of the pneumonia
was to discolor it almost  instantly, and to add  to the previous irregu-
larity a remarkable paleness.
   " Pneumonia, rare, and  without bronchitis, may be overlooked in our
investigation.   When more extensive, it is only by auscultation and  per-
cussion that it is known, and these  methods are sometimes difficult to
use ; the disgusting odor, the necessity of interposing several  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  pulmonary  disease, and
1 Diseases of Children, p. 508. 
SMALLPOX.
659
call to our aid auscultation for its detection. The prognosis of variolous
pneumonia is very serious, but  the mortality 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 gene-
rally 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 extend-
ing up the salivary ducts, or  perhaps to sympathetic irritation.
  Pseudo-membranous inflammation of the gums, mouth, or pharynx,
may occasionally be observed, and, in a very few cases, gangrene of the
mouth.
  vii.  Gastro-enteritis.   Entero-Colitis.—We have seen that smallpox
may be accompanied with great irritation  of the stomach,  vomiting',  &c.
This may continue some days,  and then cease, and it may return at  a
later period.  The digestive functions are, of course, suspended during
the disease.   Dr. Gregory states that  " smallpox  is singularly exempt
from all abdominal complications," but that mucous 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  twenty-fourth day, and rarely
before,  but in the  abnormal  it  may  show itself  on the first or  second
day.   Diarrhcea  is the  symptom which is  present in almost  all these
cases of entero-colitis, sometimes after constipation, with  swelling, ten-
sion, and tympanitis  of the abdomen, and sometimes without.  It is
always  a very serious,  often a fatal,  complication.
  Viil.  Hemorrhages.—In  severe  typhoid   cases  of  smallpox  we
occasionally find a discharge of blood  from different  organs, epistaxis,
bleeding from the gums, petechiae 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 membranes 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.  Rillet  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.              ■  ■  A
 = In the second, ulceration had taken  place; in some to a  limited
extent, and followed  by recovery; in  other cases the  eye was lost.
1 Mai. des Enfans. vol. ii. p. 503. 
660
SMALLPOX.
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
probably connected  with  rheumatism.  Rilliet and Barthez observe:
" Besides these patients six others had abscesses, more or less numerous,
in different parts  of the body, and particularly around the articulations.
Two out of twelve or fifteen of  these abscesses followed upon consider-
able 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 was  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
   xil. Rheumatism,.—The preceding paragraph will show that articular
rheumatism occurs  occasionally, though not very frequently.   Rilliet
and Barthez remark:  "Four patients  exhibited symptoms which re-
sembled  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-two  days between the inflammation of the two joints."
" 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 auo-ury."2
1 Mai. des Enfans, vol. ii. p. 495.
2 Ibid. 
SMALLPOX.
661
  xm.  Eruptions.—I have  already mentioned the  occurrence  of
petechiae,  resembling those of purpura  haemorrhagica, and  of  bullae,
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  smallpox.   Rayer,  and  Rilliet and  Barthez,
observed mercurial erythema follow the use of mercurial plasters.
  But, what  is  more remarkable, measles  and scarlatina  may  occur,
either along with smallpox, just previously, or immediately  after.
  Sydenham mentions that the irregular  black smallpox was introduced
by an epidemic of measles, in 1670, and also the singular variety which
appeared in 1674-5.
  Nay more, the vaccine vesicle'may maturate  coincidently with small-
pox.  In November,  1849, my son vaccinated an infant, and the  vesicle
rose well and maturated, but about the sixth day an eruption  appeared
over the body which  turned out to be smallpox, of which the child died.
It is to be presumed  that the child took the infection before the vaccina-
tion.  I have since seen a similar case myself.
  xiv. Other complications have been observed, but less frequently
than those I have noticed.   Anasarca occurs occasionally at the begin-
ning 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 smallpox.
  This pustule, at its origin, is but a macula resulting from  the vascular
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.  Be-
neath 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 thence-
forward only one sub-epidermic cell.
  If we divide a fully formed  pustule,  we may perceive at  its base the
pseudo-membranous  disk, underneath which the  cutis  is red and often
inflamed.
  Cotuo-no enumerates thus 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 
662
SMALLPOX.
 inflamed rete mucosum;  4. Underneath which is the unaltered chorion ;
 5.  In the centre of the pustule a small white body, whose superior fili-
 form extremity is implanted in the  centre of the depression (umbilicus),
 whilst the inferior is attached to the inflamed corpus reticulare.
   MM. Rilliet and Barthez do not  agree with M. Rayer1 as to the for-
 mation  of the umbilical  depression, because it  exists when there is  no
 membranous disk.  They prefer M. Petzholdt's2 explanation, who attri-
 butes it to the traction excited upon the epidermis by the excretory ducts
 of the cutaneous glands.3
   They have thus stated the different degrees of suppuration in different
 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 sup-
 puration, 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.4
   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 structure,
 and when the epithelium has been removed, exhibiting superficial ulcera-
 tions, 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. Rostan5 found them in the large intestines and in  the rectum, and
 Cotugno6 observed them upon  the mucous membrane of a prolapsus ani.
   Rayer and Rilliet and Barthez deny that they exist in the intestines,
 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 Philadelphia,
 in almost every case, the stomach and upper portion of  the small intes-
 tines were diseased.
  The larynx, trachea, and principal bronchial tubes exhibit the vario-
 lous pustules upon their  mucous membranes, and, in common with the
 gastro-intestinal surface, present appearances of  congestion and inflam-
 mation.
  905.  Causes.—Among the predisposing  causes are age, sex, and sea-
 sons. It occurs at all ages, nay even before birth,7 as has been observed by
Mead, Jenner,8 Laird, Hosack, Aulsebrook,9 and others, and undoubtedly
 children are more subject to it than adults, and adults than old people.
For a reason I have mentioned before,  I attribute the predominance  of

  1 Mai. de la Peau, vol. i. p. 529.     2 Archives Gen. de Mgd., 1838, vol. ii p 314
  3 Mai. des Enfans, vol. ii. p.  450.     4 Ibid., p. 453.
  5 Diet, de Med., vol. xxi. p. 196.     6 De Sede Variolarum, p. 152.
  7 Graetzer Krankheiten des Foetus, p. 27.
  s Med.-Chir. Trans., 1809, p. 269.     9 Lancet, Sept. 2, 1854. 
SMALLPOX.
663
the smallpox among young children to the fact of their taking it the first
time they are exposed to the contagion, rather than to any greater sus-
ceptibility 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.
  Smallpox, when it prevails epidemically, commences, according to
Sydenham, about the vernal equinox, and is prolonged during summer
and autumn, when the disease is mild and regular, but when it is irre-
gular it appears sooner.'
  906.  The chief agent in the spread of variola is  contagion or infec-
tion.   No one doubts, I believe, that it is contagious, or that it may be
conveyed to a distance,  but how far the sphere of  its contagion extends
is not easy to  determine.  Dr. Williams has fixed from  thirty to fifty
feet.   Dr.  Gregory thinks that  the  contagious miasm is given off at
every stage of the  disease, "from  the first invasion  of fever to  the
throwing off of the latest scabs."
   That it may be conveyed in the air and by clothes is also  admitted.
In an interesting monograph, lately published, Dr. T.  H. Buckler, of
Baltimore, conceives that it may have been transmitted  by means of the
paper-money used in that city.  From what I have already stated, it
will be  seen that the period of  incubation is not  precisely  determined.
It may be that it is not  always  precisely the  same under similar circum-
stances,  but, as far as we can judge,  it is between four days and a fort-
night generally.
   There are two other modes by which it may be communicated:  1,
through  the blood  of the mother  to the foetus in utero, whether the
mother have the disease or not, as in the cases related by Mauriceau,
Mead, Watson, Forbes,  &c.; and 2, by means of inoculation, which was
common in China, India, Africa, Turkey, from  whence it was imported
by Lady M. W. Montague in 1721.   It was introduced  into America
in the same year by the Rev. Cotton Mather.
   The disease thus produced is essentially smallpox in almost all cases;
some few  cases of  varioloid occasionally result, but it is very much
milder, not more than 1 in 500  are  said to  have died.   This practice
has, however,  been superseded everywhere by the glorious  discovery of
Dr. Jenner.
   907. The disease also  prevails  epidemically,  and none have been
more fatal.  The desolating effects have been felt by the wild tribes of
North America, some of whom  it has obliterated, as well as the civilized
inhabitants of Europe, whom it  more than decimated in former days.
   It is not, however, easy to give a list even of the principal epidemics.
Sydenham has left  an admirable description of those which prevailed in
1671  1672, 1674,  1677,  1678, and  1679 in London, where it was  also
epidemic in 1757, 1781, 1796,  1825, and 1838.
   The disease  was introduced into America  in 1527, and a severe  epi-
1 Works, by Wallis, vol. ii. p. 152. 
664
SMALLPOX.
demic occurred in 1633;  others  at Boston in 1649, 1666, 1678, and
1690.  In 1702 4.4 per cent, of the inhabitants died of it, and in 1721,
54.6 of the population had it, and 14.3 per cent, died, and it occurred
in Philadelphia in 1823.
  An epidemic prevailed  at Berghen, in  Norway,  in  1749,  and de-
stroyed 528  persons.  One occurred in Norwich in 1819, and destroyed
530 persons between May and October.
  An epidemic commenced in Sweden  in 1824, reached England in
1825, spread to France in 1826-7, and terminated in Italy in  1828-9.
In 1838 various towns and country districts of England suffered  from
this plague.
  Dr. Rogers has noticed  a very fatal epidemic which prevailed in  Cork
in 1708,  and its annual return to that city from  1718 to  1721, and
from 1728 to 1731.1
  Dr. Rutty mentions severe epidemics in Dublin in 1728, 1736, 1740,
1743, 1745, and 1752; and it appears that the  number of those who
died of smallpox was little less than those  who died of fever.2
  It prevailed here also  in 1837, 1838, 1839, and 1840.   Dr. Ring-
land has  given an account of the latter.3
  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 run-
ning on from papulae to vesicles and pustules, their confluent character,
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 smallpox, but a day or two will decide;
and in some of the anomalous  cases we may have to determine  that it
is smallpox,  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 discreet and  normal, the majority of cases recover;
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 petechiae, and the amount of passive hemorrhage.  It is unfavor-
able 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 seri-
ous to which the human frame is liable, and death often terminates it.
Variola,  with cerebral symptoms at its commencement, or in its course,

       1  An Essay on Epidemic Diseases, 1734.
       2  On the Weather, Seasons, and prevailing Diseases of Dublin, 1770.
       3  Dublin Journal, July, 1841, vol. xix. p. 429. 
SMALLPOX.
665
is  very dangerous.  Ecchymoses  and petechias  indicate often a fatal
change in the blood, and approaching death.
   "Laryngo-tracheitis, croup, and pseudo-membranous bronchitis, ren-
der the prognosis more and more serious.
   "Obstinate ophthalmia, otitis, caeco-colitis, abscess, or other affections,
augment  the  danger during convalescence."1
   It has  always been one of the most fatal diseases of children.   Before
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,-
{j<65 persons died  of it.
   In Germany, Heim states the mortality to be 20 per cent.   At the
Smallpox Hospital, the  average mortality for twenty-five years (from
1776 to 1800) was 32J 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 one in six of those
attacked  may be considered as the average mortality.
   In Dr. Geo. Kennedy's valuable report, I find that in Dublin the mor-
tality is nearly one in five, taken generally, and of the confluent cases
nearly the half died.2
   As might be expected, the  younger the child the more fatal  the dis-
ease.   Of  3022 deaths of children from  this cause in Philadelphia in
forty  years,  1810 occurred in those  under ten years  of age, and 555
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 smallpox, compared with former times ;  but even  now  we
occasionally meet with it, and our treatment must  be regulated by the
violence of the disease, the state of the patient's constitution, and the
stage of the complaint.
   The old method of close hot rooms, warm  clothing,  and hot  drinks,
may be considered as abolished since the time of Sydenham;  experience
having shown that cool, well-ventilated apartments, comfortably cool
bedclothes, and cooling drinks, are much more pleasant and 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.
   Durino- the stage of incubation we can do little or  nothing  beyond
having recourse to the  ordinary hygienic rules, but during  the  second
sta^e we may endeavor to moderate the febrile  excitement.
   When  we  have any reason to suspect the  patient of having taken
smallpox, if  the fever  be moderate there is little to be done  beyond
confinement to bed, cool drinks, and  a  dose  or two of purgative medi-
cine.

           1 Mai. de la Peau, vol. i. p. 539.
           * Report of Cork St. Free Hosp., Dublin Journal, 1S44-5, p. 45. 
666
SMALLPOX.
  But, suppose the fever to be intense, are we to resort to bloodletting?
Not for that simply, it would appear.  At the commencement an emetic,
afterwards purgatives and cool  drinks, with low diet, will answer  the
purpose, unless some complication should declare 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 rather  than  typhoid, we  must have recourse to
bleeding from the arm, or the application of leeches.   For this we have
the sanction of the highest authority, though others have objected.
  Dr.  Gregory remarks :  " 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 breath-
ing,  with a full, laboring pulse, give evidence of such  general or local
congestion ; draw blood, and  let the quantity drawn  be such' as to  re-
lieve 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's powder,  &c, by
promoting the cutaneous secretion, will moderate  the heat of the skin.
  Nitrate of potass has been recommended  as a  refrigerant by Henke
and others.  Lemonade made with  cream of tartar is a pleasant beve-
rage ; and both these salts act upon the kidneys beneficially.
  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
as a matter of cleanliness, which it will promote,  but as diminishing  the
tendency to cellular inflammation of the scalp, sore eyes, &c.
  If there be  much soreness  of the mouth  and  fauces,  an acidulated
gargle  will be useful; if the child be too young, we must use honey with
a slight proportion of borax, or sponge the mouth with  an acidulated
lotion.
  910. As soon as the  eruption appears the fever generally subsides,
and if  there be no complication, we shall scarcely need to interfere be-
yond assuring ourselves of the state of the bowels, continuing the anti-
phlogistic  regimen, and guarding against cold.
  If there be any  organic disturbance or inflammation, then our treat-
ment must be carefully directed for its relief, with such modifications 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 discrete, there will be little for us to  do.
  The  cold drinks may be continued, and some slight  stimulant allowed
if the patient be weak, such as wine whey, weak wine and water.
  Gargles will  still be necessary in most cases,  or a  linctus if the  in-
1 On Eruptive Fevers, p. 83. 
SMALLPOX.
667
 fant  be young.   Small doses of camphor or ammonia are sometimes
 beneficial;  and in consequence of the irritation and restlessness pro-
 duced by such an extent of suppurating surface, it may be advisable to
 give an anodyne,  so as to quiet the nervous system and procure sleep.
   From the relief afforded by a critical diarrhoea we are advised to the
 liberal use of purgatives at this period.
   In  severe  cases  of confluent smallpox, where the fever assumes a
 typhoid type, stimulants must be freely given during this stage.   Wine
 or brandy, chicken-broth or  beef-tea, must  be given according to cir-
 cumstances,  and in such quantities as the case may demand.
   Camphor, ammonia, musk,  &c, may also be administered with benefit.
   In petechial  or hemorrhagic cases vegetable or mineral  acids have
 been recommended,  as sulphuric, chloric, hydrochloric, and  lemon-juice,
 either alone  or in combination with quinine.
   Dr. Gregory thinks that these cases admit of no essential relief from
 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 intensity of  the
 attack, but to the present condition of the child, and the probable course
 of the disease.
   912. The  tumefaction of  the face  and state  of the eyes 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 are closed, in addition  to bathing them carefully and
 frequently,  warm water should be  thrown  into them by  means of a
 syringe, so as to cleanse them from the discharge.
   Acetate of lead dissolved in water or a decoction of poppy heads is a
 very nice 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 not be employed unless we can ascertain the state  of
 the cornea.
   In order to prevent the face from being marked, it  has been proposed
 by Velpeau and  Meyrick to  touch the  pustules with nitrate of silver
 after removing  the  epidermis ; and  Rilliet  and  Barthez  state  that,
 though painful, it  is effectual in preventing cicatrices.  MM. Serres and
 Oliffe propose to pencil the eruption with  a strong solution of nitrate of
 silver  (gr. xv to gr. xiv  to the ounce) before  it assumes  the pustular
 form.
   Medavaine employed frictions with  sulphur ointment; Dr. Steward-
 son and others the application of mercurial ointment, and keeping the
 patient in a dark room.  Of  the latter Dr. Condie and Dr. West speak
 favorably.
   Dr.  Crawford, of Montreal, and Dr. Jackson,  of U. S. America, state
 that they have obtained favorable  results  from  pencilling  the eruption
 with tincture of iodine.
   913.  During the stage of desiccation, after the secondary fever 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 
668
VACCINIA.
patient  shall not take cold,  or by imprudence  expose himself to  the
secondary affections which come on 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 restoring the
skin to its natural condition that the troublesome rheumatic affections
and abscesses may be prevented.
  As the itching at this period is very troublesome, we must adopt some
means to  relieve it, and to restrain  the child from adding to the dis-
figurement by scratching or picking itself.  Cold cream, oil, or sperma-
ceti, are recommended ; but the best remedies I know are zinc cream,
the black wash, or a decoction of poppy heads  with sugar of lead.
  The only prophylactic treatment is either inoculation or vaccination:
the former  is prohibited by  law in  these  countries, as it would be a
foolish risk where  a better and safer remedy is at our command.  I
have, therefore, not entered into the  subject ; but those who are anxious
for information  will find  sufficient in a collection  of pieces  on  the
subject  published in 1768, in Dublin, or in Dr. Thompson's work on
6mallpox.
                        CHAPTER V.

                        VACCINIA.—COWPOX.

  914. If  he who " makes two  blades of grass grow where  one grew
before" be a benefactor  to 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  con-
tributed to the preservation of families, who has enlarged and rendered
more secure the social circle, who has given permanency to holy ties, who
has multiplied the manhood of nations, and added to their true  wealth
and strength ?  It is trifling with  realities to talk of the  glory which
involves destruction, in presence of this greater glory of preservation.
In the long list of earth's benefactors, very few, if any,  will take prece-
dence of Edward Jenner, when the true importance of things is clearly
discerned.
  After having learned in the last chapter the frequency and destruc-
tive extent of the epidemics of smallpox, its proportionate  and absolute
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 observed
that the cows were subject  to an eruption upon the teats, and that the
hands of the milkers frequently took the eruption  from these cows—
were  inoculated in fact.  Those who did so  regarded themselves  as
secure from the smallpox, 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. 
VACCINIA.
669
  In  the  year 1770, when Dr. Jenner went to study in London, he
mentioned this popular opinion to  John  Hunter ; 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 record of
his  labors—the  patient, unwearied industry, the energy in overcoming
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, that having satis-
fied himself of the truth of the popular  opinion,  he conceived the grand
idea of propagating the cowpox by inoculation, as a preventive of small-
pox.   This was  about 1780, and he continued his inquiries yet  sixteen
years longer before he made his first experiment. On the 17th of May,
1796, a boy was vaccinated,  and tested with smallpox  on  the  1st of
July the same year, and found unsusceptible.  This was the hour of
triumph for Jenner, and the reward of near  thirty years' labor.   The
rest of  his life was spent in furthering the  spread of  vaccination by his
personal  influence, writings, &c.; and  he sunk to rest  with  the  con-
sciousness of having been made a blessing to all mankind.
  I  shall not enter into any detail as to the subsequent history of  vac-
cination,  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 Parliament passed in
1840, propagating smallpox by inoculation is prohibited and vaccination
prescribed to all.
   915. Dr. Gregory thus describes the regular course of cowpox :  " On
the third day from the insertion of the virus, the  wound will be  per-
ceived red and elevated.   By  aid of the microscope, the efflorescence
surrounding the inflamed point will be distinctly perceived, even on the
second day.  On the fifth 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 eighth  day the vesicle is in
its  greatest perfection ;  its margin is turgid and sensibly 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 eighth  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 mem-
brane  participates in  the  inflammatory action, and occasionally the
glands of the axilla swell.  The areola continues to advance during the 
670
VACCINIA.
ninth and tenth days.   On the eleventh 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 surgeon.  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 eighteenth  and twenty-first day,  drops off,
leaving behind it  a cicatrix of a form and size proportioned to the  prior
inflammation.  A perfect vaccine scar should  be of small size, circular,
and marked with  radiations and  indentations.   These show the charac-
ter 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 seventh or eighth day, the child becomes
restless, uneasy, and feverish, with loss of rest and diminished appetite.
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.
   916. Modifications and  Irregularities.—Let  us  first notice those
cases in which their deviations do not impeach the validity of the  vac-
cination.
   I.  The vaccine vesicle may be tardy in its appearance ; in some cases
it shows  no appearance until the sixth or eighth day, and then  runs
through its course; in other cases the delay seems to be in the matura-
tion; the inflamed spot appears at the proper time, but the vesicle is
not complete until the tenth or twelfth day, or even longer.
   Dr. Labatt has met  cases where no inflammation occurred till the
twelfth day; Mr. Bryce, others deferred a fortnight; Mr. Pearson, one
case, where it did not appear for twenty days; Mr. Ring, in one in-
stance, saw no appearance before the forty-sixth day.
   We can understand that a co-existing disease,  such as measles,  scar-
latina, diarrhcea, &c, may modify the course of vaccinia; but in many
cases no such cause exists, and  it  is  quite impossible  to  explain the
delay.
   II. In some cases, on the first appearance of the vesicle, it gets  rub-
bed, or the child  scratches off the head, and  the  character of the vesi-
cle is changed.    It loses its proper form and is more conoidal; its  con-
tents,  too, are rather thicker and  more yellow than usual, and it has
more 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 found,
which  frequently, especially in scrofulous constitutions, proves difficult
of cure.
   in.  In other cases  the  inflammation is very intense;  the areola occu-
1 Oa Eruptive Fevers, p. 189.              2 Labatt on Cowpox, p. 83. 
VACCINIA.
671
pies two or three times its usual extent, is of  a  deep red color, and re-
sembles erysipelas.   The vesicle, instead  of  drying, is  converted  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 children
beyond ten years of age, and young persons, and I attribute it to  rub-
bing during sleep for the relief of the itchiness.
  Dr.  Labatt mentions that he has met with  cases of diffuse inflamma-
tion following vaccination,  and Dr. Osbrey has given two cases  of  a
very formidable character, the arm  swollen  and inflamed, the vesicle
turned into a dark slough with the surrounding parts  livid and appa-
rently gangrenous, great fever in one  case and  stupor in the other.1
  IV.  During the course of the vaccine vesicle, we  may sometimes
observe a lichenoid eruption on the child's body, with crops of vesicles
here and  there.  It apparently arises from the peculiar irritability 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.
   917. There are other deviations from the  normal course of vaccinia,
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 smallpox four times,  and three times for cow-
pox, but  in vain.
   I have vaccinated  children seven times before the infection took, and
in obstinate cases I allow a  considerable interval to elapse before repeat-
ing the vaccination.
   In other cases, doubtless, the failure may be accounted for  either be-
 cause  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.2
   II.  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 small 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 dis-
 charge 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."3

       1 Dublin Journal, vol. xxv. p.  137.    2 Monro on Smallpox, &c, p. 109.
       3 Labatt on Cowpox, p. 68. 
672
VACCINIA.
  IV. Dr. Labatt has laid down the characters  of spurious cowpox 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 commences with
a creeping scab, of a pale brown, 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  com-
mon 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, resembling a  large
blotch ; has  a fiery or livid aspect;  is not shaded off into the surround-
ing skin; and, as Dr. Cappe  observes, seems  rather to be under  than
upon its surface, while, at the same time, it is less extensive, nor is the
hardness around it so evident.  A ragged scab prematurely 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.  Imper-
fect vesicles are, in general, smaller and more globular than the true
vaccinia; they have not  the turgid, convex  margin, but a somewhat
puckered  base, appearing to  slope off into the surrounding skin ;  they
have not a eellular structure ; contents not a clear, transparent lymph,
but a straw-colored, opaque, or purulent fluid ; the areola not defined,
nor of so vivid a  rose 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 brown or amber color, irregu-
lar, and friable, forms earlier, separates sooner, and leaves an indistinct
and not pitted cicatrix."1
  v. Smallpox and cowpox may sometimes exist together, without any
sensible modification of either, or they may each restrain or modify the
other.   If the variola have preceded the vaccinia, and the fever'be  high,
the latter will generally be, as it were, blighted.
  918.  In an enormous majority of cases, the vaccine vesicle not only
runs its proper course, but vaccination is successful, and the child is pro-
tected against the smallpox.   We have seen that the practice of inocula-
tion was attended by a greatly diminished mortality, but not to be com-
pared  with  the immunity  conferred  by vaccination.   Notwithstanding
the prevalence of natural smallpox  and  (until lately)  of inoculation, it
has  been found that the mortality has gone on diminishing 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 vaccina-
tion.
Labatt on Cowpox, p. 90. 
VACCINIA.
673
  919. I 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, smallpox 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 1 in 3000, were afterwards affected with smallpox.1
Dr. Monro thinks  that such cases are more  frequent than  here  stated.
In Dr.  Baron's Report  I  find  that,  between  1825 and 1832,  86,646
patients were vaccinated at the National  Vaccine Establishment,  and
of that number only two deaths  from  smallpox after vaccination are
mentioned.   Dodd reports 201 cases  of smallpox in the year 1837, of
which  114  were after reported vaccination; 91  cases  were mild, 23
severe, and 2 fatal.   At the Royal Military Asylum, Chelsea, between
1803 and  1833, of 2533 who had smallpox before  admission, 26  had
smallpox again, and  3 died ;  of 3688  who were vaccinated before or
after admission, 27 caught smallpox,  and none died.2
  It is to meet such cases that certain  persons  have recommended re-
vaccination after the interval of a number of years, or periodically every
seven years.  In  Prussia several extensive revaccinations have  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 these revaccinations as being unnecessary,  con-
sidering 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.3
  During the winter  of 1849-50, smallpox was epidemic in Dublin, and
most of us witnessed  cases of persons taking it, in whom vaccination had
been successfully performed during infancy.   I met with  several such
cases, but I did not meet with a single such case, nor had  those profes-
sional  brethren whom I consulted, under  16 years of age.  So far as
this  goes, it is an  evidence  undoubtedly for the exhaustion of the  pro-
tective effects of the virus  after  a certain time,  and an argument for
revaccination.
  There are some questions relating to revaccination which deserve a
further investigation.  Of those revaccinated, a large number succeed
well—it is certain that they were previously obnoxious to smallpox.  A
certain number take it in a  modified form; is that because  of their  pre-
vious vaccination ? and are we to infer their security from  smallpox ?
  Is there any doubt about their security wdth whom re-vaccination  fails
altogether ?
  The late Dr. Fisher, of Boston, who had  devoted much attention to
this  subject, arrived at the following  conclusions from extensive statisti-
cal researches:—
  1. " That one single and perfect vaccination does not for all time and
in all cases deprive the system of its  susceptibility of variolous disease.

         1  Monro on Smallpox, p 147.       2 Labatt on Cowpox, p. 14.
         3 Ibid., p. 141.
       43 
674
VACCINIA.
2. That one or more revaccinations do ;  and that consequently a phy-
sician should recommend revaccination,  when questioned as to its  ne-
cessity."1
  Or, entering more fully into the question, he concludes that,  " 1.  A
portion of vaccinated persons are protected  from smallpox through life
by one vaccination.   2. An indefinite number are protected  only for a
certain period of time.  3. The length of time they are thus protected
is undetermined.   4.  Some individuals require to be vaccinated  a num-
ber of times during life.   5. The system is protected from variolous con-
tagion when it is no  longer susceptible of vaccine influence, as tested by
revaccination.  6. The cowpox  virus does not seem to be more effica-
cious than the human vaccine virus in its  prophylactic virtues, and the
influence of the vaccine virus  does not seem to be diminished by the
number of its removes from the cow or passages through the human sys-
tem.  7. The appearances of vaccine cicatrices furnish no indication that
the system may or may not be again influenced by repeated vaccina-
tions.  8. A plurality of  vesicles have no more  effect  in rendering the
system less obnoxious to the influence of revaccination than  a single
vesicle has.  9. The lapse of time from the period of  primary vaccina-
tion to  that of revaccination has  some, though but  little effect  in pre-
paring the system to be further  influenced by the  vaccine virus.   10.
The age of puberty  tends in a degree to destroy the effect of primary
vaccination.   11.  The  virus contained in vesicles  resulting from  re-
vaccination has the same anti-vaccine and anti-variolous power  as that
which is the product of vesicles produced by the primary vaccination."
  I may also refer my readers  to  Dr. Alex. Knox's  valuable  papers2
and the conclusions elaborated  by M.  Craninx,3 for the result of  their
observations in favor of vaccination and revaccination.
  920.  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 smallpox; nor would it prove that even
in those cases vaccination was of no use,  for these exceptional cases sel-
dom 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.4
   921.  There is still a very interesting question remaining, viz :  what is
cowpox, and what relation does it bear to smallpox ?  Are they simply
different and incompatible diseases; or is the  one a substitute  for the
other, having some relation; or are they  modifications of the same dis-
ease, and identical in nature ?   Dr. Jenner  thought the latter, and fur-
ther experiments have confirmed his opinion.
  A disease resembling variola prevails among animals during epidemics
of  smallpox;  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

             1 Trans,  of the American Med. Association, vol. iii. p. 73.
             2 London Journal of Medicine, Dec, 1850.
             s Gazette Med. of Paris. No. 27.
             « Lancit, March 27, 183-'. 
VACCINIA.
675
smallpox 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 cowpock
will result:  "thus irresistibly proving," as Dr.  Baron observes, "Dr.
Jenner's fundamental proposition, that cowpock  and smallpox are not
bond fide dissimilar, but identical, and that the vaccine disease is not the
preventive of smallpox but the smallpox  itself; the virulent and  con-
tagious disease being a malignant variety."
  922.  Diagnosis.—The characters of a true vaccine vesicle, are,  that
it begins to appear on the  third or fourth day after the insertion of the
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 pustule),
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 depres-
sion.
  Dr. Labatt remarks: "  I have seen the  areola very faint, but seldom
entirely absent, nor should I be satisfied with any case unattended  with
areola and the normal circumscribed hardness, which I consider indica-
tive 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 validity of  the vaccina-
tion, 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 smallpox which  it is in the power  of
vaccination to afford;  but if  the second inoculation  be postponed be-
yond 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.
  923. Mode of Operating.—Before proceeding to the actual  opera-
tion, let me say a word about the lymph, and the best method of select-
ing it.
  I. First, then, we should  be  very particular in taking the matter
from healthy children only.   It is a popular belief that various diseases
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
1 On the Cowpox, p. 81.
* Ibid., p. 102. 
676
VACCINIA.
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 areola, the true specific
matter of cowpox becomes mixed  with variable  proportions of serum,
the result of common  inflammation, and  diluted  lymph is  always les3
efficacious  than  concentrated  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 cowpox
ground to  powder, and moistened with  lukewarm  water to the con-
sistence  of  mucilage, will sometimes  reproduce the disease  in all its
purity."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.
   III. 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  direct from  the arm of
another.
   IV. The incisions are to be made with  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
insist on twenty 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 in-
flammation 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. 
CEDEMA  OF THE CELLULAR TISSUE.
677
                       CHAPTER  VI.

            (EDEMA OF THE CELLULAR TISSUE.—SCLEROMA.

  1. The disease of which I propose now to treat, cedema of the cellular
tissue, cannot fairly be classed among the diseases of the skin ;  but, as
no other place in  the volume is  more suited for it,  I have ventured to
insert it here.
  The name  given to it in this country is " hide-bound, or skin-bound
disease," and most frequently by French writers, "induration  of the
cellular tissue;" but, as this is quite  incorrect, I have adopted the one
which expresses correctly its nature,  and which is preferred by  Billard
and Valleix.   It is a disease rare in these countries,  and still more rare
in private practice, but not uncommon in the foundling  hospitals on the
continent, and consequently it is  to the researches of continental physi-
cians that we are indebted for the most accurate account of the disease.
  From the year  1808 to 1811,  645 cases occurred  in the Hospice des
Enfans Trouve's at Paris,  and in  the year  1826, 240 cases.   On an
average, 1 in every 25 infants admitted are attacked by the  disease
a few days after birth, and not more than 12 in 100  recover.
  From the year 1828 to 1851, 53  cases occurred in the Lying-in  Hos-
pital  at Stuttgard, 10 being born at the full term of gestation,  and 43
prematurely.   The  disease  prevailed most extensively in  the years
1849-50, during which time puerperal fever was  epidemic in the hos-
pital.1
  2. Symptoms.—The attack commences shortly after birth, generally
from  the first to  the fifth day, and it shows itself sometimes by a livid
redness over the body, or by a circumscribed hard spot  on one of the lower
extremities, over which it spreads,  and gradually ascends to the trunk,
and from thence to the arms and face.   The anterior part of the chest
and the back  are  generally affected the last.  The  side on which the
disease  commences is generally more swollen than  the other.   That the
swollen parts pit on pressure, there  can be no doubt;  but when the dis-
tension is extreme, a strong  pressure of the finger may be required, and,
when slight,  the  indentation soon  disappears.  This may have given
rise to the  opinion of MM. Auvity,  Blanche, and Denis, that the tissues
do not preserve the impression of the finger.
  According as the cellular tissue becomes  infiltrated, the limb or the
trunk  swells,  and acquires a firm  or hard feel, as  though the entire
tissues were indurated, and at the same time  the temperature diminishes
very considerably.  M.  Roger says that  the coldness even precedes the
6wellino\   M. Valleix met with but one exception : most frequently the
1 Archives Gen. de Med., May, 1853, p. 539. 
678
C3DEMA  OF THE CELLULAR TISSUE.
coldness commences in the lower extremities, but sometimes in the abdo-
men.   In the  last stage of the disease, the entire body is so cold as to
be unpleasant  to  the touch.  It  is  extremely difficult to warm  the
patient, and, if we succeed, the body rapidly loses its heat.
  After a short time a change takes place  in the color of the surface ;
the lividity diminishes gradually, and is succeeded by a  yellow tinge,
especially in the face, which deepens towards the  termination  of  the
disease, and around the mouth is mixed, as it were, with a livid tinge.
The feet ordinarily,  and sometimes the hands, preserve their reddish-
blue color.
  Until the effusion becomes considerable, the  skin is quite movable,
and can be gathered  into folds, but of course this  looseness is by  de-
grees lost,  and at length  the whole of the tissues  seem  solidified  to-
gether,  which led  Underwood to  suppose that the skin  was as it were
adherent to the bone.
  The general  state of the  child is one of great weakness, its  sensi-
bilities are all  diminished, its eyelids are almost always closed, and  in
the more serious cases, it will lie  in a stupid, half insensible state, and
die without a sign.   When disturbed much, it is uneasy, and makes some
efforts with its limbs, and  if distressed it will cry, and the voice is quite
peculiar.  As M. Valleix  observes,  it  is  sharp,  broken, and very
feeble, often stifled or muffled.1   M. Auvity was right in saying that a
physician who once heard will always recognize it.  But this charac-
ter is noticeable only at first; by  degrees  the  cry becomes  stronger,
deeper,  and at length resembles that of healthy infants.  In very slight
cases, the voice is but little changed, but  only in one  serious  case  did
M. Valleix find it pure in tone, and pretty strong.
  It has been  supposed that this peculiarity of voice arises from oedema
of the glottis, and of the  chordae  vocales, but  this is  sufficiently dis-
proved  by the fact  that M. Valleix only met  one case in which  the
chordae  vocales were oedematous.   He considers  that it depends upon
the difficulty, feebleness, and incompleteness of the respiration.
  M. Duges, and others, mention the occurrence of spasmodic  move-
ments, and even of trismus and opisthotonos.   M.  Leger denies their
existence, and M. Blanche and Mr. Elsasser2 mention having observed
a degree of agitation of the limbs, but not in  the least resembling con-
vulsions.  However, as M.  Auvity found in some cases, a degree of
effusion in the arachnoid, it is possible that convulsive movements may
occur, although they are not dependent upon  the affection of the cellu-
lar tissue.   M. Valleix mentions  that he never saw either convulsions
or tetanus;  when much disturbed, the child made efforts  at flexion of
the limbs.   He never saw the rigid, stiff condition stated by M. Dugks,
in which the child could be raised like a log, by the head or the feet.
   The  state of the  respiration is peculiar.   M. Blanche mentions its
being rapid,3  but  M. Valleix found it, on the contrary, much  slower
than  usual; inspiration is sudden  and short, so that  the chest is  in-
completely dilated, but expiration is very gradual, so that the interval

  1 Chirurgie deg Ma', des Enfans.        2 Arch. Gen. de Med., May, 1853, p. 542.
  3 Essai sur l'endurcissement du tissu cellulaire chez les nouveaux-n6s, These, 1834. 
               CEDEMA OF THE CELLULAR TISSUE.           679

between the inspirations is considerable.   If the child be stripped, the
abdominal  movements will be found to be very slight, in some  cases
scarcely  perceptible,  if the child do not cry, and now and  then we
observe a great effort at inspiration, after which the parietes of the chest
resume their immobility.
   In one case, M. Valleix found an interval  of from  10  to 12 seconds
between  the inspirations,  and in four others 16 or  18  inspirations  only
in the minute.
   "In 18  cases whose bodies were subsequently  examined, there  was
dulness on percussion in two from the beginning, in one on the left side,
below and  behind;  in the  other  on the  right side, above and behind.
Three times  dulness came on in the course of the disease, in two on the
right side and in one on  the left.  In  the  first cases, the dulness re-
sulted from non-dilatation of the lung;  in  the  latter from congestion
and induration.  In my latter cases, pneumonia  was much  more fre-
quent, since it occurred  in four out of six cases; it was always cha-
racterized  by cough, dyspnoea, and dulness, the bronchial  souffle and
bronchophony were heard but three times.  These symptoms  appeared
in one case at the same time as the oedema, but in all the others at least
two or three days after the commencement."1
   The pulse is generally slower than usual, from 60 to 72, or  about 80;
 according  to Elsiisser, so weak and small as  scarcely  to be felt; indeed,
 if the oedema be considerable, that combined with  the extreme weakness
 will probably render it impossible to count the pulsations.  The heart's
 action is  weak also,  but generally  more  distinct  than the arterial.
 The digestive system seems to partake of the general torpor, the child
 shows little  or no wish  for either food or drink; the belly  is soft,  in
 some cases distended, but without pain or tenderness;  the bowels are
 generally  confined;  M.  Valleix  met  only  one case  of   diarrhoea.
 Towards the termination,  a  sero-sanguineous fluid  escapes  from the
 mouth,  as has been remarked by MM. Auvity,  Leger, and Valleix,
 which probably M. Denis mistook for vomiting, which rarely  or  never
 occurs.                                             T       ri..   ,
    The disease lasts from two to six or  eight days.   In M.  Elsasser s
 cases it terminated on the 1st,  2d, or 3d day, in  one case, on the 4th
 day, and very rarely  on  the 10th or 20th day.
    3.  Most of these symptoms are present from the beginning, but in a
 slight deo-ree, and, by degrees, they become more marked as the oedema
 increases?  The sleep becomes stupor, the respiration slower, the circu-
 lation more feeble, the cry more stifled, the cold greater and more uni-
 versal.   When this  state is  extreme,  the  sero-sanguinal fluid escapes
 by the mouth, nose, and sometimes from the  eyelids, and death takes
 place calmlv, without agitation or convulsions.
    But all cases are not fatal, and in those which have a more favorable ter-
 mination  we find the respiration become easier, the circulation stronger,
 and the infant makes an effort to awake, to open its eyes, to drink  or
 to  suck eagerly.  These efforts are repeated  from  time to time, and
 each time more successful^; the cry has  more  strength, and we can
1 Clinique des Mai. des Enfans, p. 618. 
680
C3DEMA  OF THE  CELLULAR  TISSUE.
perceive the oedema diminish, at first from the eyelids  and forearms,
then the thighs and hypogastrium, then the hands.   The legs and  feet
often retain the swelling long after the other parts have  resumed  their
natural appearance.  For some time the skin hangs loose and retains a
bluish tinge, but by degrees this disappears.
  4.  Pathology.-—A series of careful pathological researches have cor-
rected several errors in the earlier  opinions  concerning this affection.
To  M. Billard we are indebted for a knowledge of the fact that the cel-
lular tissue in this disease is not indurated  or indeed changed at all, but
that the hardness is entirely owing to the distension by  fluid, and  that
the two are in exact proportion.1   He has shown, however, that there is
such a disease as induration of the adipose tissue, occurring just before
death, with which scleroma may easily  be  confounded, and  this is his
description of it.   "It may exist with or without general infiltration of
the subcutaneous cellular tissue; the jaws, the thighs, the calves, and
the  back  are  the most common seats of this  induration, and  it  may
occur with or without  disturbance of the  respiration  and circulation.
It ordinarily comes on  just before  death, or it may be developed  after
death in infants who have been rapidly  cut off.   If the  adipose tissue
be dissected in these cases, it will be found firm, hard  like suet or tal-
low, quite coagulated,  resembling the fat of slain animals."2  This re-
ally answers very closely to the description of "skin bound," given by
Denman,3 but no such  condition is observed in the cases of oedema of the
cellular tissue, which is a different disease.
  Again, M. Breschet  considered  that  there  is something peculiar in
this oedema of infants,  in which  it differed  from that of  adults,  and he
requested M. Chevreul  to analyze carefully the serosity infiltrated.   He
states that he found the blood to  be in a morbid condition, and  that it
contained two coloring matters not found in the blood  of healthy child-
ren, and  besides a matter which  rendered the  serum  coagulable, by
which he  explains the  color of the cellular tissue and  its induration.4
This led M. Billard to  repeat the experiments, and  to  add others, and
the  conclusion at which he arrived is that " the induration of the cellu-
lar tissue of infants is  nothing more than simple oedema perfectly  ana-
logous to that in adults or old persons affected by disease of the lungs,
heart, or  bloodvessels.  We find that their limbs  occasionally are as
hard as those of infants in this disease.   If in infants the surface is
very red, it is  owing to the habitual congestion of this part."5
   5. Andry6 and Auvity state that the  lung is often gorged with blood,
and  yet filled with air; sometimes, on the other hand,  collapsed, black,
and gangrenous.
   M. Valleix merely observed  that  these  organs were livid, and  gave
issue to a considerable quantity of blood when they were cut into, that
this blood was accumulated in the most dependent parts.  The lungs  were
more or less crepitating, and floated when cut into pieces.  In two cases

     1 Mai. des Enfans nouveaux-n^s, p. 490.                         2 Ibid.
    3 Underwood's Diseases of Children, p. 273.   a
     4 Considerations Gea. sur l'Analyse organique eWur ses Applications,  p. 248.
     5 Mai. des Enfans nouveaux-n£s, p. 4U3.   ,
     6 Encycl. Method. Medicine, vol v. p. 548. 
CEDEMA  OF THE CELLULAR TISSUE.            681
only, out of twenty-four, he found true pneumonia, but he  also found
portions of the lungs not yet penetrated by air.  Troccon1 and Duges
agree with Ilulme  in  attributing this  oedema to inflammation of the
lungs, but the experiments of the former confirm  the more recent con-
clusions of MM. Legendre and Bailly, and others, who have shown that
the condition of the lung in this disease is not pneumonia, but atelectasis;
that the lung is undilated,  as in the foetus which has  never breathed;
and that it may be inflated after death and made to assume  the ordinary
aspect of that  organ.   Dr. West observes: "We are, however, certain
that the appearances, once thought to  be  the result of pneumonia, are
in reality due to the unexpanded condition of the lung, and we can un-
derstand how it may happen, if  children be exposed to cold almost im-
mediately after birth, and then transferred to the ill-ventilated wards of
a foundling hospital, and there fed with food far other than that which
nature destined for them, that respiration  may be but very imperfectly
established; that their temperature may  consequently fall, and the blood,
flowing in part through the  unclosed foetal  passages, may stagnate in its
course, may give rise to profuse  effusions  into the great cavities of the
body, and to an anasarcous  swelling of the surface."
   M. Elsasser found lobular pneumonia in one-tenth of his cases.
   In  the pleura and pericardium there  is a certain  amount  of serum
effused, and the  heart is filled with dark  liquid blood: in a few cases
there are small coagula.  The large arteries and the veins  are also full
of dark-colored fluid blood.
   Serum is also frequently found in the peritoneal cavity.  The gastro-
intestinal mucous membrane rarely exhibits  any deviation  from health,
according to MM. Billard  and  Valleix, although M. Denis mentions
that he has frequently found small ulcerations in the stomach and intes-
tines.
   M. Elsasser found hyperaemia  of  the intestines, hypertrophy of the
liver and of the spleen, hyperaemia of the kidneys, with  traces of Bright's
disease: in eight cases  peritonitis with  effusion, and one purulent infil-
tration of the mesenteric glands.
   The vessels of  the brain are generally much congested,  but  the con-
gestion is probably of a passive character.  M. Auvity and M. Elsasser
are the only writers who have  found  effusion  into the cavity of the
cranium.
   In  most of  M. Elsasser's cases the  membranes of the brain  were
filled  with black fluid blood, occasionally there was effusion of  blood or
serum in the  lateral ventricles, and in one case the spinal  marrow was
covered with  a layer of blood, the arachnoid soaked in it, and the brain
softened.3
   6.  Complications.—These do not appear to be very frequent, the un-
dilated condition of  the lungs,  or portions  of them,  being  the  most
common.  In five cases out of twenty-five, M. Valleix found pneumonia,
and in two more congestion, which was  probably inflammatory. Affec-

    1 Sur la Malade connue sous le nom  d'endurcissement du Tissu Cellulaire, 1814.
    2 Diseases of Infancy aud Childhood, p. 163.
    » Archives Gen. de Med., May, 18-53, p. 513. 
682            C3DEMA  OF THE CELLULAR  TISSUE.
tions of the nervous system, and of the digestive organs, jaundice, &c,
though not quite unknown, are rarely observed, and in one case M. Val-
leix saw an attack of erysipelas.
  7. Causes.—Palletta, in  1823,1 denied the  influence of cold in the
production of this disease, and attributed it to flaccidity of  the lungs,
especially the right, after birth, which he supposes gives ri3e  to conges-
tion of  the lungs and an arrest of circulation, which occasions engorge-
ment of the liver.  M. Valleix objects to this theory as being  opposed
by the experience of Billard, Blanche, Denis, and himself. M. Leger,2 who
probably  expresses the opinions of Breschet also, enumerates various
causes,  chiefly a disturbance of respiration  and circulation, which ren-
ders the blood more serous, also the non-obliteration of the foetal open-
ing and the excess  of coagulability of  the  serum.   Again, he regards
jaundice as the first degree of the malady, and lastly he considers that
in these cases the brevity of the intestinal tube a direct agent.   Of the
first of  these  causes there can be no doubt, but the latter  suppositions
have either been disproved by more recent researches as matters of fact,
or we may reasonably doubt their having much to do with the produc-
tion of  this disease.
  M. Denis regards the cedema  as resulting from  an  irritation of the
cellular tissue coincident  with  different internal  affections, and espe-
cially with gastro-enteritis.  The facts cited by M.  Leger, however,
sufficiently  refute  this opinion.   M.  Valleix very justly  regards  the
oedema  as dependent  upon the arrest of the blood, consequently upon
the disturbance of respiration and circulation,  and still  more recent
researches of Bailly  and Legendre and others, seemed to prove that
this disturbance is owing to  an undilated condition of  a portion of the
lungs.
  Feebleness of constitution is no doubt the chief predisposing cause;
thus, it is  very common with premature children, as was remarked by
Palletta and Valleix, and M. Lediberder saw two children  expire a few
minutes after premature birth with the characteristic respiration.  Yet
it should  be stated, on the  other hand, that the disease may occur in
healthy, well-made children  born at the full time.
   Cold is undoubtedly the principal  exciting cause,  as in  177 cases
mentioned by M. Billard,  106 occurred in  the colder months, and out
of  338 cases  given  by M. Valleix,  233  occurred in the  six winter
months.3   The latter eminent observer mentions that  children brought
to  the  hospital from  different parts of Paris, and badly  wrapped up,
are more liable to the disease than those from the Maternite.
   8. Diagnosis.—There are but two diseases with which cedema of the
cellular tissue is very liable  to be confounded,   a.  Infantile  erysipelas
with infiltration, but  the latter  disease commences  most frequently in
the face—the parts  are of  a deep red color, hot, swollen, and promi-
nent, and the  child is evidently in pain, which is  widely different from
oedema—and the peculiar character of the  respiration  and  circulation
in the latter disease, is entirely wanting in erysipelas.

                1 Memoir read before the Institute at Milan.
                2 These Inaugurate, Paris.
                8 Clin, des Mai. des Enfans, p. 649. 
               CEDEMA  OF THE CELLULAR TISSUE.            683

  b. Induration of the Adipose Tissue.—As I have mentioned, this is
an affection of  the  last moments of  life, generally, and it  may be en-
tirely a cadaveric condition, as has been  observed  by Underwood, Bil-
lard, and  Valleix.   The  aspect  of  the child  is different, its color  is
white or yellowish,  the skin and subcutaneous tissues appear  solidified,
and  the parts  attached  are generally different.  The only symptoms
common to both are the coldness and the feeble cry.
  9. Prognosis.—The prognosis is serious in all cases, both from the
nature of the attack and from the weakness of constitution of the sub-
jects of it.  By far the  greater  portion  of  the patients die, and for
premature, or especially  weakly infants, one cannot  say that there is
any hope.
  10.  Treatment.—M. Billard,  to whose researches we  are so  much
indebted,  thus  expresses the results of his  observations : " The thera-
peutic  indications which follow from  the  preceding considerations are:
1, to combat the  general plethora by a certain amount of loss of blood;
2, to excite the  skin by irritating frictions,  by the use of flannel, and
all  means proper  to establish  the  cutaneous  circulation.   The vapor
baths,  for the administration of which M. Peligot has arranged an inge-
nious plan at the  ' Hospice des Enfans Trouvds,'  have not produced,
according to M. Baron, as good effects as frictions and the  application
of flannel.  I  have  often seen these  latter means  succeed  perfectly.
The respiration, during the bath, is  sometimes  painfully impeded, and
occasionally congestions  and sanguineous effusions into  the lungs or
brain have followed their administration."1
  Andry,  Auvity,  Louvelle,  Underwood and  others, agree that the
principal means of  relief are warm baths and frictions with flannel.
  M. Valleix  is  a  decided advocate  for the  abstraction  of blood by
leeches, but even in some  cases where they had afforded relief, the  child
was carried off by erysipelas.
  In addition to  the means for  the relief of congestion, our endeavors
must be to excite  the lungs to action and to restore warmth to the
child.   It might be worth while, I think, to  try the  effect of electro-
galvanism through  the lungs, and internally we may administer ammo-
nia in  almond milk  or wine whey if the child can swallow.
  Some attention  should be paid  to the bowels,  either by purgative
enemata,  or, as  Underwood advises, by placing a  grain  of  calomel in
the mouth.
1 Mai. des Nouveaux-ne"s» p. 208. 
SECTION  VII.

       FEVERS.
                        CHAPTER  I.

                   INFANTILE REMITTENT FEVER.

  1. No doubt many of the  diseases of  infancy and  childhood are ac-
companied by fever, and  to  so great an amount  as  even to mask the
local  and primary disorder ; but besides these attacks, we find them
liable to fevers, which, to a great degree, resemble those  of the adult.
Armstrong,  Underwood, Hamilton, Butter,  and  more  recent  English
writers have given us more or less full and accurate accounts of a fever
which some call  worm-fever, others mesenteric,  gastric,  or infantile
remittent  fever, and the more  modern  French writers have added  a
description of typhoid fever.   That  these are the same in kind, but
different in degree, would, I  think, be a hazardous assertion, notwith-
standing these pathological resemblances, for the  course and symptoms
differ very considerably ; the  former being very common in  private
practice, the latter rather rare.   Amongst the poor,  and in foundling
or children's hospitals, both forms are sufficiently common.
  Infantile remittent  fever is a disease  to  which children are  very
liable from one year old to ten or twelve, or even later.  It is charac-
terized by one or  more daily exacerbations and remissions,  by disorder
of the stomach and bowels, occasionally by headache  and by its uncer-
tain duration.
   The best description of the  disease will be found in Dr. Butter's
essay ;J he divides the disease into three varieties—the  acute, the slow,
and the low remittent; the latter  appears to me to  resemble typhoid
fever.   Others speak of acute and chronic remittent.  The variations
seem to depend chiefly upon  the progress and duration of  the disease,
its  complications,  the  modifications impressed upon it by  the  peculiar
constitution of the child, or the prevailing epidemic influence.
   2.  Symptoms.—In some cases the  disease  commences quite suddenly
by  a  severe febrile  paroxysm in the night, with heat of  skin, quick
pulse, flushed face,  &c.   The thirst  is intense, the tongue dry  and
furred;  there is  restlessness  and  agitation,  perhaps  delirium ;  the
child, if old enough, complains of headache, intolerance of light  and
1 A Treatise on the Infantile Pvemittent Fever, 1782. 
INFANTILE  REMITTENT  FEVER.
685
sound, and soreness or  pain in the belly.   Nausea  and vomiting not
unfrequently occur, and the matter  vomited is  yellowish or greenish,
and  has a sour smell.   Towards morning,  these symptoms abate, the
skin  becomes cooler, the pulse quieter, and the tongue more moist, but
still  the skin remains  dry, the  tongue  loaded, and the  pulse  quicker
than natural.  The child  is uneasy and fretful,  the  abdomen more or
less  tender, the  urine  scanty and high colored, and  afterwards  often
depositing a white sediment, or  becoming white and  chalky, although
clear and of the  ordinary color  when passed.  During the day  there is
a still further improvement, and the child may even regain some of its
natural liveliness, although the occasional languor and  uneasiness reveal
the remains of indisposition.   Towards  evening  the paroxysm returns,
with fever, uneasiness, headache, &c, as before, to be succeeded by a
remission in the morning.
   3. Or, as in many other cases, the attack may come on more gradu-
ally, preceded several  days by indisposition.  The child looks unwell,
is  uneasy and fretful,  picks its nose, has  heavy, offensive breath, with
a short, dry cough, loss of appetite, pain in  the head and  abdomen, and
occasionally flatulent enlargment of  the latter.   The sleep  is uncom-
fortable, and interrupted by starting, moaning, and grinding the teeth.
The  urine is scanty, turns milky soon  after  it is passed, or deposits a
whitish sediment.   The bowels are irregular, often 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  in so quietly that its commence-
ment is not noticed.  The paroxysm comes on in the evening,  as I have
just  described, with hot skin,  quick pulse, great thirst, flushed face, &c,
lasting during the night, and followed by more or less complete remis-
sion  in  the  morning and during the day.   When the  fever  is very
severe,  the remissions are shortened and less perfect, or may even be
scarcely perceptible.
   During the exacerbations, all the symptoms are aggravated ; the child
is  drowsy, but sleeps uneasily ; it moans, starts,  and talks incoherently,
or it may wake with a  scream ; the skin is hot, the pulse rapid,  varying
from 140 to 160, the respiration quick and hurried ; there is a dry cough,
uneasiness  in the bowels, with flatulence, and occasionally nausea and
vomiting.
   Durino- the remissions, all  the symptoms  subside to a  certain point,
the patient is tolerably lively and cheerful, the skin cooler, the pulse
from 100 to 120, and if he sleep, he does so quietly and  calmly.
   In the majority of cases the paroxysms occur but once  in the  twenty-
four hours, and  in the  evening, but they may be more frequent. There
are sometimes three in the same space of  time, one in the morning,
another at noon, and a third, the longest and most severe, in the night,
but  such cases  are  very  rare.  Ordinarily, the daily paroxysm, with
remission, is  the characteristic of the  disorder, and  continues during
its entire duration,  but some changes take place in the other symptoms,
and  the impression made  upon the  child  by the pain varies in its in-
tensity.  For example, the headache,  which is generally  troublesome 
686
INFANTILE  REMITTENT  FEVER.
 at the beginning, especially during the exacerbations, gradually ceases,
 unless there occur some cerebral complications.
   The cough  continues longer, but if there be no pulmonary disease,
 it is only occasional, not very troublesome, and by degrees diminishes.
 The respiration is always hurried during a paroxysm,  and is hardly as
 quiet as  usual  during the  remission,  but nothing is heard beyond a
 mucous rale, and  percussion gives  a clear sound.   The  breath  has a
 sickly odor, and is sometimes very  offensive.
   The local irritation, which is frequently developed the  first, or  if
 not, which is  certainly the  most common,  and persists the most  obsti-
 nately, is disorder of the intestinal  canal.   The appetite entirely  disap-
 pears, but the child is  extremely thirsty.
   Dr. Pemberton observes that, " digestion seems perfectly at a  stand,
 for the food which is taken  into the stomach will often be brought up
 unaltered, though it shall have remained  down  a considerable  time.
 The intestines also seem in  a manner paralyzed ; they exert no  action
 on the food, for it passes off like a mass of putrid vegetable and animal
 matter, which has been sometimes subjected to heat and moisture, with-
 out its having the smallest resemblance, either in appearance or  smell,
 to those  fasces where the powers of digestion have been exerted.  When
 the  disease has continued  for some time, the appetite  is  so totally
 destroyed that for six or eight days together,  I have  known  the  whole
 nourishment to consist of  about half a pint of toast  and water  in the
 twenty-four hours."1
   The state of the  bowels is  very irregular  and uncertain; they are
 sometimes constipated  at the beginning and then attacked by  diarrhoea;
 or they may be too  free from the  commencement,  and afterwards  the
 diarrhoea may continue or alternate with constipation.   I think that in
 the  majority of cases  the bowels  are  too  much  moved, and with con-
 siderable irritation.  The amount of each discharge varies a good  deal:
 sometimes there are copious evacuations; in other cases, very  little
 faecal matter, with much wind.   The character of the  stools is  un-
 healthy,  and highly  offensive; they may be clay-colored, or dark and
 slimy, resembling tar, or  occasionally  mixed with  mucus, and even
 blood.  In the latter cases the attack assumes  very much the character
 of dysentery.
   The abdomen feels  very hot to the hand, is  somewhat  tender on
 pressure,  and  the child now and then complains of pain  in the bowels.
 In some cases the belly is distended with flatus, but more frequently it
 is fiat, or even concave.   Worms  are  sometimes  discharged by  stool,
 and  this  has  given  rise to the opinion that the disease is  caused by
 them ; occasionally, but very rarely, they are ejected from the stomach,
 and now  and then they have been observed to crawl  out  of the anus
 spontaneously.
   The urine,  which at first turns white soon after  it is discharged, in
general becomes yellow and highly  transparent.
  Dr. Condie  mentions that he has noticed  a rose-colored lenticular
eruption  upon the  abdomen  and inner surface  of  the thighs,  and occa-

            1  On various Diseases of the Abdominal Viscera, p.  165. 
INFANTILE REMITTENT FEVER.
687
sionally sudamina upon the abdomen or along the front and sides of the
neck.  Dr. Coley states that he  has observed a scaly desquamation of
the cuticle in remittent fever, resembling that in  scarlatina, and also
that described by Dr. Pemberton as peculiar to disease of the mesen-
teric glands.1
  4. The disease  may go on  thus  from  day to day for an indefinite
time without any very formidable symptoms arising, but without any
advance  being made  towards  cure,  the  child becoming weaker and
thinner until it is so reduced in flesh and strength that  recovery seems
most improbable, and yet even from this  state they rally astonishingly
if no complication take place.   By slow  degrees  the  bowels become
more quiet and regular, the  discharges more healthy; the urine  again
deposits a copious sediment; then the tongue becomes cleaner and the
pulse falls, a  gentle  moisture  appears on the skin, the sleep becomes
quiet and refreshing,  and the daily exacerbation ceases  to occur.   The
pulse, however, in some cases, remains quicker  than natural for a time
after the other symptoms have  disappeared.
   On the other hand,  the result in many cases is not so favorable; the
child may sink from exhaustion or from  the intestinal affection taking
on a more  serious  character, presenting  the form  of entero-colitis  or
colitis, and in its reduced state, proving  rapidly fatal to the child;  or
lastly,  and perhaps  more commonly, the nervous system may become
implicated and the child be carried off by a convulsion or by an attack
of secondary  meningitis.  Of  these  complications  I shall say a few
words presently.
   The duration of  this  fever is  both uncertain and variable ; it may
last from a week to  a month, and it very rarely  indeed  terminates by
a crisis.
   5. But not only is the duration variable, but also, if I may use the
expression, the rate of progression, and this is probably a sufficient ex-
planation of Dr. Butter's slow variety, in which he remarks that the dis-
ease comes on  gradually and unnoticed;  the child slowly declines, the
appetite  diminishes, then fails  altogether;  the breath is offensive and
the abdomen enlarged.  One daily exacerbation occurs in the evening
and  lasts until morning, succeeded .by a  profuse  sweat.  During the
dav, 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 dur-
ing  the  exacerbations.   The child  is sleepy, dozing  uneasily,  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 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, as 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:
1 Diseases of Children, p. 190. 
688
INFANTILE  REMITTENT  FEVER.
"The  exacerbations," he  says, "are of longer duration, but marked
by symptoms of less intensity than  in  the  more acute attacks of the
disease ;  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
copious white sediment,  particularly during the remissions;  the  skin
is  dry, harsh, and of a sallow or dirty hue ;  the  countenance is  con-
tracted and wrinkled, presenting the appearance of premature old age.
The  appetite is often unimpaired, and  in some cases it is even vora-
cious ; in general, however, it  is altogether lost.   The child is  very
generally affected with a short,  hacking, frequent cough.  Most  com-
monly there is urgent thirst.   There is  always more or less fretfulness
and the usual indications of suffering, and the patient exhibits a dispo-
sition to  pick almost constantly at some portions 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, however,  a common  phenomenon  in  all the
chronic affections of  childhood, and  is  often observed when no disease
whatever is present."1
  6. Yet again,  the symptoms and course of  the disease  may  bo
varied by the constitution  of the  individual, or perhaps by the atmo-
spheric constitution of 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 arms and hands are  almost  always  in  motion when  he
is awake; sometimes he flings them about, and at other times picks not
only his  nose and lips, but even his tongue, eyes, and other parts 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 speech and voice,  and the jaws are occasionally locked together.
He slumbers much during the exacerbations, and in the remissions per-
forms with  his hands the gesticulations above described.  When the low
stage sets in, the  eyes are  reddish, dull, and inattentive ;  the counte-
nance is  expressive  of distress; and the tongue,  teeth, and  lips, are
covered with a blackish fur.   The patient is  particularly uneasy before
1 Diseases of Children, p. 273. 
INFANTILE REMITTENT FEVER.
689
stools,  or  the  escape of  flatulence; the urine  and stools which are
of  unnatural  appearance,  are involuntary, yet  he  is  quite  sensible ;
the pulse, which is about 100 in the remissions, rises to 120 in the ex-
acerbations.   When the disease takes a favorable  turn, the exacer-
bations become shorter, the child  is less  drowsy, the eyes are clearer
and more observant, the countenance 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 whenever  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, 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 consid-
erable period passed involuntarily; the crying and fretfulness  long con-
tinue; 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 them 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 seems
sometimes to co-exist,  so that the  child can scarcely bear to be touched
in any part."
   7.  Complications.—As  I have already  stated,  the  child may no
doubt sink from exhaustion in this disease, but J am sure that all who
have had much experience,  will agree with me that the chief  danger is
from the complications which occur at different periods of the  fever.
The principal  ones are the  following :—
   I. Convulsions or Meningitis.—It is rarely we see convulsions at the
commencement of the  fever.   I  have,  however, known the nervous
system very much disturbed in one or  two  cases,  as  was marked by
visions  when  awake, distressing  dreams  and  startings  when asleep.
But in general.it  is only after some time when the disease has reduced
the strength of the child, and at the same time increased the irritability
of the nervous system, that the attack is to be feared.  Sometimes the
child is attacked by one or more convulsions, followed by stupor, occa-
sional  staring, twitching of  the  muscles, &c,  or  the  symptoms  of
secondary  meningitis  may  gradually  steal  on  without a convulsion.
We may find the  child heavy, with diminished  intelligence and sensa-
tion, with  the hands  clinched, the  thumbs  turned inwards,  the  eyes
starin«-  and twinkling, and  repeatedly sighing.   Or the  child may be
restless, crying, rolling the head,  picking the limbs, &c, and by and
bv there may follow an attack of  convulsions, or paralysis of one side

                   1 Cyclop, of Pract. Med., vol. ii. p. 241.
       44 
690
INFANTILE  REMITTENT  FEVER.
of the body, and  convulsive movements of the other.   The  symptoms
of meningitis are generally modified by the weak condition of the child,
and some may be absent, or  the  child may be carried off before time
has been allowed for their development.
   This attack may be regarded as a reflex irritation from the  disordered
intestinal canal, ending, in many cases, in  inflammation.  It is a very
fatal complication, and in remittent fever is always to be dreaded ; no
visit should be made without a careful scrutiny into the condition of the
nervous system, nor a moment lost when any suspicious symptom arises.
   II. Entero-colitis,  or Colitis.—That remittent fever is always  accom-
panied with more or less  gastro-enteric irritation is quite evident, but
there is room for doubt as to  whether this amounts to inflammation in
ordinary cases.  In certain cases, however, this complication  does  take
place, and  it may occur at any period, either early,  or, which is more
common, at an advanced stage.
   Enteritis will  be  marked by an increase in the intensity of the ab-
dominal symptoms, such as the  pain, tenderness, tympanites,  diarrhcea,
&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
unhealthy discharges, with tenesmus, and the other symptoms of dysen-
tery, general and local, already described.
   in. Bronchitis or Pneumonia.—From the  beginning there is gene-
rally a  troublesome  cough, indicating that the  mucous membrane  of
the bronchial tubes, as well as  that of the intestines, is  in  a state  of
irritation,  and  this  not  unfrequently degenerates into an  attack  of
bronchitis,  with the usual symptoms and signs.  It is more rare, though
not very uncommon, to find an  attack of pneumonia supervene..
   IV. Paralysis.—When an infant  recovers from remittent  fever, it is
sometimes found to have lost, partially or wholly, the  use of  a limb or
of certain muscles, as I have already noticed when treating of paralysis.
These effects  may be the  consequences of inflammation of  some portion
of the nervous system, but more frequently  they seem  to be the results
of reflex irritation.
   v. Pericarditis.—This cannot  be a frequent  complication, as it is
not mentioned by any writer, I believe, but as a well-marked and ulti-
mately fatal case occurred in my  own practice, I think it right to men-
tion it.
   8. Pathology.—In cases which  have proved fatal, we  invariably
find a certain  amount of disease of the  intestinal canal, but it  may
not be easy to separate the amount  of disease  due to  the  existing com-
plications.  Evidences of inflammation, varying in extent and intensity,
are generally found in the stomach  and small  intestines,  sometimes  in
the ilium chiefly,  or  in the ilium and colon.  The mucous  membrane
is  reddened in patches, or exhibits red striae  or points, or  it may be
thickened,  softened, or ulcerated.   The isolated follicles  are generally
enlarged, as well as the patches of follicles in the small intestines, and
they are sometimes  softened or ulcerated.  The mesenteric  glands are
frequently  enlarged, sometimes considerably, and they have been found
in  a state of suppuration, and containing tubercular matter.   The liver
is  sometimes congested, but rarely the seat  of organic  disease. 
INFANTILE  REMITTENT  FEVER.
691
  When the  patient has  been carried off by meningitis, colitis, or en-
tero-colitis,  or disease  of the  lungs, the  usual  appearances will  be
found.
  We now come to the consideration of the nature of this  fever.  Is
it a fever depending upon the presence  of worms, or  is it a gastro-
enteric, or  a  fever with gastro-enteric  complication,  but  not caused
thereby ?
  In  favor of the first opinion we have the authority of some who were
great authorities in their  day (Baglivi, Hoffmann, Sauvages, &c), and
the fact  that worms are occasionally discharged,  but neither of these
is conclusive.  In the majority of  cases no  worms at all are  discharged,
and they are rarely detected by a post-mortem examination.
  We must,  therefore, seek for some more general pathological condi-
tion to explain the disease, and as the symptoms  during life generally
indicate  gastro-enteric  disturbance, and  the post-mortem appearances
are those of  irritation or  inflammation of  the gastro-intestinal mucous
membrane, that has been generally assumed by modern writers  to be
the essential element of  the  disease.   Thus, for  example,  Dr. Under-
wood considers it merely as  an affection  of the primae viae.   Dr. But-
ter attributes it to a debilitated condition of the digestive organs, and
to an accumulation of unhealthy  secretion in  the bowels, connected
with the peculiarly sensitive  constitution  of children.   Dr. Pemberton
regards  the  fever  as  symptomatic of derangement in the intestinal
canal.   Dr.  Eberle agrees  with  those  who attribute  it  to irritation
located in the stomach and bowels,  with  disorder 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
inflammation, most commonly subacute, of  the digestive mucous mem-
brane."   Sir Henry Marsh observes that "its characteristic  symptoms,
if closely analyzed, will all of them be found to  point  to the mucous
surface  as the original seat of morbid action,"1  with  which opinion
Maunsell and Evanson concur.  Dr. Joy regards it merely as a variety
of gastric fever, modified by the irritable constitution of infancy.
  The French  authorities are nearly unanimous in regarding the disease
as " gastro-enterite," and the fever as symptomatic.
  At the same time, however, I may observe that if there be a  doubt
whether  the  morbid condition of the intestinal  mucous membrane be
the cause, or only a concurrent symptom  of the continued  form of
adults, the doubt is equally applicable to the remittent fever of chil-
dren.  I can quite easily believe  that  although  certain pathological
conditions may be found  in both, yet  in both these may not be the
essential cause, but rather the  effect  of a continuance  of the disease,
the essence of which is more general.
  9.  Causes.—Cold, teething, irregular or unwholesome food, or excess,
with neglect  of the bowels, seem to be the  principal exciting causes of
the disease.  I am not  sure whether  over-dosing  with  purgatives may
not also give rise to it.  It has been said to  be contagious, but I believe
very erroneously.  That it prevails  epidemically, appears beyond doubt.
1 Dublin Hosp. Reports, vol. iii. p. 316. 
692              INFANTILE REMITTENT FEVER.

Dr. Butter speaks of  it as either sporadic or epidemic, and Dr. Sims
has described  an epidemic which occurred  at the same time wdth  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 materially affect the practice."
  10. Remittent fever may also occur as a  secondary affection in the
course of  or subsequent to other  diseases, and when it  does so it  may
exert a very unfavorable influence upon their character and terminations.
Thus we find it complicating hooping-cough and other pulmonary affec-
tions; following upon the sudden cure of an  eruption ;  as one of  the
sequelae of scarlatina or measles; or as a  termination of dysentery.  The
characteristic  symptom, i. e., an evening exacerbation,  followed by a
remission, is always present, although from the presence of concurrent
symptoms of another kind, it may require more care than usual to satisfy
one's mind.
  11. Diagnosis.—I.  The most important point, and  in  many  cases
our greatest  difficulty,  is to distinguish remittent fever with certain
symptoms, from some forms of meningitis, and not only is  it far from
easy, but in many cases, towards the end of the disease it  may be  im-
possible, 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  me-
ningitis ; that  the disease  lasts for a much longer time; that the heat of
the head is not specially increased;  that there is not generally clinching
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  may be  occasionally
vomiting,  there is  sufficient gastro-enteric irritation to account for it,
and very much more than is usual in hydrocephalus.
  There is some degree of resemblance occasionally between remittent
fever  and mesenteric disease.  Dr. Coley observes  they may be  dis-
tinguished " by the accession of fever occurring in the latter, generally
in the evening only; by the child being more restless at that time instead
of being inclined to sleep ; by the intestinal evacuations having but lit-
tle alteration from their natural appearance; by a peculiar  mark of dis-
tress in the countenance ; by the sleep in mesenteric disease, after the
paroxysm of pain has subsided, being for the most  part undisturbed ;
and by  the length of time the complaint has existed.  The fever accom-
panying the disease in the mesenteric glands is of a hectic nature,  and
always  periodical, gradually terminates with  proper perspiration,  and
is free from delirium."1   I  should rather depend upon the latter cha-
1 On Diseases of Children, p. 192. 
INFANTILE  REMITTENT  FEVER.
693
racteristics than the former, adding to them the fact, that in an advanced
stage of tabes mesenterica, the enlarged glands can generally be felt.
  II. 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 complication.   Convulsions
or hydrocephalus, coming on after the disease has lasted some time, are
almost invariably fatal.  Pulmonary  or intestinal inflammation, though
not  so certainly mortal, are frequently so, and require  not merely great
care and skill, but a strong constitution on the part of  the child,  to en-
able it to struggle through.
   The diminution of the exacerbation, the return of healthy evacuations,
of sleep, appetite, and a quiet pulse, are  all favorable symptoms; whilst,
on the other hand, an increase of fever, with either abdominal, pulmo-
nary, or, still worse, cerebral symptoms,  is highly unfavorable.
   12. Treatment.—Very active antiphlogistic  treatment is out of the
question  in uncomplicated cases of infantile remittent,  but when the
pain and tenderness of  the  abdomen  are more  than  usual,  a few
 leeches  may  be useful,  followed  by poultices, but it is  rare that  we
 find them necessary.  In  the majority of cases, one  of_ the very first
 things to be regulated is the diet and regimen of the patient;  if he be
 not  already in bed, he should be placed  and  kept there.   The feverish
 restlessness and the natural  impatience of  children,  often render this
 unpleasant to them, and nurses are induced  to indulge them, but I  am
 satisfied that much injury may be done  by taking the child up when it
 is restless.   Let it be lightly covered, and placed in  a well-ventilated,
 cool room,  and  let it understand that it must remain in bed, and its im-
 patience will generally cease.   It will be well to examine the gums, and
 scarify them thoroughly if there be any evidence of irritation from  the

   The next question concerns the state of the bowels:  if we see the
 child early in the attack, and they be constipated, a brisk  purgative will
 be  verv useful,  either calomel with rhubarb or jalap, or calomel followed
 bv  castor oil, will generally act mildly and fully.  Dr. Butter preferred
 the sulphate of potash or some of the neutral salts; Sydenham gave an
 infusion of rhubarb in beer ;  Dr. Hosack infusion of  senna with super-
 tartrate  of potash and manna.  I do not think  it matters ranch what
 medicines we  use, provided  the  bowels are fully evacuated.   On  the
 other hand, and quite as  frequently, the bowels may be too free, or
 pui-ed frequently, but in small  quantit.es indicating a considerable
 amount of irritation ; our object in these cases will be to quiet them by
 chalk mixture  with a few drops of laudanum,  or by a mixture of muci-
 l-.-e  syrup, caraway seed water, and a  small dose of laudanum.  I have
 also'found  o-reat benefit from Prussic acid in  minute  doses (\ to ? oi  a
 drop three  or  four times a day) in quieting this irritation, and  it  has
 the advantage  of soothing the bronchial irritation at the same time.
    Dr  Butter gave hemlock when  diarrhoea was present: he dissolved
 five grains of the extract of conium in four ounce's of water,  and gave 
694             INFANTILE REMITTENT FEVER.
two teaspoonfuls for a dose to child of five years old.   He  thought it
both checked the looseness and relieved the fever.
  Having by these or similar means regulated the bowels, we may next
proceed to combat the disease by giving small doses of calomel and  an-
timonial powder, as  Dr. Cheyne advises.  He  says, " antimonials in
combination with 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 nature, 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 common purgative mixture."
  When the bowels are  too irritable to bear calomel, the  hyd. c. creta
and Dover's powder, and  sometimes  ipecacuanha, may be  substituted
with great benefit.  Two grains of the former, with half a  grain of each
of the latter, may be given three times a day  to a child  of three or four
years old.
  A saline diaphoretic or  diuretic mixture may also be  advantageously
exhibited, provided the bowels are not too irritable to bear it.
  Warm baths, fomentations, or still better, poultices to the abdomen,
afford great relief;  the latter I often  directed  to be made of linseed
meal, with a small portion of flour of mustard.   Or  we may  use rubefa-
cient or slightly irritating liniments,  containing laudanum,  if there be
much pain or irritability of the bowels.
  Dr. Merriman observes: " Some practitioners seem to rely upon purga-
tives 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 em-
ployed ; nor ought  the advantages  to be overlooked  which may  be
gained by pediluvia, fomentations to  the abdomen, and ablutions with
tepid  water.  As  the  disease  advances, bitters, ammonia, bark,  the
mineral acids, &c, may be required."
   If the cough be troublesome, some soothing, expectorant mixture may
be  ordered.  Ipecacuanha, or squills in almond milk, with a little para-
goric, answers the purpose very well, or almond milk with laurel water,
or the small doses of hydrocyanic acid I have already mentioned.
   13. When the disease has  lasted for some time (but  the precise  mo-
ment must be left to the judgment of the practioner), we  may have re-
course 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 ad-
vocate for their early employment.   After giving an emetic and a pur-
gative 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. 
TYPHOID FEVER.
695
  The diet should be very moderate, or even low, at first.  Milk in every
form, arrowroot,  sago, gruel, tea, &c, may be  permitted, with plenty
of cold water if the child be thirsty.
  When, 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 re-
peated.
  During convalescence also, great care must be used, in returning to
the usual diet, not to overfeed 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 very little, having
entered fully into the subject under the different heads, but I  may  just
observe that the activity of the treatment will be modified by the period
of the disease and the condition of the child.  If the head  be affected,
and  the  child  able  to bear them, a number (in full  proportion to the
strength) of leeches should be applied, but if the child be too  weak, we
must  rely mainly upon counter-irritations and mercurials.   The  same
remark applies to pneumonia  complicating the disease, but in no case
is an immediate impression upon the disease so urgently called for as in
convulsions  or threatened meningitis.
                        CHAPTER  II.

                          TYPHOID FEVER.

   1. Without entering into the relation of typhoid fever to remittent,
whether they are essentially different  diseases, or  different degrees of
the same affection, for which this hardly appears a suitable place, I may
remark that those who  have seen  them in private practice, and  more
especially as they occur in foundling or children hospitals, will have no
difficulty in recognizing such a difference as will justify my giving a
separate description.
   Although we occasionally meet with typhoid fever in private practice,
in this country, I do not think it is very frequent, most cases  of  fever
being rather the  infantile  remittent, but  amongst  the  children of the
very poor,  badly fed, and of deteriorated constitutions, and especially
wdien congregated together, it is sufficiently frequent  both here and  on
the continent.  It is rarely mentioned by British  or  American writers
on diseases of children.
   On  the  continent I  find that in 1834 Dr. Bell's Thesis was pub-
lished, showing that the disease was not rare  in infancy, and  this was 
696
TYPHOID FEVER.
followed by  the  reasearches  of  MM.  Constant,1 Larroque,  Gendren,
Littre', Becquerel, Taupin,2 Rilliet and Barthez, Audiganne,3Bricheteau,
and Barrier, etc.
   It appears that typhoid fever is not so common among infants as re-
mittent; it rarely occurs during the first years of life, nor is it frequent
until  8 or 9, and upwards.    M.  Charcelay,  however, has  published
some cases in new-born infants.4
   2.  Symptoms.—The attack generally commences without  anything
distinctive, resembling the febrile attacks of children in general.   The
child complains  of lassitude  and weakness, indisposition to  exertion,
either mental or physical, occasionally with rigors followed  by heat;
either he is sleepless, or his sleep is restless  and disturbed; there is
generally headache or a sense of heaviness in the head, with  aching of
the loins and limbs,  thirst, loss  of appetite, and derangement of  the
digestive functions, &c.
   These symptoms may continue for a  few days  or a  week,  the fever
becoming gradually more developed, with great thirst, sore throat, some-
times vomiting,  uneasiness or pain  in the bowels, diarrhoea, loaded
tongue, &c.  The fever is generally continuous, but occasionally with
remissions.
   The headache is still troublesome, and the child complains  of giddi-
ness in  attempting to sit up or walk;  the sleep is much disturbed,  and
sometimes the patient is harassed  by visions and hallucinations;  the
countenance  loses its natural expression and  becomes heavy.  The
intelligence is diminished,  and answers  to  questions are made slowly
and apparently with difficulty,   Epistaxis frequently occurs.
   As the  fever  increases, all these symptoms  are aggravated, diar-
rhoea  occurs, the abdomen becomes tympanitic,  the pulse  is full  and
frequent,  the skin  burning and dry, very rarely moistened by per-
spiration.  In some cases the  patient is delirious, and cough and rales
announce the presence  of bronchial catarrh; the urine is  scanty  and
of a deep color.   Sometimes  during this stage, the rose-colored lenti-
cular  eruption makes its appearance, although it is generally  some-
what later.   This stage has been regarded as analogous to the period
of invasion of eruptive fevers, and it generally continues about a week.
The next period,  analogous to the stage of eruption, is marked  by an
aggravation of the nervous symptoms, and of  those referable to  the
bowels.   For the most part, the headache disappears, or is less trouble-
some, but there is greater prostration, the expression of the face is  less
intelligent; stupor and delirium alternate, the first chiefly by  day,  and
the latter by night; the  senses are impaired and  obtuse, especially the
hearing; articulation is difficult, and the muscular strength is abolished,
the patient lying  almost  constantly on his back.   There  are  subsultus
tendinura, convulsive movements, &c, and the bladder is more or  less
paralyzed.  At the same time the diarrhoea continues, the evacuations,
which are more or less  ample,  are often  involuntary and unconscious.
The tongue, mouth, and lips are dry, and loaded with  sordes ; the patient

     1 Gazette Med., 1833-4-5-6.      2 Journ. des Connais. Med., Nov. 1839.
     3 Gaz. Modicale.               4 Journal de Tours. 
TYPHOID FEVER.
697
swallows eagerly, but with some difficulty; the abdomen is hot and tym-
panitic, with rumbling and gurgling, especially in the caecal region.  The
cough, and dyspnoea are occasionally considerable, even when the stetho-
scope indicates merely catarrh of the bronchial tubes.   The pulse  con-
tinues quick,  although smaller and weaker,  and the surface  is always
hot and dry.
  From the commencement of this period we perceive the  rose-colored
eruption, and as  it advances, sudamina, and sometimes petechiae, and
blue patches  on the skin.   Bed-sores  also occur on the sacrum or other
part upon which there has been much or continuous pressure.
  The third period varies in its characteristics, according as the fever
is to terminate favorably or unfavorably.  In the latter case, the stupor
degenerates into coma, the subsultus and starting become constant, the
intellectual functions  are obliterated, the senses nearly  extinguished,
the pulse extremely rapid, but small,  feeble and thready.   The skin is
cooler,  and either dry or covered with viscid cold sweat; there is often
complete incontinence both of urine and faeces, the emaciation is extreme,
the face becomes hippocratic, the bed-sores increase, and lastly, the res-
piration is embarrassed and becomes stertorous, and the patient expires.
   On the other hand,  when the course of the disease is more favorable,
we observe a gradual mitigation  of  the  symptoms, except in  the  few
cases where a crisis occurs.  The stupor is dissipated, the face assumes
an  intelligent  expression, the eye consciousness, and the  hearing im-
proves.  Then the  patient  recovers  the power  of speech,  he speaks
slowly, but intelligently, the mental powers are exercised feebly, but
healthily.  By slow degrees, muscular strength returns, the weakness
now being that of exhaustion and  not of nervous oppression. _ The fever
subsides, the skin becomes moist and fresh,  the respiration is  natural,
and the cough disappears.  The abdominal heat  and meteorism  dis-
appear as  the fecal evacuations  become  voluntary, less abundant, less
fetid, and  more natural;  and the return of  the appetite is an evidence
that the patient  is convalescent.   But during recovery, much annoy-
ance may be caused by indigestion or diarrhoea which follow any impru-
dence  or  excess in diet,  and which are generally  remedied  by care
and restraint, although such a relapse may prove obstinate or even fatal.
   3. Modifications  and  Complications.—Although the preceding de-
scription may answer  for  the  generality of cases, we  must expect, of
course, many modifications.  I.  The attack may be  very slight,  and
then many of the symptoms I have laid down will be absent, others will
be much slighter, and the entire  course  much shorter.  Or some par-
 ticular symptoms may offer an unusual degree  of intensity or obstinacy.
   n  Vomiting is one of these exceptional symptoms; it is much more
 common in the typhoid fever of children than of adults.   Thus M. Tau-
 pin observed it in a third  of his  cases,  MM. Audiganne  and Barrier
in  about the same, and MM. Rilliet  and Barthez  in one-half of  their
 patients.  The vomiting may come on on the first, but oftener on the se-
 cond or third day, and, according to Rilliet and Barthez, are particu-
 larly common in those cases in which we have constipation instead of
 diarrhoea.   They indicate that the case is a severe one.
   in  Diarrhcea, which is perhaps the least variable of the symptoms, 
698
TYPHOID FEVER.
is nevertheless not constant.   In about one-fourth of the cases there is
constipation; neither when it is present, does it persist so steadily as in
the adult, but it is interrupted and returns several times before ceasing
or becoming permanent.  The faecal discharges are generally fetid, yel-
low, green, or brown, but rarely bloody.   On the fifth or sixth day they
escape involuntarily.
   The tympanitis, abdominal pains, gargouillement, and the tumefaction
of the spleen are ordinarily very marked, and rarely absent in children.
   IV. The bronchial catarrh  is as common in children as  in  the  adult,
at least it is rarely absent except in very slight cases. M. Taupin found
it absent in four cases only out of 121,  and M. Barrier in  three out  of
twenty-four.
   v. The nervous symptoms are as frequent as in the adult, and of the
same character,  but of slighter intensity, which is remarkable, consider-
ing the extreme susceptibility of the nervous system in children.1
   VI. Epistaxis, which occurs occasionally, is much  more rare with chil-
dren than with adults.    M. Taupin observed it six times in 121  cases.
MM. Audiganne, Barrier, Rilliet and Barthez, in about one-fifth of their
cases.
   vii. The rose-colored  eruption and sudamina are almost always pre-
sent, but the former are, however, frequently limited to the back.  Other
eruptions, erythematous, vascular, or hemorrhagic,  are rather more fre-
quent in children than in adults.
   4.  Complications do not seem as frequent in children.   I. Intestinal
hemorrhage is  extremely rare.   M. Barrier mentions but one case  in
200.
   ii. Inflammation and softening of the gastro-intestinal mucous  mem-
brane are by no means unfrequent; they occurred in four-fifths of Rilliet
and Barthez's cases.2
   More intense inflammation, followed by perforation and peritonitis,
occurs occasionally, but it is not easy to say whether perforation is more
frequent than in the adult.   M. Taupin met with two examples in  twen-
ty-one deaths, and M.  Barrier two out of three deaths.3  The complica-
tion is  marked  by violent pain, tenderness, vomitings, meteorism, &c,
and when perforation occurs  by collapse and death.
   in.  Pneumonia is by no means rare; it affects chiefly the more de-
pendent portions of the lungs, and rarely is found beyond the first stage,
and never  beyond the  second.  MM. Rilliet and  Barthez met  with
twenty-two cases of this  complication.
   I need not say that  any of these complications will add materially to
the danger, and that some of them almost or altogether  preclude  the
possibility of recovery. In  all cases of fever it is of extreme importance
that a vigilant watch should be kept for the early detection of any com-
plication.
   5.  Morbid Anatomy.—There is almost an identity between the mor-
bid  changes accompanying typhoid fever in children and adults.   In
both we find certain changes which are almost invariable, as those in the

      1 Stocber, Clin, des Mai. des Enfans, de la Faculty, de Strasburg, 1841, p.  9
      - Mai. des Enfans, vol.  ii. p.  3D2.     3 Mai. de l'Enfance, vol. ii. p. 208. 
TYPHOID FEVER.
699
intestinal follicles and the mesenteric glands, and others which are often
wanting by their affecting the spleen, the bronchial tubes, the bladder,
&C.1
  The follicles may be found, at  different  periods of the disease, in  a
state of eruption, ulceration, or cicatrization.  The changes affect equally
the glands of Brunner and of Peyer, and may be observed in different
part of the large and  small intestines, but especially near the caecum.
  During the stage of eruption the  agminated follicles assume two ap-
pearances which are frequently united in the same subject, one of which
has been termed the soft or reticulated patches, and the other the hard
or figured.   The former present  the appearance of a membranous net-
work,  composed of a great number of small scales with depressions be-
tween  them.   The muscular tissue which is involved is always softened,
and sometimes to such a degree that it will not bear the least traction.
Thus the softer or reticulated patches are characterized by extreme de-
velopment and softening.  The hard patches  are very different; they
are prominent, with their borders raised above the level of  the  mucous
membrane, and unresisting to the touch.  If  we  make a perpendicular
section  of one, we  find first, the  mucous membrane, which appears
healthy, beneath that a moderately thick layer of a whitish, or yellowish
 substance, homogeneous, firm, and shining when  cut.   Beneath this we
 find the cellular membrane, muscular and serous tissues as usual,  lhis
 submucous deposition characterizes these hard patches.  Similar changes
 are found  in the isolated follicles.   The color  of the mucous membrane
 is  variable, sometimes it  is pale, at others of  a  vivid red, or of  inter-
 mediate shades.                           .
    In  the second period, the ulceration, which is a frequent but not neces-
 sary termination of congestion of the glands of Peyer, takes place in the
 following ways, according to M. Barrier.  " 1. It commences in the mucous
 membrane which covers the follicles, and spreads in depth and breadth.
 Occasionally several ulcerations are formed simultaneously on the surface
 of one reticulated patch, and uniting, form one large ulcer. 2. lhe sub-
 mucous deposit in the hard patches may be softened, or attacked by gan-
 grene, when it is eliminated by suppuration, and thus removes all or the
 greater portion of the mucous membrane.  The remains of these figured
 patches, when  colored  by the bile, have  received the name of yellow
 eschars. The new matter deposited in the isolated follicles often resembles
 a  core, which comes away, leaving a solution of continuity   The ulcera-
 tions are generally oval in the patches, and round at the isolated follicles;
 their extent as well  as their depth varies, the bottom being formed by
 the submucous cellular tissue,  or  by the muscular  or  by the serous.
 Lastly, in more rare cases, there is perforation of all the tissues, and it
 adhesions have not been previously-formed, the contents of the  intestine
 escape  into  the peritoneum.   The borders of the ulcer are sometimes
 thin  and clear cut, or thick, rounded, and granular, sometimes adherent,
 sometimes  separated ;  the bottom  is  either smooth and  uniform, or
 granular and unequal."2

                i Rilliet and Unrtbez, Mai.,des Enfans, vol. ii. p. Sol.
                2 Mai.  de l'Enfance, vol. ii. p.  213. 
700
TYPHOID FEVER.
   MM. Taupin,1 Rilliet and  Barthez have remarked that the  period
of ulceration is later in children than adults, although there are  excep-
tions, and also that cicatrization is more prompt and rapid.
   The stage of cicatrization is said to commence from about the fifteenth
to the  twentieth  day, and is marked by the approximation of the borders
of the ulcer,  which become flatter and thiner, and b}T the filling up of
its cavity by  granulations.  When the process is concluded, the mark of
continuity in  the mucous membrane is scarcely perceptible; it is smoother,
without villi, and somewhat depressed at their points; at first  of a deep
red color, it afterwards becomes paler, and then resumes its natural  ap-
pearance.
   MM. Rilliet and Barthez  state that the blood is  most frequently
fluid, or in dark, soft coagula, and that the vessels are often stained of
a vinous red  color.
   Such are the morbid changes found in the intestines in typhoid fever,
but all may not  always  exist; in some  only  the congestive  stage, in
others only the reticulated patches are found, and it is  quite possible
that the fever may  exist without any of these changes being  discover-
able.
   Corresponding pretty accurately with the stages of the follicular  de-
velopment, we find congestion, inflammation, and purulent infiltration
of the  mesenteric glands.   It is not found, however, that they open  for
the escape  of matter into the  peritoneum, but it  is supposed  that  the
matter is absorbed.  T|iis purulent infiltration of the mesenteric glands
is  as characteristic  of typhoid fever as the follicular changes.
   Another organic lesion, which  though by no means constant,  is yet
very frequent, is the tumefaction  and  softening of the spleen; both  are
generally coincident, but in some rare cases there is softening with  di-
minution of volume.  M. Taupin has observed apoplectic coagula, and
in one case the entire spleen resembles a large clot.
   Of course  when  complications have existed,  the usual  post-mortem
evidences will be found, but they, as we have seen, are neither numerous
nor frequent.
   There can  be no  doubt that the most important pathological change
is  in the blood itself, but unfortunately our means of investigation  are
limited, and the  results as yet by no means satisfactory.
   6. Causes.—I have already mentioned that typhoid fever can hardly
be regarded as a disease of infancy, being by no  means  frequent until
about the  8th or 9th year.
   A very curious fact connected  with the disease  is its  greater preva-
lence among boys than girls. M. Taupin states that in 121 cases, 86 were
males and 35 females, and  Rilliet and Barthez that out of 111 cases, 80
were males and 31 females.2   It is very difficult to explain this, except
by supposing a greater predisposition  in the male sex.
   Typhoid fever does not appear to occur at all  as a secondary affec-
tion in the course of or subsequent to other diseases.
   Among the predisposing causes may be placed  bad food, vitiated air,

                 1 Journ. des Connais. Med. Chir., Nov. 1839.
                 2 Mai. des Enfans, .vol. ii. p. 404. 
TYPHOID FEVER.
701
and insufficient clothing, which by impairing the constitution prepares
the child for serious illness.
  But the spread of the disease is most frequently due to epidemic in-
fluence, which, whether it originate or not in peculiarities of climate, or
of seasons, or the hygienic condition of certain localities, but which cer-
tainly is propagated, and so to speak intensified by these circumstances.
A very curious fact is recorded by  M. Rilliet, who observed in 1840, in
a village near Geneva, an epidemic of typhoid fever which was confined
to the children, and which terminated favorably in all cases.   At the
same time there prevailed in a neighboring village, among adults, a most
fatal ataxo-adynamic typhoid fever.
   Opposite  opinions have been  held  as  to the  contagion of  typhoid
fever in children as well as in adults.  The experience of French physi-
cians is against it.   Of M. Taupin's  121 cases, 5 only could have ac-
quired it in this way; of MM. Rilliet and Barthez's 111 cases, 4 only
were attacked in hospital, and they were in wards in which  there was
no case of typhoid fever, and of the 17 cases observed by M.  Audiganne
not one afforded the least presumption of contagion.
   7. Diagnosis.—There are several  diseases with which  typhoid fever
has been confounded, and from which it requires great care to distin-
guish it.
   I.  Enteritis.—In  some cases  the  history, symptoms,  and course  of
 the disease  so closely resemble typhoid fever, that MM. Rilliet and
 Barthez have come to the conclusion that it is impossible to  distinguish
 them;  a  conclusion  very  different from  that of M. Louis, as regards
 these diseases in the adult.1   In cases of secondary enteritis, the previ-
 ous affection will decide the question.
   II. Meningitis.—At the commencement these diseases resemble each
 other a good deal, but in typhoid fever the predominance of abdominal
 symptoms,  and in meningitis, of head symptoms, soon becomes manifest.
 In meningitis we have convulsions frequently;  never in typhoid fever.
 The pulse5 is occasionally irregular, the intellect less obscured for some
 time, and constipation more common; in  typhoid fever there is delirium,
 mental obscurity, bronchial  catarrh, frequent  vomiting, diarrhoea with
 tympanitic belly, and tenderness, and further, the course of the two dis-
 eases is very unlike.                             _
    in.  Typhoid pneumonia has an aspect of typhoid fever, but a careful
 investigation into  the history of the case, and an examination by the
 stethoscope, will show the presence of primary pneumonia, and we shall
 at once detect the absence of the characteristic abdominal symptoms  of
 typhoid fever.
    iv  SbVhter cases  of typhoid fever may easily be confounded with
 gastro-enferitis, or with any slight febrile attack, but  though a little
 care will probably lead us to a correct conclusion, it is a comfort that a
 mistake here will be of no consequence.                           #
    8  Prognosis.—When the fever is mild, and  without complication,
 almost all  the cases recover.  Thus of 47 such cases observed by MM.
 Rilliet and Barthez, but one death occurred.  The danger  of perfora-

                ' Recherdies sur la Fiovre Tvpboide, Paris, 1844. 
702
TYPHOID FEVER.
tion of the intestines so great in the adult, is comparatively slight in
children, as this is a rare termination.
  Even in the more severe cases a considerable proportion recover, and
the chief danger appears to arise from the complications.   As M. Tau-
fiin observes, "the  patients may die from the intensity of the pulmo-
nary, abdominal or cerebral symptoms,  from the abundant suppuration
following the fall of the eschars, from intercurrent diseases in their weak
state, from tubercular affections whose course is quickened by the fever,
and from perforations of the intestine which may occur during conva-
lescence in  severe  or  even slight cases, so  that we ought to be very
reserved in our prognosis.   However, we ought never to despair, for in
no  other malady do more  recover from such  a hopeless  condition so
promptly."1
  The intensity and persistence of the ordinary symptoms, their ataxic
character, and  the  presence of  any complication, may  be  regarded as
unfavorable, whereas a moderate degree  of diarrhoea and  tympanitis,
diminished vomiting, a clean tongue,  a fairly developed pulse,  &c, will
afford us hope of a favorable termination.
  9.  Treatment.—The principal indications are thus enumerated by
M.  Fabre:  1.  To  limit the intestinal  inflammation and  remove  any
irritating  matters  from the intestines, first by antiphlogistics, then by
purgatives.   2.  To prevent if possible the bronchial complication which
so easily  runs  on  into pneumonia by antiphlogistics, revulsives, and
change of posture. 3. By similar means to control the cerebral affection.
4. The general condition of the patient will require careful  treatment,
whether by soothing remedies, stimulants, or tonics.   5.  The  constitu-
tion of the patient  and the character  of the epidemic will also furnish
special indications.
  The treatment in fact of typhoid  fever  in children does not differ
essentially from that required by adults, and therefore I need not enter
very fully into details.
  Some modification of the antiphlogistic  treatment is generally neces-
sary,  and  in proportion to the intensity  of the intestinal irritation.  It
is rarely necessary to open a vein, except  when the fever  is intense,
but there are few cases which are not benefited by a few leeches to the
abdomen or anus.2
  After leeching, purgatives  seem to  be most beneficial; neither are
they,  according to  M.  Barrier, counterindicated  by the  presence of
diarrhcea, although  they are even more  necessary when the bowels are
constipated  and tympanitic.  Some  prefer saline  purgatives,  others
mercurials, and others, again, castor oil, or  rhubarb.
  Emetics are sometimes very useful at the commencement of the attack,
when  the tongue is loaded,  and the mouth bitter, &c, and  ipecacuanha
answers better than tartar emetic, because it causes less depression.
  During the second and third  stage, counter-irritation produces very
good  effects, and it may be  effected by dry cupping, rubefacient lini-
ments to the abdomen, or by blisters which  answer  much  better.  M.

                1 Journ. des  Connais. Med. Chir., Nov. 1839.
                2 Barrier, Mai. de l'Enfance, vol. ii. p. 284. 
TYPHOID FEVER.
703
Barrier observes that " their action is  double, at  once revulsive and ex-
citant ;  the first is useful when there is any indication of local conges-
tion  or inflammation, as  of the chest or  head, and above  all, when
antiphlogistics  are insufficient  or  counterindicated.  Their  stimulant
action, on the  other  hand,  is valuable when there is much prostration.
In other circumstances they may be injurious; when there is much agi-
tation, delirium, or other symptom's  of excitement, we  find that they
rather aggravate this condition."
   Diaphoretic, diuretic, and soothing remedies are of use, and may be
continued in  moderate  doses  until  the disease begins to decline.  Se-
datives also are beneficial in the first and second  stages, especially when
there is much disturbance of  the nervous and circulating  systems.   A
combination  of gray powder1 with James' and Dover's powder will some-
times act remarkably well,  or if there  be restlessness, sleeplessness, and
delirium, we may try  a combination  of tartar  emetic  and  opium,  in
small doses,  as recommended by Dr. Graves in the typhus of adults.
   Cold affusion has been strongly recommended  by MM. Recamier and
Gendrin, but I do not think it  is  commonly used.   It  should only  be
used when there is excitement, with heat of surface, and a pretty strong
pulse, then it calms  and quiets the patient, and leads to a  more healthy
action of the skin.
   At a certain period in the fever, but varying according  to its charac-
ter and the constitution of  the patient, we shall find it necessary to give
tonics and stimulants.  When the  pulse gives way, and the vital powers
show signs of  yielding, is our time to  interfere, which may be done  by
some  bitter  infusion—bark,  cascarilla, orange-peel, with ammonia  or
ether.   These may be given  freely, according to the condition  of the
patient and  their effects.   But in most cases we  shall also find it advan-
tageous to give wine, in water,  whey,  or arrowroot, and in  such  quan-
tities as the  case may demand.
   One of the  nicest points in practice is to  discover and to seize  the
time for the exhibition of tonics and  stimulants, and one of the most
gratifying to witness is the almost magical effect of the remedies thus
 applied at the right moment.
   Some writers have latterly recommended large doses of the sulphate
 of quinine in typhoid fever, but it is as yet extremely doubtful whether
 the results are likely to be  as favorable as is expected.
   Of course, some variation and modification will be required if  any of
 the complications I have mentioned should tak^ place.  They will rarely
 require much  addition of antiphlogistic remedies, because the patient is
 rarely in a condition to bear this.   Counterirritation by blisters to the
 head or chest, pushing the  mercury a little further, as  in cases of pneu-
 monia, the exhibition of small doses of tartar emetic, if the patient can
 bear it, are  pretty nearly all the means at our command.
   Great attention should be paid to the hygienic  condition of the patient.
 He should lie in a well-ventilated  but warm  room, lightly and comfort-
 ably clothed,  with the observance  of  scrupulous cleanliness.  His food
 and drinks must be of the  mildest, lightest character.  Water, milk,  pa-
1 [Hydrargyrum cum creta,.] 
704
TYPHOID FEVER.
nada, arrowroot, &c, will be sufficient until an advanced  stage  of the
disease, or the character of the symptoms demands a change.
  During convalescence, also, great care and watchfulness must be ob-
served.   The patient is very liable to relapses and to various complica-
tions  which  are,  of  course, much more  dangerous in the  weakened
condition of the  patient.   As soon  as he  has  sufficient  strength,  he
should be removed to the country, and allowed to be much in the open
air, but guarded from cold. 
SECTION  VIII.
INFANTILE  SYPHILIS.
   1.  Very few  of  the diseases  to  which infants are liable, possess
greater interest, and in  some points  none are of greater consequence
than the syphilitic affections of infancy.  "Whether we inquire into the
circumstances under which the diseased  parent  or parents can infect
their  offspring, or the form in which  the disease  affects  the  infant, or
the appearance and  nature of those  diseases which are  communicated
by the infant to the  nurse, or of those communicated to its other at-
tendants, and the further  propagation  of the  disease by the  nurse to
her husband, and perhaps  to a large family of children—I say, in in-
vestigating any one  of these points, we  must be struck with the fact
that we find, in each, a striking deviation from those laws which regulate
the venereal disease, as communicated by the adult to  the adult."1
   But, moreover, in this question is  frequently involved  the  peace of
families, and  upon  the  correctness of our diagnosis  may depend  the
happiness of married life.   If we hastily pronounce a  child to be syphi-
litic, we may sow distrust and suspicion between  the parents, the fruit
of which may be life-long  misery, and on the other hand, a declaration
that the affection is  not syphilitic may lead to the direct communication
of the disease to the mother or nurse, and indirectly to the rest  of  the
family.   Not merely, therefore, as a  scientific matter, but really as a
question of social  morality, the subject is deserving of the most careful
and thorough  investigation.  All  our  caution  and all our observation
will be little enough to enable us to estimate justly the history, symp-
toms, course, &c, of these cases with anything like a certainty of  ar-
riving at a correct conclusion.
   2.  Symptoms.—There has been a difference  of opinion  as to whether
the foetus in utero could be the subject of syphilis, even though some
authors admit that the disease in the mother may cause abortion or
premature  labor,  and they either  deny that  the  appearances  observed
upon the infant at birth were syphilitic, or they attribute them  to  the
child having come in  contact with a venereal ulcer of the  vagina. M. Colles
considers this latter supposition  to  have been  effectually refuted  by
cases  in which no  such ulcers existed at the time  of parturition, and by
the fact of the symptoms in the infant being present at the moment of
birth.
  The evidence of facts, however, appears to me  too strong to admit of

              1 Colles, Pract.  Obs. on the Venereal Disease, p. 262.
       45 
706
INFANTILE  SYPHILIS.
our holding this opinion; not only have we well marked cases on record,
but even in the more obscure cases, traces may often be detected, and
the success of treatment will  often clear up the difficulty altogether.
   3. I.  I shall first notice the disease occurring in utero and showing
itself in infants at birth.
   I have already mentioned  that syphilis in the mother is admitted  as
a cause  of  abortion or premature labor, but we are, I believe, indebted
to the late Dr.  Bently, of Dublin, for a knowledge of the fact that  in
many cases, when no venereal taint was suspected  in either parent, but
when the  mother has repeatedly borne  dead  and putrid children, the
true cause was  a syphilitic taint, and the cure, the  administration of
mercury.
   M. Colles has described these cases with his usual fidelity.  " The father
of the child has had primary symptoms, six or eight months before his
marriage; for these he had been  treated by mercury ; has undergone a
full course of this medicine, under which  his symptoms have been  re-
moved,  and his surgeon  has  declared himself satisfied with the treat-
ment, and  dismissed him as  perfectly cured.   In six or eight  months
after this treatment he marries.  In the ordinary time his wife becomes
pregnant, and carries the child until the seventh or eighth month, when
abortion takes place, and this without being preceded by any of those
circumstances which ordinarily contribute to its occurrence.   The same
fatality  attends on the second,  and  third, and perhaps on the fourth
pregnancy, in spite of every attention  paid  to the  directions of her
accoucheur.  At length  the  suspicion arises  in the mind  of the  ac-
coucheur : he examines the product of the next abortion, and finds that
the cuticle is loose, and that it readily peels off in patches of greater  or
less extent: thus is explained what the midwife  had termed a putrid state
of the child ; he may find  too that  the  nails are  not  formed, and in
general  that  the child appears as if it had been badly nourished.   It
should be here  remarked  that sometimes the child is born alive, in such
a weakly but emaciated state that it  does not  survive more than a few
hours, and such often bear unequivocal marks  of the venereal disease.
Until these repeated abortions have  attracted the attention of the  ac-
coucheur, there has not  been any one circumstance which could have
raised his suspicion as to  the  true cause of them ; for both parents con-
tinue, all this time, to live in  the enjoyment of perfect health—no trace
of disease is  to be discovered in either. When the husband is questioned,
he candidly avows that he had, before marriage, been affected with pri-
mary symptoms; that he had been (as he thought) cured of them, and
that having allowed six or eight  months to elapse  before his marriage
without perceiving any sign of a  return of the disease, he had concluded
that it had been perfectly eradicated from his system.  On  further in-
quiry it is ascertained that his wife had never  complained of any sensa-
tions which might lead even to a suspicion of  her having had primary
symptoms, nor has any appearance taken place  in her which can even
bear a resemblance to secondary symptoms.   In a word, both parents
are pronounced (after the most  minute investigation) to be in the en-
joyment of perfect health.   In  some cases we  may discover equivocal
appearances  of disease in the father, yet so faintly resembling syphili- 
INFANTILE  SYPHILIS.
707
tic symptoms that we could not think of considering them as venereal,
unless our suspicions came to be strengthened by some collateral  cir-
cumstances.1 Such cases are related also by Mr. Hey, M. Cazenave,  and
Mr. Whitehead.
  Cases of  this kind attracted the attention of Dr. Beatty, and he  was
led  to infer  that they were caused by venereal influence, and were pro-
bably to be  remedied by mercury, and a trial confirmed  his conclusions.
"Several similar cases," he observes, after relating  his  first case, "oc-
curred to me from  that time with similar success, which  I shall  pass
over,  as they rest only  on  my own experience, and shall therefore con-
fine myself  to a very few in which I was assisted by M.  Colles and  Mr.
Todd, in their capacity of surgeons.  In my own book,  to which I have
referred, I find  that in August, 1812,  I attended the wife of  a  stay-
maker, who  was delivered of a putrid child in the seventh or eighth month,
which she said was the  third that she had  borne dead.   I  discovered so
much of venereal affection as to recommend that they should put them-
selves under the care of some experienced surgeon for the  use of mercury.
They applied to M.  Colles, and when she was pregnant  in the following
year,  M. Colles  told me that they had not  continued a sufficient time
under his direction to satisfy him that  they were  cured  of  the venereal
complaint, which I found to be the case in July, 1813, when I again de-
livered her of a putrid child in the eighth month.   I then  declared that
I never would attend her again until M. Colles told me  he was satisfied
with the result of the mercury used.   They again returned to him,  and
fully  attending to his  directions, in Oct.,  1814, I again attended her,
when  she bore a living  girl at the full period of gestation.  'She  has  had
several living children since."3
  Drs. Campbell,3 Strange,4 and Egan,5 Drs. Coley,6 Snow, Lloyd, Wade,
&c, confirm the view taken by Dr. Beatty and M. Colles both as to the
character, cause, and cure of this class  of premature putrid births.  M.
Danyan took a similar  view, in a recent discussion at  the  Academie de
Medecine, and mentioned that he had  succeeded in putting a  stop to
abortion by  means of mercury.7   M. Dubois stated  that of the infants
born dead in hospital some offered evidences of syphilis; others who did
not, were born of syphilitic patients, and that this was sufficient to justify
mercurial treatment.8  Dr.  West speaks  of abortion being frequent,
owing to a syphilitic taint, but states that  he has never  seen an infant
at birth with evident marks  of  syphilis.9  Dr. Condie believes that the
infant may  be affected in utero.10
  On  the other  hand,  M. Acton, following the French authorities in
most points, although he admits that syphilis in the mother may  cause
abortion, does not think it frequent. 1, because  of its rarity in the vene-
real hospitals in Paris, and 2, because women so affected often go to the

   ' Pract. Obs. on the Venereal Disease, p. 266.            ^
   2 Trans, of the College of Phys. in Ireland, vol.  iv. p. 32
   » Northern Journal of Medicine, May, 1844.            4 Ibid., Sept., 1844.
   5 Med. Press, March 23, 18-51.  Dublin Journal, vol. i. p. 335.
   6 Diseases of Children, p. 458.       7 Archives G^n. de  Medecine,  Aug., 1851.
   s Gaz. Med. de Paris, 3d series, vol. v. p. 392.
   9 Diseases of Infancy and Childhood, p. 448.
   10 Diseases of Children, p. 564. 
708
INFANTILE  SYPHILIS.
full term, and bring forth  healthy children.  The first of these state-
ments is  not quite in accordance with general experience, and granting
the latter to be true, it proves nothing as to the occurrence in question.
  After examining  carefully what  has been the experience of others,
and comparing it with my own, I can have  no hesitation in concluding
that syphilitic disease—even when not well  marked—in either  parent,
may cause abortion or  premature  labor, and that in  the  majority of
such cases the infant is born dead and putrid, with the  cuticle torn and
easily peeled off.   But are we then to conclude that this appearance in
an infant is of itself a proof of venereal taint ? This is a very import-
ant question.  We know that when a child is retained in utero for some
time after death,  a  process of decomposition takes place, and the result
is a change of color and a moist  loosening of the cuticle.  Now if we
compare  the two children born under these circumstances, one of whom
we  know to be born of syphilitic  parents, and the other of parents un-
questionably free from all taint, we shall, I believe, find it quite impos-
sible to distinguish  them,  and to decide which is syphilitic and which
free from the disease.  If this be true, we must conclude that no infer-
ence can be drawn from the appearance of the child alone,  but that we
must also investigate the condition  of the  parents, remembering that
very slight evidence of previous disease is sufficient to  guide us in the
treatment of these cases as syphilitic.
  4. It is possible, however, that the infant may be born  alive, but so
weak that it dies  in a few hours or days.  In such cases the evidence of
syphilitic disease is often very plain : the skin  is loose, bagged, and
shrivelled, the face has an old withered expression, and there is a cop-
per-colored  eruption about the anus  and genitals, and in  some  cases
over the  whole body.   An experienced friend of  mine  assures me that
he has seen slight ulceration at the corners of the mouth and margin of
the anus in such cases.  It  is right to state that M. Bertin, during  ten
years at  the Hopital des Vdndriens, had but few cases born with marks
of syphilis.
   5. Dr. Condie mentions that he has known  the infants  of diseased
parents,  when born, to present irregular ulcerations or large vesications
on  different  parts of the  surface, filled with a yellow, turbid, or dark
colored fluid, and which, upon rupturing, left  ulcerations of the skin
that became  quickly covered with thin dark colored  crusts, and sur-
rounded  with a dark red or purplish margin.1
   M. Gilbert mentions that he has  seen vesicles, or papulae, or tuber-
cles upon the buttocks and genitals, but never the large blisters of pem
phigus which M. Depaul  has described.  M. Dubois regards the pem-
phigus, which is characterized by large blisters filled with a deep yellow
pus, developed upon the palms of the hands and soles of the feet, and
with the skin underneath of a bluish or violet color, as being undoubtedly
syphilitic.
 * M.  Ricord has  frequently noticed syphilitic  pemphigus as  well as
smaller  vesications.
   John  Hunter mentions  having seen a child which exhibited venereal
pustules at birth.
1 Diseases of Children, p. 566. 
INFANTILE  SYPHILIS.
709
  6. Dr. Depaul, of Paris, has recently read a paper on certain changes
in the lungs of syphilitic children, which  had been noticed by Baron,
Billard, Ilusson, &c, but which he believes to be peculiar to these cases.
"In fifteen cases the lungs were more or less studded with small nodules
composed of dense gray tissue, having a central cavity filled with sero-
purulent fluid.  In most cases the infants had also pemphigus, purulent
deposits  in the thymus gland, or enlargement of the liver, and  death
occurred shortly after birth; one or both of the parents were known to
have had syphilis."1   In the discussion which took place  at  the Aca-
de'mie de Me'decine, M. Cazeaux, the reporter, regarded the abscesses in
the lungs as nodules of pneumonia, the pemphigus and  abscess of the
thymus as not necessarily syphilitic.   MM. Gebert and Roux agreed
with him.  MM. Moreau and Danyan approved of treating these cases
as syphilitic.  MM. Dubois and Ricord considered that the state of the
lungs might result from syphilis, but that abscess of the thymus gland
and the  pemphigus were very characteristic of the disease.  From the
equal balance  of authorities, it is clear that more observation is neces-
sary to establish the accuracy of M. Depaul's conclusions.
  n.  Syphilis appearing after Birth.—In the greater number  of cases
the symptoms of the disease do not make  their appearance until a week
or more after birth;  nay, it is said that this period may be extended to
two, three, or  six months.
  M. Rizzi states that of fifty-five infants the disease manifested itself
one month after birth  in thirty-three,  at the expiration of two months
in  eleven, of  three months in four, of four  months in four, and in one
only at the expiration of eight months.2
  The child is born apparently healthy  and well nourished, but after
a time a number of copper-colored spots appear  about the anus or geni-
tals, and on the inside of the thighs, sometimes spreading over the loins
and degenerating into ulcers.
  The infant is  also attacked by snuffles; there is an acrid discharge
from the nostrils, which irritates the parts,  and, drying, forms a crust
which obstructs the nostrils and interferes with respiration.
  The voice is changed in character, it loses its clear tones and  becomes
rough, whispering, and raucous.   Superficial ulcers appear at the angles
of  the mouth, sometimes of the mucous membrane, sometimes of the
skin,  which cracks and bleeds.   Occasionally the tongue, palate,  and
throat are covered with superficial ulcers.
  Sometimes  there is slight  mucopurulent discharge from the eyes,
with redness of the tunica conjunctiva.
  If the disease be not arrested, we may  have ulcers or fissures in dif-
ferent folds of the skin, for instance in the  folds between the chin  and
throat, in the folds of the thighs, &c. The glands may become^enlarged,
those of the neck and occiput when there  is  much eruption on the head,
and others in  different parts,  but  as M.  Colles remarks, they  are
very different  from  buboes in the adult;  there is little active inflamma-
tion although some of them occasionally suppurate and ulcerate slowly.3

    ' Med. Times, July 19, 1851.           2 Gaz. Med. de Paris, Oct. 24, 1846.
    * Berton, Mai. Ven., p. 74. 
710
INFANTILE  SYPHILIS.
    The child rapidly emaciates, the skin becomes loose and flabby, the
 countenance has a worn, wrinkled and  old expression, the strength is
 exhausted, and after an uncertain interval it perishes in a state of ma-
 rasmus.
    The duration varies a good deal: in some cases death takes place  in
 a short time, but in others, the majority run on for weeks  and months,
 until the child is utterly worn out.
»   7. Such is the general course and symptoms of the disease, but from
 these there are many deviations.  Often only a portion of these symptoms
 are present, or the order in which they appear  may vary.   Sometimes
 the snuffles and hoarseness appear first, followed by the eruption about
 the anus and nates, but more generally the reverse.   "Now  and then
 no other indication of  syphilis appears (than the snuffling), but  never-
 theless the coryza does not yield until after the  child  has been brought
 under the influence of mercurial remedies, a fact which would seem  to
 show that, although unaccompanied with other signs of venereal taint,
 the snuffles of y'oung infants are produced by that cause."1
    8. At an advanced stage, pustules may form "about the  mouth, espe-
 cially upon the lower lip and  chin, which  destroy the cutis, and leave
 the surface after they have healed much  scarred by  their  cicatrices."2
 Or, according to Mr. Acton,  " the corner of the child's lips may become
 covered with condylomata, and have a great tendency to crack, forming
 syphilitic psoriasis  labialis, or  the papules  are noticed covered with
 successive scales, which falling off present a raw excoriated  surface,  and
 are very difficult of cure, as the cicatrices tear whenever the child sucks.
 The tongue is sprinkled over with white spots as large as split  peas, and
 have the appearance as if its surface had been touched and whitened
 with caustic; this appearance extends to the throat, and probably to the
 intestines, producing diarrhcea or mucous  and  sanguinolent discharges.
 The German writers have  examined these secretions from the lips  and
 mouth,  and state that they  contain  cryptogamic plants;  hence their
 belief in  the contagiousness of these complaints."3  M. Berton mentions
 the existence of phlyctenae, which burst, and are followed by ulceration
 of the cutis, which  he  calls  chancre  or  chancrous ulcer.4   They may
 occur on the skin, or in the mouth, or about the anus.
    9. The red eruption about  the anus and buttocks may not  be limited to
 a mere redness, but may assume the form of large moist papules, forming
 condylomata.   "These mucous tubercles are very characteristic, in  size
 equal to  a split pea, sometimes distinct, in other instances confluent,
 elevated  above the surrounding skin, which is of the color of boiled ham,
 in parts dry on their surface,  and becoming scaly, in other places moist,
 an<^ secreting a fetid discharge, which excoriates the  surrounding  sur-
 face, producing erythema,  eczema and psoriasis of the hands and feet,
 which presently crack and cause great pain to the child, &c."5
   10. Mr. Hay and Dr. West also mention this peculiar exfoliation of
 the epidermis of the extremities.  "The epidermis," the latter observes,

   1 Dis. of Infancy and Childhood, p. 448.  2 Ibid., p. 449.  Berton, Mai. Ven., p. 46.
   3 Diseases of the Urinary and Generative Organs, p. 612.
   4 Mai. Ven. chez les Nouv.-nes, p. 56.  5 Diseases of the Organs of Generation, p. 612. 
INFANTILE  SYPHILIS.
711
"in some bad cases peels off the hands and feet;  it generally becomes
thickened to  a kind of crust, like that which forms on the hands in pso-
riasis, and  then cracking falls off in patches, leaving the  skin fissured,
and sometimes deeply ulcerated at the bend of the wrist,  or at the flex-
ures of the fingers and toes.   The  new and  delicate  epidermis in  its
turn undergoes a similar thickening, and becomes detached in the same
manner, or else it continues white and thin, but shrivelled, and  looking
like the sodden and wrinkled skin of a washerwoman's hand, and  peeling
off in  little  fragments, leaves the  cutis,  especially  at  the tips of the
fingers and toes, red and bleeding slightly even on the gentlest touch."1
   11.  It is very seldom that severe ulceration takes place,  as in the
adult, by which the bones of the nose or palate are destroyed; so rare is
it that M. Colles states that he never met with a case.  Dr. West mentions
that he has seen one instance of destruction of the bony palate, and Mr.
Acton that he has seen the ossa nasi fall in from ulceration.
   12.  M.  Berton, in  his very valuable work, states that he has observed
bony tumors and periostosis in infants attacked with syphilis, but they
are extremely rare.2
   Causes.—That the disease is always communicated  to  the  infant is,
of course, undoubted, but the mode may vary.  It may be derived either
from the parents, or from the wet-nurse, or, perhaps, from a dry-nurse.
A few remarks upon each mode will not be out of place.
   I. Hereditary Syphilis.—a.  As we have already seen, an infant may
be born syphilitic, whose father had the disease some considerable time
before marriage, but  who at the time  of marriage and since has been
either apparently free from the disease, or in whom the symptoms have
been too slight, or too doubtful to give rise to suspicion.3
   b.  If the father contract syphilis  and communicate it to his wife, and
she conceive, the child will also be contaminated.
   c.  The mother and father  may both be healthy at the time of  im-
pregnation and for some time after, and yet if either  contract  syphilis
the child may be affected.  Mr. Porter relates a case in which the father
became  diseased about the  third month of  his wife's pregnancy, and
shortly before her confinement  several spots  resembling  button scurvy
appeared,  but nothing more.  The  child  died syphilitic in a week after
its birth.  Mr. Porter remarks: "Now this infant had been begotten in
April, three months before the father's first contraction of the  ailment,
and must,  therefore, have been poisoned by the circulation of the mother
at a considerable period subsequently.  The  question  is, how did  that
circulation become contaminated, seeing that the father had never a sore
capable of furnishing a drop of matter, and the mother never  a symp-
tom of any description, until the doubtful one of button scurvy, which
only appeared a few days before her confinement."4   Mr. Whitehead m
his recent work relates analogous cases.5   He adds that such cases  have
led him to the conclusion that  "the semen of a diseased man, deposited
in the  vagina  of a  healthy woman, by being absorbed, may contami-

   i Dis. of Infancy and Childhood, p. 450.     2 Mai. Yen. chez les Nouveaux-nes,  p. 89.
   3 Whitehead on Hereditary Diseases, p. 213.
   « Dublin Med. Press, Feb. 17, 1817, p. 110.
   s On Hereditary Diseases, p. 215. 
712
INFANTILE  SYPHILIS.
nate that woman without the necessary occurrence of a chancre, or any
open sore secreting matter in either the man or the woman."
  d. But it appears that we may go a step further and conclude that a
diseased father  may transmit  the disease  to  the infant without  the
mother  being affected at all.  Some have doubted the possibility of this,
and some  have admitted it with hesitation.  M. Bertin and Mr. White-
head, and M. Vidal  de  Cassis  distinctly maintain this  doctrine, and
quote cases.1  More recently, Mr. Parker,  of Birmingham, has  given
one and Mr. Acton three such cases, in which this appears to have been
the case, and the latter observes: "We may then, I think, lay it down as a
rule, that  a father  laboring under secondary symptoms will contaminate
the ova which he impregnates, although  his  wife  remain perfectly
healthy; and it is an error to suppose that a husband  laboring under se-
condary symptoms will first infect  his  wife, and through  her the em-
bryo."2
  Dr. West's experience confirms  this : he states that "cases are now
and then met with in which the venereal taint appears to  have been  de-
rived entirely from the father, the mother, as far as can be ascertained,
not having suffered at any time either from primary or secondary symp-
toms, although she has given birth to  an infant affected with  all the
characteristic marks of syphilitic disease."3
  e.  M. Vidal de Cassis goes further still, and states that  he saw a case
in which a husband contracted syphilis, and  infected the infant, but not
the mother.  The  husband died and the mother married again, and con-
ceived,  but although both parents  were apparently healthy,  the infant
was born syphilitic.4
  II.  Derived from the Wet-nurse.—I do not myself feel the least doubt
that an  infant may contract the disease from  a wet-nurse affected with
secondary symptoms, and this opinion, which was  held by  De Hery,
Boerhaave, Levret, Hey, and others very eminent, is, I believe, in accord-
ance with that of the profession in  this  country at least.
  Mr. Colles remarks: " There is still another manner in which the infant
may receive the infection, viz: by sucking a  nurse affected with second-
ary symptoms of syphilis, but I am in doubt whether the diseased nurse
could infect the child unless she had ulceration of the nipples, and I
cannot  at this moment recollect an instance."5
  This  coincides with the remark of Swediaur, that "  in all cases of the
kind that had come to his knowledge, either the nipples of the nurse were
infected by syphilitic ulcers in the mouth of the child, or reciprocally, the
nipples  of the nurse being attacked with ulcers, occasioned ulcers of the
same kind in the mouth, nose, and lips of the child, and thus communi-
cated to it a general infection."6
  M. Cazenave, whose eminence as a  syphilographer is admitted, has
met with a number of cases  of this kind, and fully believes in this  mode
of transmission.
  Dr. West admits the fact, but states that it is an unusual occurrence.7

  1 Mai.  Ve"n., p. 168.               2  Diseases of the Organs  o.f Generation, p. 624.
  3 Dis. of Infancy and Childhood, p. 447.
  4 Traite des Mai. Ve"neriens, p. 509.   6  On the Venereal Disease, p. 271.
  6 On Syphilis, vol ii. p. 14.         7  Diseases of Infancy and Childhood, p. 447. 
INFANTILE  SYPHILIS.
713
  Dr. Egan, whose experience in the Lock Hospital has been very con-
siderable, entertains no doubt of this  mode of infection, and coincides
with M.  Colles that ulceration of the nipple is essential.1
  M. Whitehead maintains  this doctrine very strongly, adducing  six
cases, and does not think it necessary that there should be any abrasion
of the nipple.2   He  has also brought forward  evidence  from many
authorities which it would be difficult to gainsay.   MM. Cazenave and
Vidal de Cassis also hold this opinion, the latter believing that the milk
is the vehicle by which the poison is conveyed to the child,  and he cites
a case of a healthy nurse suckling a healthy child, but who gave suck to
a syphilitic child, was infected by it, and communicated the disease  to
the first  child.   I saw  a  case  exactly similar  myself, in which the
casual suckling of a diseased child as an act of  kindness, infected both
the nurse and her proper nursling.
  On the other hand, Mr. Acton does not believe that a diseased  nurse
can communicate the disease to the infant, and  he quotes the authority
of M. Ricord to the same effect.3  At the same time it must be observed
that the  only argument he used is a negative one, viz: that nurses la-
boring under syphilis have suckled children without communicating the
disease.  No one doubts this,  but it does not prove that a child cannot so
derive the disease.   It may be that none of these nurses had ulcerated
nipples, and at any rate  they may be merely exceptions.
  Very  recently M. Cullerier, Jun., has maintained the same opinion,
and chiefly supported by the same negative proofs.4
  Some  writers, and among the more recent Mr. Lane and  Mr. Parker,
consider that the milk of a diseased nurse is capable of  conveying  in-
fection, but this appears to be a doubtful point, although MM. Ricord
and Vidal seem to admit it; thus coinciding with the opinion of Colom-
bier, Doublet, and Faguer, and contrary to the opinion of John Hunter.
  M. Bertin gives a case of a child of three years old, who was infected
by its mother, to show that contact with the lips of an infected person
may communicate the disease.5
  ill. From the Dry-nurse.—It would seem further to be possible that
the child may derive the disease from  a dry-nurse or an attendant.  M.
Colles relates a case in which the child was contaminated by the  cook,
and in turn communicated the disease to its dry-nurse, and he remarks :
" Here, then, are two examples to establish the  opinion that secondary
symptoms are capable of propagating the venereal  disease, for in this
case no suspicion whatever arose in the minds of any of the medical at-
tendants that the disease of the child had been derived from the parents;
indeed the advanced age of the child at the time  that it first exhibited
any signs of the disease,  was quite sufficient to  remove all doubt  or
suspicion on that head.6
  Consequences.—Although it is scarcely within the strict limits of this
work, yet the history of this disease would be so incomplete without some
notice of the reciprocal influence of a syphilitic infant upon the nurse,

    » Dublin Journal, N. S., vol. i. p. 334.       2 On Hereditary Diseases, p.  222.
   3 Diseases of the Organs of Generation, p. 628.
    4 (iaz. Med. de Paris, 3e serie, vol. v. p. 892.
   s Mai. Yoner. chez les Nouveaux-nes, p. 27.   6 On the Venereal Disease, p.  275.
< 
714
INFANTILE SYPHILIS.
parents, &c, that I am induced to mention briefly the principal conse-
quences.
  I. M. Ricord believes that a woman quite free from disease herself, but
carrying a diseased ovum, may become diseased  through the  medium of
the foetus, and not by the father.  Mr. Acton has seen but one such case.1
  n.  M.  Colles notices a curious fact which has been confirmed by Dr.
Egan and others, viz: that " he had never seen  or heard of a single in-
stance in  which a syphilitic infant (although its  mouth  be  ulcerated),
suckled by its own mother had produced ulceration of her breasts, where-
as very few instances have occurred  where a  syphilitic infant had  not
infected a strange hired wet-nurse, and who had  previously been in good
health."
  in.  That the child may communicate the infection to the  nurse, is, I
think,  generally admitted by the most experienced practitioners, though
there may be some difference as to the conditions.  I lately saw a case
in which the child derived the disease from one wet-nurse and communi-
cated it to another, who infected her husband.
  Whether it is essential that there should  be  a breach of surface in
the nipple, it is difficult to pronounce absolutely.  Swediaur considers it
essential that there should be ulcers of the mouth.
  Dr.  Egan states that a nurse  may suckle a diseased* infant with per-
fect safety so long as no  abrasion  of the  cuticle, or ulceration in or
about the nipple occurs, but that then she is no  longer safe,  and to this
rule he has not met with a single exception.2
  In France Doublet  and Bertin have given it as their opinion that a
child may infect its wet-nurse,  and more  recently M. Bouchut has pub-
lished  cases to prove  it.   He states  that  no one doubts that a child ac-
quiring syphilis from another person can  communicate it  to  its wet-
nurse, but the doubt has been whether congenital hereditary syphilis is
thus transmissible.3
   Cases of this kind have  also been  recorded by Lallemand, Drs. King,
Macnicke and Price.4
   M. Rizzi, of Milan, not  only entertains  this opinion, but has furnished
statistics of the comparative frequency of the symptoms presented by the
nurse who has contracted specific ulceration of the breast from suckling
an  infected infant.
   On the other hand, some high authorities are  doubtful.  Mr. Pearson
states  that he has not been able  to  arrive at absolute conclusions, but
he  does not appear to me to deny the possibility, and some instances he
mentions seem to  support  the affirmative.5
   Trousseau hesitatingly  remarks :  " Do not observations exist which
lead to the belief that these local lesions  (fissures of the lips) are trans-
mitted to .the nurse by direct inoculation,  and produce in her alterations
of  the same kind, sometimes so severe as to destroy the point of the
nipple."6

    1 Acton on Disease of Organs of Generation, p. 619.
    2 Dublin Journal, N. S., vol. i. p. 346.
    3 Gaz. Med. de Paris, 3e serie, vol. v. p. 296.
    4 Med. Times, vol. xii. p. 81, 176, 422.               s jjg. Lectures, p. 83.
    6 Archives Gen. de M6d., vol. xv. p. 165. 
INFANTILE SYPHILIS.
715
  MM. Ricord and Cullerier,1 and after him Mr. Acton, entirely deny
that venereal  can be thus communicated, and he explains  or reasons
away all the instances adduced as either not being specific, or if so, that
the nurse  has contracted  syphilis  in  the ordinary way, but conceals
or denies it.   That a sore mouth (aphthae) in the child, may occasion a
sore nipple we know,  and that this  may possibly be  mistaken,  but
this really  proves  nothing  against more carefully observed cases,  and
the latter statement is an assumption which puts a stop to all argument,
and may be applied to disprove  almost anything.
  But we do not know that aphthse will occasion a train of constitutional
affections, as rashes on the skin, ulcers in the throat, ostitis and periostitis,
which  the local infection from the mouth of a syphilitic child  causes.
  For myself, I cannot doubt, from the experience of others and my
own, that a diseased child may infect the wet-nurse.   I am not prepared
to say positively whether abrasion of  the surface is essential, although
I think it probable.
   The peculiar train of symptoms to which this infection gives rise have
been graphically described by Mr. Colles.   "In some  days, or at  least
in a very few weeks, after the nurse has observed the venereal symptoms
appear on  the child, her sufferings commence.  She is at first affected
with what  she terms a sore nipple.  On inquiry it will be  found that
one or two pimples  or pustules  have appeared near the nipple; these
soon degenerate into an ulcer, which  presents the  characters of a-se-
condary, rather than a primary venereal ulcer; this  becomes exquisitely
sensitive.  A slight enlargement and tenderness of some of the axillary
glands quickly follow, but these glands do not betray  any strong tendency
to run into suppuration; on the contrary, I must say that I  have not
seen one single instance in which this occurred.  In two or three weeks
more the nurse complains of sore throat, or of an eruption, and not un-
frequently these two symptoms appear almost simultaneously.  An eye
accustomed to view the  secondary symptoms  of syphilis  does not dis-
cover  any difference between these and the venereal sore  throat  and
eruption which follow a primary ulcer in  the  adult.   The pudenda of
the infected  nurse are very generally  beset  with  small raised ulcers
which discharge copiously—these are to be seen, perhaps, in every  case
where a general eruption of the skin exists, but not unfrequently they
may  be found accompanying  the  superficial  white ulceration of the
throat, where no  general  eruption exists, and when the skin remains
free from a general venereal eruption.  I have occasionally seen venereal
iritis also  attack  the nurse.  What  other symptoms  might arise, or
what course the disease might follow if longer unattended to, I cannot
pretend to say, because I have scarcely ever seen any  case in  which the
course of symptoms might not have been disturbed  and deranged by the
exhibition  of mercury.  But  many of those affected nurses  to whom
mercury was  administered became affected with very obstinate ulcera-
tions of the throat, and with pains of the bones and joints."2
   In M. Rizzi's able report of the Milan Hospital it is stated that of 100
women with chancres in the breast, from impure  lactation,  or in the

  '  Gazette Med. de Paris, 3e sene, vol. v. p. 892.   z On the Venereal Disease, p. 253 
716
INFANTILE  SYPHILIS.
mouth and throat, derived from contact with an infected infant; 34 had
tubercles of the vulva, 19 syphilitic angina, 2 iritis, 14 tubercles of the
vulva and angina simultaneously, 5 tubercles  of  the  vulva, and others
disseminated over other parts of the body, 6 tubercles of the vulva,
angina,  tubercles  of the skin and iritis, and 19 no secondary symptoms.1
  iv. But the evil may not stop here ; the nurse thus infected may com-
municate the disease to her husband; for according to W. Colles, and no
higher authority do I know, he "may become affected with ulcerations
on the genitals, and these in a short time are attended by superficial
ulcerations  of the throat and  mouth.  If we  have an opportunity of
examining the nurse at the time her husband first complained  of ulcer-
ation of the genitals, we shall find a greater or smaller number of small,
raspberry like, moist, raised excrescences, or as some term them, ulcers,
on the genitals, and inside of  the top of the thighs of the nurse, and
this while there is no eruption on the  general surface of the skin," &c.
  This  opinion is confirmed by the great experience of M. Rizzi in the
manner already referred to.
  v.  In this melancholy history there is yet a further step;  not  only
may the infant infect the nurse, and through her her husband,  but it is
possible that the contamination may be extended to any, or all the
members of her family, and in the following manner:   "If we suppose,
as frequently happens, that the child is suckled in the house of the wet-
nurse, and that she has a numerous family of children, to one of her
daughters (more particularly) is assigned the care of dressing and carry-
ing about this infant—this is the child that  first  suffers from  the  con-
tamination.   The whole  family being  completely ignorant  of the nature
of this disease, the girl sleeps as usual with the rest of  her brothers and
sisters—for among the lower order of Irish, that family is considered to
be in comfortable circumstances, which can afford a separate bed for the
parents, while all their numerous  progeny are huddled together in an-
other bed—the discharge from the ulcers  about the  anus and vagina
coming  in  contact with one of her brothers or sisters will produce a
similar ulcer on those persons, and in  this manner, obviously, a number
of the family contract the disease."2  Mr. Colles adduces  cases in  sup-
port of  this view.
  Diagnosis.—In many  cases  the diagnosis is environed with greater
difficulties than the treatment, for although an experienced eye will in
general  arrive at a correct conclusion, there are cases in which  it is
almost impossible to pronounce positively.  No caution can be too great
where such serious consequences are involved.
  I.  Congenital Syphilis.—a.  In such cases as Dr.  Beatty  has  de-
scribed, and in which the foetus is born dead and putrid, I have already
stated my belief that the appearance of the child, the  altered color, the
loose cuticle, &c, are not sufficient alone to enable us to pronounce the
case to be venereal; but if we can make out any trace of syphilis, in
either parent, or even the occurrence of the disease  in the  father before
marriage, I think that then the repeated births of dead and putrid chil-
dren may fairly be supposed to arise from this cause.

   1 On  the Venereal Disease, p. 290.       2 Gaz. Med. de Paris, Oct. 24,  1846. 
INFANTILE SYPHILIS.
717
  b. But the child may be born alive, and die almost immediately; ex-
hibiting an eruption of  papules, vesicles, or pemphigus.  Even in these
cases we should, perhaps, not be satisfied without some evidence to show
that one parent had had  some  form of venereal.  Ulcerations at the
angles of  the mouth, or about the anus, are strong additional evidence
of a syphilitic taint, though not absolute proof.
  M. Dubois,1 and more recently, M. Depaul, have laid some stress upon
abscess of the thymus gland, as characteristic  of syphilis in  new-born
children, and the latter has further supposed a species of abscess of the
lungs as equally valuable,  but I fear that we have not as yet a sufficient
number of observations to  establish the fact.
   11. Syphilis developed  after Birth.—Dr. Bird remarks that " there
is seldom any real difficulty in the diagnosis of  these cases when  once
the practitioner has learned to  recognize them.  The  characteristic
 snuffling will often enable  him to recognize the existence of disease even
 before he has confirmed his  opinion by visual examination.   The  puck-
 ered mouth, the position of the very characteristic eruption around the lips
 and anus, in addition to the peculiar varnished and fissured appearance
 of the parts from which the scales have faded, will seldom, if ever, fail
 to convert  a suspicion  of the true nature of the disease into positive cer-
 tainty."2   Doubtless,  as in other diseases, when we have a concurrence
 of different symptoms, the case may be clear enough, but this does not
 prove that any one or  two symptoms are pathognomonic.  In the care-
 ful estimate of these single symptoms, and in the judgment  formed of
 them collectively will consist the accuracy of our diagnosis.  "We some-
 times meet with an infant having numerous spots of moist button scurvy
 about the anus, genitals and inside of the thighs.   Should other mem-
 bers also, of the family, exhibit similar symptoms, we are not in  much
 danger of  mistaking them for syphilis, because a slight attention to the
 history of each case, and to the marked difference in the more  grown
 subjects, between button  scurvy and syphilis will alone enable us to de-
 cide' but where the infant is the only member of the family so affected,
 we are liable to commit a mistake, if we form a hasty opinion.   A little
 attention will enable us to decide correctly, for although the anus and
 external organs of generation may present appearances pretty  closely
 resembling those of syphilis, yet we shall be able to distinguish them
 from the tatter, by observing that they are raised above the surface,
  that they are most distinct and distant from  each other, while those
  in svphilis begin with a number of blotches pretty thickly set, thenl en-
  large a little tnd then ulcerate, without being at any time raised above
  the sound skin.   An eruption  of copper-colored  spots is not  unfre-
  quently seen about the anus and genitals of infants, otherwise perfectly
  healthv-these we must  not hastily pronounce to be venereal; they are
  sometimes caused by inattention to cleanliness, and sometimes by a disor-
  dered state of the alimentary canal.  But these spots remain the single
  svmptom; this disease is not found to make progress; it does not show
  itself in the mouth or throat, or on other parts of the body, and it soon

                  i Gazette Med. de Paris, 3e serie, vol. v. p. 392.
                  2 Guy's Hospital Reports, 2e serie, April, 184 j. 
718
INFANTILE SYPHILIS.
yields to persevering cleanliness, and a regulated condition of the ali-
mentary canal.  The anus of infants is subject to fissure, which begin-
ning on the skin, extends in upon the mucous membrane of the rectum.
We know that such is not  venereal when we find it remain a single soli-
tary symptom; this yields to black-wash and ordinary local treatment.
A superficial ulcer is sometimes found on the rugous skin of the  anus;
generally with one part of the edge rather deep, the rest  of  the  edge
thin.   This ulcer is not very painful, it is indolent,  and sometimes con-
tinues for many  weeks or  months, the general  health of the  child re-
maining unimpaired.   Strict attention to keeping this ulcer constantly
covered with some stimulating application will effect its cure  in a very
moderate space of time."1
   M. Trousseau  states that he depends greatly in forming his  diagnosis
upon the peculiar yellow color of the skin, which he thinks of more value
than the copper  color of the eruption.   He places  great value on the
cracks  which appear on the hands and feet, and considers them rarely
deceptive when present, which he  admits is not  always the  case; and
lastly,  the combination of  several syphilitic symptoms occurring at the
same time.2
   I think,  then,  that we may conclude that although  one symptom may
have a greater value than  another, yet that any one alone  is  not  suffi-
cient to decide the question; nay, that each symptom has its  analogue
in non-syphilitic cases; but that when several coexist, and in proportion
to their number, we shall find no difficulty in arriving at a  correct con-
clusion.  Thus if there be a spreading copper-colored eruption, a yellow
skin, ulceration of the angles of the mouth and anus, snuffles, fissures of the
skin, &c, the case may justly be assumed to be syphilitic, and, of course,
if due  care be taken, the history and condition  of  the parents or wet-
nurse will form a valuable help to us in forming our opinion.3
   Prognosis.—I have already mentioned that generally, if remedies be
not applied, the  child dies after a shorter or longer  interval, sometimes
in a few days.
   But  if proper  treatment be applied early, and the child  be  not very
deeply contaminated, we may hope to save a considerable number.
   A statistical  paper was recently read by Mr. Acton to the Med.-
Chir. Society, June 9th, from which it appears  that the greatest  mor-
tality from syphilis is in children under  one year.4
   Treatment.—I shall first speak of the treatment of those cases where
repeated abortions of dead children have occurred, and I must  differ en-
tirely from MM. Gibert, Roux, &c, who, being doubtful as to  the cause
of the abortion, object to the use of mercury.  Even if I doubted  or in
cases in which I  may still  doubt whether there be any venereal taint  I
should  still  be disposed to try mercury, simply on the  ground of ex-
perience, that in similar cases it has  succeeded in preventing  the death
and  premature expulsion of the foetus.   But believing, as I  am  com-
pelled to do, that syphilis  is the cause of this accident in many cases, I
have no hesitation in saying that we ought to give our patient the benefit

  > Colles on  Venereal Diseases, p. 275.       2 Archives Gen. de Mdd., vol. xv. p 149
  3 Acton on Dis. of  Organs of Generation, p. 640.   4 Kanking's Abstract,' vol. iv.' p.' '1'Sd. 
INFANTILE SYPHILIS.
719
of our experience.  Both parents ought to go through a regular course
of mercury, and to sustain from cohabitation until the medical man is
satisfied with  its effects.   We  have the testimony of Dr. Beatty, M.
Colles, Dr. Egan, and MM. Moreau, Danyan, Dubois, &c, as to its suc-
cess.
  M. Levret considered that it was quite  possible to cure an infant in
utero, but the difficulty would be to know that it was affected.  M. Berlin
agrees that the mother may be cured of syphilis during pregnancy, and
that the child will be born healthy.
  Dr. Egan mentions that  he succeeded in producing ptyalism in a case
of this kind, in the fifth month of pregnancy, and saved the child.1
  Then, as to the treatment of syphilis  in any form  in  infants after
birth, although doubtless many of the symptoms may be cured without
mercury, yet I do not think it would either be satisfactory or complete.
We may give hyd. c. creta gr. i. ter in die, three  times a day, or a frac-
tion of  a grain of calomel as frequently, according to the  age of the
child, and this should be continued until tne symptoms disappear.   If
the bowels are too much moved or irritated, we may combine the p.
creta* co. or the p. creta co. cm. opio, so as to restrain them.
   Mercurial inunction has been very long in use, and  is of great value;
it was used by Levret,  Fabre,  &c, and probably Sir  B. Brodie's mode
of  applying it by means of a flannel  bandage smeared with the ung.
hyd. will be found the most convenient.
   Mr. Pearson recommends that a scruple of mercurial ointment should
be rubbed on the child's body nearly every clay for five or six weeks.
   Mr. Acton states that he never gives mercury  to infants, but depends
upon its external  application, by means of this mercurial belt, and fre-
quent warm baths.
   Of course, though we must bring the system fully under the influence
of the mercury, we do not expect the usual  symptoms of it in ptyalism.
Mercurial purging we may have, and in most cases it is not a bad test,
but the best is the gradual abatement of the disease, and if there be
ulceration of the mouth, even  the diminution of the salivation  which
already existed.   The disappearance of the symptoms is  not always a
proof that the disease is entirely eradicated, as we find relapses not un-
common ; however, they will be relieved, as before, by mercury.
   The external ulcerations will require local treatment;  black wash is
one of the best, and if any one proves obstinate we may advantageously
change the  black wash for a  dressing of  dilute citrine ointment, or
washed with a weak solution of nitrate of silver,  or sulphate of copper.2
   "I am not acquainted," says M. Colles, " with any  remedy which can
be with advantage applied to the ulcers of the lips, palate, and throat;
the very act of applying anything  to them irritates the ulcers, and
 causes them to  bleed, so that  I have  imagined  that they did fully as
much harm as good, and on that account have long since relinquished
 their use altogether.  I am not aware of any local  treatment for  the
swelling of the enlarged lymphatic glands; they yield readily  to the

                   ' Med. Press, March 26, 1851, p. 195.
                   2 Condie on Diseases of Children, p. 567. 
720                   INFANTILE SYPHILIS.

constitutional influence of mercury.   The slight purulent discharge of
the eyes is benefited by a mildly astringent collyrium."1
  All authorities are agreed that the wet-nurse should be brought under
the influence of  mercury,  and some, Levret, Fabre, Bertin,  &c, have
asserted that the child may be sufficiently affected by remedies given to
the nurse; but this appears doubtful.  M. Colles saw cases in which this
failed, and he is decidedly  of opinion that the cure of the infant will be
more speedy as well  as more certain if mercury be  given to it  at the
same time as to  the  nurse.
   After the  syphilitic symptoms  have disappeared, unless the child's
health be completely restored, some tonic may be given, cascarilla, sar-
saparilla, columba, or bark, the syrup of cinchona being the pleasantest
form for young children.
   •Dr. West speaks well of minute doses of iodide of  potash in sarsapa-
rilla, if there be no irritation of the bowels, but if the  syphilitic cachexia
be well marked, the syrup of the iodide of iron.
1 On the. Venereal Disease, p. 283. 
INDEX
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.
Acton.  Diseases of the Urinary and Generative Organs.
Albert, Dr.  Hufeland's Journal der Practische Heilkunde, Aug. 1830.
Albert, Mich., M. D.  De Tussi Infantili Epidemics:  Halle, 1728.
Alcock, Dr.   Dublin Medical Journal.
Alcock, Thos., M. D.  Lectures on Surgery: London, 1830.
Alderson, Dr.   Med.-Chir. Transactions, Pathology of Ilooping-Cough, 1830.
Aldis, Dr.  Medical Gazette.
Aliprendi.   Diet, of Practical Medicine.
Alison, Scott, M. D.  On Dropsy following Scarlet  Fever: London Journal of
      Medicine, No. 3,4849.
Andral, M.  Mai. de 1'Abdomen, in Clinique Medicale.
Andry and Auvity.  Encycl. Method, de Med., vol. v.
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.
Ashwell.  On Prolonged Lactation.
Audiganne.  Gazette Medicale.

Baffos, M.   Cooper's Surgical Dictionary.
Bailly and Legendre, MM.  Archives Generates de Medecine, January and Feb-
      ruary, 1844:  Nouvelles researches sur quelques Maladies des Poumons.
Bard, S., M.'d.  Transactions of the American Philosophical Society.
Barnard, Dr.  Lancet.
Baron.   Diet, de Med., art. Cephaloematome.
Baron, Ch.  De la Pleuresie dans l'Enfance:  These, Paris, 1841.
Barrier, F.  Traite Pratique des Maladies de l'Enfance: 2d edit., Paris, 1845.
Barrin.   Mai. de l'Enfance.
Barthez,  M.   Archives Gen. 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.
Battersby's Essay.  Ed. Med. and Surg. Journal, Jan. 1851.
Baudelocque.   Lancette Franchise, 1837, art. des Accouchemens.
Baumes  J. B. T.  Traite de l'Icterus ou  Jaunisse des  Enfans  de naissance:
      Paris, 1805.
Bedor M   Dictionnaire de Medecine de Fabre.
        46 
722     INDEX  OF  AUTHORS AND WORKS  REFERRED TO.

Bennett, J. II., M.  D.   Des Vegetaux qui croissent sur l'Homme et  sur les Ani-
      maux vivans, 1847.
Bennett, Henry,  M. D.   Lancet, December 30, 1843.
Bernhardi.  Preuss. Med.  Zeitung.
Berard,  M.  Manuel d'Anatomie.
Berton,  E. A. J.  Traite des Maladies des Enfans: 2d edit., Paris, 1832.
Berton.   Mai. Ven.
Berzelius, J. J.  Traits de Chimie : Paris, 1829.
Biett; in Abrege Pratique sur les Maladies de la Peau, by Cazenave & Schedel:
      Paris, 1828.   Amer. edit., Philada., 1829.
Bigbie.  Ed. Monthly Journal, Jan. 1852.
Bigger,  Dr.  Dublin Medical Press.
Billard,  C. M.   Traite des Maladies  des  Enfans Nouveaux-nes:  Paris, 1837.
      Amer. edit.,  by Jas. Stewart: New York, 1845.
Blache.   Dictionnaire des  Sciences Med.
Blache.   Archives  Generales.
Bland and Stroehlin. Med.-Chir., April, 1839.
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-tracheite :  Paris, 1824.
Bouchut, E.  Manuel Pratique des Maladies des Enfans Nouveaux-nes et  des
      Enfans a la  mamelle : Paris, 1845.
Bouillaud, J.   Traite des Maladies du. Coeur: Paris, 1835.
Brachet.  Sur les Convulsions, 1824.
Breen.  Pract. Midwifery.
Brendel.  Prog,  de Tussi Convuls.: Gotting, 1747.
Breschet, G.  Dictionnaire des Sciences Medicales.
Bretonneau, P.   Des Inflam. Speciales  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.
Bush of Berlin, and Levy of Copenhagen.   Brit, and For. Med. Rev.
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.
Capuron.   Vol. iii.
Carmichael, Mr.  Transac. of the Association of Physicians of  Ireland.
Caspar.   Wochenschrift.
Cazenave, P. L. A.  Lecons sur les Maladies de  la Peau.
Charcelay, M.  Recueil de  la Soc. Med. d'Indre 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 Child-
      ren: Edinburgh, 1801.
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   bv 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. 
         INDEX  OF AUTHORS AND WORKS REFERRED  TO.      723

Cogswell,  Dr.   N. Y. Med. Repository.
Coley, John Milman.  Practical Treatise on the Diseases  of Children: London,
      184G.
Colles.  Dublin Hospital Report, vol. i.
Colles.  Practical Observations on the Venereal Disease.
Collins, Dr.  Practical Treatise on Midwifery.  Amer. edit., Philada.
Condie, D. F., M. D. On Diseases of Children: 4th edit., Philada., 1855.
Constant,  M.  Gazette des Hopitaux.
Constant,  M.  Gazette Medicale.
Combe, Dr. A.  On the Management of Infancy and Childhood.  Amer. edit., by
      J. Bell, M. D. : 1840.
Cooper, S.  Surgical Dictionary.
Copland, Jas.   Dictionary of Medicine.
Cormack,  Dr. Rose.  London Journal of Medicine.
Coi rigan's Lecture.  Dublin Hospital Gazette, April, 1845.
Cotugno, D.  De Sedibus Variolarum : Neapoli, 1775.
Crisp, Mr.  London Medical Gazette, Dec. 1846.   On Infantile Pleurisy.
Cruveilhier, J.  Anatomie Pathologique du Corps Ilumain : 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.

Danyau.   Archiv. Gen.  de Med., Aug. 1851.
Danz, F. G.  Versuch einer Allgemeine Geschichte des Keichhustens: Marbourg,
       1791.
Darwall.   Plain Instructions for the Management of Children.
Davis, Dr. D.   On Acute Hydrocephalus:  London, 1840.
Dease, W.  Observations on Midwifery: Dublin, 1785.
De Cassis, Vidal.  Traite des Mai. Veneriens.
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 Medecine.
De Paul.   Med. Times, July, 1851.
d'Espine, Marc.  Hufeland's Journal.
Desruelles, II. M. J.  Traite Th6orique  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 Sang. Neonatorum, in Rust's Handbuch der
       Chirurgie:  Berlin, 1830.
Doherty.   Dublin Journal, vol. xxv.
Dubois.  Gazette Med. de Paris, 3d series, vol. 5.
Dubois, 31.  Nouv. Diet, de Medecine.
Du<>i's, A.  Recherches sur les Maladies les plus importantes etles moins connues
       des Nouveaux-nes: Paris, 1821.
Duges, A.  Diet, de Med. 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.
 Dungan.   Archiv. Gen. de Med., Aug. 1851.
 Dunglison, Dr. Robley.  On Diseases of the Stomach and Bowels in Children:
       London, 1824.
 Dupuytren, Le Baron.  Lecons orales de Chnique 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.
 Egan.  Med. Press, 1851. 
724     INDEX  OF  AUTHORS AND  WORKS  REFERRED TO.

Elsasser, Dr.  Die Magenerweichung der Sauglinge: Stuttgard, 1846.
Engelmann, M.   Archives Generates de Medecine, June, 1838.   On the Treat-
      ment of Hydrencephalus by Compression.

Fabre, M.  Bibliotheque de Medecine Pratique.
Fabre.  Med. Chir. Review, July, 1851.
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.
Ferrand.  Memoires de l'Acad. de Chir., vol. v.
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.
Fliess.  Journal fur Kinderkrankheiten, June and July, 1849; Lond. Journal of
      Med., Jan. 1850.   '
Fleischmann.  Die Entziindung.
Fleischmann.  De  Vitiis Congenitis circa Thoracem et Abdomen.
Fleming, Dr.  Dublin Medical Journal.
Fortin, M.  Cephalaematoine sous pericran.
Fournet.  Reckerches  Clin, sur l'Oscultation et sur la Premiere Periode de la
      Phthisic
Francis, Dr.  New York Medical and Physical Journal.
Fried.   Extrait. des Theses de Halter.
Friedleben.  Archiv. fur Physiolog. Heilkunde, 1847.
Friedleben  & Fleisch, MM.   Zeitschrift flir Rationelle Medicin, 1846.   On  the
      Pathology of the Intestinal Mucous Membrane in Young Infants.
Furlong. Edin. Med. and  Surg. Journal.
Fyfe, Dr.  Provincial Medical and Surgical Journal, June 16, 1847.

Gardien. Traite des Accouchemens.
Gairdner and Baly. Ed. Monthly Journal,  Nov. 1850.
Gendrin, A. N.   Translation of Abercrombie.
Gerhard, Dr. W. \V.  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 Gen.  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.
Graetzer, 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 Medecine, 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 Svstem •  Lon-
      don,  1836.
Halter, A.  DeMonstris: Gotting. 1751.
Hamilton, Dr. Jas., Jr.  On Diseases of Infants : London, 1809. 
         INDEX OF  AUTHORS AND WORKS REFERRED  TO.      725

liana of Illinois.  Am. Med. Journal, Oct. 1850 and 1851.
Harris, Dr. W.  De Morbis Acutis Infantum :  London, 1705.
Hasse's Pathological Anatomy, Sydenham Society.
Hawkins, F. Bisset.  Elements of  Medical Statistics :  London, 1829.
Hayes, Pliny.  Braithwaite's Retrospect, vol. ix.
Hegcwisch, Dr.   Rust's Magazin.
Heim, M.  Hufeland's Journal.  On  Revaccination.
Ilenke, A. A.  Handbuch der Kinderkrankheiten : Frankfort, 1621.
Ilenle's Zeitschrift, vol. iii.
Herrich & Popps.  Der Plotzlichen Tod aus inneren Ursachen.
Hess, Prof.  Ranking's Abstract.
Ileyfelder.  Beobachtungen iiber der Krankheiten der Neugebornen, 1822.
Ileyfelder.  Studien in Gebiete der Heilwissenschaft.
Hillary, W., M.  D.  On the Smallpox: London, 1735.
Hillary.  Maladies des Nouveaux-nes.
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, Philada.,
       1846.
Horner, W. E.,  M. D.  American Journal of  the Medical Sciences,  1829, 1831.
       On the Pathology of Cholera Infantum and Infantile Convulsions.
Hughes, Dr.   Guy's Hospital Reports, No. 3 and 4, 1844.
Hutchinson,  A.  C.  Surgical Dictionary.

Innes.  Surgical Dictionary, art. Spina  Bifida.
Isenflamm.  Archives  Generates de Medecine.

Jackson,  S.,  M. D.  (of Northumberland).   American Journal  of the Medical
       Sciences, August, 1834.  On Gangraenopsis.
Jacques.   Journ. Gen. de Med., vol.  xxix.
Jaeger.  Hufeland's Journal, 1811.  On the Softening of the Stomach in Children.
Jahrbericht  iiber die  Leistungen  des  Unentzeldlichen Kinderkranken  Insti-
       tute, &c.
Jervis.  Journal Gen.  de Medecine.
• Joerg.  Die Foetusleunge in Neubornen Kinder.
Johnson, C.   On Hooping-Cough, in  Cyclopedia of Practical Medicine.
Joy, Dr.  Cyclopaedia  of Medicine, art.  Fever,  Infantile Remittent.

 Keilmann.  Prodrom.  Act. Havn.
 Kennedy, Dr. II.  Some account of  the Epidemic of  Scarlatina which prevailed
       in Dublin from  1834 to 1842 :  Dublin, 1843.
 Kennedy, Evory. Dublin Journal, vol.  vi.
 Kerkring, Thos.  Spicilegium Anat., obs. 57: Amsterdam, 1670.
 Kirkes. ° Med. Gazette, 1850.
 Kitsell.  Am. Journ.,  Jan. 1850.         ^
 Krukenberg.  Jahrbucher des Ambulatonschen Klinik zu Halle,  1824, I vols.

 Labatt, Dr.  On Cow-pox.
 Labatt.  Edin.  Med. and Surgical Journal. _
 Laennec  R.  T.  H.  De. l'Auscultation Mediate: 3me edit., Pans, 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.
 Lcendre  M.  Recherches,  &c, sur quelques Maladies de  l'Enfance.  Pans,
   °   1846.
 Legendre.  Am. Journal of Med. Sciences.
 Le^er, V.  Essai sur la Pneumonie des  Enfans: These, Paris, 1823.
 Lelut.' Archives Generates de Medecine.
 Ley, Dr. Hugh.  On Laryngismus Stridulus: Lond., 1S36. 
726     INDEX OF AUTHORS  AND  WORKS  REFERRED  TO.

Linna?us, C.  Diss. Exanth. xiv.;  in Amccnitat.
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 consid6re  chcz l'Adulte :
      Paris, 1826.               .   •
Luidsly, Harvey.  American Med. Journal, April, 1851.

Magendic   Sur le Fluide Cephalorachidienne.
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.
Maunsell.  On Diseases of Children.
Mauran.  Philada. Medical Journal, Aug.  1827.
Mauthner.   Die Kranken des Geherns und Eiichenmarks bei Kindern:  Vienna,
      1844.      V
Mauthner.   British and Foreign Review, April, 1846.
Mayne, Dr.  Dublin Quart. Journal of  Med.  Science,  May, 1844, and  August,
      1846.
McClean, Mr.  Visit to St. Kilda.
Mechel, 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.,
      1854.
Meine, Dr.  Osteomalacia et ejus in  partum actione.
Meissner, Henke, and Heyfelder.  Archives, 3d series, vol. v.
Michaelis.   Ueber eine eigene Art. von Blutgeschwiilsten.
Michaelis.   London  Medical Transactions, de Angina polyposa: Gottingen, 1778.
Milter.   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.
Mondierc   L'Experience, June 25.   On Intra-arachnoidean Hemorrhage.
Monc  Dublin Journal, vol. vii.
Monro, Dr.  On  the Morbid Anatomy of the Brain,  vol. i.: Lond and Edin.,
       1827.
Monro, A.  L.  On the Smallpox :  Edinburgh, 1818.
Montgomery, Dr.  Dublin Journal, vol. ix.  On the Sudden Death of Children
      from Enlargement of  the Thymus Gland.
Morgagni,  J. B.  De Sed. et Causis Morb. Epist.:  Paris edit., 1820-'23.
Morton, E., M. D.  Observations on the Healthy and Diseased Condition of the
      Breast, Milk,  &c: London, 1831.
Moscati &  Pallette.  De Abscessu Sang. Capit.   Mediol.
Moss, W.  On the Management and Nursing of Children :  London, 178?.
Munchmayer.  Schmidt's Jahrbucher, vol. xxv., 1840.

Naegele.   Erfahrungen und Abhandlungen.
Naegele, H. F.  Lehrbuch der Geburtsh'ulfe : Mainz, 1843.
Naegele.   Art. des Accouchemens.
Nairne.  Lond. Journ. of Med., Jan. 1851.
Neligan, Dr.  Eruptive Diseases of the Scalp.
Neligan, Dr.  Medicines and their Uses:  Amer. edit.
Neumeister of Arneburg.  Journal fur Kinderkrankheiten, Jan. and  Feb. 1851.
Neunham.   British Rec. of Obst. Med., No. 6. 
INDEX  OF AUTHORS AND WORKS REFERRED  TO.      (2(
Nevins.  Lond. Med. Gazette, Jan. 1850.
North, John.  Practical Observations on Convulsions of Infants:  London, 1826.

O'Ferrall, Dr.   Dublin Hospital Gazette.
Ollivier, C. P.   Traite de la Mo'elle 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. II. L.  Der Stickhusten:  Halle, 1805.
Palletta.  Memoir read before the Institute at Milan.
Palmer, Dr.  Medico-Chirurgical Journal, 1816.
Panarola.  Obs. Med. Pentecost.
Panure of Copenhagen.  Mode of Propagation of Measles.  Ed. Monthly Journ.
       of  Med., 1851.
Papavoine.   Journal des Progres, 1830.  On Tubercles and  Convulsions  in
       Infants.
rarent-Duchatelet and Martinet.  Recherches sur l'lnflammation  de l'Arach-
       noide Cerebrate et Spinale :  Paris, 1819.
Parrish,  Jos., M. D.   On Infantile Convulsions arising  from Spasm of Intestines:
       N. Amer. Med. and Surgical Journal, 1827.
Pearson, Mr.  Med.-Chir. Transactions.
Peddie.   Edinburgh Monthly Journal, Aug. 1848.
Pemberton.  On various  Diseases of the Abdominal Viscera.
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.
Peirson, M. S.   Lectures.
Petz, Abney, and Baudelocque.  North Am. Med. Journal.
Petzholdt, M.  Archives Gen. de Medecine.
Piet.  Thesis, 1836.
Piet.  American Journal of Med. Sciences.
Pigne, M.  Journal Hebdomadaire.
Planque.  Bibliotheque de Medecine, vol. iii.
Piorry, P. A.   De l'Irritation Enc6phalique des Enfans : Paris, 1823.
Porter, W. II.   Surgical Pathology of the Larynx and Trachea: Dublin, 1837.
Porter.  Dublin Medical Press.
Price.  Med. Times, vol. xii.
Purefoy,  Dr.  Dublin Journal, May, 1846.

Quetelet, 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.
Rees. Atelectasis Pulmonum.
Report of the Royal Infirmary for 1846.
Reports  of the Registrar-General.
Reveille-Parise, M.  Gazette Medicate.               _
Richerand, le Baron.   Nosographie Chirurgicale: Pans, lSiO.
Ricrby E  M. D.  A  System of Midwifery.  Amer. edit., Philadelphia, 1840.  _
Rifliet and Barthez.   Traite Clinique et Pratique des Maladies des Enfans : Pans,
       1843.
Ringland, Dr.   Dublin Journal, July, 1841, vol. xix.
Riverius.  Obs. Commun : London, 1840.
Rizzi.  Gazette Med. de Paris. 
728     INDEX  OF  AUTHORS AND WORKS  REFERRED TO.

Roe, Geo. H. Treatise  on the Nature and Treatment of Ilooping-Cough: London,
      1838.
Roeser.  Diet, of Medicine.
Rogers, Dr. Jos. An Essay on Epidemic Diseases: Dublin, 1734.
Roman, M.  Ann.  de la Soc. McdJ Prat. de.  Montpellier.
Romberg, Dr.   Wochenschrift fur die gesammt. Heilkunde,  1833:  iiber Magen,
      erweichung.
Rosenvon Rosenstein.   On  the Diseases of Children.  English edit., London,
      1776.
Rostan, M.  Dictionnaire de Medecine.
Roux.   De CarditideExsudativa.
Rudolphi.  Abhandlungen der Konigl. Acad, zu Berlin.
Rufz, F. Journal  des Connoissances Medico-Chirurgicales, 1835.
Rufz.  Arch. Gen.  de Med., 1834.
Rufz.  American Journ. Med. Sciences.
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.
Ruysch, Acrell, and Isenflaum.  Arch. Gen. de Med., vol. iv.

Saillant. Memoires de la Soc. de Medecine.
Salleneuve, M.   Mem. de l'Acad. de Chirurgie.
Salter.  Med.-Chir. Transactions, vol. x.
Sanson.  Dictionnaire de Med. et de Chir. Pratique, art. Hernie.
Sargent, Jos.  Am. Journal of Med. Sciences, July, 1849.
Sauvagc  Nosolog. Method.
Schmidtmann, Albert.  Observationes Medicse, vol. ii.
Schneider,  Dr.  Edinburgh Med. and Surg. Journal.
Scholler.  Medicinische Zeitung.
Schultz. M. N. C. Dec. 1, An. 6,  7.
Schundtmann.  Albers de Trachaeitide.
Schwartz, L. W.  Siebold's Journal, B. 7.
Schweinger.  Uber Tuberculose als die gewohnlichste Ursache der Hydrocephalus
      acutus.
Segerus.  M. N. C. Dec. 1, An. 3,  obs. 160, p. 291.
Seitz, Dr.  Ranking's Abstract.
Sentin.  Beitrage zur ausiibenden Arzneiwissenshaft.
Sestie & Cazalis, MM.  Bull, de la Soc. Anat.: 1832.
Sherwood,  Dr.  Medical Repository.
Siebold, J.  A.   Journal flir Geburtshulfe.
Simpson, J. Y.   Edinburgh Med. and Surg.  Journal.
Sims.  American Journal of Med. Sciences, April, 1846, July and Oct. 1848.
Smith, 11,  M. D.  On Hydrocephalus.
Stewart, J.  On Diseases of Children: New York, 1841.
St. Hilaire, Geoffroy Isidore.  Histoire Generate et Particuliere  des Anomalies de
      l'Organisation, &c.:  Paris, 1832.
St. Hilaire.  Art. Anencephalie, in Diet,  de  Med. et de  Chir. Prat., vol ii.
Stoeber. Clin, des Mai. des Enfants de la Faculte de Strasburg, 1841.
Stokes.  Diseases of the Chest.
Stokes, Wm,, M.  D.   Diseases of the Chest:  American  edition, Philadelphia,
      1844.                                                           *
Strange. Northern Journ. of Med., Sept. 1844.
Sturve.  On the Physical Management of Children :  Berlin, 1776.
Suiron, M.   Ranking's Abstract.
Swagemann.  Ontleed. Heilkund.   Verhandl.
Swediaur.  On Syphilis.
Sydenham.  Opera Universa : London, 1720.

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. 
         I^DEX  OF  AUTHORS  AND  WORKS  REFERRED TO.      720

Thompson.  London Medical Repository, Jan., 1814.
Thore, M.  Archives Generates  de Medecine,  1846.   De la Peritonite chez les
      Nouveaux-nes.
Todd.  Cyclopedia of Anatomy and Physiology, Part xxv.
Todo, Dr. Jas.  Medical Gazette, Dec. 25, 1846.
Tonnelle.  Maladies des Enfans.
Tretis, Dr.   Medical and Physical Journal.
Troccon.  Sur la Maladie connue sous le nom d'Endurcissement du Tissue Cellu-
      laire, 1814.
Trousseau and Lasegne.  Archives Gen. de Medecine, vol. xxvi.
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, 1816, and Sept., 1819.

Valentine, Louis.  Sur le Croup: Paris, 1812.
Valleix, F.  L. J.  Clinique des Maladies des Enfans Nouveaux-nes :  Paris, 1838.
Vauthier, Dr.  Arch. Gen.  de Medecine, May,  1848.
Velpeau, A. A. L.  M.  Nouveaux Elements  de Medecine Operatoire:  Paris,
      1832.
Velpeau, A. A. L. M.  Trait6 des Accouch. : edit, de Bruxelles.
Veron.   Recherches des Maladies des Nouveaux-nes : Paris, 1821.
Veron.   Seance de l'Acad. Roy. de Med., June 28, 1825.

Wacldington, 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, Ls13.
Webster, D.  London Med. and Phys. Journal.
Weisberg.   Dissertatio de Praeternaturali et raro intestini recti cum vesica urina-
      ria coalitu, &c, 1779.
West, Chas., M. D.  Lectures on the Diseases of Infancy and Childhood : Philada.,
      Lea & Blanchard, 1855.
Whitehead.  On Hereditary Diseases.
Whitlock, NichoU, Dr.  Practical Remarks on Disordered States of the Cerebral
      Structures, occurring in Infants :  London, 1821.
Whitney.  Am. Journ. Med. Sciences, Oct. 1843.
Whytt.   On Nervous Diseases.
Wicke.   Analeckten der Kinderkrankheiten.
Wilde.   Report upon the Tables of Death.
Wilkshirc   Lond. Journ. of Medicine, June, 1850.
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.
Williamson.  Lond. Lancet, June, 1853.
Willis.   Opera Omnia: Amst., 1682.   De Morb. Convulsiv. Puerorum, &c.
Wilson, Mr.  Philosophical Transactions.
Wooton,  Dr.  Transactions  of The College of Physicians of Philada.
Wright.  British American Journal, April, 1850.
Wrisbey, H. A.  Descriptio Anat. Embryou., 1764.
Wunderlich.  Handbuch des Pathologie und Therapic

Zeller, Ch.   Thesis de Cephakematomate :  Heidelberg, 1S22. 
 
INDEX.
                   A.

Abscess of the brain, 184
    between the pharynx and the spine,
        diagnosis of, 482
        symptoms of, 481
        treatment of, 482
Air, importance of pure, 58
Angina, pseudo-membranosa, 468
Anus, imperforate, 413
Apoplexy, 195
    causes of, 200
    cerebral, 197
    diagnosis, 200
    meningeal, 196
Aphtha?, 437
    causes of, 440
    pathology of, 438
    prognosis of,  440
    treatment of, 440
Artificial feeding,  46
Asthma, thymic, 315
Atelectasis pulmonum, 292
                   B.

Bathing, importance of, 52
Brain, abscess of, 184
    absence of, 72
    congestion of, 195
    hypertrophy and induration of, 178
    inflammation of, 176
    tubercles or tumor, 186
    pathology of tubercles of, 189
Bronchitis, 300
    diagnosis, 312
    prognosis of,  312
    pathology, 305
    modifications and complications,  307
    treatment, 312
Bronchitis, chronic, 304
                   C.

Calorification, state of it in infancy,  29
Cancrum oris, 446
Caput succedaneum, 82
Carnification of the lung, 329
Cathartics for the removal of the meconium,
  35
Cephalaematoma, sub-nponeurotic, 84
    sub-pericranial, 85
    sub-cranial, 87
    pathology of, 88
    termination of,  89
    treatment of, 89
Cerebro-spinal system, disease? of, 71
Chicken-pox, 645
Cholera infantum, 457
Chorea, 102
    causes of, 108
    complications, 105
    diagnosis of, 109
    pathology of, 106
    prognosis  of, 110
    symptoms of, 103
    treatment of, 110
Cleanliness, importance of, 52
Cleft palate, 410
Clothing of the infant, 56
Colitis, 521
Condition of the foetus in utero, 23
Congestion of the brain, 195
Convulsions, 71
    sympathetic and symptomatic, 114
    causes of,  115
    diagnosis of, 126
    prognosis  of, 127
    symptoms of, 119
    treatment of, ] 27
Coqueluche, 229
Coryza, 213
    causes of,  214
    treatment of, 215
Cowpox, vaccinia, 668
Cranium, fractures of the, 82
Croup, 259
    causes of,  272
    complications of, 273
    pathology of, 2u7
    prophylactic treatment of, 292
    stages of, 261
    symptoms of, 261
    tracheotomy of, 286
    treatment  of, 279
Cyanosis, o77
    pathology of, 381 
732
INDEX.
Cynanche parotidea, 464
    tonsillaris, 460
    trachealis, 259
                   D.

Dance of St. Guy, 102
Dentition, 416
Diarrhoea, 503
    varieties of, 504
Digestive system, diseases of, 405
Diphtherite, 468
Disease, intra-uterine, 213
Dress, changes in, 57
    materials of, 56
Dry nursing, fatal effects,  37
Dysentery, 527
    causes of, 526
    diagnosis of, 522
    morbid anatomy of, 525
    treatment of, 526
Dysentery, chronic, 528
E.
Eczema, 572
Edema of the cellular tissue, 677
    complications, 681
Encephalitis,  176
    causes of, 177
    diagnosis of, 177
    symptoms of, 176
    treatment of, 178
Encephalocele,  73
    diagnosis of, 74
    treatment of, 75
Endocarditis, 397
    diagnosis of, 403
    morbid anatomy of, 402
    prognosis of, 403
    results of, 400
    symptoms of, 397
    treatment of, 403
Enteritis, 509
    causes of, 513
    diagnosis of, 515
    treatment of, 515
Epistaxis, 215
    treatment of, 216
Exercise, importance of, during  childhood,
       59
    precautions in regard to, 59
Fever, infantile remittent, 685
    causes of, 691
    complications of, 689
    diagnosis of, 692
    pathology of, 690
    prognosis of,  693
    symptoms of, 685
    treatment of,  693
Foetus, source of disease in the, 25
Food of infancy and childhood, 40
    of newborn infant, 37
Flannel,  importance of in the clothing  of
    children, 56
Fractures of the cranium, 82
G.
Gangrene of the mouth, 446
    causes of, 455
    diagnosis of, 457
    pathology of, 452
    prognosis of, 457
    symptoms of, 446
    treatment of, 457
Gangrenous ulceration of the pharynx, 475
Gastric  fever  (see  Fever,  infantile  remit-
  tent), 614
Gastritis, 496
    causes of, 500
    diagnosis, 501
    morbid anatomy, 498
    symptoms of, 496
    treatment of, 501
Glottis,  spasm of the, 216
Growth  of  the infant, 29
H.
Hare-lip, 406
    treatment of, 406
Heart, diseases of, 374
    anomalies as to the number of, 376
    malformations of, 376
Helminthiasis, 530 '
Hernia cerebri, 73
Herpes, 571
Hooping-cough, 229
Hydrocephalus, 71
    acute,  134
        causes of, 148
        diagnosis, 151
        historical notice of, 135
        pathology of, 145
        prognosis of, 153
        stages of, 136
        terminations of, 153
        treatment of, 154
    chronic, 160
        causes of, 169
        diagnosis of, 169
        historical notice of, 172
        pathology of, 166
        symptoms of, ] 02
        treatment of, 169
Ilydrorachitis, 75
    operations for, by puncture, 81
Hypertrophy of  the brain, 178
    causes of, 181
    diagnosis of, 181
    pathology of, 181
    prognosis of, 182 
INDEX.
733
Hypertrophy—continued.
    treatment of, 182
Hydrencephaloid, 175
                    I.

Imperforate anus, 413
Impetigo, 576
Incontinence of milk, 38
Indigestion, 488
    causes of, 493
    diagnosis of, 493
    morbid anatomy, 492
    symptoms of, 488
    treatment of, 493   *
Infancy, effects of  poverty upon the mor-
  tality in, 22
Infancy and  childhood, food of, 40
    statistics of mortality in, 19
Infant,  management of at birth, 32
Infantile remittent fever, 685
Infants, peculiarities of the nervous system
       in, 29
    peculiarities of the digestive system, 29
    times of feeding newborn,  40
Inflammation of the pericardium, 385
     of the pleura,  341
Influenza, 308
Intestinal worms, 530
     causes of, 534
     treatment of,  535
     varieties of, 530
 Intra-uterine diseases, 405
 Irritations  arising from   severe  dentition,
        421
     of the nervous system, 90
                   J.

Jaundice, 538
    causes of, 540
    pathology of, 539
    prognosis of, 540
    treatment of, 541
                   L.

Lancing the gums, 421
Laryngismus stridulus, 216
Ligature of the cord, 34
Light, importance of in infancy, 62
Liver, enlargement of, 541
Lobar pneumonia, 316
    duration of, 319
    physical signs of, 318
Lobular pneumonia, 319
    duration of, 322
    physical signs of,^320
Lungs, gangrene of, 330_
    Inflammation of, 315
                  M.

Malformation of the nipple, effects of, 38
Management of the infant at birth, 32
Measles, 589
    causes of, 604
    complications of, 597
    diagnosis of, 606
    modifications of,  593
    morbid anatomy  of, 603
    prognosis of, 607
    symptoms of, 590
    treatment of, 608
Medicine,  use of in infancy, 65
Meningitis, tubercular, 205
Milk, analysis of different kinds, 46
    effects of  organic diseases upon, 39
    influence of mental emotions upon, 39
    influence of menstruation upon, 39
Mortality  in infancy, statistics,  19
    effects of poverty upon, 22
Mouth, inflammation of the, 426
Muguet, 427
    diagnosis of, 435
    pathology of, 428
    prognosis of, 435
    symptoms of, 427
    treatment of, 435
Mumps, 464

                   N.

Nervous irritation, 90
     causes of, 92
     symptoms of, 91
     treatment of, 93
Nine-day  fits, 94
     causes of, 95
     symptoms of, 95
     treatment of, 100              /
Nursery,  location and furniture, 66
     regulation of the, 67
     temperature of,  67
Nurses, 67
Nurse, domestic qualities of,  68
     duties of the, 07

                    P.

 Parotitis, 464
     causes of, 466
     symptoms of, 464
     treatment of, 466
 Pericarditis, 385
     causes of, 393
     morbid anatomy of, 392
     symptoms of, 387
     treatment of, 395
 Peritonitis, 554
     diagnosis of, 557
     morbid  anatomy of, 556
     prognosis of, 557
      terminations of, 563
      treatment of, 565 
734
INDEX.
Pertussis, 229
    causes of, 246
    complications of, 236
    diagnosis of,  247
    pathology of, 241
    prognosis of,  248
    symptoms of, 231
    treatment of, 249
Pharyngitis pseudo-membranous, 468
    causes of, 472
    complications of, 472
    diagnosis of,  473
    morbid anatomy of, 471
    prognosis of,  473
    symptoms of, 468
    treatment of, 474
Pityriasis, 569
Pleuritis, 341
    causes of, 349
    diagnosis of,  351
    morbid anatomy of, 347
    prognosis of,  351
    symptoms of, 342
    treatment of, 352
Pneumonia, 315
    complications of, 325
    diagnosis of,  327
    lobar, 316
    lobular, 319
    primary, 324
    prognosis of,  338
    secondary, 324
    treatment of, 338
Porrigo, 578
    favosa, 583
    scutulata, 578
Prurigo, 568
Putrid sore throat, 475
    causes of, 480
    diagnosis of,  480
    morbid anatomy of, 478
    prognosis of,  480
    symptoms of, 476
    treatment of,  481
Quinsy,  460
R.
Ramollissement of the brain,
    diagnosis of, 184
    pathology of, 184
Respiration in the infant, 29
Roseola, 570
Rubeola, 589
Rupea, 574

                   S.

Scald head, .578
Scalp, abscess of the, 86
Scarlatina, 610
183
Scarlatina anginosa, 616
Scarlet fever, 610
     causes of, 635
     complications of, 620
     diagnosis of, 637
Scarlatina maligna,  treatment of, 641
Scarlatina, pathology of, 633
     periods of,  613
     prognosis of, 638
     prophylaxis of,  644
     treatment of, 639
Scleroma, 677
Senses, progressive education  of  the,  in
  infant, 31
Serum, Breschet's analysis of, 167
Shower bath, tonic effects  of, 52
Skin, diseases of, 567
Skull, absence of the,  72
Sleep of infants, 63
Smallpox (see Variola), 649
Spasm of the glottis, 216
     causes of, 226
     diagnosis of, 226
     pathology of, 220
     prognosis of, 227
     symptoms of, 218
     treatment of, 227
Spleen, enlargement of, 544
Spina bifida, 75
Spinal marrow,  tubercles of,  186
Spoon feeding, 46
Staphyloraphe,  410
State of muscular action in the infant, 31
Stomach, diseases of the, 483
     inflammation of the, 496
     pathological changes  in  the   mucous
       membrane of the, 498
Softening of the stomach,  500
        brain,  183
Stomatitis, 426
     treatment of, 441
Strophulus, 567
St. Vitus' dance, 102
Syphilis,  705
     in infants at birth, 706
     the cause  of   abortion,  or  premature
       labor,  707
     appearances of  child at  birth, 708
     appearing after birth, 709
     hereditary, 711
     symptoms,  710
     derived from the wet nurse, 712
        dry nurse,  713
     consequences, 714
     diagnosis, 716
     congenital, 716
     developed after birth, 717
     prognosis, 718
     treatment, 718
Swine-pox, 645
T.
Thrush, 437 
                                    IN

Thymic asthma, 315
Tonsillitis,  460
    causes of, 462
    diagnosis of, 462
    symptoms of, 460
    treatment of, 462
Trismus nascentium, 94
Tubercular meningitis, 205
    symptoms of, 205
Tubercles of the brain, 186
    causes of, 190
    diagnosis of, 191
    treatment of, 192
    of the spinal marrow, 192
         treatment of,  192
Typhoid fever, 695
    modifications of, 697
                   U.

Ulcerated sore mouth, 442
    pathology of, 443
    symptoms of, 442
    treatment of, 444
                   V.

Vaccinia (history of), 669
    course of, 669
    diagnosis of, 675
    modifications and irregularities of, 67
    mode of operating, 675
ex.                                735

 Varicella, 645
     diagnosis of, 648
     modifications of, 647
     symptoms of, 646
     treatment of, 649
 Varieties of food and modes of administra-
   tion, 40
 Variola, 649
     causes of, 662
     complications of, 657
     diagnosis of, 664
     modifications of, 655
     pathology of, 661
     period of incubation,  650
         invasion, 650
         eruption, 651
         suppuration, 652
         desiccation, 654
     prognosis of, 654
     Symptoms of, 650
     treatment of, 665
 Varioloid, G57
 Vernix caseosa, 33
                  W.

Washing infants, mode of, 33
Walking, precautions in teaching, 59
Water stroke, 145
Weaning, 44
Weaning brash, 490
Worm fever (see Fever, remittent).
THE END. 
 
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                  Edited  by ISAAC HAYS, M. D.,
is nubli«hed Quarterly, on the first of January, April, July,  and October.  Each number contains
at least two hundred and eighty large octavo pages, handsomely and appropriately illustrated,
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2
BLANCHARD & LEA'S  MEDICAL
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            THE MEDICAL  NEWS AND  LIBRARY,

a monthly  periodical of thirty-two large octavo pages.  Its "News Department" presents the
current information of the day, while the " Library Department" is devoted to presenting stand-
ard works  on various branches of medicine.   Within a few years, subscribers have thus received,
without expense, the following works which  have passed through its columns:—
WATSON'S LECTURES ON THE  PRACTICE OF PHYSIC.
BRODIE'S CLINICAL LECTURES ON  SURGERY.
TODD AND  BOWMAN'S PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN.
  724 pages, with numerous wood-cuts, being all that has yet appeared in England.
WEST'S LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD.
MALGAIGNE'S OPERATIVE SURGERY, with wood-cuts.
SIMON'S  LECTURES ON GENERAL PATHOLOGY.
BENNETT ON PULMONARY TUBERCULOSIS, with wood-cuts,
WEST ON ULCERATION OF THE OS  UTERI, and
BROWN  ON THE SURGICAL DISEASES OF FEMALES, with wood-cuts.
      While the number for July, 1856, will commence a new and highly important work,
        WEST'S LECTURES  ON  THE DISEASES  OF WOMEN.
                           Part I.—Diseases of the Uterus.
  The very favorable reception accorded by  the profession to the valuable "Lectures on the
Diseases of Children," by the same  author, which likewise  appeared in this periodical, has in-
duced the publishers to secure the present work for their subscribers, from advance sheets, supplied
by the author.   The very high reputation of  Dr. West, and the unusual clinical advantages which
he has enjoyed,  sufficiently indicate the practical value of a  systematic work  from his  pen on so
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            EMBRACING ABOUT  FIFTEEN  HUNDRED LARGE  OCTAVO  PAGES,
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                                  Address       BLANCHARD & LEA, Philadelphia. 
AND  SCIENTIFIC  PUBLICATIONS.
3
                             ALLEN  (J.  M.),  M. DM
                  Professor of Anatomy in the Pennsylvania Medical College, &,c.

THE PRACTICAL  ANATOMIST;  or, The  Student's  Guide in the Dissecting.
  ROOM.  With over 200 illustrations.  In one handsome royal 12mo. volume, of over 500 pages.
  {To be ready for the fall sessio?is.)
  In the arrangement of this work, the author has endeavored to present a complete and thorough
course of disseclions in a clearer and more available form for practical  use, than has a* yet been
accomplished.  The chapters follow each other in the order in which dissections are usually con-
ducted in this country, and as each region is taken  up, every detail regarding it is fully described
and illustrated, so that the student is not interrupted in his labors, by the necessity of referring from
one portion of the volume to another.
                         ANALYTICAL  COMPENDIUM
OF  MEDICAL  SCIENCE, containing Anatomy, Physiology, Surgery, Midwifery,
  Chemistry, Materia Medica, Therapeutics, and Practice of Medicine.  By John Neill, M. D.,
  and F. G.  Smith, M. D.  New  and enlarged edition, one thick volume royal 12mo. of over
  1000 pages, with 374 illustrations.  I3P See Neill, p. 24.

               ABEL  (F.  A.),  F. C. S.  AND  C.  L.  BLOXAM.
HANDBOOK OF  CHEMISTRY, Theoretical, Practical, and Technical; with  a
  Recommendatory Preface by Dr. Hofmann.  In one large octavo volume, extra cloth, of 662
  pages, with illustrations. §3 25.
  It must be understood that this is a work fitted for
the earnest student, who resolves to pursue for him-
self a steady search into the chemical mysteries of
ereation. For such a student the ' Handbook' will
prove an excellent guide, since he will find in  it,
not merely the approved modes of analytical investi-
gation, hut most descriptions of the apparatus ne-
cessary, with such manipulatory details as rendered
Faraday's ' Chemical Manipulations' so valuable at
the time of its publication.  Beyond this,  the im-
portance of the work is increased by the introduc-
tion of much of the technical chemistry of the manu-
factory.—Dr. HofmaruVs Preface.
                         ASHWELL  (SAMUEL), M.D.,
                  Obstetric Physician and Lecturer to Guv's Hospital, London.
A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN.
  Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third
  and revised  London edition.  In one octavo volume, extra cloth, of 528 pages.  {Lately Pub-
  lished.)  $3  00.
  The most useful practical work on the subject in
the  English language. — Boston Med. and Surg.
Journal.
  The most able, and certainly the most standard
and practical, work on female diseases that we have
yet seen.—Medico-Ckirurgical Review.
  The young practitioner will find  it invaluable,
while those who have had most experience will yet
find something to learn, and much to commend, in a
book which shows  so much patient observation,
practical skill, and sound sense.—British and Fo-
reign Med. Review.

  We commend it to our readers as the best practi-
cal  treatise on the subject which has yet appeared.
—London Lancet.
                            ARNOTT (NEILL), M. D.
ELEMENTS   OF  PHYSICS;  or  Natural Philosophy,  General nnd  Medical.
  Written for universal use, in  plain or non-technical language.  A new edition, by Isaac Hays,
  M. D.  Complete in one octavo volume, leather, of 484 pages, with about two hundred illustra-
  tions.  $2 50.                     _________________

                           BENNETT (HENRY),  M. D.
A PRACTICAL  TREATISE  ON INFLAMMATION OF THE UTERUS,
  ITS  CERVIX AND  APPENDAGES,  and  on its connection with Uterine Disease.  Fourth
  American  from the third and revised London edition.  To which is added  {July, 1850), a Review
  of the Present State of Uterine Pathology.  In one neat  octavo volume, extra cloth, of
  500 pages, wkh wood-cuts.  $2 00.
  The addition of the "Review" presents the most recent aspects of the  questions discussed in
this well-known work, bringing it down to the latest moment.
  This edition has been carefully revised and altered,;  When, a few years back, the first edition  of the
and various additions have been made, which render  present work was published, the subject was oneal-
it more complete  and, if possible, more worthy of  most entirely unknown to the obstetrical celebrities
the hio-h appreciation  in which it is  held by the  of the day ; and even now  we have reason to know
medical profession throughout the world.  A copy I that the bulk of the profession are not fully alive to
should be in the  possession of every physician.—  the importance and frequency of the disease of which
riiarleston Med Journal and Review.             it takes cognizance.  The present edition is so much
             ',  . .    ,,. ■  „,„„„,Hr,„ no n i enlarged, altered, and improved, that it can scarcely
  We are firmly of opinion  that.inJP'oportion a. ;a    colsl^Ted ttl'e same £ork.Jj>r. Banking', Ab-
knowledge of uterine diseases becomes  more appre-
cfatXthiswork will be proportionably established  'tract.
as a text-book in the profession.—The Lancet.      I
                 Also, just ready,  by the same author, and for sale separate,

A REVIEW OF THE PRESENT STATE OF UTERINE  PATHOLOGY.
  1 small vol. 8vo. 50 cents, in  flexible cloth.
  In this little work, which can be had  either  in  connection with  the  "Practical  Treatise," or
separate  the author presents his latest views with regard to  the various doctrines which have re-
cently been brought forward on this interesting question, under the following heads:—
CHAr I  Preliminary.  II. Sketch of Uterine Pathology.  III. Objections.  IV.  The Leucorrhoea
  Theory —the Syphilis Theory —the  Ovarian Theory.  V.  The Displacement  Theory.  Vi.
  Summary. 
4
BLANCHARD & LEA'S MEDICAL
                           BROWN  (ISAAC  BAKER),
                       Surgeon-Accoucheur to St. Mary's Hospital, &c.
ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT-
  MENT.  With handsome illustrations.   One vol. 8vo., extra cloth.  {Now Ready.)  $1 00.
  Mr. Brown has earned for himself a high reputa-
tion in the  operative treatment of sundry diseases
and injuries to which females are peculiarly subject.
We can truly say of his work that it is an important
addition  to obstetrical literature.  The operative
suggestions and contrivances which Mr. Brown de-
scribes, exhibit much practical sagacity  and  skill,
and merit the careful attention  of every surgeon-
accoucheur.—Association Journal.

  We have no hesitation in recommending this book
to the careful attention of all surgeons who make
female complaints a part of their study and practice.
—Dublin Quarterly Journal.
                BENNETT (J.  HUGHES), M.D.,  F. R. S. E.,
               Professor of Clinical Medicine in the University of Edinburgh, &c.
THE  PATHOLOGY AND  TREATMENT OF  PULMONARY TUBERCU-
  LOSIS, and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken
  for or associated with. Phthisis.   In one handsome octavo volume, extra cloth, with beautiful
  wood-cuts.   pp. 130.   {Lately Issued.)  $ 1 25.
                       BUDD (GEORGE), M. D.,  F. R. S.,
                      Professor of Medicine in King's College, London.

ON  DISEASES  OF  THE  LIVER.   Second  American,  from the  second  and
  enlarged London edition.  In one very handsome octavo volume, extra cloth, with four beauti-
  fully colored plates, and numerous wood-cuts.  pp. 468.  $3 00.
  For many years, Dr. Budd's  work  must be the I  the subject has been taken up by so able and experi-
authority of the great mass of British  practitioners  enced a physician.—British and Foreign Medieo-
on the hepatic diseases ; and it is satisfactory that I  Chirurgical Review.

                          by the same author.  (Now Ready.)

ON  THE  ORGANIC DISEASES  AND  FUNCTIONAL DISORDERS  OF
  THE STOMACH.  In one neat octavo volume, extra cloth. $1 50.  A new work, 1856.
  While special treatises have been multiplying upon almost all the different classes of diseases, there
has long been felt the want of an authoritative work on the disorders of the stomach, which con-
stitute, perhaps, a larger proportion of the daily practice of the physician  than any other class of
maladies.  To supply this want has  been the object of the  author,  and his reputation is an ample
guarantee of the value of his labors.
  From the high position occupied by Dr. Budd as
a teacher, a writer, and a practitioner, it is almost
needless to state that the present book may be con-
sulted with great advantage. It is written in an easy
style, the subjects are well arranged, and the practi-
cal precepts, both of diagnosis and treatment, denot«
the character of a thoughtful and experienced phy-
sician.—London Med. Times and Gazette, Dec. 1S55.
                     BIRD  (GOLDING), A. M., M. D., &c.
URINARY   DEPOSITS:   THEIR   DIAGNOSIS,   PATHOLOGY,  AND
  THERAPEUTICAL INDICATIONS.  A new and enlarged American, from the last improved
  London edition.  With over sixty illustrations.  In one royal 12mo. vol, extra cloth, pp.372. $130.
  It can scarcely be necessary for us to say anything
of the merits of this well-known Treatise, which so
admirably brings into practical application the re-
sults of those microscopical and chemical researches
regarding the physiology and pathology of the uri-
nary secretion, which nave contributed  so much to
the  increase of our diagnostic powers, and to the
extension and satisfactory employment of our thera-
peutic resources.  In the preparation of this new
edition of his work, it is obvious that Dr. Golding
Bird has spared no pains to render it a faithful repre-
sentation of the present state of scientific knowledge
on the subject it embraces.— The British and Foreign
Medico-Chirurgieal Review.
BY THE SAME AUTHOR.
ELEMENTS OF NATURAL PHILOSOPHY;  being  an  Experimental Intro-
  duction to the Physical Sciences.  Illustrated with nearly four hundred wood-cuts.  From the
  third London edition.  In one neat volume, royal 12mo., extra cloth,  pp.402.  $125.
BILLING'S  PRINCIPLES  OF MEDICINE.—
  Second American, from the Fifth and Improved
  London edition.  In one handsome octavo volume,
  extra cloth. 250 pages.  $125.
BLAKISTON'S  PRACTICAL OBSERVATIONS
  ON  CERTAIN DISEASES OF THE  CHEST,
  and on the Principles of Auscultation. In one vol.,
  cloth, 8vo.  pp. 3S1.  $1 25.
BURROWS ON DISORDERS OF THE CERE-
  BRAL CIRCULATION, and on the  Connection
  between the Affections of the Brain and Diseases
  of the Heart.  In one 8vo. vol., extra cloth, with
  colored plates,  pp. 216.  SI  25.
BEALE ON  THE LAWS  OF HEALTH IN RE-
  LATION TO MIND AND  BODY.  A Series of
  Letters from an old Practitioner to a Patient.  In
  one volume, royal 12mo., extra cloth,  pp.  296.
  80 cents.
BUSHNAN'S PHYSIOLOGY OF ANIMAL AND
  VEGETABLE LIFE ; a Popular Treatise on the
  Functions and Phenomena of Organic Life.  In
  one handsome royal 12mo. volume, extra cloth,
  with over 100 illustrations,  pp.234.  80 cents.

BUCKLER ON THE ETIOLOGY, PATHOLOGY
  AND TREATMENT OF  FIBRO-BRONCHl-
  TIS AND  RHEUMATIC  PNEUMONIA.   In
  one8vo. volume, extra cloth,  pp.150.  $125.

BLOOD AND URINE (MANUALS ON).   BY
  JOHN  WILLIAM   GRIFFITH,  G.  OWEN
  REESE, AND  ALFRED MARKWICK.  One
  thick volume, royal  13mo.,  extra cloth,  with
  plates, pp. 460.  SI 25.

BRODIE'S CLINICAL LECTURES ON SUR-
  GERY.  1 vol. Svo., cloth.  350 pp. $125. 
AND  SCIENTIFIC PUBLICATIONS.
5
                          BARLOW  (GEORGE H.),  M.  D.
                           Physician to Guy's Hospital, London, &c.

A MANUAL  OF  THE  PRACTICE  OF MEDICINE.  With Additions by D.
  F. Condie, M.D., author of "A Practical Treatise on Diseases of Children," &c.  In one hand-
  some octavo volume, leather, of over 600 pages.  (A new vjork,just ready, 1850.)  S'2  75.
  The position of the author as physician  to Guy's Hospital and other large public institutions, is
a sufficient guarantee of the extent and value of the experience which is here systematically re-
corded and condensed.  His aim throughout has been to produce a 'practical work, on which the
student can rely as a guide, and to which the practitioner can refer with confidence.  The additions
by the editor comprise chapters on Cerebro-spinal Meningitis, Cholera Infantum, and Yellow Fever,
besides numerous notes wherever the diseases or practice  of this country seemed to render  them
necessary or desirable.
  We most emphatically commend it to the attention
of the profession, as deserving their  confidence—a
depository of practical knowledge, from which they
may draw with great benefit.—Cincinnati Med. Ob-
server, Mar. 1856.
  The student has long been in want of a good ele-
mentary work on the Practice of Medicine.   In Dr.
Barlow's Manual that want is supplied;  and we
have no question that it will  at once be installed
as the favorite  text-book in all Medical  Schools.—
Medical Times  and Gazette.
  We recommend Dr. Barlow's Manual in the warm-
est manner  as  a most valuable vade-mecum.  We
have hud frequent occasion to consult it, and have
found it clear, concise, practical, and sound. It is
eminently a practical  work, containing all that is
essential, and avoiding useless theoretical discus-
sion.  The work supplies  what has been for some
time wanting, a manual of practice based upon mo-
dern discoveries in pathology and rational views of
treatment of disease.  It is especially intended for
the use of students and junior practitioners, but it
will be found hardly less useful to the experienced
physician.  The American editor has added  to the
Work three chapters—on Cholera Infantum, Yellow
Fever, and Cerebro-spinal Meningitis.  These addi-
tions,  the two first of which are indispensable to a
work  on practice destined for the profession in thia
country, are executed with great judgment and fi-
delity, by Dr. Condie, who has also succeeded hap-
pily in imitating the conciseness and clearness of
style  which are such agreeable characteristics of
the original book.—Boston Med. and Surg. Journal,
Feb. 1856.

  We have looked  through this volume with very
great  satisfaction ; it is written in an easy and plea-
sant style, and the short though lucid expositions of
disease, clearness of description, and soundness of
precept will make it a welcome visitor in the library
of every practitioner.  It combines the simplicity of
old Cullen, with the elegance of Watson, and al-
though not so copious as other works we might men-
tion, it will, nevertheless, become a standard autho-
rity__American Lancet, Mar. 1856.
                           BARTLETT (ELISHA),  M. D.
THE  HISTORY,  DIAGNOSIS,  AND  TREATMENT  OF  THE  FEVERS
  OF THE UNITED STATES.  A new and revised edition.  By Alonzo Clark,  M. D., Prof.
  of Physiology and Pathology in the N. Y. Coll of Physicians and Surgeons, &c.  In one  octavo
  volume, of six hundred pages, extra cloth.  (Nearly Ready.)
  The masterly and elegant treatise by Dr. Bartlett
is invaluable to the American student and practi-
tioner.—Dr. Holmes's Report to the Nat. Med. Asso-
ciation.
  We regard it, from the examination we have made
of it, the best work on fevers extant in our language,
and as such cordially recommend it to the medical
public.—St. Louis Medicaland Surgical Journal.
  Take it altogether, it is the most complete history
of our fevers which  has  yet been published,  and
every practitioner should  avail  himself of its con-
tents.—The Western Lancet.
                           BOWMAN (JOHN  E.), M.D.
PRACTICAL  HANDBOOK  OF  MEDICAL  CHEMISTRY.   Second  Ame-
  rican, from the third and revised English Edition.  In one neat volume, royal 12mo., extra cloth,
  with numerous illustrations,  pp.288.  {Now Ready, 1856.)  $125.
  Presenting, in a condensed and convenient form, at a very low price, the applications of Chemistry
to the practical purposes of Clinical Medicine, this work  supplies a  want which has long been
felt by the physician.  The numerous editions which have been called for both in England and this
country, sufficiently attest the success with which the author has carried out his plan.

                                   BY THE SAME AUTHOR.

INTRODUCTION  TO   PRACTICAL   CHEMISTRY,  INCLUDING  ANA-
  LYSIS. With numerous illustrations.  In one neat vol., royal 12mo., extra cloth,  pp.350.  SI 25.
                           CURLING  (T.  B.),  F. R.S.,
             Surgeon to the London Hospital, President of the Hunterian Society, &c.

A PRACTICAL TREATISE ON  DISEASES  OF THE TESTIS, SPERMA-
  TIC CORD  AND SCROTUM.  Second American, from the second and enlarged English edi-
  tion  In one  handsome octavo volume, extra cloth, with numerous illustrations, pp. 420. (Now
  Ready, 1856.)  S"2 00.
  In the revised English edition, of which this is a reprint, the author, for want of space, omitted
the Anatomical  Introduction.  By a more condensed style of printing, room  has been found in  the
present volume  to retain this important portion without rendering the work inconveniently large.
kjine of the notes of the former American editor have also been incorporated, and a number of new
illustrations introduced. With these improvements, and the thorough revision which it has enjoyed
at the hands of  the author, it will be found fully worthy to retain the authoritative position which
it has acquired  with regard to this class of affections.
  We now take farewell, for the present, of tliis ex-
cellent treatise, placing it on our book shelves by
the side of Cooper on Fractures and Dislocations,
and other  similar standard and valuable works —
Asso. Med. Journal, Jan. 1S56.
  We shall not devote any further space to the work
under notice, as it is so well known to the profession
already.  We can only say that it should be in the
library of every practical surgeon. The present edi-
tion is much improved,  contains numerous wood-
cuts, and several accounts of cases illustrating the
various diseases of the testicles.—Med. Times and
Gazette, Feb. 1856. 
6                       BLANCHARD & LEA'S  MEDICAL
             CARPENTER (WILLIAM  B.), M.  D., F. R. S., &.C.,
           Examiner in Physiology and Comparative Anatomy in the University of London.

PRINCIPLES OF HUMAN  PHYSIOLOGY;  with their  chief applications  to
  Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from
  the last and revised London edition.  With nearly three hundred illustrations.  Edited, with addi-
  tions, by Francis Gurney Smith, M. D., Professor of the  Institutes of Medicine in the Pennsyl-
  vania Medical College, &c. In one very large and beautiful octavo volume, of about nine hundred
  large pages, handsomely printed and strongly bound in leather, with raised bands.   (Just Issued,
  1856.)  $4 *5.
  In the preparation of this new edition, the author has spared no labor to render it, as heretofore,
a complete  and lucid exposition of the  most  advanced condition  of its important subject.  The
amount of the additions required to effect this object thoroughly, joined to the former large  size of
the volume, presenting objections arising from the unwieldy  bulk of the work, he  has omitted all
those portions  not bearing directly upon Human Physiology, designing to incorporate them in
his forthcoming Treatise on General Physiology.   As a full and accurate text-book on the Phy-
siology of Man, the work in its present condition therefore  presents even greater claims upon
the student and physician than  those  which have heretofore won  for it the very wide and distin-
guished favor which it has so long enjoyed.  The additions of Prof. Smith will be found to supply
•whatever may  have been wanting to the American  student, while the introduction of many new
illustrations, and the  most careful  mechanical execution, render the volume one  of the most  at-
tractive as yet issued.
  For upwards of thirteen years Dr. Carpenter's
work has been considered by the profession gene-
rally, both in this country and England, as the most
valuable compendium on the subject of physiology
in our language. This distinction it owes to the high
attainments and unwearied industry of its accom-
plished author.  The present edition (which, like the
last American one, was prepared by the author him-
self), is the result of such extensive revision, that it
may almost be considered  a new work.   We need
hardly say, in concluding this brief notice, that while
the work is indispensable to every student of medi-
cine in this country, it will amply repay the  practi-
tioner for its perusal by  the interest and value of its
contents.—Boston Med.  and Surg. Journal.

  This is a standard work—the text-book used by all
medical students who read the  English language.
it has  passed through several editions in order to
keep pace with the rapidly growing science of Phy-
siology.  Nothing need  be said in its praise, for its
merits  are universally known ; we have  nothing to
say of its defects, for they only appear  where the
science of which it treats  is incomplete.—Western
Lancet.
  The most complete exposition of physiology which
any language can at present  give.—Brit, and For.
Med.-Chirurg. Review.

  The  greatest, the most reliable, and the best book
on  the subject which we  know of in the English
language.—Stethoscope.
  To eulogize this great work would be superfluous.
We should observe, however, that in this  edition
the author has remodelled a large portion of the
former, and the editor has added much matter of in-
terest, especially in the form of illustrations. We
may confidently recommend it. as the most complete
work on Human Physiology  in  our language.—
Southern Med. and Surg. Journal, December, 1855.
  The most  complete work on the science in our
language.—Am. Med. Journal.
  The most complete work now extant in our lan-
guage.—N. O. Med. Register.
  The best text-book in the language on this ex-
tensive subject.—London Med. Times.
  A complete cyclopaedia of  this branch of science.
—N. Y. Med. Times.
  The profession of this country,  and perhaps also
of Europe, have anxiously and for some time awaited
the announcement of this new edition of Carpenter's
Human  Physiology.  His former  editions have for
many years been almost the  only text-book on Phy-
siology in all our medical schools, and its circula-
tion among the profession has been unsurpassed by
any work in any department of medical science.
  It is quite unnecessary for  us  to  speak  of this
work as its merits  would  justify.  The mere an-
nouncement of its appearance will afford the highest
pleasure to  every student of Physiology, while  its
perusal  will be of  infinite service  in  advancing
physiological science.—Ohio Med. and Surg. Journ.
                          BY  the SAME author.  (Lately Issued.)

PRINCIPLES OF COMPARATIVE  PHYSIOLOGY.   New American, from
  the Fourth and Revised London edition.  In one large and handsome octavo volume, with over
  three hundred beautiful illustrations,  pp. 752.  Extra cloth, $4 80 ; leather, raised bands, $5 25.
  The delay which has existed in the appearance of this work has been caused by the very thorough
revision and remodelling which it has undergone at the hands of the author,  and  the large number
of new illustrations which have been prepared for it.  It will, therefore, be found almost a new
work,  and fully up to the day in every department of the  subject, rendering  it a reliable text-book
for all  students engaged in this  branch of science.  Every effort  has been made to render its typo-
graphical finish and mechanical execution worthy of its exalted reputation, and creditable to the
mechanical arts of this country.
  This book should not only be read but thoroughly
studied by every member of the profession.  None
are too'wise or old, to be benefited thereby.  But
especially to the younger class would we cordially
commend it as best fitted of any work in the English
language to qualify them for the reception and com-
prehension of those truths which are daily being de-
veloped in physiology.—Medical Counsellor.
  Without pretending to it, it is an encyclopedia of
the subject, accurate and complete in all respects—
a truthful reflection of the advanced state at which
the science has  now  arrived.—Dublin Quarterly
Journal of Medical Science.
  A truly magnificent work—in itself a perfect phy-
siological study.—Ranking's Abstract.
  This work stands without its. fellow. It is one
few men in Europe could have undertaken;  t is one
no man, we believe, could have brought to so suc-
cessful an issue as Dr. Carpenter,  ft required for
its production a physiologist at once deeply read in
the labors of others, capable of taking  a general,
critical, and unprejudiced view of those labors and
of combining the varied, heterogeneous materials at
his disposal, so as to form an  harmonious whole.
We feel that this abstractcan give the reader a very
imperfect idea of the fulness of this work, and  no
idea of its unity, of the admirable manner in which
material has been brought, from the most various
sources, to conduce to its completeness, of the lucid-
ity of the reasoning it contains, or of the clearness
of language in which the whole is clothed.  Not the
profession only, but the scientific world at large,
must feel deeply indebted  to Dr. Carpenter for this
great work. It must, indeed, add largely even to
his high reputation.—Medical Times. 
AND  SCIENTIFIC PUBLICATIONS.
7
                CARPENTER (WILLIAM B.),  M. D., F. R. S.,
          Examiner in Physiology and Comparative Anatomy in the University of London.
                                (Now Ready, June, 1856.)

THE  MICROSCOPE AND ITS REVELATIONS.   With an  Appendix con-
  taining the Applications of the Microscope to Clinical Medicine, &c.   By F. G. Smith, M. D.
  Illustrated by four hundred and thirty-four beautiful engravings on wood.  In one large and very
  handsome octavo volume, of 724 pages, extra cloth, S4 00 ; leather, $4  50.
  Dr. Carpenter's position as a microscopist and physiologist, and his great experience as a teacher,
eminently qualify him to produce what has long been wanted—a good text-book on the  practical
use of the microscope.  In the present volume  his object has been, as stated in his Preface, "to
combine, within a moderate compass, that information with regard 1o the use of his ' tools/ which
is most essential to  the working microscopist, with such an account of the objects best fitted for
his study, as might qualify him to comprehend what he observes, and might thus prepare  him to
benefit science, whilst expanding and refreshing his own mind "  That he has succeeded in accom-
plishing this, no one acquainted with his previous labors can doubt.
  The great importance of the microscope  as a means of diagnosis, and the number of microsco-
pists who are also physicians, have induced the American publishers, with the author's approval, to
add an Appendix, carefully prepared by Professor Smith, on the applications  of the instrument to
clinical  medicine, together with an  account of American Microscopes, their modifications  and
accessories.  This  portion of the work is illustrated with nearly one hundred wood-cuts, and, it is
hoped, will adapt the volume more particularly to the use of the American student.
  Every care has been taken in the mechanical execution  of the work, which  is confidently pre-
 sented as in no respect inferior to ihe choicest productions of the London press.
  The mode in which the author has executed his intentions may be gathered from the following
 condensed synopsis of the
                                      CONTENTS.
 Introduction—History of the  Microscope.   Chap.  I.  Optical  Principles of  the Microscope.
  Chap. II.  Construction of the Microscope.  Chap. III.  Accessory Apparatus.  Chap.  IV.
  Management of the  Microscope  Chap. V.  Preparation, Mounting; and Collection of Objects.
  Chap. VI.  Microscopic Forms of Vegetable Life—Protophytes.  Chap. VII. Higher Cryptoga-
   mia.   Chap. VIII. Phanerogamic Plants.  Chap. IX. Microscopic Forms of Animal Life—Pro-
   tozoa—Animalcules.  Chap. X. Foraminifera, Polycystina, and Sponges.  Chap. XI. Zoophytes.
   Chap. XII. Echinodermata.  Chap. XIII.  Polyzoa and Compound  Tunicata.  Chap. XIV.
   Molluscous Animals Generally.  Chap. XV.  Annulosa.  Chap. XVI. Crustacea.  Chap. XVII.
   Insects and Arachnida.  Chap. XVIII. Vertebrated  Animals.  Chap.  XIX. Applications of the
   Microscope to Geology.  Chap. XX.  Inorganic or Mineral Kingdom—Polarization.  Appendix.
   Microscope as a  means of Diagnosis—Injections—Microscopes of American Manufacture.
                                             and even those who have no previous acquaintance
                                             with the construction or uses of this  instrument,
                                             will find abundance of information conveyed in clear
                                             and simple language.—Med. Times and  Gazette,
                                             May, 1856.
  Those who are acquainted with Dr. Carpenter's
previous writings on Animal and Vegetable Physio-
logy, will fully understand how vast a store of know-
ledge he is able to bring to bear upon so comprehen-
sive a subject as the revelations of the microscope;
                                 BY THE SAME AUTHOR.

ELEMENTS  (OR MANUAL) OF  PHYSIOLOGY, INCLUDING PHYSIO-
  LOGICAL ANATOMY.  Second American, from a new and revised  London edition.   With
  one hundred and ninety illustrations.  In one very handsome octavo volume, leather,  pp. 566.
  $3 00.
  In publishing the first edition of this work, its title was altered from that of the London volume,
bv the substitution of the word "Elements" for that of " Manual," and with the author's sanction
the title of " Elements" is still retained as being more expressive of the scope of the treatise.
                                              Those who have occasion for an elementary trea-
                                            tise on Physiology, cannot do better than to possess
                                            themselves of the manual of Dr. Carpenter.—Medical
Examiner.
  The best and most complete expose "of modern
Physiology, in one volume, extant in the English
language.—St. Louis Medical Journal.
  To say that it is the best manual of Physiology
now before the public, would not do sufficient justice
to the author.—Buffalo Medical Journal.
  In his former works  it would seem that he had
exhausted the subjectof Physiology. In the present,
he gives the essence, as it were, of the whole.—N. Y.
Journal of Medicine.
                           by the same author.  (Preparing.)

PRINCIPLES OF  GENERAL  PHYSIOLOGY,   INCLUDING  ORGANIC
  CHEMISTRY AND HISTOLOGY.  With a General Sketch of the Vegetable and Animal
  Kingdom.  In one large and very handsome octavo volume, with several hundred illustrations.
  The°subiect of general phvsiology having been omitted in the last editions of the author's « Com-
paratfve Phvsiologv"  and "Human Physiology," he  has undertaken to prepare a volume which
shall present it more thoroughly and fully than has yet  been attempted, and which may be regarded
as an introduction to his other works.
                                 BY THE SAME AUTHOR.

 \ PRIZE ESS \Y ON THE USE OF ALCOHOLIC LIQUORS IN  HEALTH
* AND DISEASE.   New edition, with a Preface by D. F. Condie, M. D., and explanations of
  scientific words. In one neat 12mo. volume, extra cloth,  pp. 178.   {Just Issued.)  50 cents.
                            CHELIUS (J. M.), M. D.,
                    Professor of Surgery in the University of Heidelberg, &c.
\ SYSTEM OF  SURGERY.   Translated  from the German,  and  accompanied
*  with additional Notes and References, by John F. South. Complete in three very large octavo
  volumes, of nearly 2200 pages, strongly bound, with raised bands and double titles.  $>10 00. 
8
BLANCHARD & LEA'S MEDICAL
                           CONDIE (D. F.),  M. D., &c.

A  PRACTICAL TREATISE  ON THE DISEASES OF CHILDREN.  Fourth
  edition, revised and augmented.  In one large volume, 8vo., leather, of nearly 750 pages. $3 00.

                              From the Author's Preface.
  The demand for  another edition has afforded  the author an opportunity of again subjecting the
entire treatise to a careful revision, and of incorporating in it every important observation recorded
since the appearance of the last edition, in reference to the pathology and therapeutics of the several
diseases of which it treats.
  In the preparation of the present edition, as in those which have preceded, while the author has
appropriated to his use  every important fact that he has found recorded in the works of others,
having a direct bearing upon either of the subjects of which he treats, and the numerous valuable
observations—pathological as well as practical—dispersed throughout the pages of the  medical
journals of Europe and America, he has, nevertheless, relied chiefly upon his own observations and
experience, acquired during a long and somewhat extensive practice, and  under circumstances pe-
culiarly well adapted for the clinical study of the diseases of early life.
  Every species of hypothetical reasoning has, as much as possible, been avoided. The author has
endeavored throughout the work to confine himself to a simple statement of well-ascertained patho-
logical facts, and plain therapeutical  directions—his  chief desire being to render it what its title
imports it to be, a practical treatise on the diseases  of children.
  Dr. Condie's scholarship, acumen, industry, and
practical sense are manifested in this, as in all his
numerous contributions to science.—Dr. Holmes's
Report to the American Medical Association.
  Taken as a whole, in our judgment, Dr. Condie's
Treatise  is the one from  the perusal of which the
practitioner in this country will rise with  the great-
est  satisfaction.—Western Journal of Medicine and
Surgery.
  One of  the best works upon the Diseases of Chil-
dren in the English language.—Western Lancet.
  Perhaps the most full and complete work now be-
fore the profession of the United States; indeed, we
may say in the English language. It is vastly supe-
rior to most of its predecessors.—Transylvania Med.
Journal.
  We feel assured from actual experience that no
physician's library can be complete without a copy
of this work.—JV.  Y. Journal of Medicine.

  A veritable psediatric encyclopaedia, and an honor
to American medical literature.—Ohio Medical and
Surgical Journal.

  We feel persuaded that the American medical pro-
fession will soon regard it not only as a very good,
but as the very best "Practical Treatise on the
Diseases of Children."—American Medical Journal.

  We pronounced the first edition to be. the best
work on the diseases of children  in the English
language, and,  notwithstanding all that has  Deen
published, we still regard it in that light.—Medical
Examiner.
            CHRISTISON  (ROBERT), M. D., V. P.  R. S. E.,  &c.

A DISPENSATORY; or,  Commentary on  the  Pharmacopoeias of Great Britain
  and the United States; comprising  the Natural History, Description, Chemistry, Pharmacy, Ac-
  tions, Uses, and Doses of the Articles of the Materia Medica.  Second edition, revised and im-
  proved, with a Supplement containing the most important New Remedies.   With copious Addi-
  tions, and two hundred and thirteen large wood-engravings.  By R. Eglesfeld Griffith, M. D.
  In one very large and handsome octavo volume, leather, raised bands, of over 1000 pages. $3 50.
  It  is not needful that w«j should compare it with
the other pharmacopoeias extant, which enjoy and
merit the confidence of the profession : it is enough
to say that it appears to us as perfect as a Dispensa-
tory, in the present state of pharmaceutical science
could be made.  If it omits any details pertaining to
this branch of knowledge which the student has a
right to expect in such a work, we confess the omis-
sion has escaped our scrutiny. We cordially recom-
mend this work to such of our readers as are in need
of a Dispensatory.  They cannot make choice of a
better.—Western Journ. of Medicine and Surgery.
                        COOPER (BRANSBY  B.), F. R. S.

LECTURES ON  THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.
  In one very large octavo volume, extra cloth, of 750 pages.  $3 00.
COOPER  ON DISLOCATIONS AND  FRAC-
  TURES OF THE JOINTS—Edited by Bransbt
  B. Cooper, F.R.S., &c. With additional Ob-
  servations by Prof. J. C. Warren.  A new Ame-
  rican edition.  In one  handsome octavo volume,
  extra cloth, of about 500 pages, with numerous
  illustrations on wood.  $3 25.
COOPER ON THE ANATOMY AND TREAT-
  MENT OF ABDOMINAL HERNIA.  One large
  volume, imperial 8vo., extra cloth, with over 130
  lithographic figures.  $2 50.
COOPER ON THE ANATOMY AND DISEASES
  OF THE BREAST, with twenty-five Miscellane-
  ous and Surgical  Papers.  One large volume, im-
  perial 8vo., extra cloth, with  252 figures, on 36
  plates.  $2 50.,
COOPER  ON THE  STRUCTURE AND DIS-
  EASES  OF  THE  TESTIS, AND  ON THE
  THYMUS GLAND.  One vol. imperial 8vo., ex-
  tra cloth, with 177 figures on 29 plates.  $2 00.
COPLAND ON  THE CAUSES, NATURE, AND
  TREATMENT OF PALSY AND APOPLEXY.
  In  one volume, royal 12mo., extra cloth, pp. 320.
  80 cents.
CLYMER ON FEVERS; THEIR DIAGNOSIS,
  PATHOLOGY, AND TREATMENT   In one
  octavo volume, leather, of 600 pages,  f 1 50.
COLOMBAT DE L'ISERE ON THE DISEASES
  OF FEMALES, and on the  special Hygiene of
  their Sex. Translated, with many Notes and Ad-
  ditions, by C.  D. Meigs, M. D.  Second edition,
  revised and improved.  In one large volume, oc-
  tavo, leather, with numerous wood-cuts. dp. 720
  $3 50.                              rp
                           CARSON  (JOSEPH),  M. D.,
           Professor of Materia Medica and Pharmacy in the University of Pennsylvania

SYNOPSIS OF THE  COURSE  OF  LECTURES ON MATERIA  MEDICA
  AND PHARMACY, delivered in the  University of Pennsylvania.  Second and  revised edi-
  tion.  In one very neat octavo volume, extra cloth, of 208 pages.  (Now Ready.)  $1 50. 
AND  SCIENTIFIC  PUBLICATIONS.
9
               CHURCHILL (FLEETWOOD), M. D.,  M. R.  I. A.

ON THE  THEORY AND PRACTICE OF MIDWIFERY. A new American,
  from the last and improved English edition.  Edited, with Notes and  Additions, by D. Francts
  Condie, M. D., author of a "Practical Treatise on  the Diseases of Children," &c.  With 139
  illustrations.  In one very handsome octavo volume, leather,  pp.510.  S3 00.
  To bestow praise on a book that has received such
marked approbation would be superfluous. We need
only say, therefore,  that if the first edition was
thought worthy of a favorable reception  by the
medical public, we can confidently affirm that this
will be found much  more  so.  The lecturer, the
practitioner, and the student, may all have recourse
to its pages, and derive from their perusal much in-
terest and instruction  in everything relating to theo-
retical and practical midwifery.—Dublin Quarterly
Journal of Medical Science.

  A work of very great merit, and  such as we can
confidently recommend to the study of every obste-
tric practitioner.—London Medical Gazette.

  This is certainly the most perfect system extant.
It is the best  adapted for  the purposes of a text-
book, and that which he whose  necessities confine
him to one book, should select in preference to all
others.—Southern Medical  and Surgical Journal.

  The most popular work on midwifery ever issued
from the American press.—Charleston Med. Journal.

  Were we reduced to the necessity of having but
one work on midwifery, and permitted  to choose,
we would unhesitatingly take Churchill.—Western
Sled, and Surg. Journal.
  It is  impossible to conceive  a more useful and
elegant  manual than Dr.  Churchill's Practice of
Midwifery.—Provincial Medical Journal.

  Certainly, in our opinion, the very best work on
the subject which exists.—N. Y. Annalist.
  No work holds a higher position, or is more de-
serving of being placed in the hands of the tyro,
the advanced student, or the practitioner.—Medical
Examiner.

  Previous editions, under the editorial supervision
of Prof R.  M. Huston, have been received with
marked favor,  and they deserved it; but this, re-
printed from a very late Dublin edition, carefully
revised and brought up by the author to the present
time, does present  an unusually accurate and able
exposition of every important particular embraced
in the department of midwifery.  * * The clearness,
directness, and precision of its  teachings,  together
with the great  amount of statistical research which
its text exhibits, have served to place it already in
the foremost rank of works in this department of re-
medial science.—N. O. Med. and Surg. Journal.

  In our opinion, it forms one of the best if not the
very best text-book and epitome of obstetric science
which  we at present possess in the English lan-
guage.—Monthly Journal of Medical Science.

  The clearness and precision of style in  which it is
written, and the great amount of statistical research
which it contains, have served to place it in the first
rank of works in this departmentof medical science.
— N. Y. Journal of Medicine.

  Few treatises will  be found better adapted as a
text-book for the  student, or as a manual for the
frequent consultation of the young  practitioner.—
American Medical Journal.
                         BY THE SAME author.   (Now Ready, 1856.)

ON THE  DISEASES  OF INFANTS  AND  CHILDREN,   Second American
  Edition, revised and enlarged by the author. Edited, with Notes, by W. V. Keating, M. D.  In
  one large and handsome volume, extra cloth, of over 700 pages.   $3 00, or in leather, S3 25.
  In preparing this work a second time for  the  American profession, the author has  spared no
labor in giving it a very thorough revision, introducing several new chapters, and rewriting others,
while every portion of the volume has been subjected  to a severe scrutiny.  The efforts of the
American editor have been  directed to supplying  such information relative to matters peculiar
to this  country as  might have  escaped  the attention of the author, and the whole may, there-
fore, be safely pronounced one of the most complete works on the  subject accessible to the Ame-
rican Profession.  By an alteration in the size of the page, these very extensive additions  have
been accommodated without unduly increasing the size of the work.
  A few notices of the former edition are subjoined :—
                                                  The present volume will sustain the  reputation
                                                acquired by the author from his previous works.
                                                The reader will find  in it full and judicious direc-
                                                tions for the management of infants at birth,  and a
                                                compendious, but clear account of the diseases to
                                                which children are liable, and the most successful
                                                mode of treating them.  We must not close this no-
  We regard this volume as possessing more claims
to completeness than any other of the  kind  with
which we are acquainted.  Most cordially and ear-
nastly, therefore, do we commend it to our profession-
al brethren, and we feel assured that the stamp of
their approbation will indue time be impressed upon
it.  After an attentive perusal of its  contents,  we
hesitate not to say,  that it is one of the most  com-
prehensive ever written upon the diseases of chil-
dren, and that, for copiousness of reference, extent of
research, and  perspicuity of detail, it is scarcely to
be equalled, and  not  to be excelled, in any lan-
guage.—Dublin Quarterly Journal.

  After this meagre, and we know, very imperfect
notice of  Dr. Churchill's work, we shall  conclude
by saying, that it is one that cannot fail from its  co-
piousness, extensive research, and general accuracy,
to exalt still higher  the reputation of the author in
this country.   The American reader will benarticu-
iarly pleased to find that Dr. Churchill has done full
justice throughout his work to the various American
authors on this  subject.  The names of Dewees,
Eberle, Condie, and Stewart, occur on nearly every
pa»e, and these authors are constantly referred to by
the author in  terms  of the highest praise, and with
the most liberal courtesy.—The Medical Examiner.
tice without calling attention to the author's style,
which is perspicuous and polished to a degree, we
regret to say, not generally characteristic of medical
works.  We recommend the work of Dr. Churchill
most cordially, both to students and practitioners,
as a valuable and reliable guide in the treatment of
the  diseases of children.—Am. Journ. of the Med.
Sciences.

  We know of no work on this department of Prac
tical Medicine which presents so candid and unpre-
judiced a  statement or posting up of our actual
knowledge as this.—N. Y. Journal of Medicine.

  Its claims to merit both as a scientific and practi-
cal  work, are of  the highest  order.   Whilst we
would not elevate it above every other treatise on
the same subject, we certainly believe that very few
are equal  to it, and none superior.—Southern Med.
and Surgical Journal.
                                    BY THE SAME AUTHOR.

ESSAYS ON  THE  PUERPERAL  FEVER, AND  OTHER  DISEASES  PE-
  CULIAR TO WOMEN.  Selected from the writings of British Authors previous to the close of
  the Eighteenth Century.  In one neat octavo volume, extra cloth, of about 450 pages.  §2 50. 
10
BLANCHARD  &  LEA'S  MEDICAL
            CHURCHILL (FLEETWOOD),  M.  D.,  M. R.  I. A.,  &.C

ON  THE DISEASES OF WOMEN; including those of Pregnancy  and Child-
  bed.  A new American edition, revised by the Author.  With Notes and Additions, bv D  Fran-
  cis Condie, M. D., author of "A Practical Treatise on the Diseases of Children."  In one large
  and handsome octavo volume, with wood-cuts, leather, pp. 684.   $3  00.
                                                larity.  This fifth edition, before us.  is well  calcu-
  YVenow regretfully take leave of Dr. Churchill's
book.  Had our typographical limits permitted, we
should gladly have borrowed  more from its richly
stored pages.  In  conclusion, wc heartily recom-
mend it to the profession, and would at the same
time express our firm conviction that it will not only
add to the reputation of its author, but will prove a
work of great and extensive utility to obstetric
practitioners.—Dublin Medical Press.

  Former editions of this work have been noticed in
previous numbers of the Journal.  The sentiments of
high commendation expressed in those notices, have
only to be repeated in this; not from the fact that
the profession at  large are not aware  of the high
merits which this work really possesses, but from a
desire to see the principles  and doctrines therein
contained more generally recognized, and more uni-
versally carried out in practice.—N. Y. Journal of
Medicine.

  "We know of no author who deserves  that appro-
bation, on "the diseases of females," to the same
extent that Dr. Churchill does.  His, indeed, is the
only thorough  treatise we know of on the subject;
and it may be commended to practitioners and stu-
dents as a masterpiece in its particular department.
The former editions of this  work have been com-
mended strongly in this journal, and they have won
their way to an extended, and a well-deserved popu-
lated  to maintain Dr. Churchill's high reputation.
It was revised  and enlarged by the  author, for his
American publishers, and it seems to us that there is
scarcely any species of desirable information on its
subjects that may not be found in this work.—Tht
Western Journal of Medicine and Surgery.

  We are gratified to announce a new and  revised
edition of Dr. Churchill's valuable work on the dis-
eases of females   We have ever regarded it as one
of the very best works  on the subjects embraced
within its scope, in the English language; and the
present edition, enlarged and revised by the author,
renders it still more entitled to the confidence of the
profession.  The valuable  notes of Prof. Huston
have been retained, and contribute, in  no small de-
gree,  to enhance the  value of the  work.  It is a
source of congratulation that the publishers have
permitted the author  to  be, in  this instance, his
own editor, thus securing  all  the  revision  which
an author alone is capable of making.—The Western
Lancet.

  As  a comprehensive manual for students, or  a
work of reference for practitioners, we only speak
with common justice when  we say that it surpasses
any other that  has ever  issued on  the same sub-
ject from the British press.—The Dublin Quarterly
Journal.
                              DICKSON  (S.  H.),  M. D.,
       Professor of Institutes and Practice of Medicine in the Medical College of South Carolina.

ELEMENTS  OF MEDICINE;  a Compendious View  of Pathology  and  Thera-
  peutics, or the History and Treatment of Diseases.  In one large and handsome octavo volume,
  of 750 pages, leather   (Now Ready.)  $3 75.
  As an American text-book on the Practice of Medicine for the student, and as a condensed work
of reference for the practitioner, this volume will have strong claims on the attention of the profession.
Few physicians have had wider opportunities than the author for observation and experience, and
few perhaps have used them better.   As the  result of a life of study and  practice, therefore, the
present volume will doubtless be received with the welcome it deserves.
  This book is eminently what it professes to be:  a
distinguished  merit in these days.   Designed for
11 Teachers and Students of Medicine," and admira-
bly suited to their wants, we think it will be received,
on its own merits, with a hearty welcome.—Boston
Med. and Surg. Journal.
  Indited by one of the most accomplished writers
of our country, as well as by one who has long held
a high position among teachers and practitioners of
medicine,  this work is entitled to patronage and
careful study.  The learned  author has endeavored
to condense in  this volume most of  the practical
matter contained in his former productions, so as to
adapt it to  the use of those who  have not time to
devote to more extensive works.—Southern Med. and
Surg. Journal.
  We can strongly recommend Dr. Dickson's work
to our readers as one of interest and practical utility,
well deserving of a place in  their libraries as a book
of referenct ;  and we especially commend the first
part as presenting an admirable outline of  the princi-
ples of medicine.—Dublin Quarterly Journal, Feb.
1S56
  This volume, while  as its title  denotes  it is a
compendious view, is also a comprehensive  system
of practice, perspicuously and pleasantly written,
and admirably suited to engage the interest, nnd in-
struct the reader.—Peninsular Journal of Medicine,
Jan. 1S56.
  This volume is designed as a text-book for teachers
and students; but its merits extend far beyond tts
modest dedication ; it is a complete treatise upon me-
dicine, and one that will stand the test of years. The
arrangement is simple, a feature oftentimes obscured
in otherwise excellent  works.  This  Treatise is  a
valuable addition to our medical literature, and in the
clear and accurate descriptions, purity, and simpli-
city of style, and soundness of precept, the reader
will find much to admire and adopt, and not a little
that calls for deep reflection.  We cordially recom-
mend this volume to our readers, whether old prac-
titioners or students, for we take it that the physician
should always be a student.—American Lancet.
  Prof. Dickson's work supplies, to a great extent,
a desideratum  long felt in American medicine.—N.
O. Med. and Surg. Journal.
  Estimating this work according to the purpose for
which  it is  designed, we must think highly of its
merits, and we have no hesitation in  predicting for
it a favorable reception by both students and teachers.
  Not professing to be a complete and comprehensive
treatise, it will not be found full in detail, nor filled
with discussions of theories and  opinions, but  em-
bracing all that is essential  in theory  and  practice,
it is admirably adapted to the wants of the American
student.  Avoiding all that  is uncertain, it presents
more clearly to the mind of  the reader that which  is
established and verified by experience.  The varied
and extensive reading of the author is conspicuously
apparent, and all the recent  improvements and  dis-
coveries in therapeutics and pathology are chroni-
cled in its pages.—Charleston Med. Journal.

  In the first part of the work the subject of gene-
ral  pathology is presented in outline, giving a btau-
tiful picture  of  its distinguishing  features,  and
throughout the succeeding chapters we find that he
has kept  scrupulously  within the bounds of sound
reasoning  and legitimate  deduction.  Upon  the
whole, we do not hesitate to pronounce it a superior
work  in its  class, and that Dr.  Dickson merits a
place in the first rank of American writers.—Western
Lancet.
DAY'S  PRACTICAL TREATISE  ON THE DO- I DE JONGH ON COD-LIVER OIL, comparatively
  MKSTIC  MANAGEMENT AND MORE IM-    considered,  with its Chemical and Therapeutic
  PORTANT DISEASES OF ADVANCED LIFE. I   Properties. In one 12rno. vol., ex. cloth.  75 cents
  One volume, octavo, cloth, 226 pages. $1 00. 
AND  SCIENTIFIC  PUBLICATIONS.
11
                      DRUITT  (ROBERT),  M.R. C.S., &.c.
THE  PRINCIPLES  AND PRACTICE  OF  MODERN  SURGERY.   A new
  American, from  the improved London edition.   Edited by F. 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, leather, of 576 large pages.  $3 00.
  Dr. Druitt's researches into the literature of his
subject have been not only extensive, but well di-
rected ; the most discordant authors are fairly and
impartially quoted, and, while due credit is given
to each, their respective merits are weighed with
an unprejudiced hand.  The grain of wheat is  pre-
served, and  the chaff is unmercifully stripped off.
The arrangement is simple and  philosophical, and
the style, though clear and interesting, is so precise,
that the book contains more information condensed
into a few words than any other surgical work with
which we  are acquainted.—London Medical Times
and Gazette.

  No work, in our opinion, equals it in presenting
so much valuable surgical matter  in  so  small a
compass.—St. Louis Med. and Surgical Journal.

  Druitt's Surgery is too well known to the Ameri-
can medical profession to require its announcement
anywhere.  Probably no work of the kind has  ever
been more cordially received and extensively circu-
lated than this. The fact that it comprehends in a
comparatively small compass, all the essential  ele-
ments of theoretical and practical Surgery—that it
is found to contain reliable and authentic  informa-
tion on the nature and treatment of nearly all surgi-
cal affections—is a sufficient reason for the liberal
patronage it  has obtained.  The  editor, Dr. F. W.
Sargent, has contributed much to enhance the value
of the work, by such American improvements as are
calculated more perfectly  to adapt  it to our  own
views  and practice in  this  country.  It abounds
everywhere with spirited and life-like illustrations,
which to the young surgeon, especially, are of no
minor consideration. Every medical man frequently
needs just such a work as this, for immediate refer-
ence in moments of sudden emergency, when he has
not time to consult more elaborate treatises.—The
Ohio Medical and Surgical Journal.

  The author has evidently ransacked every stand-
ard treatise of ancient and modern times, and all  that
is really practically useful at the bedside will be
found in a form at once clear, distinct, and interest-
ing.—Edinburgh Monthly Medical Journal.

  Druitt's work, condensed, systematic, lucid, and
practical as it is, beyond most works on Surgery
accessible to the American student, has  hud much
currency in this country, and under its present au-
spices promises to rise to yet  higher favor.—The
Western Journal of Medicine and Surgery.

  The most accurate and ample resume of the pre-
sent state of Surgery that we are acquainted with.—
Dublin Medical Journal.

  A  better book  on  the principles and practice of
Surgery as now understood in England and America,
has not been given to the profession.—Boston Medi-
cal and Surgical Journal.

  An unsurpassable compendium, not only of Sur-
gical,  but of Medical Practice.—London Medical
Gazette.
  This work merits our warmest commendations,
and we strongly recommend it to young surgeons as
an admirable digest of the principles and practice of
modern Surgery.—Medical Gazette.

  It  maybe  said with truth  that the work of Mr.
Druitt affords a  complete, though  brief  and  con-
densed view, of the entire field of modern surgery.
We know of no work on the same subject having the
appearance of a manual, which includes so many
topics of interest to the surgeon ;  and the terse man-
ner in which each has been treated evinces a  most
enviable quality of mind on the part of the author,
who seems to have an innate power of  searching
out and grasping the leading facts  and features of
the most elaborate productions of the pen.  It is a
useful handbook for the practitioner, and we should
deem a teacher of surgery unpardonable who did not
recommend it to his pupils.  In our own opinion, it
is admirably adapted to the wants of the student.—
Provincial Medical and Surgical Journal.
           DUNGLISON,  FORBES,  TWEEDIE,  AND  CONOLLY.
THE  CYCLOPAEDIA OF  PRACTICAL MEDICINE: comprising Treatises on
  the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women
  and  Children, Medical Jurisprudence, &c. &c.  In four large super-royal  octavo volumes, of
  3254 double-columned pages, strongly and handsomely bound, with raised bands.   $12 00.
  *%.* This work contains no less than four hundred and eighteen distinct treatises, contributed by
sixty-eight distinguished physicians, rendering it  a complete library  of reference for the country
practitioner.
  The most complete work on Practical Medicine
extant;  or, at least, in  our  language.—Buffalo
Medical and Surgical Journal.
  For reference, it is above all price to every prac-
titioner.—Western Lancet.
  One of the most valuable medical publications of
the day—as a work of reference it is invaluable.—
Western Journal of Medicine and Surgery.
  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
unquestionably one of very great value to the prac-
titioner.  This estimate of it has not been formed
from a hasty examination, but after an intimate ac-
quaintance 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, Dub-
lin, and Glasgow.  It is, indeed, the great merit of
this work that the principal articles have been fur-
nished 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 Journ.
DEWEES'S COMPREHENSIVE SYSTEM  OF
  MIDWIFERY.  Illustrated by occasional cases
  and many engravings.  Twelfth edition, with the
  author's  last improvements and corrections   In
  one octavo volume, extra cloth, of 600 pages. $3 20.
DEWKI'S'S TREATISE ON THE PHYSICAL
  AND  MEDICAL TREATMENT  OF CHILD-
  REN.  Tenth edition.  In  one volume, octavo,
  extra cloth, 518 pages.  $2 80.
DEWEES'S TREATISE  ON THE DISEASES
  OF FEMALES.  Tenth edition. In one volume,
  octavo, extra cloth, 532 pages, with plates.  So 00.
DANA ON ZOOPHYTES AND CORALS   In one
  volume, imperial quarto, extra cloth, with wood-
  cuts. sl5 00.  Also, AN ATLAS, in one volume,
  imperial folio, with sixty-one magnificent colored
  plates.   Bound in  half morocco.  $30 00.
DE LA BECHE'S GEOLOGICAL  OBSERVER-
  In one very large and handsome octavo volume, ex-
  tra cloth, of 700 pages, with 300 wood-cuts. i?4 00.
FRICK ON RENAL AFFECTIONS; their Diag-
  nosis and Pathology.  With illustrations.   One
  volume, royal 12mo., extra cloth.  75 cents 
12
BLANCHARD &  LEA'S  MEDICAL
                          DUNGLISON  (ROBLEY),  M.D.,
          Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia.

MEDICAL  LEXICON;  a Dictionary of Medical Science, containing a  concise
  Explanation of the various Subjects and Terms'of Physiology, Pathology, Hygiene, Therapeutics,
  Pharmacology, Obstetrics, Medical Jurisprudence, «5cc.  With the French and other Synonymes;
  Notices of Climate and of celebrated Mineral Waters;  Formulae for various Officinal, Empirical,
  and Dietetic Preparations, etc. Thirteenth edition, revised, is now ready.  T$ one very thick
  octavo volume, of over nine hundred large double-columned pages, strongly bound in  leather,
  with raised bands.   $4 00.
  Every successive edition of this work bears the marks of the industry of the author, and of his
determination to keep it fully on a level with the  most advanced state of medical science.  Thus
nearly fifteen thousand words have been added to it within the last few years.  As a complete
Medical Dictionary, therefore, embracing over FIFTY  THOUSAND  DEFINITIONS, in all  the
branches of the science, it is presented as meriting a continuance of the great favor and popularity
which have carried it, within no very long space of time, to a thirteenth edition.
  Every precaution has been  taken in the preparation of the present volume,  to render its mecha-
nical execution and typographical accuracy worthy of its extended reputation and universal use.
The very extensive additions have been accommodated,  without materially increasing the  bulk of
the volume by the employment of a small but exceedingly clear type, cast for this purpose.  The
press has been watched with  great care, and every effort used to insure the verbal accuracy so ne-
cessary to a work of this nature.   The whole is printed on fine white paper; and, while thus exhi-
biting in every respect so great an improvement over former issues, it is presented at the original
exceedingly low price.
  We welcome it cordially; it is an admirable work,
and indispensable to all literary medical men.  The
labor which has been bestowed upon it is something
prodigious.  The work, however,  has  now  been
done, and we are happy in the thought that no hu-
man being will have  again to undertake the same
gigantic task.  Revised and corrected from time to
time, Dr. Dunglison's " Medical Lexicon" will last
for centuries.—British and Foreign  Med.-Chirurg.
Review.
  The fact that this excellent and  learned work has
passed  through  eight  editions, and that  a ninth is
rendered necessary by the demands of the public,
affords a sufficient evidence of the general apprecia-
tion of Dr.  Dunglison's labors by the medical pro-
fession in England and America.  It is a book which
will be of great service to the student, in teaching
him  the meaning of all the technical terms used in
medicine, and will be of no less use to the  practi-
tioner who desires to  keep himself on a  level with
the advance of medical science.—London Medical
Times  and Gazette.
  In taking leave of our author, we feel compelled
to confess  that  his work bears evidence  of almost
incredible labor having been bestowed upon its com-
position.—Edinburgh Journal of Med. Science.
  A  miracle of labor  and  industry in one who has
written able and voluminous works on nearly every
branch of medical science.  There could be no more
useful  book to the  student or practitioner, in the
present advancing age, than one in which would be
found,  in addition to the ordinary meaning and deri-
vation  of medical terms—so many of which are of
modern introduction—concise descriptions of their
explanation and employment;  and all this and much
more is contained in  the volume  before us.  It is
therefore almost as indispensable to the other learned
professions as to our own.  In fact, to all who may
have occasion to ascertain the meaning of any word
belonging to the many branches of  medicine.  From
a careful examination of the present edition, we can
vouch for its accuracy, and for its being brought
quite up to the date of publication ;  the author states
in his preface that he has added to it about four thou-
sand terms, which are not to be found in the prece-
ding one. — Dublin Quarterly  Journal of Medical
Sciences.
  On the appearance  of the last edition of this
valuable work, we directed the  attention  of our
readers to  its peculiar merits; and we need do
little more than state, in  reference to the present
reissue, that, notwithstanding the large additions
previously  made to it, no fewer  than four thou-
sand terms, not to be found in the preceding  edi-
tion, are contained  in the  volume  before us.—
Whilst it is a wonderful monument of its author's
erudition and industry, it  is also a work of great
practical utility, as we can  testify from our own
experience; for we keep it constantly within our
reach,  and make  very frequent  reference to it,
nearly always finding in it  the information we seek.
—British and Foreign Med.-Chirurg. Review.

  It has the rare merit that it certainly has no rival
in the English  language for accuracy and extent
of references.  The terms  generally include short
physiological  and pathological descriptions, so that,
as the  author justly observes,  tne reader does not
possess in this work a mere dictionary, but a book,
which, while it instructs him in medical etymo-
logy, furnishes  him with a large amount of useful
information.  The  author's labors  have  been pro-
perly appreciated by his own countrymen ; and we
can only confirm their judgment, by recommending
this most useful volume to the notice of  our cisat-
lantic readers. No medical library will be complete
without it.—London Med. Gazette.

  It is certainly more complete and comprehensive
than any with  which  we are acquainted in the
English language.  Few,  in fact, could be found
better qualified than Dr. Dunglison for the produc-
tion  of such  a  work.  Learned, industrious, per-
severing, and accurate, he brings to the task all
the peculiar  talents necessary for  its  successful
performance;  while, at the  same time,  his fami-
liarity  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 various modifications which medical term-
inology has undergone with the change  of theo-
ries 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.

  The  most comprehensive and best English Dic-
tionary of medical  terms extant.—Buffalo Medical
Journal.
                                   BY THE  SAME AUTHOR.

THE PRACTICE  OF  MEDICINE.    A Treatise on Special Pathology and The-
  rapeutics.  Third Edition.   In two large octavo volumes, leather, of 1,500 pages.  $6 25.
  Upon every topic embraced in the work the latest
information  will be found  carefully posted up.—
Medical Examiner.

  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.

  It is certainly the most complete treatise of which
we haveany knowledge.—Western Journal of Medi-
cine and Surgery.

  One of the most elaborate treatises of the kind
we have.—Southern Med. and Surg. Journal. 
AND SCIENTIFIC  PUBLICATIONS.
13
                         DUNGLISON  (ROBLEY),  M.D.,
          Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia.
HUMAN  PHYSIOLOGY.   Eighth  edition.   Thoroughly revised  and  exten-
  sively modified and enlarged, with five hundred and thirty-two illustrations.  In two large and
  handsomely printed octavo volumes, leather, of about 1500 pages.  (Just Ready, 1856.)  $7 00.
  In revising this work for its eighth appearance, the author has spared no labor to render it worthy
a continuance of the very great favor which has been extended to  it by the profession.   The whole
contents have been rearranged, and to a great extent  remodelled ;  the investigations which of late
years have been so numerous and so important, have  been carefully examined and incorporated,
and the work in every respect has been brought up to a level with the present state of the subject.
The object of the author has been to render it a concise but comprehensive treatise, containing the
whole body of physiological  science, to which the student and man of science can at all times refer
with the certainty of finding whatever they are in search of, fully  presented in all its aspects; and
on no former edition has the author bestowed  more labor to secure this result.
  A similar improvement will be found  in the typographical execution of the volumes, which, in
this  respect, are superior to  their predecessors. A large number of additional wood-cuts have been
introduced, and  the  series of illustrations has been greatly modified by  the substitution of many
new ones for such as were  not deemed satisfactory.   By an enlargement of the page, these very
considerable additions have  been accommodated without increasing the size of the volumes to  an
extent to render them unwieldy.
  It has long since taken rank as one of the medi-
cal classics of our language.  To say that it is by
far the best text-book of physiology ever published
in this country,  is but echoing  the general testi-
mony of the profession.—N. Y. Journal of Medicine.

  There is no single book we would recommend to
the student or physician, with  greater confidence
than  the present, because in it will be found a mir-
ror of almost every standard physiological work of
the day.  We most cordially recommend  the work
to every member of the profession, and no student
should be without it.  It is the completest work on
Physiology in the English language, and is highly
creditable to the author and publishers.—Canadian
Medical Journal.
  The most  complete  and satisfactory  system of
Physiology in the English language.—Amer. Med.
Journal.
  The best work of the  kind  in the English lan-
guage.—Silliman's Journal.
  The most full and complete system of Physiology
in our language.—Western Lancet.
                                   BY THE SAME AUTHOR.

GENERAL   THERAPEUTICS   AND   MATERIA MEDICA;  adapted  for a
  Medical Text-book.  Fifth edition, much improved.   With one hundred and eighty-seven illus-
  trations.   In two large and handsomely printed octavo vols., leather, of about HOOpages. $6  00.
  In this work of Dr. Dunglison, we recognize the
game untiring industry in the collection and  em-
bodying of facts on the several subjects of which he
treats,  that has heretofore distinguished him, and
we cheerfully point to these volumes, as two of the
most interesting that we know of.  In noticing the
additions to this, the fourth  edition, there is very
little-in the periodical or annual  literature of the
profession,  published  in the interval which  has
elapsed since the issue of the first, that has escaped
the careful  search of the author.  As a  book for
reference, it is invaluable.—Charleston Med. Jour-
nal and Review.
  It may be said to be the work  now upon the sub-
jects upon which it treats.— Western Lancet.
  As a text-book for students, for whom  it is par-
ticularly designed, we know of  none superior to
it.—St. Louis Medical and Surgical Journal.

  It purports to be a new edition, but it is rather
a new book, so greatly has it been improved, both
in the amount and quality of the matter which it
contains.—N. 0. Medical and Surgical Journal.

  We bespeak for this edition, from the profession,
an increase of patronage over any  of its former
ones,  on account  of its  increased merit. — N. Y.
Journal of Medicine.

  We consider this work  unequalled.—Boston Med.
and Surg.  Journal.
                         by the same  author.   (^4 new Edition.)

NEW REMEDIES, WITH  FORMULAE FOR THEIR  PREPARATION AND
  ADMINISTRATION.  Seventh edition, with extensive Additions.  In one very large octavo
  volume, leather, of 770 pages.  (Just Ready, May, 1856.)  $3 75.
  Another edition of the " New Remedies" having been called for, the author has endeavored to
add everything of moment that has appeared since the publication of ihe last edition.
  The chief remedial means which have obtained a place, for the first time, in this volume, either
owino- to their having been recently introduced into pharmacology, or to their having received novel
applications—and which, consequently, belong to the category of " New Remedies"—are the fol-

  Apiol Caffein, Carbazotic acid, Cauterization and  catheterism of the larynx and traehea, Cedron,
Cerium'  Chloride of bromine, Chloride of iron, Chloride of sodium, Cinchonicine, Cod-liver olein,
Congelation, Eau de Pagliari, Galvanic cautery, Hydriodic ether, Hyposulphite of soda and silver,
Inunction, Iodide of sodium, Nickel, Permanganate of potassa, Phosphate of lime, Pumpkin, Quinidia,
Rennet Saccharine carbonate of iron and manganese, Santonin, Tellurium, and Traumaticine.
  The articles treated of in the former editions will be found to  have undergone considerable ex-
pansion in this, in order that the author might be enabled to  introduce, as far as practicable, the
results of the subsequent experience of others, as well as of his own observation and reflection;
•\nd to make the work still more deserving of the extended circulation with which the preceding
editions have been favored by the profession.  By an enlargement of the page, the numerous addi-
tions  have been incorporated without greatly increasing the bulk of the volume.— Preface.
                                                 The great learning of the author, and his remark-
                                               able industry in pushing his  researches into every
                                               source whence  information is derivable, has enabled
  One of the most useful of the author's works.—
Southern Medical and Surgical Journal.
  This elaborate  and  useful  volume  should be
found in every medical library, for as a book of re-
ference  for physicians, it  is  unsurpassed by any
other work in  existence, and the double index for
diseases and for remedies,  will be found greatly to
enhance its value.—New York Med. Gazette.
him to throw together an extensive mass of facts
and statements, accompanied by full reference to
authorities; which  last feature renders the work
practically valuable to investigators who desire to
examine the original papers.—The American Journal
of Pharmacy. 
14
BLANCHARD  &  LEA'S  MEDICAL
                                  ERICHSEN  (JOHN),
                     Professor of Surgery in University College, London, &c.

THE SCIENCE  AND ART OF  SURGERY;  being a Treatise on  Surgical
  Injuries, Diseases, and Operations.  Edited by John H. Brinton, M. D.  Illustrated with
  three hundred and  eleven engravings on wood.  In one large and handsome octavo volume, of
  over nine hundred closely printed pages, leather, raised bands.   $4 25.
                                               rarely encounter cases requiring surgical manage-
                                               ment.—Stethoscope.
                                                 Embracing, as will be perceived, the whole surgi-
  It is, in our humble judgment, decidedly the best
book of the kind in the English language.  Strange
that just such books are notoftener produced by pub-
lic teachers of surgery  in this  country and  Great
Britain  Indeed, it is a matterof great astonishment.
hut no les* true than astonishing, that of the  many
works on surgery republished in this country within
ihe last fifteen or twenty years as text-books for
medical students, this is the only one that even ap-
proximates to the fulfilment of the peculiar wants of
young men justentermgupon the study ofthis branch
of the profession.— Western Jour.of Med. and Surgery.

  Its value  is  greatly  enhanced by a very  copious
well-arransed index.  We regard this as one  of the
most valuable contributions to modern surgery.  To
one entering his novitiate of practice, we regard it
the mosi serviceable guide which he can consult.  He
will find a fulness of detail leading him through  every
step of the operation, and not deserting him until the
final  issue of the case is decided  For the same rea-
son we recommend it to those whose routine of prac-
tice lies in such parts of the country  that they must
cal domain, and each  division of itself almost com-
plete and perfect, each chapter full and explicit, each
subject faithfully exhibited, we can only eypress our
estimate  of it in the aggregate.  We consider it an
excellent contribution to surgery, as probably the
best single volume now extant on the subject, and
with great pleasure we add  it to our textbooks —
Nashville Journal of Medicine and Surgery.

  Prof. Erichsen's work, for its size, has not been
surpassed; his nine hundred and eight  pages, pro-
fusely illustrated, are rich in physiological, patholo-
gical, and operative suggestions, doctrines, details,
and processes ; and will  prove a reliable resource
for information, both to physician and surseon, in the
hour of peril.— N. 0. Med. and Surg. Journal.

  We are acquainted with no other  work wherein
so much good sense, sound principle, and practical
inferences, stamp every page.—American Lancet.
                             ELLIS (BENJAMIN), M.D.
THE  MEDICAL  FORMULARY:  being a Collection  of Prescriptions,  derived
  from the writings and practice of many of the most eminent physicians of America and Europe.
  Together with the usual Dietetic Preparations and Antidotes for Poisons.  To which  is added
  an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform.   The
  whole accompanied with a few brief Pharmaceutic and Medical Observations.  Tenth edition,
  revised and much extended by Robert  P. Thomas, M. D., Professor of Materia Medica in the
  Philadelphia College of Pharmacy.  In one neat octavo volume, extra cloth, of'296 pages. (Lately
  Iss-ued.) §1  75.
  After an examination of the new matter and the    It will  prove particularly useful to students and
alterations, we believe  the reputation of the work  young practitioners, as the most important prescrip-
built up by the  author, and the late distinguished  tions employed in modern practice, which lie scat-
editor, will continue to flourish under the auspices  tered through our medical literature, are  here col-
of the present editor, who has the industry and accu-  lected and conveniently  arranged for reference.—
racy, and, we would say, conscientiousness requi-  Charleston Med. Journal  and Review.
site for the responsible task.—Am. Jour, of Pharm.
                        FOWNES  (GEORGE),  PH. D., &.C.

ELEMENTARY  CHEMISTRY;  Theoretical and Practical.   With  numerous
  illustrations.   A new American, from the last and revised London edition.  Edited, with Addi-
  tions, by Robert Bridges, M. D.  In one large royal 12mo. volume, of over 550 pages, with 181
  wood-cuts.  (Lately Issued.)  In leather, $1 50; extra cloth, $1 35.
  We know of no better text-book, especially in the
difficult department of organic chemistry, upon
which it is particularly full and satisfactory.  We
would  recommend  it  to  preceptors as  a capital
;' office book" for their  Btudents who are beginners
in Chemistry. It is copiously illustrated with ex-
cellent  wood-cuts, and altogether admirably "got
ap."—N. J. Medical Reporter.
  A standard manual, which has long enjoyed the
reputation of embodying much knowledge in a small
space.  The author hasachieved the difficult task of
condensation with masterly tact.  His book is con-
cise without being dry, and brief without being too
dogmatical or general.— Virginia Med. and Surgical
Journal.
  The work of Dr.  Fownes has long been before
the public, and its merits have been fully appreci-
ated  as  the best text-book on chemistry now in
existence.  We do not, of course, place it in a rank
superior to the works of Brande, Graham, Turner,
Gregory, or Gmelin, but we say that,  as a work
for students, it is preferable to any of them.—Lon-
don Journal of Medicine.
  A work well adapted to the wants of the student.
It is an excellent exposition of the chief doctrines
and facts of modern chemistry. The size of the work,
and still more the condensed  yet perspicuous style
in which it is written, absolve it from the charges
very properly urged against  most manuals termed
popular.—Edinburgh Journal of Medical Science.
                       FERGUSSON  (WILLIAM),  F. R.  S.,
                      Professor of Surgery  in King's College, London,  &c.

A SYSTEM  OF  PRACTICAL SURGERY.   Fourth American,  from the third
  and enlarged London edition.  In one large and beautifully printed  octavo volume, of about 700
  pages, with 393 handsome illustrations, leather.   $3 00.
  The most important subjects in connection with
practical surgery which have been more recently
brought under the notice of, and discussed by, the
surgeons of Great Britain, are fully and dispassion-
ately considered by Mr. Fergusson, and that which
was before wanting has now been supplied^ so that
we can now look upon it as a work on practical sur-
gery instead of  one  on  operative surgery  alone.
Medical Times and Gazette.

  No work was  ever written which more  nearly
comprehended the necessities  of  the  student and
practitioner, and was  more carefully arranged to
that single purpose than this.—N. Y. Med. Journal.
  The addition of many new pages makes this work
more than ever indispensable to the student and prac-
titioner.—Ranking's Abstract.
  Among the numerous works upon surgery pub-
lished of late years, we  know of none we value
more highly than  the one before us.  It is perhaps
the very best we have  for a text-book and for ordi-
nary reference, being concise and eminently practi-
cal.—Southern Med. and Surg. Journal. 
AND SCIENTIFIC  PUBLICATIONS.                   15
                              FLINT  (AUSTIN), M.  D.,
         Professor of the Theory and Practice of Medicine in the University of Louisville, &c.
                                 {An Important New  Work.)

PHYSICAL EXPLORATION AND DIAGNOSIS  OF  DISEASES  AFFECT-
  ING THE RESPIRATORY ORGANS.  In one large and handsome octavo  volume, extra
  cloth, 636 pages.  (Now Ready.)   $3  00.
  The author has aimed in the present work to supply a vacancy in  medical literature, viz: "a
work limited to diseases affecting the respiratory organs, treating inextenso and almost exclusively
of the principles and practice of physical exploration, as applied to the diagnosis of those affections."
The intricacy and importance of the subject demand a fuller and more detailed exoosition than has
been accorded to  it in any volume as yet accessible to the American profession ; while the high re-
putation which the author has acquired by his researches in kindred topics sufficiently manifests his
ability to render the present work a text-book of great practical utility for the student, and a source
to which the  practitioner can at all times refer with certainty.
  A very condensed summary of the contents is subjoined.
CONTENTS.
INTRODUCTION.
Section I. Preliminary points pertaining to the Ana-
  tomy and Physiology of the Respiratory Appara-
  tus.  Section II. Topographical Divisions of the
  Chest.

                   PART I.

     Physical Exploration of the Chest.

Chap. I. Definitions—Different Methods of Explora-
  tions—General Remarks.  Chap. II.  Percussion.
  Chap. III. Auscultation.  Chap. IV. Inspection.
  Chap. V.  Mensuration.  Chap. VI.  Palpation.
  Chap. VII. Succussion.  Chap. VIII. Recapitu-
  latory Enumeration of the Physical  Signs fur-
  nished by  the several methods  of Exploration.
  Chap. IX. Correlation of Physical Signs.
                  PART II.
Diagnosis of Diseases Affecting the Respira-
                tory Organs.

Chap. I. Bronchitis, Pulmonary or Bronchial Ca-
  tarrh.  Chap. II.  Dilatation and Contraction of
  the Bronchial Tubes—Pertussis—Asthma. Chap.
  III. Pneumonitis—Imperfect Expansion  (Atelec-
  tasis) and Collapse.  Chap. IV.  Emphysema.
  Chap. V.  Pulmonary Tuberculosis — Bronchial
  Phthisis.  Chap. VI. Pulmonary (Edema— Gan-
  grene of the Lungs—Pulmonary Apoplexy—Can-
  cer of the Lungs—Cancer in the  Mediastinum.
  Chap. VIT. Acute  Pleuritis—Chronic Pleuritis—
  Empyema—Hydrothorax—Pneumothorax—Pneu-
  mo-hydrothorax—Pleuralgia--Diaphragmatic Her-
  nia.  Chap. VIII. Diseases affecting the  Trachea
  and Larynx—Foreign Bodies in the Air-passages.
  Appendix. On the Pitch of the Whispering Souffle
  over Pulmonary Excavations.
                         .GRAHAM  (THOMAS),  F. R. S.,
                    Professor of Chemistry in University College,  London, &c.
THE ELEMENTS  OF CHEMISTRY.   Including the application of the Science
  to the Arts.   With numerous illustrations.  With Notes and Additions, by Robert Bridges,
  M.  D., &c. &c.  Second American, from the second and enlarged London edition.
PART I. (Lately Issued) large 8vo., 430 pages, 185 illustrations.  $1 50.
PART II. (Preparing) to match.

                      GRIFFITH  (ROBERT E.),  M. D., &c.
A  UNIVERSAL FORMULARY, containing the methods  of Preparing and Ad-
  ministering Officinal  and other Medicines.  The whole adapted to Physicians and Pharmaceu-
  tists.   Second  Edition, thoroughly revised, with numerous additions, by Robert P. Thomas,
  M. D.,  Professor of Materia Medica in the Philadelphia College of Pharmacy.  In  one large and
  handsome octavo volume, extra cloth, of over 600 pages, double columns, (just Issued.) $3 00;
  or bound in sheep, $3 25.
  It was a work requiring much perseverance, and
when published was looked upon as by far the best
work of its kind that had issued from the  American
press.  Prof Thomas has certainly "improved," as
well as added to this Formulary, and has rendered it
additionally deserving of the confidence of pharma-
ceuu'sts and physicians.—Am. Journal of Pharmacy.

  We are happy to announce a new and improved
edition of this, one of the most valuable and useful
works that have emanated from  an American pen.
It would do  credit to any country, and will be found
of daily usefulness to practitioners of medicine; it is
better adapted to their purposes than the dispensato-
ries.— Southern Med. and Surg. Journal.
  A new edition of this well-known work, edited by
R. P. Thomas. M. D.,  affords occasion  for  renewing
our commendation of so useful a handbook, which
ought to be  universally  studied by  medical men of
every class, and made use of by way of reference by
office pupils, as  a standard authority.  It has been
much enlarged, and now condenses a vast amount
of needful and necessary knowledge in small  com-
pass.  The more of such  books lb* better for the pro-
fession and the public— N. Y. Med. Gazette.

  It is one of the most useful books a country practi-
tioner can possibly have in his possession.—Medical
Chronicle.
  The amountof useful, every-day matter, for a prac-
ticing physician,  is really immense.—Boston Med.
and Surg. Journal.
  This is a work of six hundred  and  fiAy one pages,
embracing all on the subject of preparing and admi-
nistering medicines that can be desired by the physi-
cian and pharmaceutist.— Western Lancet.
  In short, it is a full and complete work  of the kind
and should be in the hands of every physician and
apothecary. O. Med. and Surg. Journal
  We predict a great sale for this work, and we espe-
cially recommend it to all medical teachers.—Rich-
mond Stethoscope.
  This edition of Dr. Griffith's work has been ereatly
improved by the revision  and ample  additions of Dr.
Thomas, and is now,  we believe, one  of the most
complete works of its kind in any  language.  The
additions amount to about seventy  pages, and no
effort has been spared to include in them all the re-
cent  improvements  which have been published in
medical journals, and systematic treatises.  A work
of this kind appears to us indispen-able to the physi-
cian, and there is none we can more cordially recom-
mend.—N. Y. Journal of Medicine.
BY THE SAME AUTHOR.
MEDICAL BOTANY;  or, a Description  of all  the  more important Plants used
  in  Medicine, and  of their Properties, Uses, and Modes of Administration.  In one large octavo
  volume, extra cloth, of 704 pages, handsomely printed, with nearly 350 illustrations on wood. S3 00. 
10
BLANCHARD &  LEA'S MEDICAL
                          GROSS (SAMUEL D.),  M. D.,
             Professor of Surgery in the Jefferson Medical College of Philadelphia, &c.

A  PRACTICAL   TREATISE  ON  THE   DISEASES,   INJURIES,  AND
  MALFORMATIONS OF  THE URINARY BLADDER,  THE PROSTATE GLAND, AND
  THE URETHRA.  Second Edition, revised and  much enlarged, with one hundred and eighty-
  four illustrations.  In one large and very handsome octavo volume, of over nine hundred pages.
  (Just Issued.)  In leather,  raised bands, $5 25 ;  extra cloth, $4 75.
  The author has availed  himself of the opportunity afforded by a call for  a new edition of this
work, to thoroughly revise and render it in every respect worthy, so far as in his power, of the very
flattering- reception which has been accorded to it by the profession.  The new matter thus added
amounts to almost one-third of the original work, while the number of illustrations has been nearly
doubled.   These additions pervade every portion of the work, which thus  has rather  the aspect of
a new treatise than a new edition.  In its  present improved form, therefore, it may confidently be
presented as a complete and reliable storehouse of information on this important class of diseases,
and as in every way fitted to maintain the position which  it has acquired in Europe and in  this
country, as the standard of authority on the subjects treated of.
                                            provements, it will probably remain one of the most
                                            valuable works on this subject so long as the science
                                            of  medicine  shall  exist.—Boston Med.  and Surg.
                                            Journal;
  A volume replete with truths and principles of the
utmost value in the investigation of these diseases.—
American Medical Journal.

  On the appearance of the first edition of this work,
the leading English medical review predicted that it
would have a " permanent place in the literature of
surgery worthy to rank with the best works of the
present age."  This prediction has been amply ful-
filled. Dr. Gross's treatise has  been found  to sup-
ply completely the want which  has been felt ever
since the elevation of surgery to the rank of a science,
of a good practical treatise on  the diseases of the
bladder and its accessory organs.  Philosophical in
its design, methodical in its arrangement, ample and
sound in its practical details, it may in truth  be said
to leave scarcely anything to  be desired on  so im-
portant a subject, and with the additions and modi-
fications resulting from future discoveries and im-
 7Dr.  Gross has brought all his learning, experi-
ence, tact, and judgment to  the task, and  has pro-
duced  a work worthy of his  high reputation.  We
feel perfectly safe in recommending it to our read-
ers  as a  monograph unequalled  in  interest and
practical value by any other  on the subject in our
language.—Western Journal of Med. and Surg.
  Whoever will peruse the vast amount of valuable
practical  information it contains, and which we
have been unable even  to notice, will, we think,
agree with us, that there is no work in the English
language which can make any just pretensions to
be its equal.—N. Y. Journal of Medicine.
                           BY the same author.   (Just Issued).
A PRACTICAL TREATISE ON  FOREIGN BODIES  IN THE AIR-PAS-
  SAGES.  In one handsome octavo volume, extra cloth, with illustrations,  pp. 468.   $2 75.
 A very elaborate work. It is a complete summary
of  the whole subject, and will  be a useful book of
reference.—British and Foreign Medico-Chirurg.
Review.
 A highly valuable book of reference on a most im-
portant subject in the practice of medicine.  We
                                             conclude by recommending it to our readers, fully
                                             persuaded that its perusal will afford them much
                                             practical information well conveyed, evidently de-
                                             rived from considerable experience and deduced from
                                             an  ample collection of facts. — Dublin Quarterly
                                             Journal, May, 1855.

                           by the same author.  (Preparing.)

A SYSTEM  OF  SURGERY;  Diagnostic,  Pathological, Therapeutic, and Opera-
  tive.  With very numerous engravings on wood.

                                 BY THE  SAME AUTHOR.

ELEMENTS  OF  PATHOLOGICAL ANATOMY;  illustrated by colored  En-
  gravings, and two hundred and fifty wood-cuts.  Second edition, thoroughly revised and greatly
  enlarged.  In one very large and  handsome imperial octavo volume, leather, raised bands,  pp.
  822.  $5 75.                                                                        il
                          GLUGE  (GOTTLIEB), M. D.,
        Professor of Physiology and Pathological Anatomy in the University of Brussels, &c.
AN ATLAS  OF  PATHOLOGICAL  HISTOLOGY.   Translated, with  Notes
  and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylva-
  nia.  In one volume, very large imperial quarto, extra cloth, with 320 figures, plain and colored,
  on twelve copperplates.  $5 00.
GARDNER'S MEDICAL CHEMISTRY, for the
  use of Students and the Profession.  In one royal
  1'Jmo. vol., ex. cloth, pp. 396, with illustrations.
  SI 00.
HARRISONS ESSAY TOWARDS A CORRECT
  THEORY OF THE NERVOUS SYSTEM.  In
  one octavo volume, leather, 292 pages.  $1 50.
HUGHES'  CLINICAL INTRODUCTION TO
  THE PRACTICE OF AUSCULTATION AND
  OTHER MODES OF PHYSICAL DIAGNOSIS,
  IN DISEASES OF THE LUNGS AND HEART.
  Second American, from the second London edition.
  1 vol. royal 12mo., ex. cloth, pp. 304.  $1  00.
                        HAMILTON  (FRANK H.),  M. D.,
                     Professor of Surgery, in Buffalo Medical College, &c.

A TREATISE  ON  FRACTURES AND DISLOCATIONS.   In one handsome
  octavo volume, with numerous illustrations.  (Preparing.)
  The numerous improvements which this important branch of surgery has received from the «kill
and ingenuity of American surgeons, renders particularly appropriate and valuable a complete "and
systematic original  work on the sublet.   The essays which Professor Hamilton has published on
kindred topics are already widely and favorably known, and give earnest that his forthcoming work
will prove indispensable,  both as a text-book for the student, and as a guide for the practitioner 
AND SCIENTIFIC  PUBLICATIONS.
17
                         HOBLYN  (RICHARD  D.), M. D.
A DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINE  AND  THE
  COLLATERAL SCIENCES.  By Richard D.  Hoblyn, A. M , &c   A new American  from
  the last London edition.  Revised, with numerous Additions, by Isaac Hays, M. D., editor of
  the "American Journal of the Medical Sciences."  In one large royal 12mo. volume, leather,
  of over 500 double columned pages.   (Now Ready, 1856.)  $1 50.
  The great care bestowed on the revision of this work, and the extensive additions made to it by the
editor, have caused the delay in its appearance.  While carefully excluding obsolete words, it has
been his aim to render it a complete manual of definitions, in which the student of medicine or of
its allied sciences might feel assured of being able to find concise  explanations of all terms occur-
ring  in his course of reading.  The amount of the additions thus made, may be estimated from the
fact that the present edition contains fully one-third more matter than the  last, the number of pages
having been increased by over one hundred, notwithstanding an enlargement of the size of the page,
while at the same time it has been kept at the former exceedingly low price.
  If the frequency with which we have referred to
this volume since its reception from the publisher,
two or three weeks ago, be any criterion for the
future, the binding will soon have to be renewed, even
with careful handling.  We find that Dr. HayB has
done the profession great service by his careful and
industrious labors. The Dictionary has thus become
eminently suited  to our  medical brethren in this
country.  The additions by Dr. Hays are in brackets,
and we believe there is not a single page but bears
these insignia ; in every instance which we have thus
far noticed, the additions are really needed and ex-
ceedingly valuable.  We heartily commend the work
to all who wish to be au courant in medical termi-
nology.—Boston Med. and Surg. Journal.

  To both practitioner and student, we recommend
this dictionary as being convenient in size, accurate
in definition, and  sufficiently full and complete for
ordinary consultation.—Charleston Med. Journ. and
Review.
  Admirably calculated  to  meet the wants of the
practitioner or student, who has neither the  means
nor desire to procure a larger work. — American
Lancet.
  Hoblyn has always been a favorite dictionary, and
in its present enlarged and improved form will give
greater satisfaction than ever. The American editor,
Dr. Hays, has made  many very valuable additions.
—N.J. Med. Reporter.
  To supply the want of the medical reader arising
from this cause, we  know of no dictionary better
arranged and adapted than the one bearing the above
title.  It is not encumbered with the obsolete terms
of a bygone age, but  it contains all  that are now in
use ; embracing every department of medical science
down to the very latest date.  The volume is of a
convenient size to be used by the medical student,
and yet large enough  to make a respectable appear-
ance in the library of a physician.—Western Lancet.
  Hoblyn's Dictionary has long been a favorite with
us.  It is the best book of definitions we have, and
ought always to be upon  the student's table.—
Southern Med. and Surg. Journal.
                                  HUNTER (JOHN).
TREATISE ON  THE  VENEREAL  DISEASE.   With  copious Additions, by
  Dr. Ph. Ricord, Surgeon to the Venereal Hospital of Paris.  Edited, with additional Notes, by
  F. J. Bumstead, M. 5.   In one octavo volume, with plates.  $3 25.  ISF" See Ricord.
Also, HUNTER'S COMPLETE  WORKS, with Memoir, Notes, &c. &c.  In four neat octavo
  volumes, leather, with plates.  $10 00.
                         HORNER  (WILLIAM E.),  M. D.,
                     Professor of Anatomy in the University of Pennsylvania.

SPECIAL  ANATOMY  AND  HISTOLOGY.   Eighth  edition.   Extensively
  revised and modified.   In two large  octavo volumes, extra cloth, of more than one thousand
  pages, handsomely printed, with over three hundred illustrations.  $6 00.
  This  edition enjoyed a thorough and laborious revision on the part of the author shortly before
his death, with the view of bringing it fully up to the existing state of knowledge on the subject of
general  and special anatomy.  To adapt it more perfectly to the wants of the student, he introduced
a large number of additional  wood-engravings, illustrative of the objects described, while the pub-
lishers have endeavored to  render the mechanical execution of the work worthy of its extended
reputation.

                        JONES (T. WHARTON), F.  R. S.,
          Professor of Ophthalmic Medicine and Surgery in University College, London, &c.

THE  PRINCIPLES  AND  PRACTICE OF  OPHTHALMIC  MEDICINE
  AND  SURGERY.  With one hundred and ten illustrations.  Second American from the second
  and revised  London edition, with additions by Edward  Hartshorne, M. D., Surgeon to Wills'
  Hospital, cV<\  In one large, handsome royal 12mo. volume, extra cloth, of 500 pages.  (Now
  Ready.)  §1 50.
  The thorough revisions which this work has undergone at the hands of both author and editor
have brought Tt thoroughly up to the present state of the subject, and have rendered it complete,
without detracting from its character as  a manual, or deviating from its original object of affording
a digest of the present condition of ophthalmic science for study and  reference by those whose
leisure does not admit of their perusing the larger works of Mackenzie or Lawrence.  By an en-
largement of the size of the  page, the numerous additions to this edition have been accommodated
without increasing the bulk of the volume, and at the very low price at which it is offered, a con-
tinuance of the favor which  it has hitherto received is confidently expected.
                                              ly wrought up, and digested in the author's mind,
                                              as to come forth with the freshness and  impressive-
                                              cess of an original production.  We entertain little
                                              doubt that this  book will become what its author
                                              hoped it might become, a manual for daily reference
                                              and consultation by the student and the general prac-
                                              titioner.  The work is marked by that correctness,
                                              clearness, and precision of style which distinguish
                                              all the productions of the learned author.—British
                                              and For. Med. Revieiv.
  We are confident  that the  reader will  find, on
perusal, that the execution of the work amplyfulfils
the promise of the preface, and sustains, in every
point, the already high reputation of the author as
an ophthalmic surgeon as well as a physiologist
and pathologist.  The  book is evidently the result
of much labor and research, and has been written
with the  greatest  care and attention; it possesses
that best  quality which a  general work, like a sys-
tem or manual can show, viz: the quality of having
all the materials whencesoever derived, so thorough- 
18
BLANCHARD  &  LEA'S  MEDICAL
JONES (C. HANDHELD), F.  R. S.,  &.  EDWARD  H.  SIEVEKING, M.D.,
                Assistant Physicians and Lecturers in St. Mary's Hospital, London.

A MANUAL OF  PATHOLOGICAL   ANATOMY.   First  American  Edition,
  Revised.  With three hundred and ninety-seven handsome wood engravings.  In one large and
  beautiful octavo volume of nearly 750 pages, leather.  (Lately Issued.)  S3 75.
                                               authors have not attempted to intrude new views on
                                               their professional brethren, but simply to lay before
                                               them, what has long been wanted, an outline of the
                                               present condition ofpathological anatomy.  In this
                                               they have been completely successful.  The work is
                                               one of the best compilations which we have ever
                                               perused.  The opinions  and discoveries of all the
                                               leading pathologists and physiologists are engrossed,
                                               so that by reading any subject  treated in the book
                                               you have a synopsis of  the views of the most ap-
                                               proved authors.—Charleston Medical  Journal and
                                               Review.
  Asa concise text-book, containing, in a condensed
form, a complete outline  of what  is known in the
domain of Pathological Anatomy, it is perhaps the
best work in the English  language. Its great merit
consists in its completeness and brevity, and in this
respect it supplies a great desideratum in our lite-
rature.  Heretofore the student of pathology was
obliged to glean from a great number of monographs,
and the field was so extensive that but few cultivated
it with  any degree of success.  The authors of the
present work have sought to corrrct this defect by
placing before the reader a summary of ascertained
facts, together with the opinions of the most eminent
pathologists both of the Old and New World.  As a
simple work of  reference, therefore,  it is of great
value to the student of pathological  anatomy, and
should be in every physician's library.—Western
Lancet.

  We urge upon our readers and the profession gene-
rally the importance of informing  themselves in re-
gard to modern views of pathology, and recommend
to them to procure the work  before us as the best
means of obtaining this information.—Stethoscope.
  In offering the above titled work  to the public, the
  We have no  hesitation in recommending  it as
worthy of careful and thorough study by every mem-
ber of the profession, old or  young.—N.  W.  Med.
and Surg. Journal.
  From  the casual examination we have given we
are inclined to regard it as a text-book, plain, ra-
tional, and intelligible, such a book as the practical
man  needs for daily reference.  For this reason  it
will  be likely to be largely useful, as it  suits  itself
to those busy men who have little time for minute
investigation, and prefer a summary to an elaborate
treatise.—Buffalo Medical Journal.
                    KIRKES (WILLIAM SENtfOUSE),  M.  D.,
             Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c; and
                             JAMES  PAGET, F. R. S.,
            Lecturer on General Anatomy and Physiology in St. Bartholomew's Hospital.
A  MANUAL   OF  PHYSIOLOGY.   Second American,  from the second  and
  improved  London edition.   With one hundred and sixty-five illustrations.  In one large and
  handsome royal 12mo. volume, leather,  pp. 550.   $2  00.
  In the present edition, the Manual of Physiology
has been brought up to the actual condition of the
science, and fully sustains the reputation which it
has already so deservedly attained. We consider
the work of MM. Kirkes and Paget to constitute one
of the very best handbooks of Physiology we possess
—presenting just such an outline of the science, com-
prising an account of its leading facts and generally
admitted principles, as the student requires during
his attendance upon a course of lectures, or for re-
ference whilst preparing for  examination.— Am.
Medical Journal.
  We need only say, that,  without entering into dis-
cussions of unsettled questions, it contains all the
recent improvements in this department of medical
science. For the student  beginning this study, and
the practitioner who has but leisure to refresh his
memory, this book is invaluable, as it contains all
that it is important to know, without special details,
which  are read with interest  only by those who
would make a specialty, or desire to possess a criti-
cal knowledge of the subject.—Charleston Medical
Journal.
  One of the best treatises that can be put into the
hands of the student.—London Medical Gazette.

  Particularly adapted to those who desire to pos-
sess a concise digest of the facts of Human Physi-
ology.—British and Foreign Med.-Chirurg. Review.
  We conscientiously recommend it as an admira-
ble "Handbook of Physiology."—London Journal
of Medicine.
KNAPP'S TECHNOLOGY ; or, Chemistry applied
  to the Arts and to Manufactures.  Edited, with
  numerous Notes and Additions, by Dr.  Edmund
  Ronalds and Dr. Thomas  Richardson.  First
  American edition, with Notes and Additions, by
  Prof. Walter R. Johnson.  In two handsome
  octavo volumes, extra  cloth, printed and illus-
  trated in the highest style of art, with about 500
  wood-engravings.  $0 00.
LALLEMAND ON THE CAUSES, SYMPTOMS,
  AND TREATMENT OF SPERMATORRHOEA.
  Translated and edited by Henry J. McDougal.
  In  one  volume, octavo, extra cloth, 320 pages.
  Second American edition.  $1 75.

LUDLOW'S  MANUAL OF  EXAMINATIONS
  upon Anatomy and Physiology, Surgery, Practice
  of Medicine, Chemistry, Obstetrics, Materia Me-
  dica, Pharmacy, and Therapeutics.  Designed for
  Students of Medicine throughout the United States.
  A new edition, revised and improved. In one la'ge
  royal 12mo. volume, with several hundred  illus-
  trations.  {Preparing.)
LEE'S CLINICAL MIDWIFERY.  In one  royal
  12mo. volume, extra cloth, of 238 pages. 75 cents.

LISTON'S LECTURES  ON THE OPERATIONS
  OF  SURGERY.  Edited, with numerous  Addi-
  tions and Alterations,  by T.  D. Mutter, M. D.
  In one large and handsome octavo volume, leather,
  of 566 pages, with 216 wood-cuts.  $3 00.
                     LARDNER (DIONYSIUS),  D. C. L.,  &c.

HANDBOOKS  OF  NATURAL   PHILOSOPHY  AND   ASTRONOMY.
  Revised, with numerous Additions, by the American editor.   First Course, containing Mecha-
  nics, Hydrostatics,  Hydraulics,  Pneumatics, Sound,  and Optics.  In  one  large roval  12mo
  volume, of 750 pages, with 424 wood-cuts. SI 75.  Second Course, containing Heat Electricity'
  Magnetism, and  Galvanism, one volume, large royal 12mo., of 450 pages,  with 250 illustrations'
  U 25.  Third Course (now ready), containing Meteorology and Astronomy, in one large volume'
  royal 12mo. of nearly eight hundred pages, with thirty-seven plates and two hundred wood-cuts'
  $2 00.  The whole complete in three volumes, of about two thousand large pages, with over'one
  thousand figures on steel and wood.  $5 00. Any volume sold separate, strongly bound in leather.
  The various sciences treated in this work will be found brought thoroughly up to the latest period. 
AND SCIENTIFIC  PUBLICATIONS.
19
                                 LEHMANN  (C.  G.)
PHYSIOLOGICAL   CHEMISTRY.   Translated from  the  second  edition  by
  George E. Day, M. D., F. R. S., &c , edited by R. E. Rogers, M. D., Professor of Chemistry
  in the Medical Department of the  University of Pennsylvania, wilh  illustrations selected from
  Funke's Atlas of Physiological Chemistry, and an Appendix of plates.  Complete  in two large
  and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus-
  trations.  (Now Ready.)  S6 00.
  This great work,  universally acknowledged as the most complete and  authoritative exposition of
the principles and details  of Zoochemistry, in its passage  through the  press, has received from
Professor Rogers such care as was necessary to present it in a correct and reliable form.  To such
a work additions were deemed superfluous, but several years having elapsed between the appear-
ance in Germany of the first and last volume, the latter contained a supplement, embodying nume-
rous corrections and additions resulting from  the advance of the science.  These have all been incor-
porated in the text in their appropriate places,  while the subjects have been still further elucidated by
the insertion of illustrations from the Atlas of Dr. Otto Funke.  With the view of supplying the student
with the means of convenient comparison, a  large number of wood-cuts, from works on kindred
subjects, have also  been added in the  form of an Appendix of Plate?.  The work is, therefore, pre-
sented as in every way worthy the attention  of all who desire to be familiar wilh the modern facts
and doctrines of Physiological Science.
  Already well known and appreciated by the scien-
tific world, Professor Lehmann's great work re-
quires no laudatory sentences, as, under a new garb,
it is now presented to us.  The  little  space at our
command would ill suffice to set forth even a small
portion of its excellences.  To all whose studies or
professional duties render the revelations of Physio-
logical Chemistry at once interesting and essential,
these volumes will be indispensable.  Highly com-
plimented by European reviewers, sought  for with
avidity by  scholars of every nation, and admirably
written throughout, it is sure to win a  welcome and
to be thoroughly studied.—Boston Med. and Surg.
Journal, Dec. 1855.
  The most important contribution as yet made to
Physiological Chemistry__Am. Journal  Med. Sci-
ences, Jan. 1856.
  The present volumes belong to the small class of
medical literature which comprises elaborate works
of the highest order of merit.—Montreal Med. Chron-
icle, Jan. 1856.
  The work of Lehmann stands unrivalled  as the
most comprehensive book of reference and informa-
tion extant on every branch of the subject on which
it treats.—Edinburgh Monthly Journal of .Medical
Science.
  All teachers must possess it, and every intelligent
physician ou?ht todo likewise.—Southern Med. and
Surg. Journal, Dec. 1855.

                         by the same author.  (Now Ready, 1856.)

MANUAL  OF CHEMICAL PHYSIOLOGY.    Translated  from the German,
  with Notes and Additions, by J. Cheston Morris, M. D., with an  Introductory Essay on Vital
  Force, by Samuel Jackson, M. D., Professor of the Institutes of Medicine in the University of
  Pennsylvania.   With illustrations on wood.   In one very handsome octavo volume, extra c'oth,
  of 336 pages.  82 25.
  The original of this work, though but lately  issued by its distinguished author,  has  already
assumed the highest position, as presenting in their latest development the modern doctrines and
discoveries in the chemistry of life.  The numerous additions by the  translator, and the Introduc-
tion by Professor Jackson will render its physiological aspect more complete than designed by the
author, and will adapt it for use  as a text-book of physiology, presenting more thoroughly than has
yet been attempted, the modifications arising from the vast impulse which organic chemistry has
received within a few years past.

                          From Prof. Jackson's Introductory Essay.
  In adopting the handbook of Dr. Lehmann as a manual of Organic  Chemistry for the use of the
students of the University, and in recommending his original  work of Physiological Chemistry
for their  more mature studies, the high value of his researches, and the great weight of his autho-
rity in that important department of medical science are fully recognized.
  The present volume will be a very convenient one I densed form,  the  positive  facts of  Physiological
for students, as offering a brief epitome of the more  Chemistry.—Am. Journal Med. Sciences, April, 1856.
elaborate work, and as containing, in a very con- j
                          LAWRENCE (W.), F. R. S.,  &c.

A TREATISE   ON  DISEASES   OF  THE  EYE.   A  new edition,  edited,
  with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Will's Hospi-
  tal, &c.  In one very large and handsome octavo volume, of 950 pages, strongly bound in leather
  with raised bands.  $5 00.
  This work is so universally recognized as the standard authority on the subject, that the pub-
lishers in presenting this new edition have  only to remark  that in its preparation the editor has
carefully revised  every  portion, introducing additions and  illustrations wherever  the advance of
science  has  rendered them  necessary or  desirable,  constituting  it a complete   and  thorough
exponent of  the most advanced state of the  subject.
                                               octavo pages—has enabled both author and editor to
                                               do justice to all the details of this subject, and con-
  This admirable treatise—the safest guide and most
comprehensive work of reference, which is within
the reach of the profession.—Stethoscope.

  This standard  text-book on  the department of
which it treats, has not been  superseded, by any or
all of  the numerous publications on the subject
heretofore issued.  Nor with the multiplied improve-
ments of Dr. Hays, the American editor, is it at all
likely that this great work will cease to merit the
confidence and preference of students or practition-
ers.  Its  ample extent—nearly one thousand large
dense in this single volume the present state of our
knowledge of the whole science in this department,
whereby its practical value cannot be excelled.  We
heartily commend it, especially as a book of refer-
ence, indispensable in every medical library.  The
additions  of the American editor very greatly en-
hance the value of the work, exhibiting the learning
and experience of Dr. Hays, in the light in which he
ought to be held, as a standard authority on all sub-
jects appertaining to this specialty .—N.Y. Med. Gaz. 
20
BLANCHARD  &  LEA'S MEDICAL
                            LA  ROCHE  (R.),  M. D., &c.

YELLOW  FEVER,  considered  in its  Historical,  Pathological,  Etiological,  and
  Therapeutical Relations.  Including a Sketch of the Disease as it has occurred in Philadelphia
  from 1699 to 1854, with an examination of the connections between it and the fevers known under
  the same  name  in other parts of temperate as well as in tropical regions.   In two large  and
  handsome octavo volumes of nearly 1500 pages, extra cloth.   (Now Ready.)   $7 00.
  The publishers are happy in  being able  at length to present to the profession  this great work,
which they are assured will be regarded as an honor to the medical literature of the country.  As
the result of many years of personal observation and study,  as embodying an intelligent resume of
all  that has been  written regarding the disease, and  as exhausting the  subject in all  its various
aspects, these volumes must at once take the position of the  standard  authority and work of refer-
ence on the many  important questions brought into consideration.
                                                erection of this towering monument to his own fame,
                                                and  to the glory of the medical literature of his own
                                                country.  It  is destined to remain the great autho-
                                                rity upon the subject, of Yellow Fever.   The student
 From Professor S. H. Dickson, Charleston, S. C,
              September 18, 1855.
  A monument of intelligent and well applied re-
search, almost without example.   It is, indeed, in
itself, a large library, and is destined to constitute
the special resort as a book of reference, in the
subject of which it treats, to all future time.
  We have not time at present,  engaged as we are,
by day and by night, in the work of combating this
very disease, now prevailing in  our city, to do more
than give this cursory notice of what we consider
as undoubtedly the  most able and  erudite  medical
publication our country has  yet produced   But in
view of the startling fact, that this, the  most malig-
nant and unmanageable  disease of modern times,
has for several years been prevailing in our country
to a greater extent  than  ever before; that  it is no
longer confined to either  large or  small cities, but
penetrates country  villages, plantations, and farm-
houses;  that it is treated with scarcely better suc-
cess now than thirty or forty years ago; that there
is vast mischief done by ignorant pretenders to know-
ledge in regard to the disease, and in view of the pro-
bability that a majority of southern physicians will
be called  upon to treat the disease, we trust that this
able and comprehensive treatise will he very gene-
rally read in the south.—Memphis Med. Recorder.
  This is decidedly the great American medical work
of the day—a full, complete, and systematic treatise,
unequalled by any other upon the all-important sub-
ject of Yellow Fever.  The laborious, indefatigable,
and learned author has devoted  to it many years of
arduous research and careful study, and the result
is such as will reflect  the highest'honor upon the
author and our country.—Southern Med. and Surg.
Journal.
  The genius and scholarship of this great physician
could not have been  better employed  than in the
and physician will find in these volumes a risumt
of the sum total of the knowledge of the world upon
the awful scourge which they so elaborately discuss.
The style is so soft and  so pure as to refresh and in-
vigorate the mind while absorbing the thoughts of
the gifted author, while  the publishers have  suc-
ceeded in bringing the externals into a most felicitous
harmony with the inspiration  that dwells'within.
Take it all in all, it is a  book we have often dreamed
of, but dreamed not that  it would ever meet our
waking eye as a tangible reality.—Nashville Journal
of Medicine.
  We deem it fortunate that the splendid work of
Dr. La Roche should have been issued from the press
at this particular time.  The want of a reliable di-
gest of all that is known in relation to this frightful
malady has long been felt—a want very satisfactorily
met in the work before  us.  We deem it but faint
praise to say that Dr. La Roche has succeeded in
presenting the profession with an able and complete
monograph, one which will find its way into every
well ordered library.— Va. Stethoscope.
  Although we have no  doubt that  controversial
treatises on the mode of origin and propagation of the
fever  in question  will,  as heretofore, occasionally
appear, yet it must be some time before another sys-
tematic work can  arise  in the face of so admirable
and carefully executed a one as the present.  It is a
mine of information, quite an encyclopaedia of refer-
ences, and risumcof knowledge relative to what has
been recorded upon the subject.—London Lancet.
  A miracle of industry and research, constituting
a complete library of reference on the disease of
which it treats.— Dublin Quarterly Journal.
                                    BY THE SAME AUTHOR.

PNEUMONIA; its Supposed Connection, Pathological and  Etiological, with Au-
  tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria.  In one
  handsome octavo volume, extra cloth, of 500 pages.  $3 00.
  A more simple, clear, and forcible exposition of I   Thiswork should becarefully studied by Southern
the groundless nature and dangerous tendency of |  physicians, embodying as it does the reflections of
certain pathological  and etiological heresies, has I  an original thinker  and  close observer on a subject
Beldom been presented to our notice.—JV". Y. Journal  peculiarly their own.— Virginia Med. and Surgical
of Medicine and Collateral Science.              >  Journal.
                        MULLER  (PROFESSOR  J.),  M. D.

PRINCIPLES  OF  PHYSICS  AND  METEOROLOGY.   Edited, with Addi-
  tions, by R. Eglesfeld Griffith, M. D.   In  one large and handsome octavo volume,  extra
  cloth, with 550 wood-cuts, and two colored plates,  pp. 636.  $3 50.

  The Physics of Mailer is a work superb, complete, I  tion to the scientific records of this country may be
unique: the greatest want known to English Science |  duly estimated by the fact that the cost of the origi-
could not have been better supplied.  The work is I  nal drawings and engravings alone has exceeded the
of surpassing  interest. The value of this contribu-   sum of £2,000.—Lancet.
MAYNE'S  DISPENSATORY  AND  THERA-
  PEUTICAL REMEMBRANCER.  Comprising
  the  entire lists of Materia Medica,  with every
  Practical Formula contained in the three  British
  Pharmacopoeias.  With relative Tables subjoined,
  illustrating, by upwards of bix hundred and sixty
  examples, the Extemporaneous Forms and Com-
  binations suitable  for the different Medicines.
  Edited, with the addition of the Formula? of the
  United States Pharmacopoeia, by  R. Eglesfeld
  Griffith, M.D.  In one 12mo volume, extra cloth,
  of 300 large pages.  75 cents.
MATTEUCCFS LECTURES  ON THE  PHYSI-
  CAL  PHENOMENA OF  LIVING BEINGS.
  Edited by J. Pereira, M.D.  In one neat royal
  12mo. volume, extra cloth, with cuts, 3s8 pages.

MALGAIGNE'S OPERATIVE SURGERY, based
  on Normal  and Pathological Anatomy.  Trans-
  lated from  the French by Frederick Brittan,
  A.B..M.D. With numerous illustrations on wood.
  In one  handsome octavo volume, extra  cloth, of
  nearly six hundred pages. $2 25. 
AND SCIENTIFIC PUBLICATIONS.                   21
                          MEIGS (CHARLES  D.),  M. D.,
             Professor of Obstetrics, tec. in the Jefferson Medical College, Philadelphia.

OBSTETRICS: THE  SCIENCE  AND  THE  ART.   Second  edition,  revised
  and improved.  With one hundred and thirty-one illustrations.  In one beautifully printed octavo
  volume, leather, of seven hundred and fifty-two large pages.  $3 75.

  The rapid demand for a second edition of this work is a sufficient evidence that it has  supplied
a desideratum of the profession, notwithstanding the numerous treatises on the same subject which
have appeared within the last few years.  Adopting a system of his own, the author has combined
the leading principles of his interesting and difficult subject, with a thorough  exposition of its rules
oi'practice, presenting the results of long and extensive experience  and of  familiar acquaintance
with all the modern writers on this department of medicine.  As an American Treatise on Mid-
wifery, which has at once assumed the position of a classic, it possesses peculiar claims to the at-
tention and study  of the practitioner  and  student, while the numerous alterations and revisions
which it has undergone in the present edition are shown by the great enlargement of the work,
which is not only increased as to the size of the page, but also in the number.

                          by the same author.  (Lately Issued.)

WOMAN:  HER  DISEASES  AND  THEIR  REMEDIES.   A Series  of  Lee-
  tures to his Class.  Third and Improved edition.  In one large and beautifully printed octavo
  volume, leather.    pp. 672.  $3 60.
  The gratifying appreciation of his labors, as evinced by the exhaustion of  two large impressions
of this work within a few years, has  not been lost upon the author, who has endeavored in every
way to render it worthy of the favor with which it  has been received.  The opportunity thus
afforded for a second revision has been improved, and the work is now presented as in every way
superior to its predecessors, additions and alterations having been made whenever  the advance of
science has rendered them desirable.   The typographical execution of  the work will also be found
to have undergone a similar improvement, and the work is  now confidently presented as in every
way worthy the position  it has acquired  as the standard American text-book on the Diseases of
Females.
  It contains a vast amount of practical knowledge.
by one who has accurately observed  and retained
the experience of many years, and who tells the re-
sult in a free, familiar, and pleasant manner.—Dub-
lin Quarterly Journal.
  There is an off-hand fervor, a glow, and a warm-
heartedness infecting the effsrt of Dr. Meigs, which
is entirely captivating, and which absolutely hur-
ries the reader through from beginning to end.  Be-
sides, the  book  teems with solid instruction, and
it shows the very highest evidence of ability, viz.,
the clearness with which the information is  pre-
sented. We know of no better test of one's under-
standing a subject than  the evidence of the  power
of lucidly explaining it.   The most elementary, as
well as the obscurest subjects, under  the pencil of
Prof. Meigs, are isolated and made to stand out in

                        by the same author.   (Lately Published.)

ON   THE   NATURE,   SIGNS,   AND   TREATMENT
such bold relief, as to produce distinct impressions
upon the mind and memory of the reader. — The
Charleston Med. Journal.
  Professor Meigs has enlarged and amended  this
great work, for such it unquestionably is, having
passed the ordeal of criticism at home and abroad,
but been improved thereby ; for in  this new edition
the author has introduced real improvements,  and
increased the  value and utility of the  book  im-
measurably.  It  presents  so  many novel,  bright,
and sparkling thoughts; such an exuberance of new
ideas on almost  every page, that  we confess our-
selves to have become enamored  with  the book
and its author; and cannot withhold our congratu-
lations from our Philadelphia confreres, that such a
teacher is in their service.—N. Y.  Med. Gazette.
                                                                   OF  CHILDBED
FEVER.  In a  Series of Letters addressed to the Students of his Class.  In one handsome
octavo volume, extra cloth, of 365 pages.  $2 50.
                                             This book will add  more to his fame than either
of those which bear his name.  Indeed we doubt
whether any material improvement will be made on
the teachings of this volume for a century to come,
since it is so eminently practical, and based on pro-
found knowledge of the science and consummate
skill  in the art of healing, and ratified' by an ample
and extensive experience, such as few men have the
industry or good  fortune to acquire.—N.  Y. Med.
Gazette.
  The instructive and interesting author of this
work, whose previous labors in the department of
medicine which he so sedulously cultivates, have
placed his countrymen under deep and abiding obli-
gations, again  challenges  their admiration in  the
fresh and vigorous, attractive and racy pages before
us.  It is a delectable book. *  *  * This treatise
upon child-bed  fevers  will have an extensive sale,
being destined, as it deserves, to find a place in  the
library of every practitioner who scorns to lag in the
rear of his brethren.—Nashville Journal of Medi-
cine and Surgery.

             by the same author ; with  colored plates.  (Lately Published.)

A TREATISE ON  ACUTE AND  CHRONIC DISEASES  OF  THE  NECK
  OF THE  UTERUS.  With numerous plates, drawn and colored from nature in the highest
  style of art.  In one handsome octavo volume, extra cloth.  $4 50.

  The object of the author in this work has been to present in a small compass the practical results
of his long experience in this important and distressing class of diseases.  The great changes intro-
duced into practice, and the accessions to our knowledge on the subject, within the last few years,
resulting from the  use of the  metroscope, brings within the ordinary practice of every physician
numerous cases which were formerly regarded as incurable, and renders of great value a work like
the present combining practical directions for diagnosis and treatment with an ample series of illus-
trations, copied accurately from colored drawings made by the author, after nature.

                                  BY THE SAME  AUTHOR.

OBSERVATIONS  ON   CERTAIN  OF  THE   DISEASES   OF   YOUNG
  CHILDREN.   In one handsome octavo volume, extra cloth, of 214 pages.   SI  75. 
22
BLANCHARD  &  LEA'S  MEDICAL
                        MACLISE (JOSEPH),  SURGEON.
SURGICAL  ANATOMY.   Forming  one volume, very  large  imperial  quarto.
  With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored.  Con-
  taining one hundred and  ninety Figures, many of them the size of life.  Together with copious
  and explanatory letter-press.   Strongly  and handsomely bound  in extra cloth, being one of the
  cheapest and best executed Surgical works as yet issued in this country.  $11 00.
  %* The size of this work prevents its transmission through the post-office as a whole, but those
who desire to have  copies  forwarded  by  mail, can receive  them  in  five parts, done  up in stout
wrappers.  Price $9 00.
  One of the greatest artistic  triumphs of the age
in Surgical Anatomy.—British American Medical
Journal.
  Too much cannot be said in its praise; indeed,
we have not language to do it justice.—Ohio Medi-
cal and Surgical Journal.
  The most admirable surgical atlas we have seen.
To the practitioner deprived of demonstrative dis-
sections upon the human subject, it is an invaluable
companion.—JV. J. Medical Reporter.
  The most accurately engraved  and beautifully
colored  plates  we have ever seen in an American
book—one of the best and cheapest surgical works
ever published.—Buffalo Medical Journal.
  It is very rare that so elegantly printed, so well
illustrated, and so useful  a work, is  offered at so
moderate a price.—Charleston Medical Journal.
  Its  plates can boast a superiority which places
them almost beyond the reach of competition.—Medi-
cal Examiner.
  Every practitioner, we think, Bhould have a work
of this kind within reach.—Southern  Medical and
Surgical Journal.
  No such lithographic illustrations of surgical re-
gions have hitherto, we think, been given.—Boston
Medical and Surgical Journal.

  As a surgical anatomist, Mr. Maclise has proba-
bly no superior.—British and Foreign Medico-Chi-
rurgical Review.

  Of great value to the student engaged in dissect-
ing, and to the surgeon at a distance from the means
of keeping up his anatomical knowledge.—Medical
Times.
  The mechanical execution cannot be excelled.—
Transylvania Medical Journal.

  A work which has no parallel in point of accu-
racy and cheapness in the English language.—N. Y.
Journal of Medicine.
  To all engaged in  the study or practice of theil
profession, such a work is almost indispensable.—
Dublin Quarterly Medical Journal.

  No practitioner  whose means will admit should
fail to possess it.—Ranking's Abstract.

  Country practitioners will find these plates of im-
mense value.—N. Y. Medical Gazette.
  We are extremely gratified to announce to the
profession the completion of this truly magnificent
work, which, as a whole,  certainly  stands unri-
valled, both for  accuracy of drawing, beauty of
coloring, and all the requisite explanations of the
subject in hand.—The  New Orleans  Medical  and
Surgical Journal.

  This is by far the  ablest work on Surgical Ana-
tomy  that has come under our observation.  We
know of no  other work that would justify a stu-
dent, in any degree, for neglect of actual dissec-
tion.  In those  sudden emergencies that so often
arise, and which require the instantaneous command
of minute anatomical knowledge, a work of this kind
keeps the details of the dissecting-room perpetually
fresh in the memory —The Western Journal of Medi-
cine and Surgery.
  gggf The very low price at which this work isfurnished, and the beauty of its execution,
require an extended sale to compensate the publishers for the heavy expenses incurred.
      MOHR  (FRANCIS)  PH.D., AND REDWOOD  (THEOPHILUS).
PRACTICAL  PHARMACY.   Comprising the  Arrangements,  Apparatus, and
  Manipulations of the Pharmaceutical Shop and  Laboratory.  Edited, with extensive Additions,
  by Prof. William Procter, of the Philadelphia  College  of Pharmacy.  In one handsomely
  printed octavo volume, extra cloth, of 570 pages, with over 500 engravings on wood.   $2 75.
                             MACKENZIE  (W.),  M.D.,
                 Surgeon Oculist in Scotland in ordinary to Her Majesty, &c. &c.

A PRACTICAL  TREATISE  ON DISEASES  AND  INJURIES  OF   THE
  EYE.  To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section of
  the Human Eyeball, by Thomas  Wharton Jones, F. R. S.  From the Fourth Revised and En-
  larged London Edition.  With Notes  and Additions by Addinell Hewson, M. D., Surgeon to
  Wills Hospital, &c. &c.  In one very large and handsome octavo volume, leather, raised bands, with
  plates and numerous wood-cuts.  (Now Ready.)  $5 25.
  The treatise of Dr. Mackenzie indisputably holds
the first place, and forms, in respect of learning and
research, an Encyclopaedia unequalled  in extent by
any other work of the kind, either English or foreign.
—Dixon on Diseases of the Eye.

  Few modern books on any department of medicine
or surgery have met with such extended circulation,
or have procured  for their authors a like amount of
European celebrity.  The immense research which
it displayed, the  thorough  acquaintance  with the
subject, practically as well as theoretically, and the
able manner in which the author's stores of learning
and experience were rendered available for general
use, at once procured for the first edition, as well on
the continent as in this country,  that high position
as a standard work which each  successive edition
has more firmly established, in spite of the attrac-
tions of several rivals of no mean  ability.  This, the
fourth edition, has been in a great measure re-writ-
ten ;  new matter, to the extent of one hundred and
fifty pages, has been added, and in several  instances
formerly  expressed opinions have been modified in
accordance with the advances in the science which
have'been made of late years.  Nothing worthy of
repetition upon any branch of the subject appears to
have escaped the author's notice.  We  consider it
the duty of every one who has the love of his profes-
sion and the welfare of his patient at heart, to make
himself familiar with this the most complete work
in the English language upon the diseases of the eye.
—Med. Times and Gazette.               .
  The fourth edition of this standard work will no
doubt be as fully appreciated as the three former edi-
tions.  It is unnecessary to say a word in its praise,
for the verdict has already been passed upon  it by
the most  competent judges, and " Mackenzie on the
Eye" has justly obtained a reputation which it is
no figure of speech to call world-wide.—British and
Foreign Medico-Chirurgical Review.
  This new  edition of Dr. Mackenzie's celebrated
treatise on diseases of the eye, is truly a miracle of
industry  and learning.  We need scarcely say that
he has entirely exhausted the subject of his specialty.
—Dublin Quarterly Journal. 
AND SCIENTIFIC  PUBLICATIONS.                   23
                           MILLER (JAMES),  F. R. S. E.,
                     Professor of Surgery in the University of Edinburgh, ice.

PRINCIPLES  OF  SURGERY.   Fourth American, from  the  third and  revised
  Edinburgh edition.  In  one large  and very beautiful volume, leather, of 700  pages, with  two
  hundred and forty exquisite illustrations on wood.  (Now Ready, 18-56.)    $3  75.
  The extended reputation enjoyed by this work will be fully maintained by the present edition.
Thoroughly revised by the author, it will be found a clear and compendious exposition of surgical
science in its most advanced condition.
  'In connection with the recently  issued third edition of the author's "Practice of Surgery," it
forms a very complete system of Surgery in all its branches.
  The work of Mr. Miller is too well and too favor-
ably known among us, as one of our best text-books,
to render any further notice of it necessary than the
announcement of a new edition, the fourth in our
country, a proof of its extensive circulation among
us.  As a concise and reliable exposition of the sci-
ence of modern surgery, it stands deservedly high—
we  know not its superior.—Boston Med. and Surg.
Journal, May, 185G.
  The works of Professor Miller are so well known
to the profession, that it is unnecessary for us say
anything in relation to their general  merits.  The
present edition of his " Principles," however, de-
serves a  special  notice, from the number, variety,
and faithfulness of its illustrations.  The wood-cuts
are beautifully executed, and many of them are new
and exceedingly instructive, particularly those illus-
trating mortification, diseased and fractured  bones,
and the varieties of aneurism.—Western Lancet, May,
1856.
  This edition is far superior, both in the abundance
and quality of its material, to any of the preceding.
We hope it will be extensively read, and the sound
principles which are herein taught treasured up for
future application.   The  work  takes  rank with
Watson's Practice of Physic; it certainly does not
fall behind that great work in soundness of princi-
ple or depth of reasoning and research.  No physi-
cian who values his reputation, or seeks the interests
of his clients, can acquit himself before his God and
the world without making himself familiar with the
sound and philosophical views developed in the fore-
going book.—New Orleans Med. and Surg. Journal.
  Without doubt the ablest exposition of the  prin-
ciples of that  branch of the healing art in any lan-
guage.  This  opinion, deliberately formed after a
careful study of the  first edition, we have had no
cause to change on  examining  the  second.  This
edition has undergone thorough  revision by the au-
thor; many expressions have  been modified, and a
mass of new matter introduced.  The book is got up
in the finest style, and is an evidence of the progress
of typography in our country.—Charleston Medical
Journal and Review.
  We recommend it to both student and practitioner,
feeling assured that  as it now comes to us, it pre-
sents the most satisfactory exposition of the modern
doctrines of the principles of surgery to be found in
any  volume in  any  language.—N.  Y.  Journal  of
Medicine.
                          by the same author.  (Lately Published.)

THE PRACTICE OF  SURGERY.   Third American  from the second  Edin-
  burgh edition.  Edited, with Additions, by F. W. Sargent, M. D.,  one of the Surgeons to Will's
  Hospital,  &c.  Illustrated by three hundred and nineteen engravings on wood.  In one large
  octavo volume, leather, of over 700 pages.  $3 75.
  No encomium of ours could add to the popularity
of Miller's Surgery.  Its  reputation in this country
is unsurpassed by that of any other work, and, when
taken in connection with  the author's Principles of
Surgery, constitutes  a  whole, without reference to
which  no  conscientious  surgeon would be willing
to practice his art.  The  additions, by Dr. Sargent,
have materially enhanced the value of the work.—
Southern Medical and Surgical Journal.
  It is seldom that two volumes have ever made so
profound an impression  in so short a  time as the
"Principles" and the "Practice" of  Surgery by
Mr. Miller—or so richly merited the reputation they
have acquired.  The author is  an eminently sensi-
ble, practical, and well-informed man, who knows
exactly what he is talking about and exactly how to
talk it.—Kentucky Medical Recorder.
  By the almost unanimous voice of the profession,
his works, both on the principles and practice of
surgery have been assigned the highest rank.  If we
were limited to but one work on surgery, that one
should be Miller's, as we regard it as superior to all
others.—St. Louis Med. and Surg. Journal.

  The author, distinguished alike as a practitioner
and writer, has in this and  his " Principles," pre-
sented to the profession one of the most complete and
reliable  systems of Surgery extant.  His style of
writing is original, impressive, and engaging, ener-
getic, concise, and lucid. Few have the faculty of
condensing so much in small space, and at the same
time so  persistently holding the attention;  indeed,
he appears to make the very process of condensation
a means of eliminating  attractions.  Whether as a
text-book for students or a book of reference for
practitioners, it cannot be too strongly recommend-
ed.— Southern  Journal of Med. and Phys. Sciences.
                               NEILL  (JOHN),  M. D.,
                  Professor of Surgery in the Pennsylvania Medical College, &c.
OUTLINES OF THE  ARTERIES.    With short Descriptions.   Designed  for
  the Use of Medical Students.  With handsome colored plates.  Second  and improved edition.
  In one octavo volume, extra cloth.  $1 25.
OUTLINES OF THE  NERVES.  With  short Descriptions.   Designed  for  the
  Use of Medical Students. With handsome plates.  Second and improved edition.  In one octavo
  volume, extra cloth.  $1 25.
OUTLINES  OF  THE  VEINS  AND LYMPHATICS.   With  short Descrip-
  tions.  Designed for the Use of Medical Students. With handsome colored plates. In one octavo
  volume, extra cloth.  SI 25.                      ,,,,,,..            i  .
ALSO—The three works done up in one handsome volume, half bound, with numerous plates, pre
  senting a complete view of the Circulatory,  Nervous, and Lymphatic Systems,  '
S3 25.
  This book should be in the hand of every medical
Btudent.  It is cheap,  portable, and  precisely the
thing needed in studying an important, though diffi-
cult  part of Anatomy. — Boston Med. and  Surg.
Journal.
  We recommend every student of medicine to pur-
chase a  copy  of this work,  as  a labor-saving ma-
chine, admirably adapted to refresh  the  memory,
with knowledge gained by  lectures, dissections,
and the reading of larger works.—iV". Y. Journal of
Medicine.
  This work is from the pen of a Philadelphia ana-
tomist, whose familiar knowledge of the subject has
been aided by the press, the result of which is a vo-
lume of great beauty and excellence.  Its fine exe-
cution commends it to the student of Anatomy. It
requires no other recommendations.—Western Journ.
of Medicine and Surgery. 
24
BLANCHARD &  LEA'S  MEDICAL
                               NEILL (JOHN),  M. D.,
                          Surgeon to the Pennsylvania Hospital, &c; and
                       FRANCIS GURNEY  SMITH,  M.D.,
              Professor of Institutes of Medicine in the Pennsylvania Medical College.

AN  ANALYTICAL  COMPENDIUM  OF   THE   VARIOUS   BRANCHES
  OF MEDICAL SCIENCE;  for the Use and Examination of Students.   A new edition, revised
  and improved.  In one very large and  handsomely  printed royal 12mo. volume, of about one
  thousand pages, with three hundred and seventy-four illustrations on wood.   Strongly bound in
  leather, with raised bands.  (Now Ready,  1856.)  $3 00.
  The very flattering reception which has been accorded to this work, and the high estimate placed
upon it by the profession, as evinced by the constant and increasing demand which has rapidly ex-
hausted two large editions, have stimulated the authors to render the volume in its present revision
more worthy of the success which has attended  it.  It has accordihgly been thoroughly examined,
and such errors as had on former occasions escaped observation have been corrected, and whatever
additions were necessary to maintain it on a level with the advance of science have been introduced.
The extended series  of illustrations has been  still further increased and much improved, while, by
a slight enlargement  of the page, these various additions have been incorporated without increasing
the bulk of the volume.
  The work is, therefore, again presented as eminently worthy of the favor with which  it has hitherto
been received.   As a book for daily reference by  the student requiring a guide to his more elaborate
text-books, as a manual for preceptors desiring to stimulate their  students by frequent and accurate
examination,  or as a source from which the practitioners of older date may easily and cheaply acquire
a knowledge of the changes and improvement in  professional science,  its reputation is permanently
established.
  In the rapid course of lectures, where work for
the students is heavy, and review necessary for an
examination, a compend  is not only valuable,  but
it is almost a sine qua non.  The one before us is,
in most of the divisions, the most unexceptionable
of all books of the kind that we know of.   The
newest and soundest doctrines  and the latest im-
provements and discoveries  are explicitly, though
concisely, laid before the student.  Of course it is
useless for us to  recommend it to all last course
students,  but  there is  a class to whom  we very
sincerely  commend this cheap  book  as worth its
weight in silver — that class is the  graduates in
medicine  of more than ten  years' standing, who
have not studied medicine since.   They will perhaps
find out from it that the science is not exactly now
what it was when they left it ofT.—The Stethoscope
  We recommend it to our readers as the best work
of the kind with which we are acquainted.—Med.
Examiner, April, 185G.
  Having made free  use of this volume in our ex-
aminations of pupils, we can speak from experi-
ence in recommending it as an admirable compend
for students,  and as especially useful to preceptors
who examine their pupils.  It will save the teacher
much labor by enabling him readily to recall all of
the points upon which his pupils  should be ex-
amined.  A work of this sort should be in the hands
of every one who takes pupils into his office with a
view of examining them;  and this is unquestionably
the best of its class.—Transylvania Med. Journal.
&.C.
                NELIGAN  (J. MOORE), M. D., M. R. I. A.
                              (A splendid work.  Now Ready.)

ATLAS  OF  CUTANEOUS DISEASES.   In one beautiful quarto volume, extra
  cloth, with splendid colored plates, presenting nearly one hundred elaborate representations of
  disease.  $4 50.
  This beautiful volume is intended as a complete and accurate representation of all the varieties
of Diseases of the Skin.  While it can be consulted in conjunction with any work on Practice, it has
especial reference to the author's " Treatise on Diseases of the Skin," so favorably received by the
profession some  years since.  The publishers feel justified in saying that no  more beautifully exe-
cuted plates have ever been presented to the profession of this country.
  The diagnosis of eruptive disease, however, under
all circumstances, is very difficult.   Nevertheless
Dr. Neligan has  certainly, "as  far as possible,"
given a faithful and  accurate representation of this
class of diseases, and there can  be no doubt  that
these plates will be  of great use to the student and
practitioner in drawing a diagnosis as to the class,
order, and species to which the particular case  may
belong.  While looking over the " Atlas" we have
been induced to examine also the " Practical Trea-
tise."  This was published in 1852, and we are in-
clined to consider it a very superior work, combin-
ing accurate verbal description, with sound views
of the pathology and treatment of eruptive diseases.
—Glasgow Medical Journal.
  The profession owes its thanks to the publishers of
Neligan's Atlas of Cutaneous Diseases, for they have

                                   BY THE SAME AUTHOR.

A  PRACTICAL  TREATISE   ON   DISEASES  OF  THE  SKIN.   In one
  neat royal 12mo. volume, extra cloth, of 334 pages.  $1 00.
  We must say he bears off the palm for clearness,
conciseness, and rigid plainness of expression.  This
style enables him to compress much in a single  sen-
placed within its reach and at a moderate cost a most
accurate and well delineated series of plates illus-
trating the eruptive disorders.  These plates are all
drawn from the life, and in many of them the daguer-
reotype has been employed with great success. Such
works as these are especially useful to country prac-
titioners, who have not an opportunity of seeing the
rarer forms of cutaneous disease, and hence need the
aid of illustrations to give them the requisite infor-
mation on the subject.  With these plates at hand,
the inexperienced practitioner is enabled to discri-
minate with much accuracy, and he is thus, com-
paratively speaking, put  oh an  equal  footing with
those who have had the opportunity of visiting the
large hospitals of Europe and America.—Va. Med.
Journal, June, 1856.
tence, without in any degree injuring the sense, but,
on the contrary, making it more comprehensive and
impressive.  By far the largest  proportion of the
volume  is devoted to therapeutic considerations.
Not merely are full details of treatment and formulae
given at the close of each section, but an entire
chapter is devoted to " those general points in thera-
peutics which are specially applicable  to this class
of affections."  The present work forms a favorable
contrast to the voluminous and disputed details of
many of its predecessors, and will, we feel assured,
be admirably conducive  to facilitating  the study of
the student, and improving the practice of the prac-
titioner.—Dublin Quarterly Journ. of Med. Science.
flgT" The two volumes will be sent by mail on receipt of Five Dollars.
OWEN ON  THE DIFFERENT  FORMS  OF
  THE SKELETON,  AND  OF THE  TEETH.
One vol. royal 12mo., extra cloth, with numerous
lllURtrntinna   I T.iet To«..-^ \  at, nc 
AND SCIENTIFIC PUBLICATIONS.
25
                                      (Now Complete.)
             PEREIRA (JONATHAN), M. D.,  F. R.  S., AND  L. S.
THE  ELEMENTS  OF  MATERIA  MEDICA   AND  THERAPEUTICS.
  Third American edition, enlarged and improved by the author;  including Notices of most of the
  Medicinal Substances in use in the civilized world, and forming an Encyclopaedia of Materia
  Medica.  Edited, with Additions, by Joseph Caeson, M. D., Professor of Materia Medica and
  Pharmacy in the University of Pennsylvania.  In two very large octavo volumes of 2100 pages,
  on small type, with about  500 illustrations on stone and wood, strongly bound in leather, with
  raised bands.  $9 00.
  Gentlemen who  have the first volume  are recommended to complete their copies without delay.
The first volume will no longer be sold separate.  Price of Vol. II. $5  00.
  When we remember that Philology, Natural His-
tory, Botany, Chemistry, Physics, and the Micro-
scope, are all brought forward to elucidate the sub-
ject, one cannot fail to see that the reader has here
a work worthy of the name of an encyclopaedia of
Materia Medica.  Our own opinion of its merits is
that of its editors^ and also that of the whole profes-
sion, both of this and foreign countries—namely,
" that  in copiousness of details, in extent, variety,
and accuracy of information, and  in lucid explana-
tion of difficult and recondite subjects, it surpasses
all  other works on Materia Medica hitherto pub-
lished." We cannot close this notice without allud-
ing to the special additions of the  American editor,
winch  pertain to the prominent vegetable produc-
tions of this country, and to the directions  of the
United States Pharmacopoeia, in connection with all
the articles contained in the volume which are re-
ferred toby it. The illustrations have been increased,
and this edition by Dr.  Carson cannot well  be re-
garded in any other light than that of a treasure
which  should be found in the library of every  physi-
cian.—New York Journal of Medical and Collateral
Science.
  The third edition of his " Elements  of Materia
Medica, although completed under the supervision of
others, is by far  the most elaborate treatise in  the
English language, and will, while medical literature
is cherished, continue  a monument alike honorable
to his  genius, as to his  learning and  industry.—
American Journal of Pharmacy.
  The work, in  its present  shape, forms the most
comprehensive  and  complete treatise on materia
medica  extant  in  the English  language.—Dr.
Pereira has been at great pains to introduce into
his work, not  only  all  the information  on,  the
natural, chemical, and commercial history of medi-
cines, which might be serviceable to the physician
and surgeon, but whatever  might enable his read-
ers to understand thoroughly the mode of prepar-
ing and manufacturing various articles employed
either for preparing medicines, or for certain pur-
poses in  the arts connected with  materia medica
and the practice of medicine.  The accounts of  the
physiological and therapeutic effects of remedies are
given with great clearness  and accuracy, and in a
manner calculated to interest as well as instruct the
reader.—Edinburgh Medical and Surgical Journal.
                             PEASELEE (E.  R.),  M.  D.,
                 Professor of Anatomy and Physiology in Dartmouth College, &c.

HUMAN HISTOLOGY, in its applications to Physiology and General Pathology;
  designed as a Text-Book for Medical Students.   With numerous illustrations.  In one handsome
  royal 12mo. volume.  (Preparing.)
  The subject of this work is one, the  growing importance of which, as the basis of Anatomy and
Physiology, demands for it a separate volume.  The book will therefore supply an acknowledged
deficiency in medical text-books, while the name of the author, and his experience as a teacher for
the last thirteen years, is a guarantee that it will be thoroughly adapted to the use  of the student.

                         PIRRIE  (WILLIAM), F. R.  S. E.,
                       Professor of Surgery in the University of Aberdeen.

THE  PRINCIPLES  AND  PRACTICE  OF SURGERY.   Edited by John
  Neill, M. D., Professor of Surgery in the Penna.  Medical College, Surgeon to the Pennsylvania
  Hospital, &c.  In one very handsome octavo volume, leather, of 780 pages, with 316 illustrations.
  $3 75.
                                               arrived.  Prof. Pirrie, in the work before us,  has
                                               elaborately discussed the principles of surgery,  and
                                               a safe and effectual  practice predicated upon  them.
                                               Perhaps no work upon this subject heretofore issued
                                               is  so full upon the  science of the art of Burgery.—
                                               Nashville Journal of Medicine and Surgery.
                                                One of the best treatises on surgery in the English
                                               language.—Canada Med. Journal.
                                                Our impression is, that, as a manual for students,
                                               Pirrie's is the best work extant.—Western Med.  and
                                               Surg. Journal.
  We know of no other  surgical work of a reason-
able size, wherein there is so much theory and prac-
tice, or where subjects are more soundly or clearly
taught.—The Stethoscope.

  There is  scarcely a disease of the bones or soft
parts, fracture, or dislocation, that is not illustrated
by accurate wood-engravings.  Then, again, every
instrument employed hy the surgeon is thus repre-
sented.  These engravings are not only correct, but
really beautiful, showing the astonishing degree of
perfection to which the art of wood-engraving  has
                               PANCOAST (J.), M.D.,
              Professor of Anatomy in the Jefferson Medical College, Philadelphia, &c.

OPERATIVE  SURGERY;  or,  A Description and  Demonstration of the various
  Processes of the Art; including all the New Operations, and exhibiting  the State of Surgical
  Science in its present advanced condition.   Complete in one royal 4to. volume, extra cloth, of
  380 pages of letter-press description  and eighty large 4to. plates, comprising 486 illustrations.
  Second edition, improved.  $10 00.
  This excellent work is constructed on the model
of the French Surgical Works by Velpeau and Mal-
gaigne;  and, so far as the English language is con-
cerned, we aTe proud as an American to say that,
o* its KIND it has no superior.—N. Y. Journal of
Medicine.
                              PARKER  (LANGSTON),
                         Surgeon to the Queen's Hospital, Birmingham.

THE MODERN TREATMENT  OF SYPHILITIC DISEASES, BOTH  PRI-
  MARY AND SECONDARY;  comprising the Treatment of Constitutional and Confirmed Syphi-
  lis  by a safe and successful method.  With numerous Cases, Formulae, and  Clinical Observa-
  tio'nsf  From the Third and entirely rewritten London edition.  In one neat octavo volume,
  extra cloth, of 316 pages.  (Just Issued.)  $175. 
26
BLANCHARD  &  LEA'S  MEDICAL
                                PARRISH  (EDWARD),
  Lecturer on Practical Pharmacy and Materia Medica in the Pennsylvania Academy of Medicine, &c.

AN INTRODUCTION  TO PRACTICAL  PHARMACY.  Designed as a  Text-
  Book for the Student, and as a Guide for the  Physician  and Pharmaceutist.  With many For-
  mulae and Prescriptions.  In one handsome octavo volume, extra cloth, of 550 pages, with 243
  Illustrations. (Now Ready, 1856.)  $2 75.
  This work, while  necessary to the educated pharmaceutist, will also be found  of the greatest
importance  to those practitioners who, residing at a distance from apothecaries, are called upon to
dispense as well as to prescribe.   The author has not only given a thorough outline of the principles
of pharmacy and its general processes, but has also presented their special applications in the details
of preparing all the different classes of medicines, illustrated with numerous engravings of apparatus
and implements, which, in all cases, are of the simplest description.  Under the  different heads
are contained  many tables and syllabi of classes of medicines, presenting the remedies  of  the
United States Pharmacopoeia, together with many new ones, so arranged as to render their relations
of easy comprehension, and embodying all the more  important  formulae of the Pharmacopoeia, as
well as many others from the practice of distinguished physicians, not hitherto in print.  Especial
notice  has been taken of the numerous important remedies recently obtained from our indigenous
flora, and their composition and preparation pointed out.
  The long experience of the author as a teacher of pharmacy has rendered him familiar with  the
wants of students, and entirely competent to supply them.   He has accordingly descended to those
minutiae which so often interpose difficulties in the way of the young practitioner, who has hitherto
had no practical guide to point out the modes  of overcoming them.
  A careful examination of this work enables us to
speak of it in the highest terms, as being the best
treatise on practical pharmacy with which we are
acquainted, and an invaluable vade-mecum, not only
to the apothecary and to those practitioners who are
accustomed to prepare their own medicines, but to
every medical man and medical student.  Through-
out the work are interspersed valuable tables, useful
formulae, and practical hints, and the whole is illus-
trated by a large number of excellent wood-engrav-
ings.—Boston Med. and Surg. Journal.
  This is altogether one of the most useful books we
have seen. It is just what we have long felt to be
needed by  apothecaries, students, and practitioners
of medicine, most of whom in this country have to
put up their own prescriptions.  It bears, upon every
page, the impress of practical knowledge, conveyed
in a plain common sense manner, and adapted to the
comprehension  of all who may read it.  No detail
has been omitted, however trivial it may seem, al-
though really important to the dispenser of medicine.
—Southern Med. and Surg. Journal.
  To both the country practitioner and the city apo-
thecary this work of Mr. Parrish is a godsend. A
careful study of its contents  will give the young
graduate a familiarity with the value and mode of
administering his prescriptions, which will be of as
much use to his  patient as to himself.— Va. Med.
Journal.
  Mr. Parrish has rendered a very acceptable service
to the practitioner and student, by furnishing  this
book, which contains the leading facts and principles
of the science of Pharmacy, conveniently arranged
for study, and with special reference to those features
of the subject which possess an especial practical in-
terest to the physician.  It furnishes the student, at
the commencement of his studies, with that infor-
mation which is of the greatest importance in ini-
tiating him into the domain of Chemistry and Materia
Medica; it familiarizes him with the compounding
of drugs, and supplies those minutitE which but few
practitioners can impart.  The junior  practitioner
will, also, find this volume replete with instruction.
—Charleston Med. Journal and Review, Mar. 1850.
                 PHYSICIAN'S  DAILY RECORD  FOR 1857.
COMPRISING A REGISTER OP VISITS, ENGAGEMENTS, AND CASES.
  Together with Tables of Doses, Weights and Measures, Poisons and Antidotes, and other Memo-
  randa for Clinical Reference.  A neat volume, for the Pocket.  (Preparing.)
For 25 patients, flexible cloth, 50 cents; leather, tucks, 75 cents.
For 50    "          "      75   "      "     "    $1 00.
  The object of this  little volume is to afford the physician a convenient means of recording and
arranging his daily practice, and of registering under every day and for  every patient what visits
have been paid, so that they can readily and expeditiously be charged for collection, besides keep-
ing such memoranda of cases and treatment  as may be  deemed desirable for  future reference;
thus at once enabling him to regulate his business, and to preserve and  accumulate  the  record of
his clinical experience.  Space is  also furnished for such memoranda as are most likely  to be re-
quired in a physician's daily avocations; while a portion of the work comprises in a condensed form
such  information as  is likely to prove convenient for reference at the bedside.   The copies in
leather have pockets for loose memoranda, prescription papers, &c.  The very low price at which it
is offered places it within  the  reach  of every practitioner, in the expectation that  all will  avail
themselves of the great advantages which it offers.
                                RICORD (P.), M. D.,
A TREATISE ON THE VENEREAL DISEASE.  By John Hunter, F. R. S.
  With copious Additions, by Ph. Ricord, M. D.  Edited, with Notes, by Freeman J  Bumstead
  M. D.  In one handsome octavo volume, extra cloth, of 520 pages, with plates.   $3 25.
  Every one will recognize the attractiveness and
value which this work derives from thus presenting
the opinions of these two masters side by side.  But,
it must be admitted, what has made the fortune of
the book, is the fact that it contains the "most com-
plete embodiment of  the veritable doctrines of the
Hopital du Midi," which has ever been made public.
The doctrinal ideas of M. Ricord, ideas which, if not
aniversally adopted, are incontesiably dominant, have
heretofore only been interpreted by more or less skilful sician.— Virginia Med. "and "surgJournal
                                  BY THE  SAME AUTHOR.
ILLUSTRATIONS  OF SYPHILITIC DISEASE. I LETTERS ON SYPHILIS addressed to the Thief
  Translated by Thomas F: Betton, M.D.  With |   Editor of the Union MedicaU^  Transiated b^ W
                                                P. Lattimore, M. D.  In one neat octavo vol-
secretanes, sometimes accredited and sometimes not.
  In the notes to Hunter, the master substitutes him-
self for his interpreters, and gives hisoriginal thoughts
to the world in a lucid and perfectly intelligible man-
ner.  In conclusion we can say that this is  incon-
testably the best treatise on syphilis with which we
are acquainted, and, as we do not often employ the
phrase, we may be excused for expressing the hope
that it may find a place in the library of every nhv-
fifty  large quarto colored plates.   In one larcre
quarto volume, extra cloth. $15 00.
urne, of 270 pages, extra cloth.  %2 00. 
AND SCIENTIFIC  PUBLICATIONS.                   27
                      RAMSBOTHAM  (FRANCIS H.), M.D.
THE PRINCIPLES  AND  PRACTICE OF OBSTETRIC MEDICINE AND
  SURGERY, in reference to the Process of Parturition.  A new and enlarged edition, thoroughly
  revised by the Author.   With Additions by W. V. Keating, M. D.  In one large and handsome
  imperial octavo volume, of 650 pages, s-trongly bound in leather, with raised bands; with sixty-
  four beautiful Plates, and numerous Wood-cuts in the text, containing in all nearly two hundred
  large and beautiful figures. (Lately Issued,  1856.) $5 00.
  In calling the attention of the profession to the new edition of this standard work, the publishers
would remark that  no efforts have been spared to secure for it a continuance and extension of the
remarkable favor with which it has been received.  The last London issue, which was considera-
bly enlarged, has received  a further revision from  the author, especially for this country.   Its pas-
sage through the press here has been supervised by Dr. Keating, who  has made numerous addi-
tions with a view  of presenting more fully  whatever was necessary  to adapt it thoroughly to
American modes of practice.  In its mechanical execution, a like superiority over former editions
will be found.
                            From Prof. Hodge, of the University of Pa.
  To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being
the best authorized exponent of British Midwifery.  Its circulation will, I trust, be extensive throughout
our country.
 cine and Surgery to our library, and confidently
 recommend it to our readers, with the assurance
 that it will not disappoint their most sanguine ex-
 pectations.—Western Lancet.
  It is unnecessary to say anything in regard to the
 utility of this work. It is already appreciated in our
 country for the value of the matter, the clearness of
 its style, and the fulness of its illustrations.  To the
 physician's library it is indispensable, while to the
 student as a text-book, from which to extract the
' material for laying the foundation of an education on
 obstetrical science, it has no superior.—Ohio Med.
 and Surg. Journal.

  We -will only add that the student will learn from
 it all he need to know, and the practitioner will find
 it, as a book of reference, surpassed by none other.—
 Stethoscope.
   The character and merits of Dr. Ramsbotham's
 work are so well known and thoroughly established,
 that comment is unnecessary and praise superfluous.
 The illustrations, which are numerous and accurate,
 are executed in the highest style of art.  We cannot
 too highly recommend the work to our readers.—St.
 Louis Med. and Surg. Journal.
  The publishers have shown their appreciation of
the merits of this work and secured its success by
the truly elegant style in which they have brought
it out, excelling themselves in its production, espe-
cially in its plates.   It is dedicated to Prof. Meigs,
and has the emphatic endorsement of  Prof. Hodge,
as the best  exponent of British Midwifery.  We
know of no text-book which deserves in all respects
to be more highly recommended to students, and we
could wish tosee'it in the hands of every practitioner,
for they will find it invaluable for reference.—Med.
Gazette.
  Butonce in a long time some brilliant genius rears
his head above the horizon of science, and illumi-
nates and purifies every department that he investi-
gates ; and his works become types, by which innu-
merable imitators model their  feeble  productions.
Such a genius we find in the younger Ramsbotham,
and such a type we find in  the work now before us.
The binding, paper, type, the engravings and wood-
cuts are all so excellent as  to make this book one of
the finest specimens of the  art of printing that have
given such a world-wide  reputation  to its enter-
prising and liberal publishers.  We welcome Rams-
botham's Principles and  Practice of Obstetric Medi-

                           ROKITANSKY (CARL),  M.D.,
     Curator of the Imperial Pathological  Museum, and Professor at the University of "Vienna, Sec.

A   MANUAL  OF  PATHOLOGICAL  ANATOMY.   Four  volumes,  octavo,
   bound in two, extra cloth, of about 1200 pages.  (Now Ready.)   $5 50
Vol. I.—Manual of General Pathological Anatomy.  Translated by W. E. Swaine.
Vol. II.—Pathological  Anatomy  of  the  Abdominal Viscera.  Translated by Edward Sieveking,
    'm.d.
 Vol. III.—Pathological Aftatomy of the Bones, Cartilages, Muscles, and Skin, Cellular and Fibrous
     Tissue, Serous and Mucous Membrane, and Nervous System.  Translated by C. H. Moore.
 Vol. IV.—Pathological Anatomy of the Organs of Respiration and Circulation.  Translated by G.
     E. Day.
 To render this large and important work more easy of reference, and at the same time less cum-
   brous and costly, the four volumes have been arranged in two, retaining, however, the separate
   paging, &c.
   The publishers  feel much pleasure in-presenting to the profession of the United States the great
 work of Prof. Rokitansky, which is universally referred to as the standard of authority by the pa-
 thologists of all nations.   Under the auspices of the Sydenham Society of London, }he combined
 laborof four translators  has  at length overcome the almost insuperable difficulties which have so
 lono- prevented the appearance of  the work in an English dress, while the additions made from
 various papers and essays of the author present his views on all the topics embraced, in their latest
 published form.   To a work so widely known, eulogy is unnecessary, and  the publishers would
 merely state  that it is  said to contain the results of not less  than thirty thousand post-mortem
 examinations  made by the author,  diligently compared,  generalized, and wrought into one com-
 plete  and harmonious  system
  The profession is too well acquainted with the re-
putation of Rokitansky's work to need our assur-
ance that this is one of the most profound, thorough.
and valuable books  ever  issued from the medical
press.  It is sui generis, and has no standard of com-
parison.  It is only necessary to announce that it is
issued in  a form as cheap as is compatible  with its
size and  preservation, and  its sale follows as  a
matter of course.  No library can be called com-
plete without it.—Buffalo Med. Journal.

  An attempt to give our readers any adequate idea
of the vast amount of instruction accumulated in
these volumes, would be feeble and hopeless.  The
effort of  the distinguished author to concentrate
in a small  space his great fund of knowledge, has
so charged his text with valuable truths, that any
attempt of a reviewer to epitomize is at once para-
lyzed, and must end in a failure.—Western Lancet.
  As this is the highest  source of knowledge upon
the  important  subject of which it treats, no real
student can afford to be without it. The American
publishers have entitled  themselves to the thanks of
the profession of their country, for this timeous and
beautiful edition.—Nashville Journal of Medicine.
  As a  book of reference, therefore, this work must
prove of inestimable value, and we cannot too highly
recommend  it  to the profession.—Charleston Med.
Journal and Review, Jan. 1S56.
  This  book is a necessity to every practitioner.—
Am. Med. Monthly. 
28
BLANCHARD &  LEA'S  MEDICAL
RIGBY'S SYSTEM OF MIDWIFERY.   With  Notes and Additional Illustra-
  tions.  Second American Edition.  One volume octavo, extra cloth, 422 pages.  $2 50.
ROYLE'S  MATERIA   MEDICA  AND  THERAPEUTICS;   including the
  Preparations  of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States.
  With many new medicines.  Edited by Joseph Carson, M. D.  With ninety-eight illustrations.
  In one large octavo volume, extra cloth, of about 700 pages.  $3 00.
                           SMITH  (HENRY  H.),
                    Professor of Surgery in She University of Pennsylvania, &c.
MINOR  SURGERY;  or, Hints on the Every-day Duties of the Surgeon.   Illus-
  trated by two hundred and forty-seven illustrations.  Third and enlarged edition.  In one hand-
  some royal 12mo. volume,  pp. 456.  In leather, $2 25; extra cloth, 5?2  00.
  And a capital little book it is. .  . Minor Surgery,
we repeat, is really Major Surgery, and anything
which teaches it is worth having.  So we cordially
recommend this little book of Dr. Smith's.—Med.-
Chir. Review.
  This beautiful little work has been compiled with
a view to the wants of the profession in  the matter
of bandaging, &c.,and well and ably has  the author
performed his  labors.  Well  adapted to give the
requisite  information on the subjects of which  it
treats.—Medical Examiner.
  The directions are plain, and illustrated through-
out with clear engravings.—London Lancet.
  One of the best works they can consult on the
Bubject of which it treats.—Southern Journal of
Medicine and Pharmacy.
                               BY THE SAME AUTHOR, AND

                         HORNER (WILLIAM E.), M.D.,
                  Late Professor of Anatomy in the University of Pennsylvania.

AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body.
  In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful
  figures. $3 00.
  A work such as the present is therefore highly
useful to the student, and we commend  this one
to their attention.—American Journal of Medical
Sciences.
  No operator, however eminent, need hesitate  to
consult this unpretending yet excellent book. Those
who are young in the business would find Dr. Smith's
treatise  a necessary companion, after once under-
standing its true character.—Boston Med. and Surg.
Journal.

  No young practitioner should be without this little
volume; and we venture to assert, that it maybe
consulted by the senior members of the profession
with more real benefit, than the more voluminous
works.—Western Lancet.
  These figures are  well  selected, and present a
complete and accurate representation of that won-
derful fabric, the human body.  The  plan of this
Atlas, which renders it so peculiarly convenient
for the student,  and its superb artistical execution,
have been already pointed out.  We must congratu-
late the student upon the completion of this Atlas,
as it is the most convenient work of the kind that
has yet appeared ; and we must add, the very beau-
tiful manner in which it is " got up" is so creditable
to the country as to be flattering  to our national
pride.—American Medical Journal.
                             SARGENT  (F. W.), M.  D.
ON BANDAGING  AND OTHER OPERATIONS OF  MINOR SURGERY.
  Second edition, enlarged.  One handsome royal 12mo. vol., of nearly 400 pages, with 182 wood-
  cuts.  (Now Ready, 1856.)  Extra cloth, $1  40; leather, $1  50.
  This very useful little work has long been a favor-
ite with practitioners and students.  The recent call
for a new edition has induced its author to make
numerous important additions.  A slight alteration
in the size of the page has enabled him to introduce
the new matter, to the extent of some fifty pages of
the former edition, at the same time that his volume
is rendered still more compact than its less compre-
hensive predecessor.  A double gain in thus effected,
which, in a vade-mecum of this kind, is a material
improvement.—Am. Medical Journal.

  Sargent's Minor Surgery has always been popular,
and deservedly so. It furnishes that knowledge of the
most frequently requisite performances of surgical
art which cannot be entirely understood by attend-
ing clinical lectures.  The  art of bandaging, which
is regularly taught  in Europe, is very frequently
overlooked by teachers in this country; the student
and junior practitioner, therefore, may often require
that knowledge which this little volume so tersely
and happily supplies.  It is neatly printed and copi-
ously illustrated by the enterprising publishers, and
should be possessed by all who desire to be thorough-
ly conversant with the details of this branch of our
art.—Charleston Med. Journ. and Review, March,
1856.
  A work that has been so long and favorably known
to the profession as Dr. Sargent's Minor Surgery,
needs no commendation from us. We would remark,
however, in this connection, that minor surgery sel-
dom gets  that attention in our schools that its im-
portance deserves.  Our larger works are also very
defective in their teaching on these small practical
points.  This little book will supply the void which
all must feel who have not studied i'ts pages.—West-
ern Lancet, March, 1856.
  We confess our indebtedness to  this little volume
on many occasions, and can warmly recommend it
to our readers, as it is not above the consideration
of the oldest and most experienced.—American Lan-
cet, March, 1856.
SKEY'S OPERATIVE SURGERY.  In one very
  handsome octavo volume, extra cloth, of over 650
  pages, with about one hundred wood-cuts. $3 25.
STANLEY'S TREATISE  ON DISEASES OF
  THE BONES. Inonevolume, octavo, extra cloth,
  886 pages.  81 50.
SOLLY ON THE HUMAN BRAIN; its Structure,
  Physiology, and Diseases.   From the Second and
  much'enlarged London edition.  In  one octavo
  volume, extra cloth, of 500 pages, with 1-20 wood-
  cuts.  S2 00.

SIMON'S  GENERAL PATHOLOGY, as conduc-
  ive to the  Establishment of Rational Principles
  for the prevention and Cure of Disease.  In onu
  neat octavo volume, extra cloth, of 212 paeea.
  $1 25.                                  s
                             STILLE (ALFRED),  M. D.
PRINCIPLES   OF   GENERAL  AND  SPECIAL   THERAPEUTICS.   In
  handsome octavo.  (Preparing.) 
AND  SCIENTIFIC PUBLICATIONS.
29
       SHARPEY (WILLIAM),  M.D.,  JONES  QUAIN,  M.D.,  AND
                         RICHARD QUAIN,  F. R.  S.,  &c.
HUMAN ANATOMY.  Revised, with Notes and Additions, by Joseph Leidy,
  M. D., Professor of Anatomy in the University of Pennsylvania.  Complete in two large octavo
  volumes, leather, of about thirteen hundred pages.  Beautifully illustrated with over five hundred
  engravings on wood.  $6 00.
  It is indeed a work calculated to make an era in
anatomical study, by placing  before the  student
every department of his science, with a view to
the relative importance of each ; and so skilfully
have the different parts been interwoven,  that no
one who makes this work the basis of his  studies,
will  hereafter have any excuse for  neglecting or
undervaluing any important particulars connected
with  the  structure of the human frame;  and
whether the bias of his mind lead him  in a more
especial manner  to surgery, physic, or physiology,
he will find here a work at once so comprehensive
and practical as to defend him from exclusiveness
on the one  hand, and  pedantry on  the other.—
Journal and Retrospect of the  Medical Sciences.
  We have no hesitation in recommending this trea-
tise on anatomy as the most complete on that sub-
ject in the English  language; and the only one,
perhaps, in  any language, which brings the state
of knowledge forward  to  the most recent  disco-
veries.—The Edinburgh Med. and Surg. Journal.
OF
                           SMITH  (W. TYLER), M.D.,
                        Physician Accoucheur to St. Mary's Hospital, &c.

ON  PARTURITION,  AND  THE  PRINCIPLES  AND  PRACTICE
  OBSTETRICS.  In one royal 12mo. volume, extra cloth, of 400 pages.  $125.

                           BY THE SAME AUTHOR.—(Just Issued.)

A PRACTICAL  TREATISE  ON  THE  PATHOLOGY  AND  TREATMENT
  OF LEUCORRHCEA.  With numerous  illustrations
  extra cloth, of about 250 pages.   $ 1 50.
  We decide this book to be one of the most useful
monographs which has appeared in  this country.
What was before unutterable confusion in regard to
its subject has now the order, regularity, and  har-
mony of a most beautiful science. Dr.  Smith has
placed  the whole profession directly, and mankind
        In one very handsome octavo volume,


indirectly, under abiding obligations. — Nashville
Journ. of Medicine.
  We hail the appearance of this practical and in-
valuable work, therefore, as a real acquisition to
our medical literature.—Medical Gazette.
                           SIBSON  (FRANCIS),  M. D.,
                               Physician to St. Mary's Hospital.
MEDICAL  ANATOMY.   Illustrating  the Form, Structure, and Position of the
  Internal Organs in Health and Disease.  In large imperial quarto, with splendid colored plates.
  To match "Maclise's Surgital Anatomy."  Parti.  (Preparing.)
                      SCHOEDLER (FRIEDRICH),  PH.D.,
                        Professor of the Natural Sciences at Worms, &c.

THE BOOK  OF NATURE;  an  Elementary  Introduction to  the  Sciences  of
  Physics, Astronomy, Chemistry, Mineralogy, Geology, Botany, Zoology, and Physiology.  First
  American  edition, with a Glossary and other Additions and Improvements; from  the second
  English edition.  Translated from the sixth German edition, by Henry Medlock, F. C. S., &c.
  In one thick volume, small octavo, extra cloth, of about seven hundred pages, with 679 illustra-
  tions on wood.  Suitable for the higher Schools and private students.  (Now Ready.)  $1 80.
                             TANNER (T. H.),  M.  D.,
                           Physician to the Hospital for Women, &c.

A  MANUAL OF  CLINICAL  MEDICINE  AND PHYSICAL DIAGNOSIS.
  To which is  added The Code of Ethics of the American  Medical Association.  In one neat
  volume small 12mo.  Price in extra cloth, 87 £ cents; flexible style, for the pocket, 80 cents.
  (Lately Published.)
  In this admirable little work the author's object has been to give the young practitioner that kind
of information which enables him to make practical application of the knowledge acquired by his
studies  and which is not to be found in the text-books.  Such a manual has been  much wanted,
as it fills a void which has long been felt, but which there has hitherto been no attempt to supply.
That the author has succeeded  in his endeavor, is sufficiently shown by the unusually favorable
reception which the  work has  already received, although only just published.
  Dr. Tanner has, in a happy and successful manner,
indicated the"leading  particulars to which, in the
clinical study of a case of disease, the attention of
the physician is to be directed, the value and import
of the various abnormal phenomena detected, and the
several instrumental and accessory means which
maybe called into requisition to facilitate diagnosis
and increase its certainty.—Am.  Journal of Med.
Sciences.
  In this small work is collected a fund of such in-
formation as the student at the commencement, and
even during the continuance of his studies, is often
sadly troubled to know where to look for .—Montreal
Med. Chronicle.
  The work is an honor to its writer, and must ob-
tain a wide circulation by its intrinsic merit alone.
It seems to us that but slight effort on the part of the
publishers will be requisite to exhaust even a large
edition.  Suited  alike to the wants of students and
practitioners, it has only to be seen, to win for itself
a place upon the shelves of every medical library.
Nor will it be " shelved" long at a time; if we mis-
take not, it will be found,  in the best sense of the
homely but expressive word, " handy."  The style
is admirably clear, while it is so sententious as not
to burden the memory.  The arrangement is, to our
mind, unexceptionable.  The  work, in short, de-
serves the heartiest commendation.—Boston Med.
and Surg. Journal
  We cordially recommend  every young practitioner
who wishes to reap the greatest possible benefit from
his observation of disease to  make  this book his
daily companion.—New Hampshire Journal of Medi-
cine.
  As a convenient and suggestive book of reference,
we accord it our hearty praise—Va. Med. and Surg.
Journal. 
30
BLANCHARD  &  LEA'S  MEDICAL
                     TAYLOR (ALFRED S.), M. D.,  F. R. S.,
               Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital.

MEDICAL JURISPRUDENCE.   Fourth American, from the fifth improved and
  enlarged English  Edition.  With Notes and References to American Decisions, by Edward
  Hartshorne, M.  D.  In one large octavo volume,  leather, of over seven hundred pages.   (Just
  Ready, June, 1856.)  $3 00.
  This standard work has lately received a very thorough revision at the hands of the author, who
has introduced whatever was necessary to render it complete  and satisfactory in  carrying out the
objects in view. The editor has likewise used every exertion to make it equally thorough witli
regard to all matters relating to the practice of this country.  In doing this, he has carefully ex-
amined all that has appeared on the subject since the publication of the last edition, and has incorpo-
rated all the new information thus presented.  The work has thus been considerably increased in
size, notwithstanding which, it has been kept at its former very moderate price, and in every respect
it will be found worthy of a continuance of the remarkable favor which has carried it  through so
many editions on both sides of the Atlantic.  A few notices of the former editions are appended.
  We know of no work on Medical Jurisprudence
which contains in the same space anything like the
same amount of valuable matter —N. Y. Journal of
Medicine.
  No work upon the subject  can  be put into the
hands of students either of law or  medicine which
will engage them more closely or  profitably; and
none could be  offered to the  busy practitioner of
either calling, for the purpose of casual  or hasty
reference, that would be more likely to afford the aid
desired.  We therefore recommend it as the best and
safest manual for daily use.—American Journal of
Medical Sciences.
  So well is this work known to the members both
of the medical and legal professions, and so highly
is it appreciated by them, that it cannot be necessary
for us to say a word in its commendation; its having
already reached a fourth edition being the best pos-
sible testimony in  its  favor.  The author has ob-
viously subjected the entire work to a very careful
revision.—Brit, and Foreign Med. Chirurg. Review.
  This work of Dr. Taylor's is generally acknow-
ledged to be one of the  ablest extant on the subject
of medical  jurisprudence.  It is certainly one of the
most attractive books that we have met with ; sup-
plying so much  both to interest and instruct, that
we do not hesitate to affirm that after having once
commenced its perusal, few could be prevailed upon
to desist before completing it.   In the last London
edition, all the newly observed and accurately re-
corded facts have been inserted, including much that
is recent of Chemical, Microscopical, and  Patholo-
gical research, besides papers on numerous subjects
never before published .-Charleston Medical Journal
and Review.

  It is not excess of praise to  say that the volume
before us is the very best treatise extant on Medical
Jurisprudence.  In saying this, we do not wish to
be understood as detracting from the merits of the
excellent works  of  Beck, Ryan, Traill, Guy, and
others; but in interest and value we think it must
be conceded that Taylor is superior to anything that
has preceded it.  The author is already well known
to the profession by his valuable treatise on Poisons;
and the present volume will add materially to his
high  reputation for  accurate and  extensive know-
ledge and discriminating judgment.—N. W. Medical
and Surgical Journal.
                                  BY THE  SAME AUTHOR.

ON POISONS,  IN RELATION  TO  MEDICAL  JURISPRUDENCE  AND
  MEDICINE. Edited, with Notes and Additions, by R. E. Griffith, M. D.  In one large octavo
  volume, leather, of 688 pages.  $3 00
        TODD (R. B.),  M.  D., AND BOWMAN (WILLIAM), F.  R. S.
PHYSIOLOGICAL   ANATOMY  AND   PHYSIOLOGY  OF  MAN.   With
  numerous handsome wood-cuts. Parts I, II, and III, in one octavo volume, 552  pages.   $2  50.
  Part IV will complete the work.

  The first portion of Part IV, with numerous original illustrations, was published in the Medical
News and Library for 1853, and the completion will  be issued immediately on its appearance in
London.   Those who  have subscribed since the appearance of the preceding portion of the work
can have the three parts by mail,  on remittance of $2 50 to the publishers.

                       WATSON  (THOMAS),  M.D., &c.

LECTURES  ON  THE  PRINCIPLES   AND  PRACTICE OF  PHYSIC.
  Third American edition, revised, with Additions, by D. Francis  Condie, M. D., author of a
  " Treatise 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 sub-
ject 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's Rep.
to Nat. Med. Assoc.

  By universal  consent  the work ranks among the
very best text-books in our language.—Illinois and
Indiana Med. Journal.

  Regarded on  all hands as one of the very best, if
not  the very best, systematic treatise on practical
medicine extant.—St. Louis Med. Journal.
$3 25.

  Confessedly one of  the very best works on the
principles and practice of physic in the English or
any other language.—Med. Examiner.
  Asa text-book it has no equal; as a compendium
of pathology and practice no superior.—New York
Annalist.
  We know of no work better calculated for being
placed in the hands of the student, arid 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. — N. Y.  Med.
Journal.
                               WHAT  TO  OBSERVE
AT  THE   BEDSIDE  AND  AFTER  DEATH,   IN  MEDICAL  CASES.
  Published under the authority of the London Society for Medical Observation.  A new American
  from the second and revised London edition.   In one very handsome volume, roval 12mo  extra
  cloth.  (Just Issued.)   §1 00.                                          '   '        '
  To the observer who prefers accuracy to blunders
and precision to carelessness, this little book is in-
valuable.—N. H. Journal of Medicine.
  One of the finest aids to a young practitioner we
have ever seen.—Peninsular Journal of Medicine. 
AND  SCIENTIFIC  PUBLICATIONS.
31
  In many, if not all the Colleges of the Union, it
has become a standard text-book.  This, of itself,
is sufficiently expressive of its value.  A work very
desirable  to the student; one, the  possession  of
which will greatly facilitate  his progress in  the
study of Practical Anatomy.—New York Journal of
Medicine.

  Its author ranks with the highest on Anatomy.—
Southern Medical and Surgical Journal.
                    WILSON  (ERASMUS), M.D.,  F. R. S.,
                               Lecturer on Anatomy, London.

A SYSTEM OF HUMAN  ANATOMY, General and Special.   Fourth Ameri-
  can, from the last English edition.  Edited by Paul B. Goddard, A. M., M. D.  With two hun-
  dred  and fifty illustrations.  Beautifully printed, in one  large octavo volume, leather, of nearly
  six hundred pages. $3 00.
                                              It offers to the student all the assistance that can
                                             be expected from such a work.—Medical  Examiner.
                                              The most complete and convenient manual for the
                                             student we  possess.—American Journal  of Medical
                                             Science.
                                              In  every respect,  this  work as an  anatomical
                                             guide for the student and practitioner,  merits  our
                                             warmest and most decided praise.—London Medical
                                             Gazette.

                          BY THE SAME author.  (Now Ready.)

THE   DISSECTOR'S MANUAL; or, Practical  and  Surgical Anatomy.   Third
  American, from the last revised and enlarged English edition.   Modified and rearranged, by
  William Hunt, M. D., Demonstrator of Anatomy in the University of Pennsylvania.  In  one
  large and handsome royal 12mo. volume, leather, of -532 pages, with 154 illustrations.  $2 00.
  The modifications and additions which this work has received  in  passing  recently through the
author's hands, is  sufficiently indicated  by the fact that it is enlarged by more than one hundred
pages, notwithstanding  that it is printed  in smaller type, and with a greatly enlarged page.  So com-
plete has  the author rendered it, that the editor has  found but little  to do, except in rearranging
it to suit the  mode of dissection practised  in  this country,  and  in introducing a large  number of
additional illustrations.  Of these, many new ones have been  engraved expressly for  the  work,
and the series throughout will be found greatly enhanced  in value.   The  typographical execution
of the volume has undergone a like improvement, and in every respect the work is presented as merit-
ing an increase of the favor which it has hitherto enjoyed as  a sound practical guide to the study of
anatomy.
  It remains only to add, that after a careful exami- I ing very superior claims, well calculated to facilitate
 nation, we have no hesitation in recommending this | their studies, and render their labor less irksome, by
 work to the notice of those for whom it  haB been  constantly keeping before them definite objects of
 expressly  written—the students—as a guide possess- | interest.—The Lancet.

                                  BY THE SAME  AUTHOR.

 ON  DISEASES  OF  THE  SKIN.   Third American, from the  third London
   edition.  In one neat octavo volume, of about five hundred pages, extra cloth.  $1 75.
   The "Diseases of the  Skin," by Mr. Erasmus I in that department of medical literature.—Mtdico-
 Wilson, may now be regarded as the standard work | Chirurgical Review.

                                  BY THE SAME  AUTHOR.

 ON  CONSTITUTIONAL  AND   HEREDITARY  SYPHILIS,  AND   ON
   SYPHILITIC ERUPTIONS.   In one small octavo volume, extra  cloth, beautifully printed, with
   four exquisite colored plates, presenting more than thirty varieties  of syphilitic eruptions. $-2 if>.
                           BY  THE SAME AUTHOR.  (Just Issued.)

 HEALTHY SKIN; A Popular Treatise on  the Skin and Hair,  their  Preserva-
   tion and  Management.  Second American,  from the fourth London edition.  One neat volume,
   royal 12mo., extra cloth, of about 300 pages, with numerous illustrations.   $1  00; paper cover,
   75 cents._________________

                     WHITEHEAD (JAMES), F.  R. C. S., &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.  Second American Edition.   In  one volume, octavo, extra cloth, pp. 368.  §1 75.

                              WALSHE (W.  H.),  M.  D.,
           Professor of the Principles and Practice of Medicine in University College, London.

  DISEASES   OF   THE   HEART,   LUNGS,  AND   APPENDAGES;  their
   Symptoms and Treatment. In  one handsome volume, extra cloth, large royal 12mo., 512 pages.
   $i  50.
   We consider this as the ablest work in the En- I the author being the first stethoscopist of the clay. —
  glish  language, on the subject of which it treats; | Charleston Medical Journal.

                                     WILDE (W.  R.),
                    Surgeon to St. Mark's Ophthalmic and  Aural Hospital, Dublin.

  AURAL SURGERY,  AND THE  NATURE  AND TREATMENT OF DIS-
    EASES OF THE  EAR.   In  one  handsome octavo volume, extra  cloth, of 476  pages, with
    illustrations.   §2 80.
   Thi* work certainly contains more information on laws, and amenable to the same general methods of
  the subject to which it is devoted  thari  any other treatment as other morbid processes.  The work is
  with  which we are acquainted. We feel grateful to  not written to supply the cravings of popular patron-
  ihe author for his manful effort to rescue this depart-  age, but it is wholly addressed to the profession, and
  merit of surgery from the  hands of the empirics who  bears  on every page the impress of the reflections
  nearly monopolize it. We think he  has successfully  of a sagacious and  practical surgeon.— Va. Surg, and
  shown that aural disease? are not beyond  the re-  Med. Journal.
  sources of art j that they are governed by the same | 
32       BLANCHARD & LEA'S  SCIENTIFIC PUBLICATIONS.
                          WEST (CHARLES),  M. D.,
Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for
                                   Sick Children, &c.

LECTURES   ON  THE  DISEASES  OF  INFANCY AND  CHILDHOOD.
  Second American, from the Second and Enlarged London edition.   In one volume, octavo,
  extra cloth, of nearly five hundred pages.  (Just Issued.)  $2 00.
                                           ligation by this able, thorough, and finished work
                                           upon a subject which almost daily taxes to the ut-
  We take leave of Dr. West with great respect for
his attainments, a due appreciation of his acute
powers of observation, and a deep sense of obliga-
tion for this valuable contribution to our profes-
sional literature.  His book is undoubtedly in many
respects the best we possess on diseases of children.
Dublin Quarterly Journal of Medical Science.
  Dr. West has placed the profession under deep ob-
most the skill of the general practitioner. He has
with singular felicity threaded his way through all
the tortuous labyrinths of the difficult subjecthe has
undertaken to elucidate, and has in many of the
darkest corners left a  light, which will never be
extinguished.—Nashville Medical Journal.
                        by the same AUTHOR.  (Nearly Ready.)
                 Publishing in the "Medical News and Library," for 1S56.

LECTURES  ON  THE DISEASES  OF WOMEN.   In two  parts.
  Part I. 8vo. of about 300 pages, comprising the Diseases of the Uterus.
  Part II. (Preparing), will contain  Diseases of  the Ovaries, and of  all the parts connected
    with the Uterus ; of the Bladder, Vagina, and  External Organs.
  The object of the author in this work is to  present a complete but  succinct treatise on Female
Di>eases. embodying the results of his experience during the last ten years at St. Bartholomew's
and the Midwifery Hospitals, as well as in private practice.  The  characteristics which have se-
cured to his former works  so favorable a reception, cannot fail to render the present volume a
standard authority on its important subject.  To show  the general scope of the work, an outline of
the Contents of Part I. is subjoined.
Lectures  I, II.—Introductory—Symptoms—Examination  of Symptoms—Modes of Examina-
  tions.  Lectures III, IV., V—Disorders  of Menstruation, Amenorrhoea, Menorrhagia, Dys-
  menorrhoea.  Lectures VI., VII, VIII.—Inflammation of the Uterus, Hypertrophy, Acute
  Inflammation, Chronic Inflammation, Ulceration of the Os Uteri, Cervical Leucorrhcea.  Lectures
  IX., X, XL, XII, XIII.—Misplacement of the Uterus, Prolapsus, Anteversion, Retrover-
  sion, Inversion.  Lectures XIV., XV., XVI, XVII.—Uterine Tumors and Outgrowths,
  Mucous, Fibro-cellular, and Glandular Polypi, Mucous Cysts, Fibrinous Polypi, Fibrous Tumors,
  Fibrous Polypi, Fatty Tumors, Tubercular Diseases.   Lectures XVIII., XIX., XX.—Cancer
  of the Uterus.
Part II. will receive an equally extended treatment, rendering the whole an admirable text-book
  for the student, and a reliable work for reference by  the practitioner.

                          BY THE SAME AUTHOR.   (Just Issued)

AN ENQUIRY  INTO THE PATHOLOGICAL IMPORTANCE OF ULCER-
  ATION OF THE OS UTERI.   In one neat octavo volume, extra cloth.  $1 00.
                   WILLIAMS  (C. J.  B.),  M. D.,  F. R. S.,
                Professor of Clinical Medicine in University College, London, &c.

PRINCIPLES  OF  MEDICINE;  comprising General Pathology and Therapeu-
  tics, and a brief general view of Etiology, Nosology, Semeiology, Diagnosis, Prognosis, and
  Hygienics.  Edited, with Additions, by Meredith Clymer, M. D.  Fourth American, from the
  last and enlarged London edition.  In one octavo volume, leather, of 476 pages.  $2 50.
                                             Few books have proved more useful, or met with
  The best exposition in our language, or, we be-
lieve, in any language, of rational medicine, in its
present improved and rapidly  improving state. —
British and Foreign Medico-Chirurg. Review.
a more ready sale than this, and no practitioner
should regard his library as complete without it.
—Ohio Med. and Surg. Journal.
                          YOUATT (WILLIAM),  V. S.
THE   HORSE.   A new edition, with numerous  illustrations;  together with a
  general history of the Horse;  a Dissertation on the American Trotting Horse; how Trained and
  Jockeyed;  an Account of his Remarkable Performances;  and an Essay on the Ass and the Mule.
  By J. S. Skinner, formerly  Assistant  Postmaster-General, and Editor of  the Turf Register!
  One large octavo volume, extra cloth.  $1 50.
  The attention of all who keep horses is requested to this handsome  and complete  edition of a
work which is recognized as the standard authority on all matters connected with veterinary medi-
cine.  The very low price at  which it is now offered, free by mail, places it  within the reach of
every one.
                                BY THE SAME AUTHOR.

THE  DOG.   Edited hy  E.  J. Lewis, M. D.   With  numerous  and beautiful
  illustrations.  In one very handsome volume, crown Svo., crimson cloth °-ilt. §1 25.
              ILLUSTRATED  MEDICAL  CATALOGUE.
  BLANCHARD  & LEA have lately issued a Catalogue of their Medical, Surgical, and Sci-
entific Publications, containing descriptions of the works, with Notices of the  Press and
specimens of the lUustrations, making a very handsome pamphlet of sixty-four large octavo
pages.  Copies will be sent by mail, and the postage paid, on application to the Publishers
by inclosing six cents  in postage stamps. 
 
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